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Environmental Health Department( <br />Date(s):1. <br />2. <br />Address: <br />Phone: ■ ( <br />List food to be sold or given to the public:3. <br />4. <br />5. <br />( <br />6. <br />9. <br />meats, tamales, cooked beans, rice, <br />I <br />7. <br />8. <br />May 5, 2024 \ <br />209) <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 />Lodi St Fairs <br />1868 E. Hazelton Avenue I Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />EHDIG-’OZ .............................. Pagezofll TEMP EVENT API’ <br />07/3/1Z <br />^SANJOAQUIN <br />V ■' 7 ----COUNT Y----- <br />Greatness yrov/s here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />321-1817 Alternate: ( ) ______________ <br />~ Freeze dried candy, freeze dried fruit, freeze <br />dried vegetables, seasonal Italian/French baked <br />goods <br />I am providing food that is NOT prepared at home: Yes 0 No <br />All food is prepared on-site oris from approved commercial facilities: KI Yes No <br />Name of facility: FreezyFrostyLLC Phone: ( 209)321-1817 <br />Address of facility 79 N Menlo Park St., Mountain House CA 95391 <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 />[Xj 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 />Approved Water for drinking, utensil and hand washing will be provided In my booth by the following methods: <br />0 Approved bottled water. <br /> On-site hose bib that is connected to a potable water source. <br />s Other (specify): CFO Pre-packaged Food --------------- <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 />■foods during all times of bdoih operation: □.Yes 0 No , . • - <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />j35°F: <br />0 Camp stove Sterno & hotel trays <br /> Double steamer Steam table & lids <br /> Electric stove top Other (specify) <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />I.Name of Event: <br />The following is information about my organization/business: <br />Name of organization/business: FreezyFrostyLLC-------------------------- <br />79 N Menlo Park St, Mountain House CA 95391