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27.■Yes No Is at least 16' of separation or proper bafflers 16"tall provided between all food <br /> preparation sinks and any source of contamination? <br /> 28.■Yes 0 No Is at least 163'of separation or proper bafflers provided between all produce preparation <br /> sinks and raw meat, poultry, and or seafood? <br /> 29. © Yes ■ No Are 16"high splash guards installed between all sinks that are less than 16" apart? <br /> 30.I•Yes U No Are soap and paper towel dispensers installed inside the splash guard area at all <br /> handwash sink locations? <br /> 31. IN Yes ❑ No Are all handwash sink basins at least 10"long by 10"wide and 5"deep?(Required) <br /> 32.■ Yes 0 No Do you have a designated mop sink? (Required) <br /> 33. ■Yes U No Is the mop sink located so food and equipment are not contaminated when used? <br /> 34. ■Yes 0 No Does the mop sink have a vacuum breaker installed? <br /> 35. 0 Yes II No Will a chemical dispensing system be installed at the mop sink? <br /> 36. 0 Yes a No II N/A If a soda fountain system is used, is a reduced pressure backflow assembly <br /> (RPBA)installed and tested? <br /> 37. 0 Yes 0 No ■ NA If a soda fountain system is used, are all pipes and fittings used downstream of <br /> the reduced pressure backflow assembly(RPBA)non-corrodible? (copper or brass are prohibited) <br /> 38.■ Yes © No Is all equipment commercial grade, NSF certified or equivalent?(Required) <br /> 39.LI Yes ■ No Will any food be stored or prepared at another location? If yes,list name and address <br /> where food will be stored or prepared: <br /> 40. 0 Y: • No Will any food be cooked or hot held unattended (i.e. overnight or more than 2 hours of <br /> unattended cooking)? If yes, the questionnaire for cooked or unattended food must be completed. <br /> 41.U Yes • No Will there be any cooking or food preparation outside the establishment?All locations <br /> must be dearly marked on floor plans. <br /> 42..El Yes ■ No Will any food of animal origin be undercooked at the customers request, such as steaks, <br /> eggs,or hamburger?If yes, list: <br /> Environmental Health Division <br /> 3020 Rucker Avenues Suite 104 U Everett,WA 98201-3900 111 fox:425.339.5254 0 tel:425.339.5250 <br />