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J3/23, 4:52 PM /9F370/8-C6B6--454E-96E 3-425099743129 ipeg <br />SAN JOAQUIN <br /> <br />Environmental Health Department <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 <br />1 Name of Event, /11(,,o,firr,-) <br /> <br />Date(s): - in Zu'i: <br />2 The following is information about my organization/business <br />, <br />Name of organization/business. 11-)4\n <br />Address 1.-11 Pie., t <br /> <br />1 7 5Q ,t;c-; <br /> <br />Phone ( -4(.71 ) ,f3t21' 11-10.7 <br /> <br />Alternate ( 46 ) <br /> <br />3 List food to be sold or given to the public. <br /> <br />4 I am providing food that is NOT prepared at horai>E] Yes D No <br />All food is prepared on-site or is from approved commercial facilities)ii Yes 0 No <br />Phone: ('le,1) <br />Address of facility, 7,..1 (-4 <br /> <br />5 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 />D 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 .• 2 . •• • 9 • e acceptable) and constructed to separate food and food preparation <br />areas from the publi <br />Other (specify). <br />Note: The The only ope ions n eguwed 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 />D Approved bottled water <br />EIjj On-site hose bib that is connected to a potable water source <br />Other (specify): 5(.. CAI <br />7. Electricity is provided for my booth's use' Yes 0 No <br />8 I am providing an accurate probe theernnter to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operationU Yes No <br />9 I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135'F' <br />fl Camp stove Sterno & hotel trays <br />E) Double steamer Steam table & <br />Electric stove top 0 Other (specify) <br />Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, rico, <br />vegetables, potato salad, eggs, and dairy products. <br />L1. . /•• ;Ix it'o ui s9 'i2;.' 7 , 468-3420 I F 209 464-0138 wmv sigov org chd <br />ID 42 pgIcIlI TEMP EVENT AP') <br />06/14110 <br />qir ve wont° corel1.le1d'1HDACcV190-61F KVISe3ANP1tRGJR0Xutiv-ew <br />Name of facility, C—frr FT, •dtk-)