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Seattle & King County D
Use of Restroom Agreement
All Food Establishments must provide restroom facilities for employees. This form shall be completed if you will be using
restroom facilities that are owned by someone else.
Restroom facilities must be readily accessible within five hundred (500) feet of the food establishment during all times of
operation. In addition, Mobile Food Units must also have access to restrooms if in any one location for more than one
hour.
Indicate which of the following is available at the restroom location:
□Hot water at hand-wash sink(s) at or above 100 °F□Hand soap□Disposable hand towels or other acceptable hand drying device□Required sign or poster which notifies food employees to "wash their hands" clearly visible□Key accessibility to restroom (if applicable)□Distance from food service to restroom shall be 500 feet or less□If seating is provided, then a plumbed restroom allowing customer access must be available within 500 feet.
Restroom Accessibility Information: Name of Business: ___________________ _ Address: ___________________ City: ______ Zip: ______ _
Contact Person: ____________ Title: ______ Phone: ___________ _Business Hours of Operation: _____________________________ _ Email: --------------------------------------What retail/service activity takes place at this facility? _____________________ _
Mobile Unit/Food Vendor Information: Name of Business: ___________________ _ Owner/Operator: ____________________ Phone: __________ _ Address: ____________________ City: ______ Zip: ______ _ Days/Time at Restroom: _____________________________ _Email: --------------------------------------
(Restroom Owner/Agent-Printed Name & Title) (MobileNendor-Printed Name & Title)
(Restroom Owner/Agent-Signature & Date) (MobileNendor-Signature & Date)
This agreement between the owner/agent of the restroom and the owner/vendor of the food establishment signifies that
both parties agree to the allowed use of the restroom facilities as specified. Note that this agreement is not
transferable. Should there be a change in ownership of either the restroom or food establishment or should there
be any modification or cancelation of this agreement between parties, then the Public Health -Seattle & King
County Food Service Operators Permit may be suspended.
Notice to operators of Mobile Food Units
A copy of this completed Use of Restroom Agreement must be kept onboard the Mobile Food Unit.
Available in alternative format upon request pursuant to ADA
DISTRICT HEAL TH CENTERS
DOWNTOWN
401 5th Ave, 11th Floor
Seattle, WA 98104
206-263-9566
EASTGATE
14350 S.E. Eastgate Way
Bellevue, WA 98007
206-4 77-8050
Wizards of the Coast
1107 Lake Wa Blvd Eric Ranking 253-973-7013
eric.rankin@wizards.com
9-4
Office Complex
Eric Rankin