HS FORM /92 2 5 .m] 3
HARNETT COUNTY PLAN REVIEW APPLICATION COVER LETTER
FOOD SERVICE ESTABLISHMENTS
Review for Compliance with NC Rules Governing the Sanitation of Food Service
Establishments (15A NCAC 18A .2600)
All items are to be submitted through the Central Permitting Office at 108 East Front St.,
Lillington, NC 27546 or by mail to PO Box 65, Lillington, NC 27546. You may contact the
Central Permitting Office at 910 - 893 -7525, Ext. 2. However, please contact our office with
questions regarding the contents of this application.
The North Carolina Rules Governing the Sanitation of Food Service Establishments require that
plans be submitted for approval prior to construction, renovation, or modification of such
facilities by the local Health Department.
Plans are reviewed using North Carolina's "Rules Governing the Sanitation of Food Service
Establishments," 15A NCAC 18A .2600. You may view these rules at
www. deh .enr.state.nc.us /ehs /rules.htm or obtain a copy from our office at 307 Cornelius Harnett
Boulevard, Lillington, NC 27546. For additional information regarding facility design and
layout, you can access the "Guidelines for the design, installation and construction of food
establishments in North Carolina" by going to the web page:
http: // www. deh.enr.state.nc.us /ehs /food /plan2.htm
Plans for franchised, chain, and prototyped facilities are required to be submitted to the North
Carolina Department of Environment and Natural Resources, Division of Environmental Health,
Facility and Plan Review Unit, Room 1A109, 2728 Capital Blvd., Raleigh, NC 27604. Checks
must be made payable to DENR/EHSS.
If you have questions, contact one of the following Food and Lodging staff listed below at 910-
893 -7547:
Gale Violette Greene, REHS Jamie Turlington, REHS
Food and Lodging Program Specialist Environmental Health Specialist
Cindy Pierce, REHS
Environmental Health Specialist
Plans must be submitted with the following supporting documentation:
Complete set of plans drawn to scale showing the placement of each piece of food
service equipment, storage areas, trash can wash facilities, etc. along with general
plumbing, electrical, mechanical, and lighting drawings
Plans must include a site plan locating exterior equipment such as dumpsters or
walk ins
A complete equipment list and corresponding manufacturer specification sheets
A proposed menu
A completed Food Service Plan Review Application
$200 Plan Review Fee
3/10
gg
Page 1 of 9
Food Service Plan Review Application
Type of plan: New Remodel `' Change of Ownership
Name of Establishment: - / - j ge J /, .
Physical Address: ,Q,5q 5 , P ,/,
City: A fl 14 State: W - Zip: . : 5®
Phone (if available): q i q - geqc(- en.29 Fax: y - 33 ` - OW)
Website:
Applicant: PAP( P R TU.
Address: 25 5. PDI&yL st
Cit An q b-i 1z__ State: N( Zip: 0
75 1
Phone: Fax: jAnag I - 00 817
Email: a
Owner (if different from Applicant):
Address:
City: State: Zip:
Phone: Fax:
Email:
I certify that the information in this application is correct, and I understand that any deviation
without prior approval from this Department may nullify plan approval.
Signature: tar r ► Date: ci - ) 3 - f 0
(Applicant o f esponsible Representative)
Page 2 of 9
Hours of Operation:
Mon toli Tues f to ttWed 6 ja t,i Thurs Lto Fri A6 Sat ttoa Sun tO
Number of Seats: 0
Facility total square feet: M y,O
Projected start date of construction / change of ownership:
Food Safety Knowledge:
Do any members of management have current ServSafe or equivalent food service
certification? MO
Type of Food Service: Check all that apply
Restaurant Sit down meals
Food Stand X Take -out meals
Drink Stand Catering
Commissary
Meat Market
Other (explain):
Utensils:
Multi -use (reusable): Single -use (disposable): D(
Food delivery schedule (per week): Z
Indicate any specialized process that will take place:
Curing Acidification (sushi, etc.) Smoking
Reduced Oxygen Packaging (e.g. vacuum packaging, sous vide, cook - chill, etc.)
Explain checked processes:
Indicate any of the following highly susceptible populations that will be catered to or served:
Nursing/Rest Home Child Care Center Health Care Facility
Assisted Living Center School with pre- school aged children or an immuno-
compromised population
Page 3 of 9
Water Supply:
Type of water supply: (check one)
❑ Non - public
Community/Municipal
❑ Non - transient, non - community
❑ Transient, non - community
Is an annual water sample required of your establishment? (check one)
❑ Yes
g, No
Wastewater System:
Type of wastewater system: (check one)
r. Public sewer
❑ On -site septic system
Number of current seats: 0
Number of seats applying for: 0
Water Heater: (� p
Manufacturer and Model: kC,\\ c e: tl'� O' V y b V q c �
Storage Capacity: ' gallons
• Electric water heater: L '( 1'1 a kilowatts (kW)
• Gas water heater: BTU's
Water heater recovery rate (gallons per hour at 100F rise): 5 GPH
If tankless, GPM ; Number of heaters:
*Water heater calculator on the Plan Review Unit web page at
www.deh.ennstate.nc.us/ehs/foodiplan3.htm
Page 4 of 9
HOT HOLDING
Foods that will be held hot before serving: (' k i( ittri Te odor (c C n Ln a f i
hn(S (lJu1° ' Laie,.,(gv S
COLD HOLDING
Foods that will be held cold before serving: rifriF
DRY STORAGE
Frequency of deliveries per week: ' Square feet shelf space: J ft
Is a separate room designated for dry storage? Nu
FINISH SCHEDULE
Floor, wall and ceiling finishes (vinyl tile, acoustic tile, vinyl baseboards, FRP, etc.)
AREA FLOOR BASE WALLS CEILING
Kitchen
Bar Kitt/ -- Food Storage V
Dry Storage
Toilet Rooms i
Garbage & Can / 4
Wash Areas Outs
Other
Other
Page 5 of 9
FOOD PREPARATION FACILITIES
Number of food prep sinks: 1 Are separate sinks provided for vegetables and meats? N /6 No.
Aid Size of sink drainboards (inches):
How will sinks be sanitized after use or between meat species? 5 eGi, ,4ot wasl-cr C gun"I
rz
DISHWASHING FACILITIES
Hand Dishwashing
Number of sink compartments: 3
Size of sink compartments (inches): Length Width Depth
Length of drainboards (inches): Right Left
Are the basins large enough to immerse your largest utensil? �/Gf
What type of sanitizer will be used ? /
Chlorine Quaternary ammonium ✓ Hot water Other (specify)
Mechanical Dishwashing
Will a dishmachine be used? Yes No
Dishmachine manufacturer and model: Of A
Hot water sanitizing? or chemical sanitizing?
How will large utensils such as prep tables, dough mixing bowls, slicers, and other food contact
surfaces that cannot be submerged in sinks or put through a dishwasher be cleaned and sanitized?
, a ,7-d e
How many air drying shelves will you have?
Calculate the square feet of total air drying space: 1 'fit ft
HANDWASHING
Indicate number and locations of ha sinks in th establishment:
rune (501-4 #i 4 R &r -
Page 6 of 9
EMPLOYEE AREA
Indicate location for storing employees' personal items: one,nt4ii) £Q L he m'
GARBAGE, REFUSE AND OTHER
Will trash be stored in the restaurant overnight? Yes No If so, how will it be stored
to prevent contamination?
Location and size of can wash facility: S I cLwla
Are hot and cold water provided as well as a threaded nozzle? '1 CS
Will a dumpster be provided? yF4 Do you have a contract with the dumpster provider
for cleaning? 90
How will used grease be handled? .F CQ.t
Is there a contract for grease trap cleaning?
Are doors self - closing? y o Fly fans provided?
Where will chemicals be stored? UM /17_ kl` 1tr B SI k
Where will clean linen be stored? 1 / net/ tit /4e1
Where will dirty linen be stored? d l ch. 4 ( 61n
Page 7 of 9
FOOD HANDLING PROCEDURES
Explain the following with as much detail as possible. Complete descriptions including specific
areas of the kitchen and corresponding items on the plan where food is handled will expedite the
plan review process.
Explain the entire food handling procedure for each food item on the proposed menu. Including:
• How the food will arrive (frozen, fresh, packaged, etc.)
• Where the food will be stored
• Where and how the food will be thawed
• Where (prep tables, sink, counter, etc.) the food will be handled (washed, cut,
marinated, breaded, cooked, etc.)
• When (time of day and frequency /day) food will be handled
• Whether or not the food or any part of the food will be used as leftovers or as any
ingredient in a future dish
• How the food will be cooled if applicable I^
FOOD PRODUCT 'a rn L R p Co r /� cJn I - k &n
• Prot n
• F rz e_ter p
• Ito pre_r -t c. c
Maw, - /4 prn
' r J a A09k.b Ic__
FOOD PRODUCT tom\ <l a\ I tut cies - S
Page 8 of 9
FOOD PRODUCT r k Ic ktr 'i 1 1 e �g
FOOD PRODUCT C* IC -ICCV, (/) t n S
FOOD PRODUCT POD -L0 LAJ2G1 Oe S
** *ADDITIONAL SHEETS ARE AVAILABLE
Page 9 of 9
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