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Enviror ental Health Department< <br />^017 <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />5(2.F.^A.I.Name of Event: <br />2. <br />Address: <br />Phone: <br />List food to be sold or given to the public:3. <br />4. <br />1 <br />5. <br /> Other (specify): <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 />9.'.A <br />meats, tamales, cooked beans, rice, <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 />] Yes No <br />Phone: (___ <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />EHD 16-02 Page 7 of 11 TEMP EVENT APP <br />07/3/17 <br />8. <br />A <br /> On-site hose bib that is connected to a potable water source. <br />SAN Jr OUIN <br />------COUNTY------ <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <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. <br />CCG£>SS-fe>L2>r> J <br /> Other (specify): ____________________________________________ <br />Electricity is provided for my booth’s use: Yes43 No <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 0No <br />I am providing the following hot temperature controlfor the hot holding of all potentially hazardous foods above <br />135°F: <br /> Camp stove <br /> Double steamer <br /> Electric stove top <br />The following is information about my organization/business: . <br />Name of organization/business: —Lj* <br /> <br />( ) H,73~~7IQ'K 1 Alternate^ ) <br />F~T S r) <br />I am providing food that is NOT prepared at home:JZl Yes No <br />All food is prepared on-site or is from approved commercial facilities^Ej <br />Name of facility:P <br />Address of facility: <br />I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, <br />dust and the public) <br /> A booth with walls and ceiling consirdgiptf of either wood, canvas, plastic, similar material and fine mesh fly <br />screening, completely enclosing qphn rood 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 />Date(s): a/ iQXJtva <br /> Sterno & hotel trays <br /> Steam table & lids <br /> Other (specify)