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10 <br />11 <br />OH <br />12 I am providing the following for adcgualc hand washing facilities, but separate from utensil wash within my <br />booth <br />[3 Paper towels and pump-style soap container <br />13 <br />Q 23 7. '55^^ <br />'‘Important** <br />Completed by 14. <br />Health Permit <br />SIi-i'ih) a C <br />P H)r( H.i kJ I. <br /> Suap <br />r i.liwwi Btpini <br />ProiM'w Slov<- <br />.nut W *!• i Hu i .«■ W.ili'i <br />Ice Cooler <br />rFMP FVf NT API(■ i.|.' Hi'l II <br />minimum of 100 F (re 5-20 gallon container with spigot) <br />One separate tub (bucket or basin) for the collection of rinsc/wastcwater <br />l <br />I + <br />I hp I xfinqutsiMi <br />□ Refrigerator <br />3] Ice bath and tubs <br />I xll.l <br />W il« I <br />O.Fiih/pr tn,i kt-t <br />till*, n »> A a it.-i f< i <br />liHruI wipi'M) * <br />FHD 16 0? <br />.iH’in 11_; <br />5 20 G,|I <br />H.inci w.ish Writer <br />_______ <br />Signature Title <br />I <fr,i h f> H. I'/*- A I (Hut ( (>ii! iitu-i . tnu' f H <br />.ti>n-il t irn In", i >lf t<1 fhr tjtt ,imi' HI <br />this event. <br />(3 Water supply dispenser with warm water at a <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensils <br />EJ I hree compartment sink <br />6^3/23 <br />Date <br />Names of responsible persons to bo present in booth during all hours of operation <br />//zF/j 7 237. <br />Garbage <br />Can <br />I am providing the following cold temperature control tor the cold holding of potentially hazardous foods below <br />(if food is used the following day. maintain below 4 I I temperature) <br />Ice chests <br />□ Refrigerated truck <br />□ Other (specify) <br />Booth must t>i' on <br />Concrete Asphai' <br />Plywood or a Tarp <br />_______________z <br />Q 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 />□ Detergent bleach, and wiping cloths (cleaning towels) <br />□ Tub to Store wiping Cloths in bleach solution <br />All food vendor booths are subject to inspection. Please make a copy of this application m <br />preparation for this event A copy of this checklist must be in the booth at all hours of <br />preparation and operation Return original to festival coordinator three weeks prior to