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:

  1. Site plan
  2. Dimensional Floor Plan
  3. Proposed Menu
  4. Equipment Layout and Schedule
  5. Mechanical Schedule
  6. Plumbing Schedule
  7. Electrical Schedule
  8. 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








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*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




 

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