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Environmental Health Department Environmental Health Department 10TEMPORARY FOOD VENDOR'S APPLICATION All food vendors (both for profit and non-profit) are required to return a signed and completed copy of tna checklist to the festival coordinator three (3) weeks poor to lh«s event i Name of Event Mountain House Block Party1 ii OR Addiess Phono ( 209Z12469t Alternate: ( 123Lisi food to be sold or given Io the pu Water supply dispenser with warm water at a minimum of 100'F (i e 5-20 gallon container with spgot) O One separate tub (bucket or basin) for the collection of nnseAvastowaler K Paper towels and pomp-stylo soap container 5 13 •■Important" Other (specify): Owner 10/22/2025Completed by Sig nature 6 Approved water for drinking utensil and hand washing wilt be provided in my booth by the following methods K Approved bottled water On-site hose bib that is connected to a potable water source e 9 a meats, tamales, cooked beans, rice. Jis. ■ Mtoarto*or«oan .c-.-w .i^ui aco* m r»5»< c* v>u/**<* AT»Q*| ACORD 2* MMlUllU C tm-N19 ACORD CORPORA now All Th» ACORD and nurti ACORD , ax 40$ l-rf-KCsJ At* ® A booth with wait and ceding constructed of either wood, canvas, plastic, similar material and fine mesh fly screening, completely enclosing open food areas It will also have a smooth and cleanable floor (concrete, asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation areas from the public Note: The only operations not reqused to provide enclosed booths are those which sell beverages from approved dispensers, or prepackaged foods from approved sources swoutOMrvor neAaoveMSCwocoeoucesMCSMSUIOMroec IK CIMUnon CITI r-u*ro* NOncl Wi. M MLIWMO * Accoacwaez witm tw eosicv reovisaws I am providing the following for adequate hand washing facilities but separate from utensil wash within my booth Sterno & hotel trays Steam table & lids K Other (specify) Names of responsible persons to be present m booth during all hours of operation Rowena Rono / Joy Ramirez Name of organizabonfousiness 16201 S Harlan Rd Lathrop CA 95330 The following is information about my organizationfousincs* Row's Roll Booth fnu-M be on Concrete A»pn*r. Piy-AOC-J <x a T*p BH...nt SAN JOAQUIN - -COUNTY SAN JOAQUIN -----COUNTY Mr*av’c .• M>rrao>£« E i lazciton Avenue | Stockton Califcxnui 95205 | EMO P»je or.ct’ros j|i.W9W« re.-XKr y» • > J OOO0M >5 itS$i£U »U*U.» MroOMG COv«<AC« ataKHA sreWanre Mu •IWMKO llrrro. ____I aruMt MAU* ■••ASM 1't»J Car**''*'! "*4/ faf ■ l‘Cv PtR<C MMCM fHiS h< HRU3 h SIX CERTtftCATE MCXDER ® Three deep tubs (basins 6-8 nches minenum) one for soapy water, one for rmsmg and one tor a bleach solution (one tablespoon of bleach per gallon of water) Detergent, bleach, and wiping cloths (cleaning towels) Tub to store wiping cloths In bleach solution Note: Examples of potentially hazardous food include: vegetables, potato salad, eggs, and dairy products. Other (specify) ________________________________________________ Electricity is provided for my booth s use O Yes ® No I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous foods during all times of booth operation ® Yes No I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above 135T Camp stove Double steamer Electric stove lop Ice Cooler j —L UH UVt CERUACATf £ O.* v K4n *o T*rr» . coeaw.NCLA* CdSMKA* ! <i«A« WW [ ' ' OU All food vendoi booths are sub)ect to inspection Please make a copy of Uns appticauon in preparation for this event A copy of this checklist must be in the booth at ail hours of prepaiabon andjaawabon Return original tp ftlt>V*l coordinator thret weeks Prior to IMS event, /V-Tp I am provdng the following cold temperature control lor the cold holding of potentially hazardous foods below 45’F (if food is used the following day. maintain below 41’F temperalure) ® Ice chests Refrigerator Refrigerated truck Ice bath and tubs Other (specify)________________________________ I am providing the following items within my booth for the sanitary cleaning of food preparation utensil Three compartment sink • , -«r| ___£ . K-va .a-. J . • It 1 c»x*m utrnwi;t f . «x>r,w , Ml i 1 T 209 468-34201 F 209 464-0138 | www s^ov org-chd ioftl TEMPEVCNT APP COVtRACES_______________________CERTTFtCATE NUMBER ’_____________________________________REVISION NUMBER___________ IMS » ro CERTIFY T.u’ THt POOCCS OF «<SVR4MCE LISTED MlOV* »UVE BEEN iSSvCO TO T»< 0 KAVtL FOR TK *Cn_ATtC> NOrwTteilAH&Nv RtQkMMVfNT H»‘<M CVHDtlK*. OF ANY CONTRACT OR UT»<« CeClANNT WIT». «WfCT TO * CIRTtfICAfE WAY M tSSUfO C* MAY PtRTAts THT IN’ARANCX MfORfMO RY r»«t D( SCAMD »«fR| tN I’- VIOXCT TO A4L t E»CVJ*ONSANDCONOitK>»9 0* SuC»«PCOCKS LAHTI SHCMNWY MAVt BUNREOUCCO 0v PAOCLAVS wr _ rSJSK — ’ ww-ATr i- I ».< » OttAMt'At a«**AU to •t•<•10 , MAMUA1 JU . n.VAN.fl7.A-^ Lt" CERTIFICATE OF LIABILITY INSURANCE | THIS CERTNtCATE IS ISSUED AS A MATTER OF MFORMAnON ONLY ANO CONFERS NO R»GMTS UPON THE CERT*KATE NOC-DER TWS CERTVICATE DOCS NOT AFFIRMATIVELY OR NEGATIVELY AMEND. EXTEND OR ALTER TME COVERAGE AFFORDED BY TME ROUCKS BELOW THIS CERT*KATE OF MSURANCE DOCS NOT CONSTTTUTI A CONTRACT BETWEEN THE ISSUWO MSURfRfSl AUTHORIZED RERRESEWTATWE OR PRODUCER. ANO TME CERTlFtCATENOLDCR__________________________________________________________________________________ WRORTANT H IH hHtWf N w LDOIIlOIlM RMtfD ri* mtHl Ktw ADCMTIOIUL RUMtD >fWtU>fH «f WnHmt R SUBROGATK* IS WAIVED. Mb|*ct In Vm lMm» and c*naM«M M tha pMKy. cartain pnhckaa «n*y ra^ura an andorwmant. A alatemant on tAM cartHkaw doaa not confa* fl/dt >a tha cartilkxa hoMar in Uau T awch andxaaimc^tl Mtf *ob«>'we? F*»-, Kt-. tAMKA >__________ Lumpia. pancit. Ube horchata. Ube iced coffee. cSla'mamsi juice, tube lemonade & I ang I am providing food that is NOT prepared at home ® Yes No All food is prepared on-site « is from approved commercial facilities ® Yes No Name of tony. Lathrop Food Plaza phonc ,209^124696 Address of facility 16201 S Harlan Rd Lathrop CA 95330 I am providing a booth with die following (to protect my unpackaged food and food-preparation areas from flies dusl and the public) 1868 E H.we’lon Avenue | Stockion Cakfomin 95205 | T 209 468-34201 F 209 464-0138 | www sjgov otg/eha EMO 1042 PajeTtFl! TEMP EVENT APP 0?.G1'20» _t r.'ivto r* ua> rr RtAPt t XXMTKroO* SUCMKX.KJES I - ABM'W ' — .MTfrtWCAGIGL Dale(s): IVI/25 Health Permit 1