Food Service Permit Application FORM – English Required Contact Information Plan Review Application Part A Facility Information: Architect/Design Professional: Project Contact: *Please attach the following required information before a plan review will be started. Incomplete plans not meeting the following requirements may be subject to additional fees: Site plan Dimensional Floor Plan Proposed Menu Equipment Layout and Schedule Mechanical Schedule Plumbing Schedule Electrical Schedule Equipment Cut Sheets Plan Review Application Part B New Remodel Conversion Change of Ownership Choose all that apply: Health Care Facility Beverage Service Group Home Caterer Child Care Center Concessions Residential Treatment Jail, Detention Center Mobile Public Lodging Restaurant, non-plated Restaurant, plated When were plans submitted to the following authorities: City/County Business License Division Planning/Zoning Building Fire Other (Please list): Food Preparation Review [t ext lunch class:one-third-col placeholder "Lunch"] *It is important to know this information. With this we will know how much space will be needed for refrigeration and dry storage. Food Supplies Check categories of Potentially Hazardous Foods (PHF's) to be handled, prepared and served. Category A. Thin meats, poultry, fish, eggs (hamburger; sliced meats; fillets) YesNo B. Thick meats, whole poultry (roast beef; whole turkey, chickens, hams) YesNo C. Cold processed foods (salads, sandwiches, vegetables) YesNo D. Hot processed foods (soups, stews, rice/noodles, gravy, chowders, casseroles) YesNo E. Bakery goods (pies, custards, cream fillings & toppings) YesNo 1. Are all food supplies from inspected and approved sources? YesNo 2. What are the projected frequencies of deliveries for (ex: 2x/week): 3. Provide information on the amount of space (in cubic feet) allocated for: 4. How will dry goods be stored off the floor? 5.Please list foods or categories of foods prepared more than 12 hours in advance of service. 6. Provide a HACCP plan for specialized processing methods such as vacuum packaged food, sous-vide, or cook-chillitems prepared on-site or otherwise required by the regulatory authority. 7. Will the facility be serving food to a highly susceptible population? YesNo If yes, how will the temperature of foods be maintained while being transferred between the kitchen and service area? 8.Are containers constructed of food-grade materials to store bulk food products? YesNo COLD STORAGE 1. Does each refrigerator/freezer have a thermometer? YesNo 2. Is there a bulk ice machine available? YesNo COOKING and HOT/COLD HOLDING 1. What type of temperature measuring device will be used to ensure proper cooking temperatures? 2. How will hot foods be maintained at 135oF (60oC) or above during holding for service? Indicate type and number of hot holding units. 3. How will cold PHF's be maintained at 41oF (5oC) or below during holding for service? Indicate type and number of cold holding units. 4.How will reheating food to 165oF for hot holding be done rapidly and within 2 hours? Is there a written policy to exclude or restrict food workers who are sick or have infectedcuts and lesions? YesNo Will employees have paid sick leave? YesNo How will rodents, insects, and other pests be excluded from entry to the establishment? Will air curtains be used? YesNo How will cooking equipment, cutting boards, counter tops and other food contact surfaces which cannot be submerged in sinks or put through a dishwasher be sanitized? Will all produce be washed on-site prior to use? YesNo Is there a planned location used for washing produce? YesNo Describe If not, describe the procedure for cleaning and sanitizing multiple use sinks between uses. GARBAGE AND REFUSE 1. Will refuse be stored inside?YesNo 2. Is there an area designated for garbage can or floor mat cleaning? YesNo 3. Is there an area to store returnable damaged goods? YesNo Outside 4. Will a dumpster be used? YesNo 5. Will a compactor be used? YesNo 6. Will garbage cans be stored outside? YesNo 7. Describe surface and location where dumpster/compactor/garbage cans are to be stored 8. Describe location of grease storage receptacle 9. Is there an area to store recycled containers? YesNo Water Supply 1. Is the water supply: PublicPrivate If private, has source been approved? Please attach copy of written approval and/or permit. YesNoPending 2. Is ice made on PremisesPurchased Commercially If made on premise, are specifications for the ice machine provided? YesNo 3. What is the capacity of the hot water generator? 4. Is the hot water generator sufficient for the needs of the establishment (take into account handwashing, dishwashing, cooking and customer usage)? YesNo 5. Is there a water treatment device? YesNo If yes, how will the device be inspected & serviced? Sewage Disposal 1. Is building connected to a municipal sewer? YesNo If no, is private disposal system approved? Please attach copy of written approval and/or permit. YesNoPending Do you acknowledge that all sewage disposal must be done in accordance with all state, federal, and local laws and regulations; Do you acknowledge that no sewage may be disposed of down a storm drain or on the ground? YesNo 2. Do local regulations require a grease trap at this establishment? YesNo Provide schedule for cleaning & maintenance General 1. Are all containers of toxics, including sanitizing spray bottles, clearly labeled? YesNo 2. Will linens be laundered on site? YesNo If yes, what will be laundered and where? If no, how will linens be cleaned? 3. Is a laundry dryer available? YesNo 4. Location of clean linen storage: YesNo 5. Location of dirty linen storage: YesNo 6. Is a mop sink present? YesNo If no, please describe facility for cleaning of mops and other equipment: DISHWASHING FACILITIES 1. Will sinks or a dishwasher be used for warewashing? Dishwasher3-Compartment Sink Is ventilation provided? YesNoPending Hot Water Sanitizing Chemical Sanitizing 2. Are there drain boards on both ends of any pot sinks (deep sinks)? YesNo 3. Are test papers and/or kits available for checking sanitizer concentration? YesNo HAND-WASHING/TOILET FACILITIES Is there a hand-washing sink in each food preparation and ware-washing area? YesNo Do all hand-washing sinks have a mixing valve or combination faucet? YesNo Are covered waste receptacles available in each restroom? YesNo Are all toilet room doors self-closing? YesNo Are all toilet rooms equipped with adequate forced air ventilation? YesNo Is a hand-washing sign posted in each employee restroom? YesNo STATEMENT: I hereby certify that the information in Plan Review Part A & B is correct, and I fully understand that any deviation from the above without prior permission from this Health Regulatory Office may nullify final approval. I acknowledge that the information in Part A & B is not a comprehensive list of all food regulations and that it will be my responsibility to be familiar with and follow all applicable laws and rules. Approval of these plans and specifications by this Regulatory Authority does not indicate compliance with any other code, law or regulation that may be required federal, state, or local. It further does not constitute endorsement or acceptance of the completed establishment (structure or equipment). A preopening inspection of the establishment with equipment in place & operational will be necessary to determine if it complies with the local and state laws governing food service establishments. FOOD SERVICE PERMIT APPLICATION Transaction type: New/Remodeled Facility Renewal Transfer of Ownership Facility Information Owner Information Owner Type: Sole Owner Partnership Corporation Other: Send Bill to: Owner Facility Third Party, If third party fill out information below Send Permit to: Owner Facility Third Party, If third party fill out information below Click the SEND button only once. It will take just a moment to process your information. You will receive a confirmation email if your submission was successful.