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SA N .10AQU I N Environmental Health Department <br /> ?w COUNTY <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 priorto this event. <br /> 1. 1.Name of EvenPiYYI eX�L7P�lr1Y1 G L.45Q►'l- yezf' TuSf Date(s): J�-� -�� <br /> 2. The following is information about my organization/business: <br /> Name of organization/business: 1 aGl��is M644u' ,Y7 �e ureLvt f <br /> Address: / S�J� �Q L'[d�C_ �U�. 135,-- -4 <br /> Phone: (.p6q ) Alternate: ( ) <br /> 3. List food to be sold or given to the public: aeQ/YS , <br /> 4. 1 am providing food that is NOT prepared at home: [ -Yes ❑ No <br /> All food is prepared on-site or is from approved commercial facilities: [ es❑ No <br /> Name of facility: G �S M 4&vyl Phone: <br /> Address of facility: <br /> 5. 1 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 /> [}Other(specify): oca! u��jc SG�I-t� in can P�Y)ClaSed �GLilally�9 <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 /> 6. Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br /> ❑ Approved bottled water. <br /> ❑ On-site hose bib that its connected toa potable water source- <br /> ["Other(specify): -[5vilall-,Ou �'l/ ,5 ot d"b U i de-S (,U r -7G C2!11�/eS <br /> 7. Electricity is provided for my booth's use: ©'Yes F1 No 'e4L A-f i&�j has . <br /> 8. 1 am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br /> foods during all times of booth operation: ['Yes ❑ No <br /> 9. 1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> 135°F: <br /> ❑ Camp stove ❑ Sterno& hotel tra s <br /> ❑ Double steamer ❑ Steam table 8 <br /> ❑ Electric stove top ❑ Other(specify) <br /> Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, <br /> vegetables, potato salad, eggs,and dairy products. <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 16-02 Page 7 of 11 TEMP EVENT APP <br /> 07/3/17 <br />