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15. Completed by: <br />Signature <br />HMBhPamw <br />*«**uw« r«<w« <br />| **«■ ———' I ---- <br />L~ <br />f <br />ZJ <br />TBMPKVKM ATP <br />"ii'itaw I <br /> tammMMt* <br />Comavai, AafM*. RyMMaft *r ■ nvp <br />«M-«aawi <br />■*■11 MB- Qu —1| <br />tl ■■> — <br />Gurtao* <br />Ca* <br />l/2113- <br />Date <br />KUUMhO rvww <br />(itAvCcA- -VW <br />•Haaperttmt** <br />Title <br />Mi cm <br />I <br />ice Cooter <br />-•■—■CMMMB ev» <br />n—W— | | IM— —W— j <br />T/ <br />Bi— ■iBf-l—- I <br />t’MFt.——i ] <br />Neer. EuueplMef potmtfadly iMnrdow feed totMr om^t»Baleft,c«elLet! beua, rice regotabta, <br />petaeo aated, capead deky predecta. <br />10.1 am providing the following cold temperature control for the cold holding of potentially hazardous foods <br />below 45 degrees Fahrenheit (if food is used the following day, maintain below 41 degrees Fahrenheit): <br />| lice chests | J Refrigerator ( ] Refrigerated truck <br />( }lce bath and tubs ( | Other (specHV). <br />II. I am providing the following items within my booth for ware washing: <br />[ | Three compartment sink <br />OR <br />( ] Three deep tubs (basins 6-8 inches nnnhnum), one for soupy water, one for rinsing and one for a bleach <br />solution (one tablespoon of bleach per gallon of water). <br />[ ] Detergent, bleach, and wiping cloths (cleaning towels). <br />( ] Tub to store wiping cloths in bleach solution. <br />12.1 am providing the following items within my booth for the sanitary cleaning of food preparation utensils: <br />[ ] Detergent, bleach, wiping cloths (cleaning towels), and a tub to store wiping cloths in bleach solution. <br />13.1 am providing the following for adequate hand washing facilities, but separate from utensil wash within my <br />booth: <br />Water supply dispenser with warm water at a mimmum of 100 degrees Fahrenheit (Lc. 5-20 gallon <br />container with spigot). A separate tub (bucket or basin) for the collection of rinse/wastewatcr. Paper towels <br />and a pump-style soap container. <br />14. Names of responsible persons to be present m booth during all hours of operation: <br />CArfS VSreiuJrx _______________________ <br />__ ____________________ <br />AU food vendor booths are subject to inspection. Please make a copy of this application <br />in preparation for this event. A copy of this checklist must be in the booth at all hours of <br />preparation and operation. Rclm ortowl fo frmllMtor tfewc wtcfo prior <br />tofefrewfpt