20140270 Health Dept. application 07-21-14; 11 :06AM; ; 3604588866 # 1/ 2
Public Health&So,
ial Scn+ices Department
JUL 2 ' 2 111 412 Lil]E or nmental H0810 Division
THURSTON COUNTY Olympia,WA 98506
ENVIRONMEN i�iL HEAD ire TDD Line��e hem 2667 Fax(360)867.2600
g impaired(360)867-2603
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w .m ftm wa�th/e food_
Donated Food Application Distribution A •On &
W Worksheet 246-21 s-151
Organization: E p T-/d /V C40�
Site Address: `
Mfg Address- ,
Street
Phone Number:
City State zip
-- _
Fax Number:
Contact Person:
Phone Number: D
Email Address(optional):
Food Source(s):
Food Storage Location:
Food Preparation Location: ^�
Food Deli very Location(s):
on(s): P
Food Distribution Day(s): s
Estimated number of meals:
Typical Menu:
olY� Y/Montlily
c/ .
a.
Q s
Please see other side for additional questions
07-21-14; 11 ;05AM; 3604688866 # 2/ 2
A sketch or pictures of the kitchen would be helpful
Description ofXitchen:
(Attach extra sheet f fr doescn lion
)
Number&Size of Sulks:(ie: 1,2,3 comparbmeat sink,hand wash sink)
Equipment List&Type ofEquipment(Commercial or Home Style)
Water Source: Private well
Sewage Disposal: d public Water System Name:
Onsite Septic System p Sewer
Notes: v
Signature: ,
Title:
Date: 7
This information will need to be updated every year.
Reviewed by:
Reviewers Notes: Date:
Version 0246014