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Environmental Health Department <br />Date(s)1 <br />2 <br />Address <br />Phone ) <br />?i ~7 7 /) >3 <br />4 <br />5. <br />6 <br />9 <br />above <br />meats, tamales, cooked beans, rice, <br />F 209 464-0133 ( wvvw sjgov org/enc <br />7 <br />8 <br />Alternate ( <br />Approved water for drinking, utensrl and hand washing will be provided in my booth by the following methods <br />[^Approved bottled water. <br />Astyp'-J_________________ _ <br />Uo\.e\ The only operations not required to provide enclosed booths <br />approved dispensers, or prepackaged foods from approved sources <br />1868 E <br />EHD 1&-02 <br />OA/IQ/to <br />are those which sell beverages from <br />Hazelton Avenue f Stockton California 95205 | T 209 468-3420 | <br />Page 7 ot 11 <br />O On-site hose bib that is connected to a potable water source <br /> Other (specify): ___________ __________________ <br />Electricity is provided for my booth's use: 0Yes O No ” ------------------- <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods <br />1 VW F*. <br /> Camp stove Sterno & hotel trays <br /> Double steamer Steam table & lids <br /> Electric stove top -^-Other (specify) <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />I am providing food that is NOT prepared at home Q Yes I5TNo <br />All food is prepared on-site or is from approved commercial facilities S^Yes [j No <br />Name of facility Phone: cS/q ) €^5- ^32^ <br />Address of facility JlMo S- A *>-3^/ <br />I am providing a booth with the following (to protect my unpackaged food and food-preparation areas from flies. <br />dust and the public) <br /> A booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly <br />screening, completely enclosing open food areas It will also have a smooth and cleanable floor (concrete, <br />asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />areas from the public <br />pother (specify): <br />All food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to <br />the festival coordinator three (3) weeks prior to this event <br />1 Name of Event ’DO/V'Dl VZ? <br />The following is information about my organizabon/business <br />Name of orgamzation/busmess Pz2, 2-/9 <br />_imo S (2ft ^-53^1 <br />(SIo ) <br />List food to be sold or given to the public <br />SANJOAQUIN <br />-----COUNTY <br />v’ Gf€Gfne»i hf'f <br />TEMPORARY FOOD VENDOR’S APPLICATION