Laserfiche WebLink
Environmental Health Department <br />17 * <br />2. <br />Phone: <br />3. <br />4. <br />5. <br />6. <br />9. <br />meats, tamales, cooked beans, rice, <br />7. <br />8. <br />5 <br />iO±__y1 -S p/ u i t cm <br />cte> UCh^hing-icv\ <br /><r>C9) b i Alternate: (^)cj ) <br />List food to be sold or given to the public:_____j <br />,u-? [equi5ed t0 return a s'9ned and completed copy of this checklist to <br />1. Name of Event: DTi rr|- lUft y-y 1 y /pm, /y j i/g I <br />The following is information about my organization/business: <br />Name of organization/business: <br />Address: <^03 £ UCkXShi Hgi <br />SAIWOAOUIN <br />------COUNTY------ <br />Greatness grows here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />All food vendors (both for profit and non-profit) ‘' <br />the festival coordinator three (3) weeks prior to this event. <br />1. Date(s): fiaq <br />7 631 ftdciS_/ftl-f DittelO / f-jctuQs <br />I am providing food that is NOT prepared at home: |3.Yes No <br />All food is prepared on-site or is from approved commercial facilities: 0 Yes No <br />Name of facility: ________________________Phone: ( } <br />Address of facility: <br />' ^sTandthe puMc? Wi’h f°"0Win9: (t° Pr°teCt my unpacka9ed food and food-preparation areas from flies, <br />Const;uct®d of eith®r wood' camas' Plastic, similar material and fine mesh fly <br />asphal clean t n P a ar6aS W'" a'S° haVe 3 Smoo,h and cleanabte floor (concrete <br />Xs from the puMc acceptable) and constructed to separate food and food preparation <br /> Other (specify): <br />NOt6: looroved XTn°nS nOt reqUi''ied t0. Pr°Vide enC'°Sed b00ths are those which sel1 Averages from <br />approved dispensers, or prepackaged foods from approved sources. <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />E Approved bottled water. <br />On-site hose bib that is connected to a potable water source. <br /> Other (specify): <br />Electricity is provided for my booth’s use: JS-Yes No------------------------------------------------- <br />1the hot and cold hold^pf p™'y ba-dops <br />' a^5P0rFOVldin9 the followin9 hot temperature control for the hot holding of all potentially hazardous foods above <br />^■Camp stove Q Sterno & hotel trays <br /> Double steamer steam table & lids <br />O Electric stove top other (specify) j i Oh <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />S"“'C—’ ™«»-3420| F 209.64-013S j "™.,SShip