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I <br />Environmental Health Department <br />1. <br />2. <br />Address: <br />3. <br />4. <br />5. <br /> Other (specify): <br />those which sell beverages from <br />6. <br />9.ling of all potentially hazardous foods above <br />meats, tamales, cooked beans, rice, <br />7. <br />8. <br /> Stemo & hotel trays <br /> Steam table & lids <br /> Other (specify) <br />A</ <br /><0 <br />SAN JOAQUIN <br />COUK • <br />)— _________ <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 404-0138 | www.sjgov.org/ehd <br />EHD 16-02 Page 7 of 11 TEMP EVENT APP <br />07/01/2024 <br />I am providing food that is HQI prepared at home: Yes & No <br />All food Is prepared on-site or Is from approved commercial facilities: Yes 0 No <br />Name of facility: ____________ _ Phone: £1 <br />Address of facility:_______________ <br />1 dusTand foe puSfo^ f0,,0Win9: ^to protect mV unpackaged food and food-preparation areas from flies, <br />^.A booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh flv <br />screening completely enclosing open food areas. It will also have a smooth and cleanable floor (concrete <br />areas fromth" tar^ and smooth wood are acceptable) and constructed to separate food and food preparation <br />j5}No <br />torheasure the hot and cold holding of potentially hazardous <br />— <br />Phone: (<20^) <br />List food to be sold or given to the public: <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, egge, and dairy products. <br />Note: The only operations not required to provide enclosed booths are <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 />13. Approved bottled water. <br />O On-site hose bib that is connected to a potable water source. <br /> Other (specify):_ <br />Electricity is provided for my booth's use: Yes <br />I am providing an accurate probe thermometer to .... <br />foods during all times of booth operation: Yes S No ** 1 <br />I am providing the following hot temperature control for the hot holdin <br />135’F: <br /> Camp stove <br /> Double steamer <br /> Electric stove top <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />W)^Ktahr: zr,o return a si9ned and compie,ed °f ,his <br />I.Name of Eventfi^[rA(N OfAt DateW: <br />The following is information about my organlzation/business: <br />Name of organlzation/business: <br /> <br />__ Alternate: ( <br />-opliUu X-*