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S A NW Q U!N Environmental Health Department <br /> JT , <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 to this event. l <br /> 1 1.Name of Event: Date(s): Z ,Z0GZ <br /> 2 The following is information about my o <br /> rg <br /> anization/business: <br /> Name of organization/business: <br /> Address 441/ /�;►r► <br /> Phone: (2oq) q`YD ` o Alternate:( ) <br /> 3. List food to be sold or given to the public: ._ r s <br /> Fathome: <br /> ,. JfC.41 �J4. I am providing food that is NOT prepare Yes❑No �7Yes <br /> % rn�{� r Orf1JrYJ,�t/a t�a <br /> All food is prepared on-site or is from approved commercial facilities: ❑No <br /> Name of facility: Z f Phone:( 1 <br /> Address of facility 61 <br /> 5. 1 am providing a booth with the following:(to protect my unpackaged food and food-preparation areas from flies, <br /> dust and the public) <br /> 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 preparafion <br /> areas from the public. <br /> ❑Other(specify): <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 /> 6. Approved water for drinking,utensil and hand washing will be provided in my booth by the following methods: <br /> roved bottled water. <br /> ❑On-site hose bib that is connected to a potable water source.. <br /> ,0 Other(specify): 6 I_aw 4--1 N1 e q 4 -54 o(G /���i� Lflar✓Lv n c. S� .', l(��Sn��., f <br /> 7. Electricity is provided for my boo s use:❑Yes❑No Ve4r7w fit d k e4- <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:[;�4es❑No <br /> 9. I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> 135'F: <br /> ❑Camp stove ❑Stemo&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( Stockton,California 95205 1 T 209 468-3420 I F 209 464-0138 1 www stcehd.com <br />