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SAN JOAQUIN Environmental Health Department <br /> nl V v <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. <br /> 1. 1,Hama of went: 41 j T , i'} Date(s) _ LI <br /> 2. The following is information about my organizationtbusiness: Name of organ ization/business: <br /> Address: <br /> Phone: .� )_ _ /V / ! <br /> 3, Ust food to be sold or given to thepublic: Alternate: ( / ) <br /> 4. 1 am providing food that is NOT prepared at home: Yes(]No <br /> All food is prepared on-site or is from approved commercial facilities:91 Yes Ll No <br /> Name of facility: Phone: <br /> Address of facility: <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 /> ❑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 /> 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 /> `I Approved bottled water. <br /> L] On-site hose bib that is connected to a potable water source. <br /> Other(specify): <br /> 7. Electricity is provided for my booth's use: 0 Yes❑No <br /> B. 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❑ No <br /> 9. 1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> 135°F: <br /> Camp stove ❑ Sterno&hotel trays <br /> [] Double steamer n Steam 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 F. Hazelton AvenUe I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.arglehd <br /> V1 ID 1&02 E'nge 7 of 11 TEMP EVFNT APT <br /> OW19f19 <br />