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Environmental Health Department <br />Date(s): 1.I.Name of Event: <br />2. <br />Address: <br />523-1905 221-5088( 80Q)Phone: <br />List food to be sold or given to the public:3. <br />4. <br />5. <br />B Other (specify): <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods:6. <br /> Approved bottled water. <br />9. <br />meats, tamales, cooked beans, rice, <br />7. <br />8. <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 />Product will be stored in storage bins <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 />The following is information about my organization/business: <br />Queen B's Herbal Teas and More <br /> Sterno & hotel trays <br /> Steam table & lids <br /> Other (specify) <br />Name of organization/business: <br />1075 Carrie Street, Stockton California 95206 <br /> On-site hose bib that is connected to a potable water source. <br />N/A <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />EHD 16-02 Page7of11 TEMP EVENT APP <br />cniin <br />I am providing food that is NOT prepared at home: Yes Q No <br />All food is prepared on-site or is from approved commercial facilities: Yes Q No <br />Name of facility: N/A Phone: ( ) <br />Address of facility; <br />I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, <br />dust and the public) <br />foods during all times of booth operation: Yes [3 No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br /> Camp stove <br /> Double steamer <br /> Electric stove top <br /> Other (specify): _________________________________________________ <br />Electricity is provided for my booth's use: Yes 0 No <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <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. S £• , <br />Lodi Street Fairs <br />______________ Alternate: ( 209 ) <br />herbal tea blends, capsules, tinctures, and honey <br />SANJOAQUIN <br />' ------COUNT Y------- <br />Greatness grov/s here. <br />TEMPORARY FOOD VENDOR’S APPLICATION