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#555 P.002/00203/29/2016‘ FromillPS STORE 1064 925 458 0915 <br />Page 2FOOD VENDOR PERMIT APPLICATION <br />10. <br />11. <br />12. <br />13. <br />Completed by:.14. <br /> Hand T0WC15 <br />Pmpnnn Rtnvo <br />Fla) Eitinflutahcr <br />Ice Cooler <br />Pnoe W 10n*W!> <br /> Refrigerator <br /> Ice bath and tubs <br />2-1/2 Gd. <br />Hand Wash Wolo* <br />Musi be Ort <br />Concrete, Asphali. <br />Plywood or a Tarp <br />$lqnw7 w/Chntfirty <br />Dkh <br />S a*! Hand Wwdi <br />Warto Waler Cnntamo* <br />Garbage <br />Can <br />JzTlce chests <br />Q Refrigerated truck <br /> Other (specify):.__ <br />I am providing the following items within my booth for the sanitary cleaning of food-preparation utensils: <br />Health Permit s <br />I Bleach and Water <br />( Cxire ' <br />I Wrrtwr <br />I I- • - <br />io x m K frxxn <br />[ BlMJCh <br />Q Three compartment sink. <br /> Two deep tubs (basins 6-8 inches minimum), one for soapy water, the other for rinse and bleach solution. <br />j^Cietergent, 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 />.p^fwater supply dispenser (e.g. 5-20 gallons, Igloo or Coleman container with spigot). <br /> One separate tub (bucket or basin) for the collection of rinse/waste water. <br />Q Paper towels and pump-style soap container. <br />Names of responsible persons to be present in booth during all hours of operation: <br /> Zz/z Kfe____________________________ <br />^■46 <br />IMPORTANT . .... <br />Afi food vendor booths are subject to inspection. Piease make yourseff a copy of this application in preparation ,or this <br />event. A copy ot this checfdisi must be in the booth at all hours of preparation and operation. <br />Return cnginal months pngrto thts event.. <br />Signature/Title <br />Disponxtt <br />lar (fms m/9t tut 9tcvvfi ntt <br />iff thv nnrmtUl <br />ftxjd C>Dntt>liK>ai 0O irorod <br />ofltticnoMt <br />VBtidars^SsHJea^Eii'ifis^sragtisFe'MivBl.riet * SIS-370-3647 phsiie • ?.68-234-i7S8 hx. <br />I Boup and Water <br />] <br />I am providing the following cold temperature control for the cold holding of potentially hazardous foods <br />below 45° F: <br />' ? $Wo Sookmg -Sign <br />H <br /> <br />| f,rop,>,w? Tank I | <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 />I C^inp BwmJ