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H & S Plan ReviewI Type of plan: New vZ — Remodel Name of Establishment: ,j C0 Physical Address: I CD 0 U-1 a A \),k City: CQVk'v'o'f' State: M C. Zip: Phone (if available): ' ( D -Hj� Fax: 4 01 6�q- X93010 P (�OVI -1 Email: ----------------------- ------------------- , 5- 00 3 --,?C)7 - - - - -- - - - - - - - - - - - - Applicant: )0-VJVY4 ills j� U u( '4� Address., City: / State: Zip: Phone: Fax: Email: �-Y Owner (if different from Applicant): Address: City: — Phone: Email: State: Zip: Fax: dlk�' 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:,_:::� Date: (Applicant or Responsible Representative) Page 2 of 10 Hours of Operation- VJ ry-1 Yh wu 3 _'i�ed_� rs i S�Oat - Sun "o 10 -S111"T`ues__ 4-V h Number of Seats: Facility total square feet: Projected start date: Type of Food Service: Check all that apply Restaurant -40 Sit down meals Food Stand "/Take -out meals Drink Stand Catering ��i` Commissary A Meat Market -"'-Other (explain): (��J Utensils: Multi-use (reusable): Sjm�ge-use (disposable): Food delivery schedule (per week): 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.) Has the process been approved by the Variance Committee of the DPH Food Protection Branch? 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 immunocompromised population Page 3 of 10 •• Type of water supply: (check one) ❑ Non - public (well) [P—'dommunity /Municipal Is an annual water sample required of your establishment? (check one) ❑ YES © .-No Wastewater System: Type of wastewater system: (check one) n-"Public sewer ❑ On -site septic system Water Heater: Manufacturer and Model: `7� 8- Storage Capacity: 6 0 gallons • Electric water heater: 1 B kilowatts (kW) • Gas water heater: A BTU's Water heater recovery rate: (o GPH If tankless, GPM ; Number of heaters: Page 4 of 10 Person in Charge (PIC) and Employee Health Are Persons in Charge certified food protection managers who have passed a test accredited by an approved ANSI program? Eligible Person In Charge: C9-4 Program �'"� Cert. # E p. a e For multiple shifts and /or occasions of absences, list all eligible Persons in Charge: Eligible Person In Charge:�'� -� cz�US Program Cert. # r7 k--/ t 3 S Eligible Person In Charge: Y4 4M Programx Cert.#—qi3 �5 Exp. Date ,( Exp. Date *Attach a copy of your establishment's Employee Health Policy Are copies of signed Employee Health Policies on file? Food Sources Namesjof food distributors: 4c? 4 Page 5 of 10 Deliveries /wk Time/Temperature Control for Food Safety Foods that will be held hot before serving: FTd1 that will be held cold before serving: A /11 JG�, '4114s, l�ur , Will time be used as a method to control for food safety? Will a buffet be provided? If so, attach a list of foods that will be on the buffet. ,, List foods that will be ingredient: and cooled for later use or added to another food as an Describe utensils and methods used to cool foods: Dry Storage Frequency of deliveries per week: 4— Number of dry storage shelves: Square feet shelf space: ftZ Is a separate room designated for dry storage? A/ Food Preparation Facilities Number TT fd prep sinks: —L Are separate sinks provided for vegetables and meats? Size of sink drain boards (inches): , How will sinks be sanitized after use or between meat species? Page 6 of 10 Dishwashing Facilities Manual Dishwashing Number of sink compartments: Size of sink compartments (inches): Length Width Depth _ Length of drain boards (inches): Right Left Are the basins large enough to immerse your largest utensil? What type of anitizer will be used? f Chlorine Quaternary Hot water (171 °F) A Other (specify) Mechanical Dishwashing Will a dishmachine be used? Yes No Dishmachine manufacturer and model: 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 'n sinks or put through a dishwasher be cleaned and sanitized? � � i 1 I How many air drying shelves will you have? _ "- Calculate the square feet of total air drying space: ft Hand washing Indicate number and locations of hand sinks in the establishment: Ll Employee Area Indicate location for storing employees' personal items: Page 7 of 10 ciurc-1- 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. Incomplete descriptions may result in the application being returned. 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 ••,D PRODUCT ' M M/ Page 9 of 10 'ADDITIONAL SHEETS ARE AVAILABLE Page 10 of 10