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8. Other provisions as may be required by this dept. <br />9. State, County and City Health Department <br />Approved by <br />Ref: Spclevnt <br />Signature Title <br />1. Food and /or beverages 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 <br />required <br />16 <br />