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10 <br />11. <br />CJ Three compartment sink. <br />14. <br />15.Completed by: <br />Title <br />Health Permit VSoap dispenser <br />Cutting Board <br />/P.-apano Stove Bleach <br />0T <br />Bleach and Water <br />Fire Extinguisher <br />Ice Cooler <br />Rinse Water <br />separate tub (bucket or basin) for the collection of rinse/wastewater <br />container. <br />□ Ice chests <br />Q Refrigerated truck <br />CJ CXher (specify) <br />Extra lao Hags i Food Containers must be <br />otorod 6 mchea off of the ground' <br />5 Gal Hand wash <br />Wastewater Container <br />Garbage <br />Can <br />Stemo w/Chaffirig <br />Dtsh <br />Refrigerator <br />^0 Ice bath and tubs <br />Extra <br />Water <br />5-20 Gal <br />Hand wash Water <br />Suniteer Uuekat- <br />bleach & water for <br />storing wiping cloths <br />Booth must be on <br />Concrete. Asphalt, <br />Plywood, or a Tarp <br />| Paper Hand Toweiti 1 <br />Soap and Water <br />1 am providing the following items within my booth for warewashing: <br />12. ! 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 />Signature x. " <br />%-x2.-rt <br />DateCT <br />I hree deep tubs (basins 6-8 inches minimum), one for soapy water, one for rinsing and one for a bleach <br />solution (one tablespoon of bleach per gallon of water). <br />Names of responsible persons to be present in booth dunng all hours of operation <br />_ <br />I am providing the following v_.u temperature control for the cold holding oi potentially hazardous foods below <br />45°F (if food is used the following day, maintain below 41 °F temperature): <br />“Important*”1 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 />13. I am providing the following for adequate hand washing facilities, but separate from utensil wash within my booth: <br />vVater supply dispenser with warm water at a minimum of 100°F (i.e. 5-20 gallon container with spigot). A <br />Paper towels and a pump-style soap <br />ProDoneTank---------------\ <br />)