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FOO*D vendor permit application Page 2 <br />10. <br />11. <br />12. <br />Nai13. <br />14.Completed by:. <br />Health Permit10X10 ft. Booth <br />No Smoking Sign <br />Paper Hand Towels <br />Soap Dispenser <br />Cutting Board <br />Bleach <br />Propane Stove <br />Propane Tank <br />Soap and Water Bleach and Water <br />Fire ExtinguisherQ <br />Ice Cooler <br />Stemo w/Chaffing <br />Dish <br />□ Refrigerator <br />□ Ice bath and tubs <br />5 Gal Hand Wash <br />Waste Water Container <br />Garbage <br />Can <br />Must be on <br />Concrete, Asphalt, <br />Plywood or a Tarp <br />^flce chests <br />□ Refrigerated truck <br />□ Other (specify): <br />Water supply dispenser (e.g. 5-20 gallons, Igloo or Coleman container with spigot). <br />^0TDne separate tub (bucket or basin) for the collection of rinse/waste water. <br />P'Paper towels and pump-style soap container. <br />Your hot & cold food temperatures will be monitored. Your hand washing and sanitation processes will <br />be checked. PLEASE meet the required standards as addressed herein. <br />□ Three compartment sink. <br />Q Two deep tubs (basins 6-8 inches minimum), one for soapy water, the other for rinse and bleach solution. <br />□ Detergent, bleach and water (one cap full per gallon of water). <br />I am providing the following for adequate hand washing facilities, but separate from utensil washing <br />within my booth: <br />Extra <br />Water <br />2-1/2 Gal. <br />Hand Wash Water <br />I am providing the following cold temperature control for the cold holding of potentially hazardous foods <br />below 45° F: <br />I am providing the following items within my booth fo^r the sanitary cleaning of food-preparation utensils: <br />4^ <br />Extra Ice Bags must be stored off <br />of the ground! <br />Food Containers must be stored <br />off the floor! <br />is of responsiblei persons to be present in booth during all hours of operation: <br /><n.zA|____ __________________