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10. <br />11. <br />12. <br />13. <br />â– 14.Names of responsibis <br />15.Completed by: <br />Title <br />Health Permit <br />]Peper Hand Towois <br />Soap dispenser <br />Bleach <br />0 <br />Proosns Tank <br />Fire Extinguisher <br />ice Cooler <br />Soap and Water Rinse Water <br />Signature <br />' am providing the following items within my booth for the sanitary cleaning of food preparation utensils: <br />j Detergent, bleach, wiping cloths (cleaning towels), and a tub to store wiping cloths in bleach solution. <br />Extra Ico Bags & Pood Containers must be <br />stored 6 inches off of the ground1 <br />Refrigerator <br />Ice bath and tubs <br />Extra <br />Water <br />5 Gal Hand wash <br />Wastewater Container <br />5-20 Gal <br />Hand wash Water <br />Garbage <br />Can <br />Booth must be on <br />Concrete. Asphalt, <br />Plywood, or a Tarp. <br />Stemo w/Chsffirig <br />Dish <br />Sflhitiser buekot- <br />bleach & water for <br />storing wiping cloths <br />Date <br />>ponsibiepersons to be oresent in booth during all hours of operation. <br />________________ <br />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 />** Important** <br />I am providing the following for adequate hand washing facilities, but separate from utensil wash within my booth: <br />Water supply dispenser with warm water at a minimum of 100°F (i.e. 5-20 gallon container with spigot). A <br />separate tub (bucket or basin) for the collection of rinse/’wastewater. Paper towels and a pump-style soap <br />container. <br />am providing the following items within my booth for warewashing: <br />L J Three compartment sink. <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 />I am ^providing the following temperature control for the cold holding or potentially hazardous foods below <br />45T (if food is used the following day, maintain below 41°F temperature): <br />Ice chests <br />Refrigerated truck <br />[j Other (specify) <br />Cutting Board