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SAN JOAQUIN <br /> <br />Envi mental Health Departmert <br />CD- NTY <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: -1-11-C1-C>4 ?MCA 9.62A Date(s): 0 2- <br /> <br />The following is information about my organization/business: <br />Name of organization/business: ( P' V I <br />Address: 1)---(MCX- t,) l'151-59)vex-e. C,A. 1'4 c6c- <br /> <br />Phone: ('1LS) 591 6 3 -2---5 Alternate: (672,4) z-Th (e 2—/ el <br />List food to be sold or given to the public: 1313‘-‘ t(---re'AX.14---_, LL-1-40119, _ , ...1 ci evo rbol c1c4iFittAki, faa) <br />900v1---r-x) vivamite i 1 , <br />I am providing food that is NOT prepared at home: es 0 No ,/ <br />All food is prepared on-site or is from approved commercial facilities: rfill Yes 0 No <br />Name of facility: ‘0‘40-11 PL-a-ct- pl 7-44cliAc( Phone: (41 tS) 40 '58Ô <br />Address of facility: 6/C 13=c1 1,1°‘/A PI UAT-G, Scivkl-4,41-tv11-42 O., f43 i 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 />ZA- 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 taps and smooth wood are acceptable) and constructed to separate food and food preparation <br />areas from the public. <br />D 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 />Kpproved bottled water. <br />On-site hose bib that is connected to a potable water source. <br />El Other (specify): 6P-A 14-6 V}(-AN-r%-- (A-164 11'4 tP aNY) C,..X.--e-44 SA' Le.0 <br />Electricity is provided for my booth's use: 0 Yes E'No <br />I am providing an accurate probe thermornetepto measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: 'Yes No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br />g-C-amp stove F<terno & hotel trays <br />0 Double steamer Steam table & lids <br />D Electric stove top LI 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. Hazeiton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehcl <br />EHD 16-02 Page lot 11 TEMP EVENT APP <br />06119/19