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Environmental Health Department <br />1. Name of Event: 1. <br />2. <br />Address: <br />Cgy s'(W)Phone: <br />3. <br />4. <br />5. <br />those which sell beverages from <br />6. <br /> Approved bottled water. <br />9. <br />meats, tamales, cooked beans, rice, <br />TEMP EVENT APP <br />7. <br />8. <br />Ar-g rupQate(S): <br />1868 E Hazelton Avenue I Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />EHD 16-02 Page 7 of 11 TEMP EVENT <br />07/3/17 <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 />Ar^r^Datefs): Oci 70 <br /> On-site hose bib that is connected to a potable water source. <br />t(21 Other (specify): ~Y\<Arn, ' AA k-x --------------------------------------------------- <br />Electricity is provided for my booth’s use: O Yes 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: Ep'xes No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br /> Camp stove LH 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 />SANJOAOUIN <br />10 LU i’ ‘ COUNT Y <br />Greotness grows here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />The following is information about my organization/business. <br />Va. C£$\(Xu<<xyvV~ <br />QofcxAo AV______________ <br />cHOH Alternate: <br />Name of organization/business: <br />'IO N. 71 <br />aw) Tk - <br />List food to be sold or given to the public: <br />I am providing food that is NOT prepared at home: g Yes O No <br />All food is prepared on-site or is from approved commercial facilities: Yes No <br />Name of facility: (5 sMoA/ i 5Vcx 1g‘S Yet y (txrxF-Phone: f^U^) ---------------- <br />Address of facility: WO M- 5 I OoTtA-fLe__YYz--------------------------------------------------------------7— <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 />0 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): j/VoCA <br />Note: The only operations not required to provide enclosed booths are <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: