HS REVIEW 47 —Fo0 22/&E,
ARNETT COUNTY
HOSPITALS, NURSING AND REST HOMES AND OTHER INSTITUTIONS PLAN
REVIEW APPLICATION
Review for Compliance with NC Rules Governing the Sanitation of Hospitals, Nursing and Rest
Homes and other Institutions (15A NCAC 18A .1300)
All items are to be submitted through the Central Permitting Office at 108 East Front St.,
Lillington, NC 27546 or by mail at PO Box 65, Lillington, NC 27546. You may contact the
Central Permitting Office at 910- 893 -7525, Ext. 2. However, please contact our office at 910-
893 -7547 with questions regarding the contents of this application.
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:
✓ Plans which include food service facilities must also complete the Food Service
Establishment Plan Review Application to provide information on this aspect of
the operation.
v Plans must include drawings showing the placement of equipment in the facility,
including any storage areas, toilets and bathing facilities, laundry, trash can wash
facilities, emesis and personal contact item wash areas, along with general
plumbing, electrical, and mechanical and lighting drawings.
✓ Plans must include a room finish schedule.
,/ Plans must include a site plan locating exterior equipment such as dumpsters or
compactors, and indicating the proposed connections to approved sewer and water
connections. 1
APPLICANT: I4AtZ+d£ H
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ADDRESS: 2I 'P.A1614TVS DPtQr -, LtU.tipkmtS, 4C
MAILING ADDRESS: &V rn1.4Hil Kti DP -IUD-, 1 )uNa, '73334
PHONE: 910 2(000 K sl06
EMERGENCY PHONE: q t q 4.30 44 00
EMAIL: ytx,o @ 6JrL,,,or c
# RESIDENTS: # EMPLOYEES: 150
MULTI -USE UTENSILS? YES ✓ NO
WATER SUPPLY: Ho n4e W (.00 N ,
WASTEWATER DISPOSAL TYPE (Check one): SEWER ✓ SEPTIC
HARNETT COUNTY PLAN REVIEW APPLICATION COVER LETTER
FOOD SERVICE ESTABLISHMENTS
Review for Compliance with NC Rules Governing the Sanitation of Food Service
Establishments (ISA NCAC 1 8A .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/ modification/ change of
ownership 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 Comelius Hamett
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 Depml ment 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, RS Jamie Turlington, RS
Food and Lodging Program Specialist Environmental Health Specialist
Cindy Pierce, RS
Environmental Health Specialist
Plans must be submitted with the following supporting documentation:
1 ,,/ 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
j z Plans must include a site plan locating exterior equipment such as dumpsters or
walk ins
.2 [A complete equipment list and corresponding manufacturer specification sheets
�A proposed menu
A completed Food Service Plan Review Application
,/ $200 Plan Review Fee
Page 1 of 11
Food Service Plan Review Application
Type of plan: New _ X Remodel Change of Ownership
Name of Establishment: Harnett Health System Central Campus Hospital Facility
Physical Address: 215 Brightwater Drive
City: Lillington State: NC Zip: 27546
Phone (if available): 910 - 892 - 1000 Fax:
Website: www.birh.org
Applicant: Harnett Health System
Address: 800 Tilghman Drive
City: Dunn State: NC Zip: 28334
Phone: 910 -892 -1000 Fax:
Email: miones(&,birh.org
Owner (if different from Applicant): same
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.
.ait V
Signature:Ats :.l Date: I/ 2 / 9
Applicant or R-spo ie Representative)
Page 2 of 11
Hours of Operation:
Mon X Tues X Wed X Thurs X Fri X Sat X Sun X
Number of Seats: 54
Facility total square feet: 4627 square feet
Projected start date of construction / change of ownership: 09/06/2010
Food Safety Knowledge:
Do any members of management have current ServSafe or equivalent food service
certification? Yes
Type of Food Service: Check all that apply
X Restaurant X Sit down meals
Food Stand X Take -out meals
Drink Stand Catering
Commissary
Meat Market
X (explain): Hospital
Utensils:
Multi - use (reusable): X Single - use (disposable): X
Food delivery schedule (per week): 5
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 X Health Care Facility
Assisted Living Center School with pre- school aged children or an immuno-
compromised population
Page of 11
Water Supply:
Type of water supply: (check one)
Non - public
X CommunitylMunicipal
Non - transient, non - community
Transient, non - community
Is an annual water sample required of your establishment? (check one)
X Yes
No
Wastewater System:
Type of wastewater system: (check one)
X Public sewer
On -site septic system
Number of current seats: NA
Number of seats applying for: 54 ,
Water Heater:
Manufacturer and Model: AO Smith BTP - 400 - 1500
Storage Capacity: 400 gallons
• Electric water heater: kilowatts (kW)
• Gas water heater: 1,500,000 BTU's
Water heater recovery rate (gallons per hour at IOOF rise): 1455 GPR
If tanldess, N/A GPM ; Number of heaters: 2
*Water heater calculator on the Plan Review Unit web page at
www.deh.enr.state.nc.usiehs/food/plan3.htm
Page 4 of 11
HOT HOLDING
Foods that will be held hot before serving:
COLD HOLDING
Foods that will be held cold before serving:
DRY STORAGE
Frequency of deliveries per week: Square feet shelf space: 1428 ft2
Is a separate room designated for dry storage? Yes
FINISH SCHEDULE
Floor, wall and ceiling finishes (vinyl tile , acoustic tile , vinyl baseboards , FRP, etc)
AREA FLOOR BASE WALLS CEILING
Kitchen Sheet Vinyl Sheet Vinyl FRP Acoustical Tile
Bar NA NA NA NA
Food Storage Walk -In Refrigerator/ Freezer Units — Dry Storage Sheet Vinyl Sheet Vinyl Paint Acoustical Tile
Toilet Rooms Tile Tile Paint Paint
Garbage & Can Sheet Vinyl Sheet Vinyl FRP Acoustical Tile
Wash Areas
Servery Tile Tile Tile Acoustical Tile
Dining Tile Tile Tile Acoustical Tile
Page 5 of 11
FOOD PREPARATION FACILITIES
Number of food prep sinks: 2 Are separate sinks provided for vegetables and meats? No
Size of sink drainboards (inches): 30
How will sinks be sanitized after use or between meat species?
DISHWASHING FACILITIES
Hand Dishwashing
Number of sink compartments: 3
Size of sink compartments (inches): Length 27 Width 26 Depth 14
Length of drainboards (inches): Right 34 Left 48
Are the basins large enough to immerse your largest utensil? Yes
What type of sanitizer will be used?
Chlorine _ Quaternary ammonium _ Hot water _ Other (specify)
Mechanical Dishwashing
Will a dishmachine be used? Yes X No
Dishmachine manufacturer and model: Hobart C144e
Hot water sanitizing? X 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?
• How many air drying shelves will you have?
Calculate the square feet of total air drying space: ft2
HANDWASHING
indicate number and locations of hand sinks in the establishment: 6 - hot food production, try assembly,
cold food prep, dishroom, grill/deli counter, salad bar counter
Page 6 of 11
EMPLOYEE AREA
Indicate location for storing employees' personal items: Staff Locker Room 1109, adjacent to kitchen.
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: 91 sf, located at the back of the Kitchen, adjacent to the
Service Corridor
Are hot and cold water provided as well as a threaded nozzle?
Will a dumpster be provided? Yes Do you have a contract with the dumpster provider
for cleaning? _Yes
How will used grease be handled? Recycled
Is there a contract for grease trap cleaning? Yes
Are doors self - closing? Yes Fly fans provided? 140
Where will chemicals be stored?
Where will clean linen be stored?
Where will ditty linen be stored?
Page 7 of 11
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
FOOD PRODUCT
Food will be purchased from a certified food service company. US Food Service, Fords Produce
Company, Pet Dairy, Pepsi, Flowers Bread. It will come in all varieties.
The food will be stored in the walk -in freezer, walk -in cooler and dry storage.
The food will be thawed in refrigerated units at a temperature not to exceed 45.F (7 °C)
The Kitchen will have a prep area designated for prepping of all foods to be consumed. In this
area, there will be color coded cutting boards, prep tables with back splash, plastic cambro storage
container for meats, and produce.
At no time will leftovers be used.
All foods that require a cooling process will follow strict HCCAP Guidelines. We will use ice baths,
frozen ice cooler sticks separating foods into smaller containers and also quick chiller.
Foods from 1350F to 700F within 2 hours
Foods from 135.F to 45 *F within or Tess than a total of 6 hours.
Potentially hazardous foods shall be cooled to 45.F or less within 4 hours
Page 8 of 11
FOOD PRODUCT
FOOD PRODUCT
FOOD PRODUCT
** *ADDITIONAL SHEETS ARE AVAILABLE
Page 9 of 11
The following questions will test how much you already know about food safety. Please answer
to the best of your ability and as clearly as possible in order that the EHS understands what you
are trying to say.
1. What are the final cook temperatures ( °F) for the following foods?
a. Chicken 165
b. Hamburger _ 155
c. Ground Sausage _ 150
d. Pork _ 150
e. Eggs _ 135
f. Steaks _ 130
2. In the following list, place in order from top to bottom, how the following will be
stored in a cooler and/or freezer: raw chicken, raw eggs, vegetables, foods that are
cooling, raw pork, raw hamburger, beef steak.
Top cakes, vegetables, condiments, steaks
Roast beef, raw fish, seafood, eggs, uncooked
Pork, raw ground beef, tenderized meat
Bottom raw chicken
3. Describe how you would cool hot foods for the next day's usage. Explain specific
examples, stating temps, time of cooling process, and size of containers.
Potentially hazardous food shall be cooled to 45 °F or less within four hours, quick
chiller, pan reducing, ice bath to include ice sticks
4. What minimum temperature ( °F) must leftovers be reheated to? 165 °F or higher before
being served
5. Describe your sanitizing procedures for your pots, pans and other utensils. Be
specific. Scrap 170 °F / Wash 170 °F / Rinse 170 °F / Sanitize/ Quatenary Ammonium
200ppm 75 °F/ Test Strips
Page 10 of 11
6. Describe how you will sanitize the cutting boards, prep area tables, prep sinks, and
knives when switching from one food to another. Describe what products will be
used to clean this area and the contact time for the sanitizing chemicals used.
We will use all color coded cutting boards that will go through the dishwash
machine. All utensils will go through too. Sinks will be scrubbed, rinsed, and
sanitized with Quatenary Ammonium 200ppm
7. Please list the hot holding and cold holding temperatures of foods that are held on a
buffet bar or held in the walk -in cooler.
Hot Holding _ 165 (OF)
Cold Holding 45 (OF)
8. Describe when you and your employees are required to wash your hands.
At all times after any event, such as trash handling, prep work, serving etc.
9. Describe your sick employee policy.
Employees who are sick, are sent home and they must return through our employee
health nurse.
10. Explain how to use and calibrate a thermometer.
Calibrate the thermometer every day. We use a digital thermometer. After each
use we use alcohol wipes.
11. Explain the policy if there are cuts or bums on the hands of an employee.
The employees are sent to the employee health nurse.
12. Explain the procedure for making up a sanitizing solution.
We use Quatenary Sanitizing solution at 200 ppm
13. Will staff be allowed to smoke? Where will they be allowed to smoke?
No smoking on the property. Non - smoking policy environment.
14. What distributors will be used to purchase the food being sold?
US Food Service, Pet Dairy, Pepsi, S +D Coffee, Fords Produce, Franklin Bread
15. Where will personal drinks be stored and how will they be stored?
Under working areas with a covered lip.
These questions must be answered correctly to demonstrate whether the restaurant owner or
operator is knowledgeable enough to receive a Permit/Transitional Permit from this office.
Page 11 of 11