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Environmental Health Department <br />1. Name of Event:1. <br />2. <br />Address: <br />) <br />3. <br />4. <br />5. <br />G. <br />9. <br />moats, tamales, cooked beans, rice, <br />||:MI>I VI Nl Al’P <br />7. <br />8. <br />SAN JOAQUIN <br />GOUNIY <br />•. .p-fhi • <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />1868 1:. Hazelton Avenue | Stockton. California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcchd.com <br />PHD 16-02 I’.idoZofll !•?/!:?!! <br />0 7/V 17 <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 />| I Stcrno & hotel trays <br />| | Steam table & lids <br />f^Other (specify) . <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />The following is information about my organlzation/business: <br />Name of organization/business:..____ <br />______ <br />Phono: Q,q£\) -Alternate: ( <br />List food to be sold or given to the public: <br />I am providing food that is NOT prepared at homc'.'^l Yes O No <br />All food is prepared on-site or is from approved commercial facilities:^] Yes | | 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 flics, <br />dust and the public) <br />Nj/\ 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 cloanable 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 />O Other (specify):_ _ <br />Note: The only operations not required to provide enclosed booths arc 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 />•^l Approved bottled waler. <br />4^1 On-site hose bib that is connected to a potable water source. <br />| | Other (specify):_______________ >----- ---------------------------------------------------------------------------------- <br />Electricity is provided for my booth's use.’XI 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: Yes (.J 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 />| 11 Jectric stove top <br />DAtn(s>: SEP 14-17, 2023