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Environmental Health Department <br />1. <br />2. <br />Phono: <br />3. <br />4. <br />5. <br />thoco which soli bovoragos from <br />6. <br />9. <br />moats, tamales, cooked beans, rice, <br />r\ A <br />7. <br />8. <br />SANJOAOUIN <br />------COUNTY <br />Grtofn.'S5 orj i)f>-i <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />Noto: I ho only operations not required to provido enclosed booths are <br />approved dispensers, or prepackaged foods from approved sources. <br />I. J Slerno 8, hotel trays <br />LI Steam table & lids <br />^Othor (specify) f\ <br />Noto: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <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 throe (3) weeks prior to this event. <br />I.Name of Event: LODI GRAPE FESTIVAL <br />The following Is information about my organization/business: <br />Name of organization/business: (-1 1S <br />Address: Vp C/7.C \ O.A X53 \______________ <br />( l(('G Alternate: (9c>7 ) 9 S 7 ’ 3'V^") <br />List food to be sold or given to the public: z <br />SU A kCT 'S , p/X'risrx-A <br />I am providing food that is NOT prepared at home: Yes No <br />All food is prepared on-site or is from approved commercial facilities: Q Yes No <br />Name of facility: Phono: () <br />Add ress of facil ity:___ __________________ ____ <br />I am providing a booth with the following: (to protect my unpackagod food and food-preparation areas from flies, <br />dust and the public) <br />1£[)A booth with walls and coiling 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 aro acceptable) and constructed to separate food and food preparation <br />areas from the public. <br />L.J Other (specify):__ <br />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 />Electricity Is provided for my booth’s use: [2»Yes I I 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 booth operation: Yes 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 />[ J Double stoamer <br />L J Electric stove top <br />„Date(s):^1±l^?2?i