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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 />1.Name of Event: in 0-5 ‘' i Juneteenth <br />Date(s): S.% /4‘, <br />4 of July Cultural Celebration <br />The following Is information about my organization/business: <br />Name of organization/business: 13‘„ l Cc- <br />6/15 7/4 7/20 8/17 9/21 <br />12/6 <br />Light up Main Street <br />DocuSign Envelope ID: A6E74685-DEDE-4900-90F6-8D6DC4F9DF9A <br />SAN,JOAQUIN <br />c c)(J1,1 I .Y <br />R EC-008 <br />Environmental Health Department <br />TEMPORARY FOOD VENDOR'S APPLICATION <br />Address: I r•-•)(3 "7 0'1 (1.-r e-Nct LAIr rop, C.S\ 953 SO <br /> <br />Phone: ( - LS 0. Alternate: <br />List food to be sold or given to the public: 123„...\_,:\ cs,y0:60_ bL44 <br />I am providing food that Is NOT prelpared at home: 0 Yes No , <br />(1•11-Pr° °(g8 -0 All food is prepared on-site or is from approved commercial facilities: 0 Yes RNo 7 7 ( <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 Hies, <br />dust and the public) <br />t5t 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 (boor (concrete, <br />asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />areas from the public. <br />0 Other (specily): C <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 />.Approved bottled water. <br />0 On-site hose bib that Is connected to a potable water source. <br />0 Other (specify): <br />Electricity is provided for my booth's use: 0 Yes No <br /> <br />8, I am providing an accurate probe thermometer o measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: 0 Yes No <br /> <br />9. I am providing the following hot temperature control for the hot hording of all potentially hazardous foods above <br />135°F: <br />ID Camp stove <br />0 Double steamer <br />El Electric stove lop <br />Note: Examples of potentially hazardous food Include: meets, tamales, <br />vegetables, potato salad, eggs, and dairy products. <br />cooked beans, rice, <br />1868 E. Hazet1on Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 www.sjgov.olgielid <br />EFID 15 02 Page 2et II TEMP EVENT MP <br />OW19:19 <br />LI Sterne & hotel trays <br />El Steam table & lids <br />0 Other (specify)