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Environmental Health Department <br />I.Name of Event:1. <br />2. <br />____ Alternate: (Phone: <br />3. <br />4. <br />5. <br />6. <br />9. <br />meats, tamales, cooked beans, rice, <br />■r <br />TEMP EVENT APRPage 7 of 11 <br />7. <br />8. <br />Name of facility: V? i Vl CxVK LA <br />Address of facility: ’i \ LV-’O <br />1868 E Hazelton Avenue I Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />EHO 16-02 Page 7 of 11 TE'"P EVEN1 <br />07/3/17 <br />SANJOAQUIN <br />------COUNTY------- <br />Greatness grows here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <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. i i. H .I r, ( <br />F Qu'It- Date(s): t <br />The following is information about my organization/business: <br />Name of organization/business: W- ~Tn ------------------- <br />Address: ____kC-i------------------------------------------------------------------ <br />( ) ___________ __ Alternate: ( )_________________________ <br />List food to be sold or given to the public: 2 JQ 4vp fixnrkotckpS; Tries, Seda, <br />I am providing food that is NOT prepared at home: [J-Y65 d N° <br />All food is prepared on-site or is from^approved commercial facilities: ^Yes No . <br />________ _________rid J <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 />{^f Other (specify); -------------------------------------------------------------—------------------ <br />Note: The only operations not required to provide enclosed booths are those which sell beverages from <br />approved dispensers, or prepackaged foods from approved sources. <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />[XLApproved bottled water. <br />Q On-site hose bib that is connected to a potable water source-.-- <br />fT|-Other (specify ):At\AL-^- ------------------------------------------------------ <br />Electricity is provided for my booth's use: O Yes [3 No <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: [3 Yes No <br />1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br />[3 Camp stove O Stemo & hotel trays <br /> Double steamer 'plsteam table & lids <br /> Electric stove top Other (specify) <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products.