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App! 1cation for exemption from permit This application is based on WAC 246-215-08305 (Rules and Regulations of the State Board of l luuliilf iio V Food items that may be exempted from permit: s Popcorn (including kettle corn) Cotton candy ■ Dried herbs and spices (if processed in an approved facility) • Machine -crushed ice drinks (if made with nonpotentially hazardous ingredients and ice from an approved source) • Corn on the cob (if roasted for immediate service) • Whole roasted peppers (if roasted for immediate service) a Roasted nuts and peanuts (including candy -coated) • Chocolate -dipped ice cream bars (if made with commercially packaged ice cream bars) • Chocolate -dipped bananas (if made with bananas peeled and frozen in an approved facility) Sliced fruits and vegetables for sampling (if used for individual samples of nonpotentially hazardous produce) • Kittitas County Public Health Department hhailw' Coulit." 1`,Ep1ic 7l1' \n;tu?rr SI �1,ll zirte !O? 0 Q) t) r5 J / 5 Applicant and Event I Business Name, Office use only: ❑ Approved ❑ Denied ❑ Plans and specifications requested �r%ci7 Daytime Contact 2;S,) .-vi C. 1C R10C E ��t zz� S`z4 Mailing Address ►r�scxnd enols a+ rn-} 5♦uafT ON Mate, Zip SclnoOI .moi S-6 6+k VO kA k s �- f7 Event o tion Date of Event Food Items, check all that apply: ❑ Popcorn ❑ Whole peppers ❑ Cotton candy ❑ Roasted nuts ❑ Herbs and spices ❑ Chocolate -dipped ice cream bars © mks bot,} Ic�l wa'�erg ❑ Chocolate -dipped bananas ❑ Corn on the cob ❑ Fruit and vegetable samples +rYi y1Q� ` O tO.YY Food Safety Requirements: wv 1p inaj Food handlers are required to make sure that food sa et y ru es are o owe . Read the statements below and mark Yes (Y), No (l), or Not Applicable (N/A). Y N N/A ❑ ❑ 1. At least one person in the establishment will have a valid Washington State Food Worker Card. Q ❑ ❑ 2. You will enforce an illness and handwashing policy and provide a handwashing facility during food preparation. ❑ 113. You will provide water, ice and food from approved sources. Home storage or preparation is not allowed. QI ❑ ❑ 4. You will use approved barriers including utensils, paper wraps, and gloves (which must be changed when contaminated, ripped, or after changing tasks) to prevent bare hand contact with all ready -to -eat foods. ® ❑ ❑ 5. You will make sure that your employees have accessible restrooms. All employees must wash their hands after using the restroom. Ul ❑ ❑ 6. You will provide an ade9uatenumber of clean utensils or a 3 basin dish - wash facility. All utensils will be washed in hot, soapy water (basin 1), rinsed in clean water (basin 2), sanitized (basin 3); and air dried before use. ® ❑ ❑ 7. You will store all food, ice and single -service products off the ground and away from sources of contamination. You will only use food -grade containers for food storage and transport. ® ❑ ❑ 8. You will make sure all food -contact surfaces are sanitized prior to, and during, food preparation. After receiving your application, an inspector will review your plan with you. You may be asked to provide additional information. Once the application is approved, NO changes may be made without approval from this depar4ent., t s- 7 Z- 22 - Si ature 2- Signature of ppneant I Dare Slgnature of Regulatory Authority Date Sc!r U- 1 nj 5 rr pL r ka,� -A art -5'' S s kk)1 e Dr Y`� l �' z -4a +�o� i '4 G!'f ► S 14\\ v0 1LtVN �c times wear o41ovo-s -�4 ? leas t-_ '(moA i vy.& c..o v