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S A N J O A Q U I N Environmental Health Department <br /> —COUNTY <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: . Lodi Farmers Market {pt-� G1 YCl Date(,): May 15-Aug 28 20, <br /> 2. The following is information about my organizationlbusiness: 10 15 Vz 0 Z <br /> Name of organizationlbusiness: Nana Bear's Mini Donuts <br /> Address: 680 Town SQ <br /> Phone: ( . ) 510-304-9350 Alternate:( ) <br /> 3. List food to be sold or given to the public: Mini Donuts <br /> 4. 1 am providing food that is NOT prepared at home:X^des❑ No <br /> All food is prepared on-site or is from approved commercial facilities: Xyes❑ 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 /> XA 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 /> [Approved 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:XYes❑No <br /> 8. 1 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 ❑Stemo&hotel trays <br /> ❑Double steamer ❑Steam table&lids Nla for us <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 E. Hazelton Avenue I Stockton,California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 16-02 Page 7 of 11 TEMP EVENT APP <br /> 0713117 <br />