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Environmental Health Department <br />1. Name of Event:1. <br />The following is information about my organization/business:2. <br />Name of organization/business: <br />C\S \ 'JAddress: <br />Alternate: ()_Phone: <br />3. <br />4. <br />5. <br />6. <br />9. <br />meats, tamales, cooked beans, rice, <br />I IMP I VI Ml API* <br />7. <br />8. <br />Noto: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />Q 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 bo provided in my booth by the following methods: <br /> Approved bottled water. <br />f'/| On-site hose bib that is connected to a potable water source. <br /> Other (specify):__________ <br />Electricity is provided for my booth's use: <br />SANJOAOUIN <br />------COUNTY------- <br />Greatness grows here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | v/v/w.sjcehd.com <br />i-:iid ig 02 I’aflo z oi 11 i:'”:* ■rn>" ‘ <br />0Z/3/I7 <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 GRAPE FESTIVAL <br />Yes I I No <br />I am providing an accurate probe thermoifieter to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation:^ Yes LJ 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 Sterno & hotel trays <br /> Double steamer Rj Steam table & lids <br /> Electric stove top |_] Other (specify) <br />Datefs): SEP 11-14,2025 <br />•3 <br />I am providing food that is NOT prepared at home: [Jtyes No <br />All food is prepared on-site or is from approved commercial facilities: fsjYes No <br />Name of facility: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 />[VIA booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly <br />Greening, 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 />( <br />List food to be sold or given to the public: , c.Xxues <br /><'o <br />•'./foV'