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Environmental Health Department <br />I.Name of livont:1. <br />2. <br />Address: <br />3. <br />4. <br />5. <br />| J Other (specify): <br />Note: Tlio only operations not required to provide enclosed booths <br />6. <br />| | Approved bottled water. <br />9. <br />II MP I VI Ml API’Pago 7 of 11 <br />7. <br />8. <br />SAN JOAQUIN <br />COUNIY <br />i ,i< het- <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />-oi'i'V <br />meats, tamales, cooked beans, rice, <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 l-ESTIVAl <br />| | Stcrno & hotel tr ays <br />Steam table & lids <br />(J Other (specify) \\p,v\ I <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 1 I-' 209 464 0138 | www.sjcehd.com <br />1 *7 f < 4 KMO C ‘\/C -Ml <br />( I II.) 16 02 Pago 7 of 11 ...................... <br />0//.VI7 <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 />The following is information about my organization/business: <br />Name of organization/business: CVm. i——------------- <br /> Phono: (^uS"). 1 L - Alternate: () J1£U ------------- - <br />List food to be sold or given to the public:V^(^^VjA^X^-l^ \> <br />I am providing food that is NOT prepared at homo:^ Yes [ I No <br />All food is prepared on-site or is from approved commercial facilities:^ Yes | | No <br />Name of facility: Phone..(------)------------------------------------- <br />Address of facility:— -----------------------——— ------------——------ <br />I am providing a booth with (he following: (to protect my unpackaged food and food-preparation areas from flies, <br />dust and the public) <br />4/|/A booth with walls and coiling constructed of either wood, canvas, plastic, similar material and fine mosh 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 />^/fOn-site hose bib that is connected to a potable water source. <br />[ | Other (specify):------------------ ------ -------------- ----------------- ------------------------------------------------------------- <br />Electricity is provided for my booth’s use:P1 Yes [.J No <br />I am providing an accurate probe thermomotpr to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: OYes | J No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135T: <br />| | Camp stove <br />| | Double steamer <br />| | Electric stove top <br />....DaMs):.81!13.12:!5'2024