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SAN JOAQUIN Environmental Health Department <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,Name of Event: I TOPS&GOBLINS BEM TEST _ Date s OCTOBER 29 2022 <br /> 2, The following is information about <br /> 1 o,ut y or anizallonlbusiness:Name of organization/business: <br /> Address 'S0 F l�tl1� r• I 0nt� C A- 5�yo <br /> Phone: 2 619 I. It <br /> 3. List food to be sold or cjiven to the blic: Alternate;(�/ ) "f 4 <br /> K 6+4-l e co t-A X.-t r-n al er l Lbrn <br /> 4, 1 am providing food that is NOT prepared at home;9 Yes❑No <br /> All food is prepared on-site or Is from approved commercial facilities Yes❑No <br /> Name of facility: Phone:I <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 /> 10A booth with walls and ceiling constructed of either wood,canvas,plaslfc, 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 /> Approved battled water. <br /> U 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: Yes[] No _. <br /> 8. 1 am providing an accurate probe thermometer 10 measure the hot and cold holding of potentially hazardous <br /> foods during all times of booth operation:IKYes❑No <br /> S. 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 ❑Steam table&lids <br /> ❑Electric stove top ®Other(specify) <br /> Note: Examples of potentially hazardous food Include: meats, ta+nales, cooked beans, rice, <br /> vegetables,potato salad,eggs,and dairy products. <br /> 1808 E.liazelton Avenue j Stockton.Gahfornia W05 1 T 209 466-3420 1 F 200 464-0138 1 www.sjgov.orglehd <br /> ENO[G02 Page 7 of 11 TENP EVENT APP <br /> OGfI$119 <br />