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Environmental Health Department <br />All food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to <br />1.I.Namc of Event: <br />2. <br />Address: <br />Phono: <br />3. <br />4. <br />5. <br />M.w <br />6. <br />9. <br />meats, tamales, cooked beans, rice, <br />Note: The only operations not required to provide enclosed booths arc (hose which sell beverages from <br />approved dispensers, or prepackaged foods from approved sources. <br />I.'.] A 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 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 />[y/Other (specify):. <br />I | Stcrno & hotel trays <br />I | Steam table & lids <br />I | Other (specify) <br />8. <br />SANJOAOUIN <br />COUNTY <br />< Il I. fi-.v. hi < <■ <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />L\}^\pprovod bottled water. <br />[yOn-site hose bib that is connected to a potable water source. <br />1868 IE. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | I- 209 464-0138 | www.sjcehd.com <br />1111)16 0? I’JKIO /Of II IliMPLVI Ml API’ <br />07/3/17 <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />the festival coordinator three (3) weeks prior to this event. <br />LODI GRAPE FESTIVAL <br />I | Ollier (specify):___________________________________________ <br />iEloctricity is provided for my booth's use; j I Yes [ | No <br />I am providing an accurate probe thermomotor 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 />135OF: <br />I I Cajnp stove <br />|\p5ouble steamer <br />I I Electric stove top <br />The following is information about my organlzation/business: <br />Name of organization/business:. 5s W IVl' \31 ____Wf../_________ _'_______ <br /> 0k (1^) _Alternate: <br />List food to be sold or given to the public:. <br />I am providing food that is NOT prepared at home: |.7J Yes TJ No <br />All food is prepared on-site or is from approved commercial facilities: El Yes | J 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 /> Date(s): SEP 14-17, 2023