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Environmental Health Department <br />I.Name of Event:1. <br />2. <br />Address: <br />Phone: <br />3. <br />4. <br />5. <br />6. <br />9. <br />meats, tamales, cooked beans, rice, <br />7. <br />8. <br />0 Approved bottled water. <br /> On-site hose bib that is connected to a potable water source. <br />Name of organlzation/buslness: <br />856 N Sacramento St Ste C Lodi, CA 95240 <br />The following is information about my organization/business: <br />Mar Vai Food Stores <br />(209 <br />1868E Hazelton Avenue | Stockton. California 95205 1 T 209 468-3420| F 209464-0138 | www.sjcehd.con <br />EHD 164)2 Pogo 7 0< 11 TEMP EVhNT AFP <br />07/3/17 <br />135°F: <br /> Camp stove <br /> Double steamer <br />Q Electric stove lop <br />Note: Examples of potentially hazardous food Include: <br />vegetables, potato salad, eggs, and dairy products. <br /> Other (specify):-------------------------------------------------------------------------------------------------------------------------- <br />Electricity is provided for my booth's use: Yes S 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: E Yes No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> Stemo & hotel trays <br /> Steam table & lids <br />Other (specify) N/A <br />.^7% SAN JOAQUIN <br />'■ Lili . ' ------COUNTY------ <br />r • -'■•hGreolnt'ss growi Ik-i,. <br />TEMPORARY FOOD VENDOR’S APPLICATION <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 Street Faire ' Lodi Farmers Market Dflte(s).5-202^/ <br />Alternate: (209 ) 747-7452 <br />List food to be sold or given to the public: Smoked Sausage, Bacon, Smoked Cheese <br />) 369-3611 <br />I am providing food that is NOT prepared at home: H Yes No <br />All food Is prepared on-site or is from approved commercial facilities: S Yes No <br />Name of facility: Artisan Butcher, Mar Vai Food Stores Phone: (209) 772-2393 <br />Address of facility: 55 Hwy 26 Vallet Springs, CA 95252 ________________ <br />l 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 celling constructed of either wood, canvas, plastic, slm-lar 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 />[x] Other (specify): Food in packaged ___ <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.