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lecx��., m+ G,J}�rpvr, l RECEIVED, APR 042019 Application for exempt on.from permi. t This application is based on WAC 246-215-08305 (bides and Regulations of ihr y'"'" " ctit Food items that may be exempted from permit. • Popcorn (including kettle corn) ■ Cotton candy • Dried herbs and spices (if processed in an approved facility) • Machine -crushed ice drinks (if made with noupotential ly 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) 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) +s+tTiia� county Public Health Kitritas Coun& Public Health 507 X. Nanion St. Suite 102 Ellensburg, W4 98926 (509) 962-7515 f c► (509) 962-7-581 hrrp, -1ru,r. co.Aatrtas.0 a. us,'healrlr J,, -6. Applicant and Event Information: (1 cre use only; -approved ❑ Denied ❑ Plans and specifications requested t} r 50q 9c� z - 3 11 Applicant Name ll Daytime Contact Phone P —16 a U 1. 0. ri l 1C1L°. gve?01 Business Name, if applicable Z h.l . 1 11 Zlo kJoilitig .4ddrese 15.r�s vro�a eats CL -t- O'Y4- SA- CI ern Scvrtpci) Cit) , Stott; zip Uvenl Location Cxla,riol !olJ 4ellY V 1C+e Ys + S zo, Dale ofEi nt t Food Items, check all that apply: ❑ Popcorn ❑ Whole peppers ❑ Cotton candy ❑ Roasted nuts ❑ Herbs and spices ❑ Chocolate -dipped ice cream bars ® Iced drinks i? at+lc wc,, ❑ Chocolate -dipped bananas [] Corn on the cob © Fruit and vegetable samples -wow 1r_ Food Safety Requirements: nn-ew60 ` haw►a.raxa 1 0yo.r,gr S t � , Food handlers are required to make sure that foo safety mules are f I1 w d abar5 Read the statements below and mark Yes (Y), No (N), or Not Applicable (N/A). Y N N/A 911111. 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 hand►washing facility during food preparation. ® ❑ ❑ 3. You will provide water, ice and food from approved sources. Home storage or preparation is not allowed. 23 ❑ ❑ 4. You will use approved barriers including utensils, paler ►wraps, and gloves (which must be changed when contatninatcd. ripped, or after changing tasks) to prevent bare hand contact with all ready -to -eat foods. Q3 ❑ ❑ 5. You will make sure that your employees have accessible restrooms. All employees must wash their hands after using the restroom. ❑ ❑ ® 6. You will provide all adequate number of clean utensils or a 3 basin dish - wash facility. All utensils will be washed in hot, soapy water (basin 1), rinsed ill clean water (basin 2). sanitized (basin 3), and air dried before use. 9� ❑ ❑ 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 911 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 Appilo ton is approved. NO changes inay be made without approval from this pienamne„ii l e7 P 3 17 Sil;r.ta_4e of pplicanl Dale 5 e -r v', (wl pr, (Aa c I is cin ct- ' Signature of Regulatory Authority Date