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SAN 10AQUIN 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: FLOPS&GOBLINS BREWF Date(s)OCTOBER 28 2023 <br /> 2. The following is information about my organization/business: Name of organization/business: <br /> I tiC6t'0. f-Gr w. � �CAwj� �-� <br /> Address: IL -----p- <br /> Phone: (20`j I. <br /> 3. List food to be sold,or given to the <br /> public' L Alternate: — <br /> /"��C��A�`- 1004� /�t��4J� Pc�►�-Y l(.��°- �.l��/.• /VEt-G(�N c9 SO� �t�`L.�.L`!�� <br /> 4. 1 am providing food that is NOT prepared at horne:[I Yes❑No <br /> All food is prepared on-site or <br /> its from approved commercial facilities: es❑No <br /> Name of facility: xzw li!700,eY,1� s j' Phone:L_ <br /> Address of facility: :5 t- <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 /> [--pproved bottled water. <br /> ❑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; es❑ No <br /> 8. 1 am providing an accurate probe thermomete measure the hot and cold he <br /> of potentially hazardous <br /> foods during all times of booth operation:Eryes❑No <br /> 9, 1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> 135° : <br /> amp stove P15 Brno&hotel trays <br /> double steamer ❑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 dalry products. <br /> 1868 E.I iazelton Avenue I Stockton.California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgoMP EvENT teli(J P <br /> @NO 16-02 Page 7 of 11 <br /> agMsns <br />