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EptCA-4 )1 <br />t. SANJOAQUIN <br />—COUNTY— <br />Greatness 9row5 here. <br />Environmental Health Departmeni <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 the festival coordinator three (3) weeks prior to this event. <br /> <br />1. 1. Name of Event: <br /> <br />2. The following is information about my organization/business: <br />5.f am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, <br /> <br />4. I am providing food that is NOT prepared at home: [ 0 P(1-es No <br /> <br />3. List food to be sold or given to the public: f y6 Oaf, ,r/jv ietc4-,<Ar/a y=67-, af4h4,4t <br />Address of facility: Z? A1.4. <br />All food Is prepared on-site or is fromapproved commercial facilities: ilKes 0 No <br />Name of facility:Clhafiefifilf Phone: Off 99. 43 <br />Phone: (2,9' A5:74/*-- 496',`*" Alternate: ( ) <br />Name of organization/business: Parcky.. FM> <br />Address: /10 /10 AMM/f00 (1) 17-Coc7i,l)f <br />dust and the pubfic) <br />ooth 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 areas from the public. <br />0 Other (specify); <br />Note: The only operations not required to provide enclosed booths are those which sell beverages from <br />approved dispensers, or pngpackaged foods from approved sources. <br />Approved water for drinking, utensil and hand washing will be provided In my booth by the following methods: <br />trA;proved bottled water. <br />On-site hose bib that is connected to a potable water source. <br />0 Other (specify): <br />Electricity Is provided for my booth's use: IErces 0 No <br />I am providing an accurate probethermom_!_tej.to measure the hot and cold holding of potentially hazardous foods during all times of booth operation: &-Yes 0 No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />—YOamp stove 0 Sterna & hotel trays <br />0 Double steamer 0 Steam table & lids <br />0 Electric stove top K)ther (specify) Ole a-IX& ATV e./4/40167t. t <br />Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, <br />vegetables, potato salad, eggs, and daily products. <br />1868.E. flazelton Avenue Stockton, California 95205j T 209 468-3420 F 209 464-0138 www.sjgov.org/ehd <br /> EHD 10-02 <br />, Page 7 °VII <br />TEMP EVENT APP <br />06/19/i8 <br />ezo, Lvie Date(s): 21,z11