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SAN JOAOUIN Envirort e tal Health Department <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)weeks prior t this event. ` <br /> M(�rcoy.�u n I l O Ooftu1. 1.Name of Event: ate s : E 1 <br /> 2. The following is information about m organization/business: Y <br /> Name of organization/business: MT 1 <br /> Address: S W101 <br /> Phone: ( ) �'/ Alternate: ( ) <br /> 3. List food to be sold or given to the pubjic:"S t `_� t I U om 1 y tv <br /> �1a fWA ��;1 w C►���� �� C �-e� ,T� ���c <br /> 4. 1 am providing food that is NOT prepared at home�meV;31 <br /> Yes ❑ No ��,� �� <br /> All food isprepared on-site or is fro a rov o fa ilities: Yes No <br /> Name of fa fli : VYgpt j�0 " P �!Z ' � ����w c it 1 w% l hone. <br /> Address of facility: 1011 <br /> 5. 1 am providing a booth with the following: (to protect my unpackaged food and food-prepar tion 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 /> 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 publi � ( Oy)}R i M <br /> O 1 \j, v—rvv-TT I t 11 U 11 <br /> ther(specify): WOk `k �VW v 1� ' i " ` <br /> ote: 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 /> 6. Approved water for drinking, 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 connectedate <br /> 1 to a potable rr sou`rc0 <br /> Other(specify):(speci � l.' Y 7. lectricity is provided for my booth's use: Yes ❑ No <br /> 8. 1 am providing an accurate probe thermo e er to measure the hot and cold holding of potentially hazardous <br /> foods during all times of booth operation: Yes ❑ No <br /> 9. 1 am providing the following hot temperatur control for the hot holding of all potentially hazardous foods above <br /> 135°F: <br /> Camp stove ❑ Sterno& hotel trays <br /> Double steamer team table & lids <br /> Electric stove top Other(specify) <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, 1 Stockton, California 95205 1 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 16-02 Page 7 of 11 TEMP EVENT APP <br /> 07/3/17 <br />