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10 <br />I am providing the following items within my booth for warewashing11 <br />□ Three compartment sink <br />OR <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensils12 <br />^Detergent bleach wiping cloths (cleaning towels), and a tub to store wiping cloths in bleach solution <br />I am providing the following for adequate hand washing facilities but separate from utensil wash within my booth13 <br />14 <br />••Important" <br />Completed by15. <br />Health Permit <br />Paper Here 'owe-. <br />taeacr. <br />It <br />Ptucmh* fare <br />• r« <br />Ice Cooler <br />1= <br />i <br />ITEVPEVEM APPP«Qe 8 o' 11 <br />® Ice chests <br />L ] Refrigerated truck <br />Other (specify) <br />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 coW holding of potentially hazardous foods below <br />45 F (rf food is used the following day maintain below 41T temperature) <br />□ Refrigerator <br />□ Ice bath and tubs <br />5 G* Hprw «•»* <br />W4/V buCMI <br />t>** t> A MW kw <br />•Krwg wt*-; ocr-s <br />EhO 1®C2 <br />r 1445 <br />Swnn •rr'TwWig <br />CW- <br />Can <br />Booth must be on <br />Concrete Asphalt <br />PtywuoC or a I «*f p <br />1= <br />Title <br />rI <br />P^m^o^espons^^^^s^ in^oothdcrnng all hours of operation <br />o» 1 *«xJ Co-a***! ta I <br />4 ncn*i r/r* TTcno <br />Date <br />9 Water supply dispenser with warm water at a minimum of 100T (i e 5-20 gallon container with spigot) A <br />separate tub (bucket or basin) for the collection of rm se waste water Paper towels and a pump-style soap <br />contamer <br />S2C G4 <br />r- -WC amr Wwr <br />S<mc I . - \ <br />All food vendor booths are subject to inspection Please make a copy of this appi cation in <br />preparation for this event A copy of this checklist must be in the booth at all hours of <br />preparation and operation Return pnginal to festival coordinator three weeks prior to <br />t|is event. . <br />luxUicu Jdk <br />Signature