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10. <br />11. <br />OR <br />12. <br />13. <br />'‘Important <br />14.Signature <br />Health Permit <br />Paper Hand T oweis <br />Soap dispenser <br />Cutiinq Board <br />iBleach <br />Propane Stove <br />I <br />Propane Tan* <br />Fire Fxtinqmsher <br />Ice Cooler <br />ft MP r\ ▼ urr <br />/ <br />Rinse Water <br />Eitra leu Bags S Food CrMiuuners injit De <br />stored 6 rKhes ott oi the ground' <br />□ Refrigerator <br />□ Ice bath and tubs <br />Extra <br />Water <br />Garbage <br />Can <br />Booth must be or <br />Concrete. Asphal <br />Plywood, or a Tar <br />0 Ice chests <br />□ Refrigerated truck <br />□ Other (specify) <br />Sterno wChaffing <br />Drsh <br />5 Gal Hand wash <br />Wastewater Container <br />5-20 Gal <br />Hand wash Water <br />Sanitizer bucket <br />bleach & water for <br />storing wiping cloths <br />0 Paper towels and pump-style soap container. <br />Names of responsible persons to be present in booth during all hours of operation: <br />r_z <br />Soap and Water <br />Date <br />□ 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 <br />booth: <br />All food vendor booths are subject to inspection. Please make a copy of this application in <br />oleoa^fon for te 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 pnor_to <br />this event. <br />Completed by: V_ <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 />0 Water supply dispenser with warm water at a minimum of 100"F (i.e. 5-20 gallon container with spigot). <br />0 One separate tub (bucket or basin) for the collection of rinse/wastewater. <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensils <br />Title <br />□ Three compartment sink. <br />0 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).