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Environmental Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />SEP 12-15,2024Dato(s):1.I.Name of Event: <br />2. <br />Address: <br />Phono: <br />3. <br />4. <br />5. <br />Approved water for drinking, utensil and hand washing will bo provided in my booth by the following methods:6. <br /> Approved bottled water. <br />9. <br />moats, tamales, cooked beans, rice, <br />Noto: 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 />Q Stcrno & hotel trays <br /> Steam table & lids <br />M Other (specify) Honey does not require heating or cooling <br />7. <br />8. <br /> 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 />171 Other (specify): Honey doos not r°quire this-______________________ ____________ ____ <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | l: 209 464 0138 | www.sjcohd.com <br />(Hl) 1607 Pao<i7of11 H MP I V1:NI API’ <br />07/3/17 <br />( 559 )377-0206 Alternate^ 559)377-9905 <br />List food to be sold or given to the public: Hloney, pollen, honey sticks and honey comb <br />The following is information about my organization/business: <br />Name of organization/business: Madera's Queen Honey LLC <br />124 Susan Ln, Madera CA 93638 <br />SAN JOAQUIN <br />C ( > l J N I Y <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 three (3) weeks prior to this event. <br />LODI GRAPE FESTIVAL <br /> On-site hose bib that is connected to a potable water source. <br />I7I Other (specify): Honey does not require this.____________ <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 booth operation: Yes 0 No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br />LI Camp stove <br />[Z] Double steamer <br /> Electric stove top <br />I am providing food that is NOT prepared at home: Yes 0 No <br />All food is prepared on-site or is from approved commercial facilities: 0 Yes El No <br />Name of facility: Madera's Queen Honey LLC Phone: ^59} 377^0206 <br />Address of facility: 124 Susan Madera CA 93638 <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)