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Environmental Health Department <br />Date(s): APRIL 27, 20191. Name of Event: LODI BEER FEST 1. <br />2. <br />95751Address: <br />Phone: <br />List food to be sold or given to the public:3. <br />4. <br />5. <br />( <br />6. <br />the hot and cold holding of potentially hazardous <br />9. <br />/ <br />vegetables, potato salad, eggs, and dairy products. <br />\ <br />7. <br />8. <br />1868 E. Hazelton Avenue | <br />EHD 16-02 <br />07/3/17 <br />^Approved bottled water. <br />H'On-site hose bib that is connected to a potable water source. <br />i <br /> Other (specify): ------------------------------------------------------------------------ <br />Note: The only operations not required to provide enclosed booths <br />I < <br />i <br />! <br />i <br />i <br />i <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 />135°F: <br /> Camp stove <br /> Double steamer <br /> Electric stove top <br />Note: Examples of potentially hazardous food include: <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 />I am providing food that is NOT prepared at home: [Q^es No <br />All food is prepared pn-site or is from approved commercial facilities: [^Ves No <br /> Name of facility. Phone: (-)___------------------------------------------ <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 />0XA 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 fconcree <br />asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food prepaiatio <br />areas from the public. <br />Stockton, California 95205 | T 209 468-34201 F 209 464-0138 | www.sjcehd.corn <br />Page 7 of 11 TEMP EVEN I Arr <br /> Other (specify):--- ----------- <br />Electricity is provided for my booth’s use: 0 Yes LJ No <br />1 am providing an accurate probe thermometepto measure <br />foods during all times of booth operation: E/Yes No . „ . . t <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> Sterno & hotel trays <br /> Steam table & lids <br />pother (specify) <br />meats, tamales, cooked beans, rice, <br />4*®^ SANsJOAQUIN <br />r —county— <br />Greatness grows here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />The following is information about my organization/business: <br />Name of organization/business: -------------------- <br />() qSb-SOoH- Alternate: ( )