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10. <br />11. <br />OR <br />12. <br />13. <br />Paper towels and <br />14. <br />‘"Important** <br />15.Completed by: <br />Health Permit <br />Paper Hana TcweH <br />I Soap dispenser <br />Culling Board <br />Propane Stove Biaach <br />Propane Tans <br />Rinse Wator <br />Plre ExSnguisner <br />Ice Cooler <br />Page 8 of 11 TEMP EVENT AP^ <br />□ Refrigerator <br />□ Ice bath and tubs <br />5 Gai Hand wash <br />Wastewater Container <br />Garbage <br />Can <br />Booth must be on <br />Concrete. Asphalt, <br />Plywood, or a Tarp. <br />EHD 1802 <br />7/14/15 <br /> Etfra /C» Bans 4 Food Containers must be <br />stored 8 Inches off of the ground' <br />5-20 Gal <br />Hana wash Water <br />Sanitizer Pocket <br />bleach ft water tor <br />storing wiping cloths <br />Stemo w/Chaffing <br />DM <br />Title <br />Soap and Water <br />Tzan dtottoT <br />Date ' <br />I am providing the following items within my booth for warewashing: <br />□ Three compartment sink. <br />^^o™(one tabtes^on^bleach^e^gaTon ofwst^)16 °ne n"8in9 and °"e for a bleach <br />1 4S-Frnf foSd ru^XOld ,e"?pera,ure contro1 tor ,he “Id holding of potentially hazardous foods below <br />4b 1- (rf food is used the following day, maintain below 41CF temperature): <br />[fflce chests <br />□ Refrigerated truck <br />□ Other (specify) <br />I am providing the following for adequate hand washing facilities, but separate from utensil wash within my booth <br />Bsacn and Water | <br />Names of responsible persons to be present in booth during all hours of operation: <br /> <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensils: <br />(/Detergent, bleach, wiping cloths (cleaning towels), and a tub to store wiping cloths in bleach solution. <br />n™O^en?°r ,l?OlhS are ^h'60'10 'nsPection Ptease make a copy of this appl,cation in <br />preparation and operafon Return origTnllto^ti^coortinator three w^k's p°rior to <br />/ Signature