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9. STATE, COUNTY AND CITY HEALTH DEPARTMENT <br /> I <br /> Approved by: <br /> Signature Title <br /> I <br /> Date: <br /> � 1. Food and/or beverage served. <br /> 2. Permit(s) attached. <br /> 3. Food cooked. <br /> 4. Permit(s) attached. <br /> . 5. List other health licensing obligations as may be require: <br /> i <br /> � <br /> � <br /> I � <br /> Page 10 of 10 <br />