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SAN., JOAQUIN Environmental Health Department <br /> Y—.-- <br /> i . <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)weeds prior to this event. <br /> 1.Name of Event WYA nkLA_ P Date <br /> ,e6, r) <br /> L <br /> The following to information about my organization/business: <br /> Name of organization/business: <br /> Address: <br /> Phone. Alternate: 5,11, R7 0 <br /> 3. List food to be sold or given to the public: SAY 'I C-(2- <br /> 4. 1 arnprovidingfood that is NOT prepared at home:fO Yes r!No <br /> All food is prepared on-site or is from approved commercial facilities: [V Yes C]No <br /> Nacre bffac!lltV­. Phone: <br /> Address of fbcility:, <br /> 5. 1.am providing a booth with the following:(to protect my u <br /> npackaged food and food-preparation areas from files, <br /> dust,and the public) <br /> El A booth with walls and ceiling constructed of either wood, canvas,plastic,similar material and ftne mesh fly <br /> screening, 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).- 5 bAV e <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. . from <br /> Approved water for:dfting,utensli and hand washing will be provided n:my bo th,0 . by the following methods- <br /> O-Approved bottled water. <br /> [I On-stle hose bib that is connected to a potable water source. <br /> 0 Other(,s pecify): <br /> XL <br /> 7. 91-ectricity is provided for my booth's use: El YesV NO <br /> 8. 1 am providing an accurate probe thermometer to measure the hot,and cold holding of potentially 'hazardous <br /> foods during all times of booth operation:q-Yes El No <br /> 9, lam providing the following hot temperature control for the hot he of all potentially,hazardous foods:above <br /> 135'F: <br /> 0 Camp stove Ej Sterno&hotel trays <br /> 0 Double steamer r_1 Stearn table&lids <br /> Electric stove top Mer(specify) VIA <br /> Note: Examples of potentially hazardous food include: meats, tamales, cooked: beans, rice, <br /> Vegetables,Potato salad,eggs,and dairy products. <br /> 1868 E. Hazelton Avenue[ Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 Www-sjgov.org/ehd <br /> E110 I6�02 Page 7ofll <br /> TEM.FJ EVFJYI"APP <br />