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10. <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensils:11. <br />0 Three compartment sink. <br />OR <br />□ Detergent, bleach, and wiping cloths (cleaning towels). <br />□ Tub to store wiping cloths in bleach solution. <br />12. <br />H Water supply dispenser with warm water at a minimum of 100°F (i.e. 5-20 gallon container with spigot). <br />0 One separate tub (bucket or basin) for the collection of rinse/wastewater. <br />0 Paper towels and pump-style soap container. <br />13./V <br />14. <br />Health Permit <br />Paper Hand Towels <br />Soap dispenser <br />Cuttng Board 1 BleachPropane Stove <br />DUO:n <br />Propane Tank <br />Bleach and WaterRinse Water <br />Fre Extingueher <br />Ice Cooler <br />TEMP EVENT APPPane 8 nf11PHD ifi-n? <br />Jx] Ice chests <br />□ Refrigerated truck <br />□ Other (specify) <br />I am providing the following cold temperature control for the cold holding of potentially hazardous foods below <br />45°F (if food is used the following day, maintain below 41°F temperature): <br />□ Three 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 for adequate hand washing facilities, but separate from utensil wash within my <br />booth: <br />Extra Ice Bags & Food Containers must be <br />stored 6 inches off of the ground' <br />0 Refrigerator <br />□ Ice bath and tubs <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 />Stomo w/Chaffing <br />Dish <br />5 Gal Hand wash <br />Wastewater Container <br />Sanitizer bucket­ <br />bleach & water for <br />storing wiping doths <br />Signature7 Title <br />J <br />Soap and Water <br />Date <br />Names of responsible persons to be present in booth during all hours of operation; <br />U c -2 fJ !&' Z_______J7, jT > / r? - Cr O > c 1 CL______J OS O- C Cc <br />CLCfCi. Cy-il <br />‘‘Important** 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 />Completed by: