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SQN �QQQQ � N Environmental Health Department <br /> COUNTY--- <br /> Circutnt ss grot:s lier[. <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 threeec(3)weeks prior to this event. Q 5124 6� , zz <br /> 1. 1.Name of Event: s+ne + �LaI r ffa��5 V-" ' e+Date(s): S 15 " 8 1Zg <br /> 2. The following is information about my organniizaationlbussiiness: �T r �,o ,� �/�� <br /> Name of organizationlbusiness:Toms porf a o-e �[�iJ! �r/1uLi / Q J� P� <br /> Address: V� � �/f 7�11 r1YL/ c�l�l.l.tO[ 1 553a,D <br /> rram.�,5� <br /> Phone: (v) 5J u 5— U�i�l Alternate.( ) <br /> 3. List food to be sold or given to the public: B a Ked &i 0 o4S <br /> 4. 1 am providing food that is NOT prepared at home:XYes❑No <br /> All food is prepared on - or is from proved commercial <br /> lffaci 4T�ie,s:j�9/Yes❑ No �} <br /> Name of facility: oc� 6 #�orft� West, lJG�.wv( Aa — 5$6 "99 21 <br /> Address of facility:q} SQ G0l°i <br /> 5. 1 am providing a booth with the fo1owing: (to protect my unpackaged food and food-preparation areas from flies, <br /> dust and the public) <br /> WA 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): <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 is connected to a potable water source. <br /> ❑Other(specify): <br /> 7. Electricity is provided for my booth's use: ❑Yes DAo <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 trays <br /> ❑ Double steamer ❑Steam table&lids <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 /> 1568 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 E 209 464-0138 1 www.sjcehd.com <br /> EHQ 16-02 Page 7 or 1 i TEMP EVENT APP <br /> 0713M7 <br />