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Environmental Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />1 Name of Event Datefs) <br />2 <br />v ty ChAddress <br />Phone <br />3.List food to be sold or given to the public <br />4. <br />5 <br /> Other (specify) <br />those whch sei beverages from <br />6 <br />9 <br />meats, tamales, cooked beans, rice. <br />IRRfi F Ma>altnn flvoniio I ^irvirtnn CaMnrnia I T 4AA."X47n I F 7f>Q dA4-01 tR I www/ sinnu nm/ohrl <br />Scanned with CamScanner <br />7. <br />8 <br />Approved waler for drmiung. utensl and hand washing wd be provided in my booth by the foltowing methods <br />'-t^Approved bottled water. <br />SAN JOAQUIN <br />-----COUNTV <br />Note: The only operations not requred to provide enclosed booths are <br />approved dispensers, or prepackaged foods from approved sources <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />Al food vendors (both for profit and non-profit) are required to return a signed and comptetod copy of this checklist to <br />3^? vj -lcl y <br />I am providing food that is NOT prepared at home VZfYes No <br />AM food ts prepared on-site or is from approved commeroal facilities "^fYes No <br />Name of facility FA 6*0 Z-g ^6?/ ALOQ60 7zf-2- Phone H 7S j ^7 > - 6 O / 0 <br />Address of facility >>oOl ftN i'CtvIp.aJ tsiVD T J <br />I am providing a booth with the foiowing (to protect my unpackaged food and food-prep««rabon areas from flies. <br />dust and the public) <br /> A booth with waRs and ceding constructed of either wood, canvas, piasbc. simdar material and fme mesh fly <br />screening, completely enclosing open food areas It wil also have a smooth and deanabte floor (concrete <br />asphalt, dean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />areas from lf»e public <br />d On-site hose bib that is connected to a potable water source <br /> Other (specify) <br />tenOnctoi is provided for my booth’s use J/T Yes No <br />I am provicfing an accurate probe thermometer to measure the hot and cold holding of potentialy hazardous <br />foods during all times of booth operation 0 Yes No <br />I am providing the folowing hot temperature control for the hot holding of al potentially hazardous foods above <br />V0 Camp stove O Stemo & hotel trays <br />O Double steamer Steam table & lids <br /> Etectnc stove lop Other (specify) <br />the festival coordnator three (3) weeks prior Io Uus event <br />pooRiSA__Hou i <br /> u-■J 141S 3 <br />j <br />_________ Alternate (H\ ) S 7 V A <br />£ U ( ViTU_ V H VI C <br />The foitowng is information about my organizabon/busness: <br />Name of orgamzatiorvtxjsjness I K I .1 ,C AJ <br />. 1 Jr 'Vv'c rj <br />(9?\') 27/ - 6 Pio _______