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10 <br />11 <br />OR <br />12 <br />0 Water supply dispenser with warm water at a minimum of 100T (i.e 5-20 gallon container with spigot). <br />0 One separate tub (bucket or basin) for the collection of rinse/wastewater. <br />0 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 />Pape< Hand Towels <br />Propane Stove <br />it i) <br />Bleach and Water <br />Fire Ertnqurebcr <br />Ice Cooler <br />> ww <br />1^-7 •.....■,.77 <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensils <br />[V| Three compartment sink <br />I am providing the following for adequate hand washing facilities, but separate from utensil wash within my <br />booth: <br />Extra <br />Water <br />San.tizcr bucket­ <br />bleach 8 woter for <br />storing wptng cloths <br />Booth must be on <br />Concrete, Asphalt, <br />Plywood, or a Tarp <br />0 Three deep tubs (basins 6-8 incites minimum), one for soapy waler, one for rinsing and one for a bleach <br />solution (one tablespoon of bleach per gallon of water). <br />H Detergent, bleach, and wiping cloths (cleaning towels). <br />L0 Tub to store wiping cloths in bleach solution <br />0 Ice chests <br />□ Refrigerated truck <br />0 Other (specify)✓ ' <br />I am providing the following cokt temperature control for the cold holding of potentially hazardous foods below <br />45T (if food is used the following day. maintain below 41 F temperature) <br />SJrmo WChafhng <br />Osh <br />0 Refrigerator <br />Q Ice bath and tubs <br />5 Gal Hand var.li <br />Wa-lrwuti'i CoritairM'r <br />Garbage <br />Can <br />5-20 Gal <br />Hand wash Wuh-r <br />**lmportarif* <br />Title <br />I /Ui/ <br />Signature <br />I Soap disinnscr <br />. ^oplitA tvlg cuts ~ <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 all hours of <br />preparation and operation Return original to festival coordinator three weeks prior to <br />this event. <br />5 <br />Date <br />I <br />Soap and Water <br />IT_z <br />Rinse Water <br />I Propane T an* <br />1-1 <br />£»lro Ice 4 Food Caorii»»T5 rrx^f bo <br />atzcd 6 nches r/ToT trie ground’