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Mar. 4. 2016 12:53 PM GHI RARDELL I No. 2854 P. 13 <br />io. <br />11. <br />OR <br />12. <br /> Paper towels and pump-style soap container. <br />13. Names of responsible persons to be present in booth during all hours of operation: <br />14.Completed by: <br />Health Permit <br />Pacw Hand 1 <br />5(xsd dupecur <br />CuihQ boM <br />Ftopww SUV®6M9CA <br />ito*? and A*:*r R DM WAtM DH wxl Wotw <br />Pte EMJti'JJbI'c* <br />6 oH 1 T£MP EVEN” Ar-p <br />Received Time Mar. 4. 2016 1 2:50 PM No. 0539 <br />O Ice 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 4TF temperature): <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensils: <br /> Three compartment sink <br /> Refrigerator <br />O Ice bath and tubs <br />5 Cd Herdv^vti <br />Czrtirer <br />Garbage <br />Can <br /> Booth muat be on <br /> Concrete. Asphalt <br />Ptywood. or a Tarp. <br /> Detergent, bleach, and wiping cloths (cleaning towels) <br /> Test strips to measure sanitation levels for bleach solution measuring IQOppm <br /> Tub to store wiping cloths in bleach solution measuring lOOppm. <br /> Water supply dispenser with warm water at a minimum of 100‘F (i.e. 5-20 gallon container with spigot). <br /> One separate tub (bucket or basin) for the collection of rinse/wastewater. <br />St«mo <br />Cam <br />tonP/c'bucka!- <br />bfcnfti t woeter to* <br />sWnQ w4p'ng daT> <br />F>C <br />11^.14 <br />& r^d •TtAsl t*C <br />sKy w 6 wr ol toe gt&jMI <br />5-20 Gai <br />Hard wafch <br />Ptqpww TarK <br />’'Important** <br />I am providing lhe following for adequate hand washing facilities, but separate from utensil wash within my <br />booth: <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 wafer). <br />(0uil?r <br />TWe Date <br />j Ice Cooler <br />Sp\niYI _____________' _______ _ <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 must be in the booth at ail hours of <br />preparation and operation. RefqrO Qrldlnal to fogtlYfil coordinator three weeks pripr fpthta^evenf, ' — . - <br />(KVaxu <br />— Signature <br />EH’a