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7 of 11 <br />1. <br />2. <br />Mdrezs <br />Phone: <br />3. <br />4. <br />5. <br />6. <br />9, <br />bJ/Pi <br />meats, tamales, cooked beans, rice, <br />TEMP EVENT AFP <br />7. <br />8. <br />135’F: <br /> Camp stove <br />Q Double steamer <br /> Electric stove top <br />Environme .al Health Department <br />rv <br />All food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to <br />Datejs): <br />SANJOAOu.N <br />OUNTY <br />teri hgf^ <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />1868 E. Hazelton Avenue I Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.orgtehd <br />* ’pt-Kir1* terr if irrEHD 1502 P»^e7of11 ----- ------- <br />MH STS <br />Electricity is provided for my booth's use: L 1 Yes ['JNo <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: Yes 0 No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />O Stemo & hotel trays <br />O Steam table & lids <br />O Other (specify) <br />* <br />the festival coordinator three (3) weeks prior to this event. <br />1 .Name of Event: kAcxV'^'V <br />The following is information about my organization/business: <br />Name of organization/business: V5l w\a nri corny p faa.o/)_______ <br />\05Zg V2C (.''VAqAe, ‘VyXol <br />( 2.^) Alternate: ( 2jO^) 5^-1* <br />List food to be sold or given to the public: QfC ~HaYV\0C/P\ACCM-(M f 0, <br />I am providing food that is NOT preparedrat home: G^Yes No ’ 7 fp -Wr 5 v <br />All food is prepared on-site or is from approved commercial facilities: Ef Yes No <br />Name of facility: ACiCtl'fUV) n Phone: (2-0^ ) <br />Address of facility: C^Y'C\c5^ ^( <br />I am providing a booth with the following: (to protect my unpad/aged food and food-preparation areas from flies, <br />dust and the public) <br />O 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. <br />tS-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 />— ! <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />QfApproved bottled water. <br /> On-site hose bib that is connected to a potable water source. <br /> Other (specify): . < ...... ...