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<br />9. STATE, COUNTY AND CITY HEALTH DEPARTMENT <br /> <br />Approved by: <br /> <br />Signature <br /> <br />Title <br /> <br />Date: <br /> <br />1. _ Food andlorbeverage 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 /> <br />Page 10 of 10 <br /> <br />115 <br />