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10. 1 am providing the following cold tempernturc control for the cold holding of potentially hazardous foods below <br /> 45'F(if food is used the following day, maintain boiow 41'F temperaturo): <br /> ® IM chests ❑ RefrigerDtor <br /> ❑ Refrigorated truck ❑ Ice bath and tubs <br /> ❑Other(specify) -- <br /> 11_ 1 am providing the foW►vlrig items witty my booth for the sanitary cleaning of food prepargtion utensils: <br /> ® Three compartment sink. <br /> OR <br /> ❑ Three deep tubs (basins 6-8 Inches minlmum), 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 tovrnts). <br /> ❑ Tub to store wiping doths In bleach solution. <br /> 12.. 1 am providing the following for adequate hand washing faalliles, but separate from utensil wash within my <br /> booth: <br /> ® Water Suppty dispenser with warm water at a minimum of 1007(I.e. 5-20 gallon container with spigot). <br /> ® One separato tub(bucket or basin)for the collection of dr*Wwastewater <br /> ®Paperiowals and Pump-style spa container. <br /> 13, Names of responsible persons to be present in booth during all hours of operation_ <br /> OOminklim Jackson rs Jacob Tarros <br /> "Important" Jill food vendor booths are subject to inspection. Please make a copy of this appfication in <br /> preparation for this ovenf. A copy of this checklist must be In the booth at all hours of <br /> proparabm and operation, Rallum orE o festiv 1 coordInalor th oks Drior <br /> this event_ <br /> 1A. Completed by: Dominique Jackson 4/1/2026 <br /> Signa ribe Date <br /> Health Porrrit law <br /> R.:.r►,rd Tra..,. <br /> �ua.P d�.rt.w <br /> Cu7>`4�7rsard _� !..Mwr UeYlg <br /> Aupd�•9t„• 61.r.� -3 �crtq r}uW r..Yw <br /> Booth crust be on <br /> Concrete,Asphalt- <br /> ;, Plywood,or a Tafp <br /> Pk-[--Tank <br /> S,wp S-d 0J1.0 FSn.n Yrpa N.w7 f4'NJ- <br /> �Q <br /> r..klin�drr /' Can <br /> r.trs <br /> ors i <br /> IOU Cooler D G&ftaW wash <br /> r.ta 44 aj./rm-f n"Ar a ntrw M tla"a Wl►CmHdir <br /> _..� 11tVYJ/Yw.Y�drdCr�R.� <br /> E.f 47 T 5-W F'dr]n!!¢r 11 <br /> D691t16 TEND EVBYT l.NN <br />