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5209862181 <br />10. <br />I <br />( <br />11. <br />□ Test strips to moaeure eanltetlon levels for bleach solution measuring lOOppm. <br />12. <br />13. <br />14. <br />Date <br />Health Permit <br />PBp«.rH»rtd Tow«l< <br />8anp dJoponlor <br />Culling aor.fd <br />EhuuiiPiupino aovo <br />JS’&S®''!MCI <br />Rime WlUiir <br />TEMP EVE N'rAl’PPnQn H of 11 <br />Received Time Mar. 4. 20 1 6 1 2:50 PM No. 0539 <br />ehd ie-oa <br />11/4/14 <br />O Water supply dispenser with warm water al a minimum of 100T (l.e. 5-20 gallon container with spigot). <br />□ One separate tub (bucket or basin) for the collection of rinae/wastewater. <br />Extra <br />WfllOf <br />Garbags <br />dan <br />Booth muot be on <br />Concrete, Asphsll, <br />Plywood, or a Tarp. <br />Mar. 4. 2016 1 2:55 PM <br />Feb.24.2016 01:04 AM <br />pH Tub to store wiping cloths in bleach solution measuring lOOppm. <br />I am providing the following for adequate hand washing facilities, but separate from utensil wash within my <br />booth: <br />B^lfe IcoB^Qi fl /*coti Cohlohoi^ btj <br />slo/wf ff Incbos o/Z odho Qiv{(n(Jl <br />UGuJ Hand wnvK <br />Waetcv/nior conlalnoi' <br />5(inKtaf blipRol- <br />bifioc^ flkw/jior for <br />alortrtQwlpina dotho <br />No. 2854 <br />PAGE. <br />P. 17 <br />2/ <br />soap nnawaw | RlrwWlW BluiuHi undWaHr <br />Fira ExKnamthCT- [ <br />GHIRARDELLI <br />CRFudg > <br />Propane Tank |r <br />□ (ce chaste <br />□ Refrigerated truck□ Other (specify) M/A <br />I am providing th® following cold (amperalure control for the cold holding of potentially hazardous foods below <br />45’F (If food Is usad the following day, maintain below 4rp temperature):. <br />□ Three deep tubs (basins 6-8 Inches minimum), one for soapy water, one (or rinsing and ope for a bleach <br />solution (ona tablespoon of blagoh per gallon of water). <br />□ Detergent, bleach, and wiping cloths (cleaning towels). <br />5-20 Gul, <br />Hund vv«ih Wallf <br />9temo v//ChBfllrxi <br />Dinh <br />Q Paper towels and pgmp-etyle &O9I3 container. <br />Nairas of responsible persons to be present in booth during all hours of operation: <br />Cpjrm\ <br />“Important*’ <br />O Refrigerator <br />□ les balh and tubs <br />j e <?<xri-Vt p <br />I am providing the following Items within my booth for the sanitary cleaning of food preparation utensils: <br />□ Three compartment sink. <br />OR. <br /> <br />_ <br />Ail rood vendor booths are subject to Inspection. Pleasa make a copy of this application in <br />preparation for this event. A copy of this checklist must ba In (he booth at all hours of <br />preparation and operation. Return original tgdfastival cooi'dlpfltor three waakff prior to <br />flite-ayant, <br />Completed by: Vj p <br />’ Stgnatbre <br />• IIIRI <br />—— <br />Ice Cooler | >