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I <br />10. <br />11. <br />OR <br />12. <br />13. <br />14.Completed by: <br />Signature <br />Health Permit <br />Stet no w/Chaffing <br />! Dish <br />Papet Hand Towels <br />Soap dispenser <br />Cutting Board <br />BleachPropane Stove <br />'X <br />Propane Tank <br />Rinse Water Bleach and Water <br />:ire Extinguishera <br />Ice Cooler <br />TEMP EVENT APRPage 8 of 11 <br />Extra <br />Water <br />5 G<il I land wasti <br />Wastewater Container <br />Garbage <br />Can <br />Sanitizer bucket­ <br />bleach & waler for <br />storing wiping cloliis <br />Booth must be on <br />Concrete. Asphalt, <br />Plywood, or a Tarp. <br />5 20 GhI <br />Hand wash Waler <br />EHD 16-02 <br />nR/ni/i«I <br />□ Refrigerator <br />Ice bath and tubs <br />Title <br />Soap aix! Water <br />**lmportant** <br />Extra Ice Srjgs & Food Containers must be ■ <br />stored 6 inches off of the ground! | <br />-----------1-------------------------------’ <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensils: <br />J^Three compartment sink. <br />/^LThree deep tubs (basins 6-8 inches minimum), one for soapy water, one for rinsing and one for a bleach <br />■ solution (one tablespoojr of bleach per gallon of water). <br />jA,Detergent, bleach, ajnd wiping cloths (cleaning towels). <br />J^kTub to store wiping tploths in bleach solution. <br />I am providing the following for adequate hand washing facilities, but separate from utensil wash within my <br />booth: j <br />j^Water supply disperser with warm water at a minimum of 100°F (i.e. 5-20 gallon container with spigot). <br />( I <br />JaJ One separate tub (b jcket or basin) for the collection of rinso/wastewater. <br />a Paper towels and pump-style soap container. <br />Names of responsible persons to be present in booth during all hours of operation: <br />All food vendor booths are subject to inspection. Please make a copy of this application in <br />preppration 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 <br />this event. <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 />l^Jce chests <br />□ Refrigerated truck 1 <br />□ Other (specify).