The growing street food sector in low-income countries offers easy access to inexpensive food as well as new job opportunities for urban residents. While this development is positive in many ways, it also presents new public health challenges for the urban population. Safe food hygiene is difficult to practice at street level, and outbreaks of diarrheal diseases have been linked to street food. This study investigates local perceptions of food safety among street food vendors and their consumers in Kumasi, Ghana in order to identify the most important aspects to be included in future public health interventions concerning street food safety. This qualitative study includes data from a triangulation of various qualitative methods. Observations at several markets and street food vending sites in Kumasi were performed. Fourteen street food vendors were chosen for in-depth studies, and extensive participant observations and several interviews were carried out with case vendors. In addition, street interviews and Focus Group Discussions were carried out with street food customers. The study found that although vendors and consumers demonstrated basic knowledge of food safety, the criteria did not emphasize basic hygiene practices such as hand washing, cleaning of utensils, washing of raw vegetables, and quality of ingredients. Instead, four main food selection criteria could be identified and were related to (1) aesthetic appearance of food and food stand, (2) appearance of the food vendor, (3) interpersonal trust in the vendor, and (4) consumers often chose to prioritize price and accessibility of food—not putting much stress on food safety. Hence, consumers relied on risk avoidance strategies by assessing neatness, appearance, and trustworthiness of vendor. Vendors were also found to emphasize appearance while vending and to ignore core food safety practices while preparing food. These findings are discussed in this paper using social and anthropological theoretical concepts such as ‘purity’, ‘contamination’, ‘hygiene puzzles’, and ‘impression behaviors’ from Douglas, Van Der Geest, and Goffman. The findings indicate that educating vendors in safe food handling is evidently insufficient. Future public health interventions within the street food sector should give emphasis to the importance of appearance and neatness when designing communication strategies. Neglected aspects of food safety, such as good hand hygiene and cleanliness of kitchen facilities, should be emphasized. Local vendor networks can be an effective point of entry for future food hygiene promotion initiatives.