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APPLICATION FOR EXEMPTION Goldendale Office Klickitat County Health Department White Salmon Office 115 W. Court St 501 NE Washington St/ PO Box 159 Box 103 White Salmon, WA 98672 Goldendale, WA 98620 [PHONE REDACTED] [PHONE REDACTED] LIST OF APPROVED FOODS EXEMPT FROM PERMIT FEE An application is still required 1. Beverages Coffee, with powdered creamer or ultra-high pasteurized half and half in individual servings (does not include any espresso beverages) Tea, with powdered creamer or ultra-high pasteurized half and half in individual servings Commercially made high acid beverages (orange juice, lemonade, limeade, apple juice, apple cider--pH 4.6 or less) Carbonated beverages, mineral water 2. Popcorn with butter and/or shake on topping 3. Commercially made caramel apples or made on site with adequate facilities¹ 4. Cotton candy pre-packaged or made on site with adequate facilities 5. Commercially prepared dried fruit 6. Commercially prepared honey, jams, and jellies 7. Commercially prepared and package frozen confections, packaged and sold in individual servings 8. Whole, “farm-cut” fruits or vegetables – no additional processing or cutting 9. Snow cones and shaved ice utilizing ice from an approved source; booth with adequate facilities. 10. Slushies or slurpies made from non-potentially hazardous ingredients. Ice from an approved source and booth with adequate facilities. 11. Corn on the cob. Booth with adequate facilities. 12. Chocolate-dipped ice cream bars/fruit. Booth with adequate facilities. 13. Cookies baked on site from commercially prepared, frozen dough. Booth with adequate facilities. 14. Pretzels with non- potentially hazardous toppings. Booth with adequate facilities. 15. High acid beverages made on site with adequate facilities. 16. Elephant ears with non-potentially hazardous toppings. Booth with adequate facilities. 17. Non-potentially hazardous baked goods made at home. Items such as cakes or pies must be sold whole, uncut, made with no custards or creams, identified as baked in a private home kitchen, & wrapped in a sanitary manner for sale or service by a nonprofit organization operating for religious, charitable, or educational purposes. 18. Non-potentially hazardous baked goods prepared on site. Booth with adequate facilities. 19. Food prepared for intra-church, grange, private club events for members and guests only, events not open to the general public (does not include routine/regular food services for clubs, restaurants and lounges) NOTE: If any non-TCS foods require repackaging prior to service, they must be properly labeled. TCS foods are foods that require temperature or time as a public health control. ¹Adequate facilities include a proper hand wash station, utensil washing facilities, proper storage and display of foods, etc. ²Non-temperature/time-controlled foods are usually considered to be pre-packaged foods only. They are not likely to grow germs that cause food poisoning. ---PAGE BREAK--- APPLICATION FOR EXEMPTION Goldendale Office Klickitat County Health Department White Salmon Office 115 W. Court St 501 NE Washington St/ PO Box 159 Box 103 White Salmon, WA 98672 Goldendale, WA 98620 [PHONE REDACTED] [PHONE REDACTED] APPLICANT INFORMATION Name: Address: City: State: Zip: Contact Phone: Contact Email: Event Name: Event Date: What are you serving? As the applicant and operator of this booth, I do hereby make application for a permit to operate a temporary food service establishment in compliance with the Rules and Regulations of the State Board of Health for Food Service Chapter 246-215 WAC. I understand that this permit is NON-REFUNDABLE and NON-TRANSFERABLE to a new owner, operator, or location. Applicant’s signature: Date: A HAND WASHING STATION is required at all events. Handwash sinks must be located in the food preparation, food dispensing, and warewashing areas and used exclusively for hand washing. Storage and Display of Foods must prevent contamination. All food must be stored or covered in a manner to protect against rodents, insects, airborne debris, dust, rain, or other environmental contaminants. Ready to eat foods must not be handled with bare hands. Use utensils, gloves, tissue paper, or an approved barrier to prevent bare hand contact. Sick service workers are not allowed in any food concession booth. Any food service worker with a communicable disease, such as the flu, a cold, or has an open sore or infected cut on their hand is prohibited from working in an exempt booth. Washington State Food and Beverage Worker cards are not required for exempt booths, but are strongly encouraged. Counters and service surfaces must be waterproof, smooth, and easily cleanable. Raw wood is not allowed. 5 Gallon Thermal Container