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01/05/2017 15:57 916899L PAGE 04 <br />10. <br />11. <br />OR <br />□ Detergent, bleach, and wiping cloths (cleaning towels). <br />□ Tub to store wiping cloths in bleach solution. <br />12. <br />13. <br />D(XC\-^vn< SosvnC <br />Cxajv\<C' \/5// 7 <br />Title Date <br />Completed by:14. <br />Health Permit <br />Paper Mamj ToMntfj <br />ei&acnPrncar.s Slovs <br />I <br />Sfcjch Mnd w«or <br />Fire En.-w-r.lw <br />Ice Cooler <br />Page 8 of 11 TEMP EVENT APP <br />lgl‘ <br />EHD 16-02 <br />7<28/10 <br />I am providing the following for adequate hand washing facilities, but separate from utensil wash within my <br />booth: <br />tXjce chests <br />□ Refrigerated truck <br />□ Other (specify) <br />I am providing the following cold temperature control for the cold holding of potentially hazardous foods below <br />45<>F (if food is used the following day, maintain below 41 "F temperature): <br />□ Refrigerator <br />□ Ice bath and tubs <br />Garbage <br />Can <br />Extra Ko Buga & Qcntalrxrrs mult ba <br />rtartxt i /'K^or off v/tbv gnxjnOt <br />Woio- <br />5 G3I kj nci •.•oar. <br />Wanw.v3tcT Container <br />Booth must be on <br />Concrete. Asphalt <br />Plywood, or a Tarp. <br />S<emo * (Chaffing <br />DW. <br />SsrtBier bvOM- <br />Hrscn 5 wator <br />ilcdn^ wljxng ckrthj <br />I Soao Oaca-viM <br />2Z <br />’^Important'* <br />7 <br />Rrioc Waler <br />$-20 Gof <br />r- HaMWMh Water <br />h\ <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensils: <br />^^Three compartment sink. <br />□ Three deep tubs (basins 6-8 inches minimum), one for soapy water, one Tor rinsing and one for a bleach <br />solution (one tablespoon of bleach per gallon of water). <br />Tar* <br />-----------------------1 <br />:^7 <br />yTWater supply dispenser with warm water at a minimum of lOO’F (i.e. 5-20 gallon container with spigot). <br />^Sjone separate tub (bucket or basin) for the collection of rinse/wastewater. <br />^Paper towels and pump-style soap container. <br />Names of responsible persons to be present in booth during all hours of operation: <br />Sgskn-C y D(XC\-^v>< SoSsYlC j <br />All food vendor booths are subject to inspection. Please make a copy of this application in <br />preparation tor this event. A copy of this checklist must be in the booth at all hours of <br />preparation and operation. Return original to festival coordinator three weeks prior to <br />this event .