RSVP Manastash Metric Bike Ride Special Event Application

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Appl kation for exemption from permit This application is based on WAC 246-215-08305 (Rules and Regulations of the State Board of l i�^rdkhjnr 1:1)ori.Ser-v ,4 Food items that may be exempted from permit: o Popcorn (including kettle corn) o Cotton candy ® Dried herbs and spices (if processed in an approved facility) e Machine -crushed ice drinks (if made with nonpotentially hazardous ingredients and ice from an approved source) 8 Corn on the cob (if roasted for immediate service) e Whole roasted peppers (if roasted for immediate service) Roasted nuts and peanuts (including candy -coated) a Chocolate -dipped ice cream bars (if made with commercially packaged ice cream bars) m 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) i Nittitas County Public Health Department Office use only: ❑ Approved ❑ Denied ❑ Plans and specifications requested _....J Applicant and Event Information: Ub . (AKoI Ptn, t. _ sadg4z-y31) Applicant Name j Daytime Contact Phone Business Name, if Mailing Address % City, State, Zip AAT. S+uc4r-1 SC,tiod Location V Date of Event Food Items, check all that apply: "iG C.. 1=.1.t_� + ❑ Popcorn ❑ Whole peppers ❑ Cotton candy ❑ Roasted nuts ❑ Herbs and spices ❑ Chocolate -dipped ice cream bars ® Iced drinks 100+6Aec . V)OL� ❑ Chocolate -dipped bananas ❑ Corn on the cob ® Fruit and vegetable samples U_*06 6wUmS, d vq V� ' C, -,p lO Its , Food Safety Requirements: CiP"X01"A 1 I'tvns k,1Lk. ?DWdw %aYs Food handlers are required to make sure that food safety rules are followed. Read the statements below and mark Yes (Y), No (N), 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. ❑ ❑ 2. You will enforce an illness and handwashing policy and provide a handwashing facility during food preparation. ® ❑ ❑ 3. You will provide water, ice and food from approved sources. Home storage or preparation is not allowed. ® ❑ ❑ 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. C] ❑ ® 6. You will provide an adequate number 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. G1 ❑ ❑ 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 de artmen4 A ��t e ter- �o t.►r.o e� /- to -1 Signature ofApplicant Date Seg"Y�tjimy snacks qt �Z-5A S�Dfs W�k'a ov 1pre 7Qc-V4�SeGj i S Gklk QOUAV%k�eyS Wear 51 OVA 5 Urv, kk4voY K °Wk 'p Yo V l ae c% dt a �\ G v\.dl. cal Cal n4e Ck ctv-k w'% p- s �I li __ Signature t f Regulatory Authority Date e_d'P`.l 01) 0_1P(3