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.,9SANJOAQUIN Environmental Health Department <br /> COUNTY <br /> '1/ 6teall/rtc growl hew. <br /> TEMPORARY FOOD VENDOR'S APPLICATION <br /> Ali food vendors(both for profit and non-profit)are required to return a signed and meted copy of this checklist to <br /> the festival coordinator three(3)weeks prior tothis event. ,��---- <br /> 1. 1.Name of Event Cl rGn�`f �/rr� 'n 7'Qi�' Date(s): j"glel /&2 <br /> 2, The following Is information about my organlzationRwsiness: <br /> Name of organization/tsusiness: .ea 1'y-)0rn <br /> Address: ,( laic- i le Z L)a (:j 012r77lZea-- /'1,9 <br /> Phone: 9,5 ,3/a.? Alternate:(JOII- ) -2 2S"6;?/,2 9 <br /> larx3, List food to be sold or given to the public io n cv�r/ ,(I dt�s/o��'•�✓ /�cr;,Fi�Qdyc.c <br /> jtmcrX�1- c;'J�rts'/ �%t/i- G.i�.t SGu�ic��,L�r.1�r�-C/�i�xt �'ofFet <br /> 4. 1 am providing food that is NOT prepared at home:0 Yes❑ No <br /> All food is prepared on-site or is from approved commercial facilities:%Yes❑No <br /> Name of facility: / res / h4 hone:jam?! (p 3V' <br /> Address of facility: RcV. <br /> 5. 1 am providing a booth with the following: (to protect my unpadcaged food and food-preparation areas from files, <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 public. r-- <br /> X Other(specify): /—dGc �►'Q� Y <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 /> ❑Approved bottled water. <br /> ❑On-site hose bib that is connected to a/pota_blle/water <br /> fsource. L <br /> �Other(specify): ��'i/�, 5 i.'> tG:7- 77C1, er- ✓� �% <br /> 7. Ekectridty Is provided for my troth's use: 0 Yes❑No ,_/ <br /> 8. 1 am prov`kfing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br /> foods during ail times of booth operation:M Yes❑No <br /> 9. 1 am providing the following hot temperaWrg control for the hot holding of all potentially hazardous foods above <br /> 135'P: <br /> ❑Camp stove n Sterno&hotel trays <br /> ❑ double steamer ©Steam table&lids <br /> ❑ Electric stove top JKOther(specify) <br /> Note: Examples of poterAWW hazartiom food hi de: meats, males, cooked beans, rice, <br /> vegetables, potato salad,eggs,and dairy products. <br /> 1868 L. Hazelion Avenue I Stockton, California 96205 j Y 209 468-3420 j E 209 464-0138 j www sjgov.ory/ehd <br /> EM 18112 Page 7 d t l YEW EVEtVfi APP <br /> 0W19l19 <br />