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- SH AW I N Environmental Health Department <br /> --COUNTY <br /> [rej:rCSS CrC,v; hrrr. <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)JJweeks prior to this event <br /> 1 1 Name of Event 4-`' �- �. I e �_ <br /> 2 The following is information about my or anizatlon1busfness: <br /> Name of organization/business- <br /> Address. TJ E4`' `S L11 _!t <br /> r �7 �' <br /> Phone ( [( } } -/ �� _� ,- Alternate. [ � ) <br /> 3. List food to be sold or given to the public G • <br /> 4. 1 am providing food that is NOT prepared at homer Yes ❑No <br /> All food is prepared on-site or is from approved commercial facilities: ] Yes❑No <br /> q p <br /> Name of facility: phone. <br /> Address of facility. 01 d rnf,l✓l- �-C(� , Cr" g rL�" <br /> 5 1 am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, <br /> dust and the public) <br /> ` A booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly <br /> /Scre ning, 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 /> OA-pproved 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❑ No <br /> 8 1 am providing an accurate probe thermo ter to measure the hot and cold holding of potentially hazardous <br /> foods during all times of booth operation r Yes ❑No <br /> 9. 1 am providing the following hot temperature c ntroi for the hot holding of all potentially hazardous foods above <br /> 135°F. <br /> ❑camp stove ❑ Sterno& hotel trays <br /> ❑ Double steamier ❑ Steam table & lids <br /> ,5�lectrlc stove top ❑ Other(specify) <br /> Nato: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, <br /> vegetables,potato salad, eggs,and dairy products. <br /> 1668 E Hazelton Avenue I StccF,ton, California 95205 1 T 209 465-3420 i F 209 464-0135 ) «v:v: slgov orgrehd <br /> E Ito V7­02 page 7 of 11 TE1.1r k VC Nr Af r <br /> n7;01 rr 324 <br />