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Environmental Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />required to return a signed and completed copy of this checklist to <br />Date(s):*3yy4 ■ I 2. I 511. <br />2. <br />3. <br />4. <br />5. <br />6. <br />9. <br />7. <br />8. <br /> Sterno & hotel trays <br />O Steam table & lids <br />CS Other (specify) (7 3 <br />meats, tamales, cooked beans, rice, <br />SAN JOAQUIN <br />GOUN'* <br />AvcAt l-e <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />S Approved bottled water. <br />Ii On-site hose bib that is connected to a potable water source. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420) F 209 464-0138 | www.sjgov.org/ehd <br />EHD 16-02 Page 7 ol 11 TEMP EVENT APP <br />06/29/2023 <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />I am providing food that is NOT prepared at home: (3 Yes No <br />All food is prepared on-site or is from approved commercial facilities: Yes No <br />Name of facility: N/ l4-Phone: f] <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 /> A booth with walls and ceiling 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 are acceptable) and constructed to separate food and food preparation <br />areas from the public. <br />P Other (specify): Cc-vx (\ <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 /> Other (specify): <br />Electricity is provided for my booth’s use: t/j Yes 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: 0 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 /> Double steamer <br /> Electric stove top <br />All food vendors (both for profit and non-profit) are r . ' '' <br />the festival coordinator three (3) weeks prior to this event. <br />1. Name of Event: Lodi <br />The following is information about my organization/business: <br />Name of organization/business: P;l/v\ |.p/ V\^\\ IQ ,q VV\ J - Q->/ <br />Address: 2'7-1 b | r i4 <br />Phone: (03 -~7 OOq Alternate: (7U7 ) yy <br />List food to be sold or given to the public: P ( £ GVYl <> <2 A H 115 +