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Environmental Health Department <br />1. Name of Event:1. <br />2. <br />Address: <br />AJh iu I3. <br />4. <br />5. <br />6. <br />9. <br />meats, tamales, cooked beans, rice, <br />vegetables, potato salad, eggs, and dairy products. <br />[i/l Approved bottled water. <br />| >f6n-sitc hose bib that is connected to a potable water source. <br />7. <br />8. <br />SANJOAOUIN <br />GOUNfY <br />H !. . I';.-'-. hei. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />.DateCs):.8^.!?!^2?2.4. <br />1868 E. Hazelton Avenue | Stockton. California 95205 | T 209 468-3420 | F 209 464 0138 | www.r.jcehd.com <br />MID Ki 02 r.if|0 7<>r II HMPI-.VI NI API <br />07/3/1/ <br />[ | Other (specify): ---------- --- ----------- -....... <br />Electricity is provided for my booth’s use: |£<| Yes IJ 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: [7] Ves | J No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />13$T: <br />| l-| Camp stove ILI Storno & hotel trays <br />111 Double steamer I I Steam table A lids <br />| | Electric stove top I I Other (specify) <br />Note: Examples of potentially hazardous food include: <br />Uja. . ----------------- <br />_____ Alternate: ( ) _____________ <br />Il^5 S <br />' ' )c >(Ll > < > // r- z' • <br />|. J Other (specify):.. . <br />Note: I ho 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 />The following is information about my organization/business: <br />Name of organization/business: <br />Z 5 Y / / 4 v c <br />Phono: ------------ <br />List food to be sold or given to the public: Jf'\i <br />I am providing food that Is NOT prepared at homo: |£] Yes No <br />All food is prepared on-site or is from approved commercial facilities: lirTYes |.._| NoName of facility: ..J2 ’hone: .Ciffi')----- <br /> <br />Address of facility:.,71... /.V. 2 C ____iz./--------A.i vcir'A'.. ------------------- -------- <br />I am providing a booth will) the following: (to protect my unpackaged food and food-preparation areas from fhos, <br />dust and the public) <br />PVfbooth with walls and ceiling 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 clcanablo floor (concrete, <br />asphalt, clean tarps and smooth wood arc acceptable) and constructed to separate food and food preparation <br />areas from the public. <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 />LODI GRAPE FESTIVAL