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Mar. 4. 2016 1:00PM GHI RARDELL I No. 2854 P. 33 <br />10. <br />ii. <br />OR <br />/-Y□ D&targent, bleach, and wiping cloths (cleaning towels). <br />□ Test strips to measure sanitation levels for bleach solution measuring lOOppm. /^/7y <br />□ Tub to store wiping cloths in bleach solution measuring 100ppm.z'A <br />12. <br />O Paper towels and pump-style soap container. <br />13. <br />14. Completed by: <br />Title DateSignature <br />Health Permit <br />Ptjpsr H^nd Towels <br />Soap dispenser <br />CuHlno Board <br />BleachPropene Slava <br />filnseWBlsr Blench «nd Waler <br />Ffre Ertinpmuwr <br />11 <br />□ Three compartment sink. <br />O Three deep tubs (basins 6-8 Inches minimum), one for soapy water, one for rinsing and one for a bleach <br />solution (one tablespoon of bleach per gallon of water). <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 />Stamo w/Gharfing <br />Dish <br />Q Refrigerator <br />□ ,lce bath and tubs <br />Extra <br />Watisr <br />5 Gal Hand wash <br />WBsletvatw Ccntalw <br />6.20 O«l. <br />Hand svash Water <br />Garbage <br />Can <br /> Booth must ba on <br />Concrete, Asphalt, <br />Plywood, or a Tarp, <br />□ Ice chests <br />□ Refrigerated truck <br />O Other (specify) <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensils: <br />///A <br />Soap and Waler <br />'•Important’* <br />6 grtfae r bucket' <br />bfoaeA for <br />slDnrjg wiping clottis <br />Received Time I pMa. r. <br />I 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 ata minimum of 100T (i.e. 5-20 gallon container with spigot). <br />O One separate tub (bucket or basin) for the collection of rinse/wastewater. 7^/ <br />4 <br />I IT. j <br />4.12M6Sf12:50PMJo. 053V <br />1 I Cyira I'-aPlf'O H ’ W <br />ZV y4/ <br />Names of responsiblejjersons to be presejt in booth during all hours of operation:A /y _ <br />All food vendor booths are subject to Inspection. Please make a copy of this application in <br />preparation for this event. A copy of this checklist muet be in the booth at all hours of <br />preparation and operation. Return original to festival coordinator three weeks prior to <br />this p vent. <br />Pfppwia Tank