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'I l <br /> SA N,- J O A Q U I N Environmental Health Department <br /> COUNTY - <br /> 1 ' <br /> i TEMPORARY FOOD VENDOR'S APPLICATION <br /> AM food vendors(Moth for profit and non-profit)are required to return a signed and completed copy of this checklist to <br /> l� the festival coordinator three(3)weeks prior to this event. <br /> I� 1. 1_Name ofEvent: Almood /0Sfo ''��� ' ✓ date(s): c7'a�' <br /> 2. The following is information about my orgenization/business: L t <br /> Name of organization/business: _.._ I IrrI �(i'A tom, E-j T),,2 To l isco LL( <br /> Address: 300 N - F tJ e <br /> Phone: { ) <br /> 2'15 • 3 `f-0 Alternate:(,:904 (00'7• a 73 � <br /> i <br /> 3. list food to be sold or given to the public: b 11'r�Crt ��(LJJ P �GftA t rrs <br /> jrrrlGa S PA $rrr;a• l3�G�� U2.la OUIfav/ airn1O P'cAtcs !gr-taj <br /> 4. 1 am providing Food that is NOT prepared at home: Yes[]Na <br /> AN food is prepared on-site or is from approved commercial facilities: Yes❑No <br /> Name of facility Di'\ $ l'tp, Phone:( l <br /> Address of facility: <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 /> screaming, completely enclosing open food areas. It will also have a smooth and cleanable floor (concrete, <br /> asphalt, dean tarps and smooth wood are acceptable) and constructed to separate food and food Preparation <br /> areas from the public. <br /> 0 Other(specify): <br /> Note: The onfy 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 Wit be provided in my booth by the following methods: <br /> Approved bottled water. <br /> Q On-slte hose bib that is connected to a potable water source. <br /> Other(spec4Y <br />[ 7, Electricity is provided for my booth's use: Yes No <br /> 8, 1 arcs providing an accurate probe therrnomet r to measure the hot and cold holding of potentially hazgrdous <br /> foods during all times of booth operation:0Yes❑No <br /> 9. 1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> 95•F: <br /> Q i� <br /> Camp stove Sterno hotel trays <br /> [Double steamer gSteam table&lids <br /> 0 Electric stove top ❑Other(specify) <br /> Nate: Examples of potentially hazardous food Include: meats, tamales, cooked beans, rice, <br /> vegetables,potato salad,eggs,and dalry products. <br /> 1868 E. Hazelton Avenue j Stockton,California 952051 T 209 468-34201 F 209 464-0138 I www.sjcehd•com <br /> Pape 7 d 11 TEIIP EVENT JIVE' <br /> EHD 1"2 <br /> 07/3h7 <br />