Laserfiche WebLink
I <br />Environmenta! Health Department. <br />3. <br />4. <br />/] Yes U NO i , <br />Phone: <4^ <br />6. <br />6. <br />liieats, tamales, cooked beans, rice, <br />1. <br />2. <br />7. <br />8. <br />9. <br />SAMAQUIN <br />-----COUNTY'----- <br />i — V ? ■ / . <br />'A'k<Kov''''V/ GreuIncss yrov/s hera, <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />All food vendors (bpl.h for profit and nonprofit) are required to return a sighed and completed copy of this checklist to <br /> Date(s): ZS <br />the^o^iydd^oldl^g of potentially hazardous <br />the festival coordinator three (3) weeks prli> ’ this event. n <br />i Name of EvenC <br />The following Is Infoni hiliv.Mvtu i . iiumoutHnc ; <br />Name of organization/business: -—---------------t----------- <br />Addresa: <br />Phone: • - Alternato: (4 5^ <br /> <br />UstfoMtoheSpldon^h^ <br />I ahi providing food that Is NOT prepared at home: Yes No <br />All food is prepared on-site or Is from approved commercial facilities: (H Yes No If /’Z, Q <br />Name of facility: --------- ---------/hone: <br />Address of facility: <br />I am providing a bo^bwith the folldwing: (to prdSt my unpackaged food and fppd-preparation areas from flies, <br />dust and the publid) \ .... .. <br /> A booth wlili walls and celling constructed of either wood, Canvas, plastic, similar materialfine mesh fly <br />screening completely enclosing open food areas, it will also have 9 smooth and cleanable-floor (concrete <br />asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food piepaiation <br />areas from the public, L / . ' <br /> [^the^Apeoify):- ————- <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 />Approved water for dripklna, 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 waler source. <br />tzrdlher(specify):________ --------------------------------------- <br />tleclrldily Is provided for my booth s use. LJ Yes til No <br />I am providing an accurate probe thermometer to measure <br />I XS theXtg“:S:X coX^re hot ^UTa»ally hazardous foods above <br />'I35OF‘ Gamp stove □SlernoS hotel trays . / J> / <br /> Double steamer Steam table & lids <br /> Electric stove top Other (specify) <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />1808 E. Hazelton Avenue I Stockton, California 95206 | I 209 468-3420 I P 209464-0138 | www.ajcehd.corp, <br />EIID16 02 ’ nH <br />h7/.V<7