HS REVIEW 11S °° Z‘ Z3
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, RENS
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
V' A complete equipment list and corresponding manufacturer specification sheets
V A proposed menu
V/ A completed Food Service Plan Review Application
$200 Plan Review Fee
3/10
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Page 1 of 9
)
Food Service Plan Review Application
Type of plan: New ✓ Remodel Change of Ownership
Name of Establishment: W I 7 1 C S&/ ;x ?2-Gs5
Physical Address: 544 atiru4S7
City: ,4(/ 1 t- State: /46 Zip: 'Z 15
Phone (if available):(9 M) 93/' 06 99 Fax: 4797' 7/73
Website: WW [! . (4/1/ TEEWfpij6.1 r - • Co r't--
Applicant: /1:1 //0Cp1T/5`L 11 rt4
Address: Sit 011.421/"/ S% //
City: '6 /CIZ tate: �� /IG Zip: p 2i SO/
Phone: efivigI. 0k99 fts 4o /0 ' x: (BUf� 7/73
Email: ✓ I e, br/ ?Pe5pe4't/ES.Gdrt-
Owner (if different from Applicant): f crtita
Address:
City: State: Zip:
Phone: Fax:
Email:
I certify that the information in this application is correct, and 1 understand that any deviation
without prior approval from this Department may nullify plan approval.
f ✓:� • .0/ rt ate: '7�
Signature: a A /J/1� - l Z / ///
(s •p1ic. - or • espo sibl Representative)
Page 2 of 9
I
f
Hours of Operation:
Mon ✓ Tues ✓ Wed ✓ Thurs ✓ Fri ✓ Sat ✓ Sun
Number of Seats: 54
Facility total square feet: 1 itl
Projected start date : // /1
Food Safety Knowledge:
Do any members of management have current Sery afe or equivalent food service
certification? do, (07 Sit�pgLEED 1/ 1/ tee Co at.
/W 4 irwIct - (vfv C ,o croft Dv-re
Type of Food Service: Check all that apply
✓ Restaurant ✓ Sit down meals
Food Stand ✓ Take -out meals
Drink Stand ✓ Catering
Commissary
Meat Market
Other (explain):
Utensils:
Multi -use (reusable): Single -use (disposable): I/
Food delivery schedule (per week): 3
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:
i4/
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)
❑ on- public
CV' Community/Municipal,
❑ Non - transient, non - community
❑ Transient, non - community
Is an annual water sample required of your establishment? (check one)
❑ Yes
lV No
Wastewater System:
Type of w stewater system: (check one)
IbrPublic sewer
❑ On -site septic system
Number of current seats:
Number of seats applying for: Sb
Water Heater: twat? Manufacturer and Model: ) wad ! C
Storage Capacity: 7S gallons
• Electric water heater: II //� kilowatts (kW)
• Gas water heater: (p (0 BTU's
Water heater re very rate (gallons per hour at 100F rise): (p —GPH
If tankless, GPM ; Number of heaters: ti'
*Water heater calculator on the Plan Review Unit web page at
www.deh.enr.state.nc.us /ehs /food /plan3.htm
Page 4 of 9
HOT HOLDING
Foods that w be held hot before serving: eta, / ..veR E3,
/ $�5, 5r eA /sr&i✓ c
COLD HOLDING //�� �
Foods that will be hel. cold before serving: £ O' e nu; /onP-ro ,f3
u . .,. « 7
wen t. Car
DRY STORAGE /
Frequency of deliveries per week: 3 Square feet shelf space: 7 Z ft g, e ,
Is a separate room designated for dry storage? Alp Z9 ri 3 7�
FINISH SCHEDULE
Floor, wall and ceiling finishes (vinyl tile, acoustic tile, vinyl baseboards, FRP, etc.)
AREA FLOOR BASE WALLS CEILING
Kitchen ✓c% vi wit_ rCKP /ficaJSneTLG
Bar vet ✓I 140_ r iiC'i° , ,
Food Storage
✓cf VI ,f) yi_ pKl
Dry Storage V'C ✓r'AWL- reP
Toilet Rooms VCT ✓r`IiyL 1
Garbage & Can /
Wash Areas Co,JOU7E 5To/l e STOIIC /ll 0,4E
Other
Other
Page 5 of 9
FOOD PREPARATION FACILITIES
Number of food prep sinks: 1 Are separate sinks provided for vegetables and meats? ilh
Size of sink drainboards (inches): gel
How will sinks be sanitized after use or or between meat species? C/// /3 oat RAW pv
9
DISHWASHING FACILITIES
Hand Dishwashing
Number of sink compartments: 3
Size of sink compartments (inches): Length gil Width Depth 1
Length of drainboards (inches): Right __ Left
Are the basins large enough to immerse your largest utensil?
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: 0 ter
Hot water sanitizing? i4I A' or chemical sanitizing? 14I t
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 b cleaned and sanitized?
tit rli(/kr;'tt 13jtN�4'CblLl/ATe►2 E/4&f+/« / /neetig'smece-erebt
How many air drying shelves will you have? 1
Calculate the square feet of total air drying space: '3G, ft2
HANDWASHING
IndicateMumber and locations of hand sinks in the establishment: 3
t Y1cp fro rd-t-al i N a p -Fr i rcNC+d
Jll7l7��ii�///)) Es/2 of AnTt#i -I
Page 6 of 9
EMPLOYEE AREA //��"�,��,, /
Indicat- location for storing employees' personal items: afe4EZ3 (ob ettrer
i _ - eAdr !i 'a.... ,nz ♦fas -, .
GARBAGE, REFUSE AND OTHER
Will trash be stored in the restaurant overnight? Yes No ✓ If so, how will it be stored
to prevent contamination? ltl /S
Location and size of can wash facility: 6 s ' Ow r%' R/t firth ,on
Are hot and cold water provided as well as a threaded nozzle? VEj
Will a dumpster be provided? ( Do you have a contract with the dumpster provider
for cleaning? tl E
How will used grease be handled? V(47206/11-- Stin✓I C e
Is there a contract for grease trap cleaning? lir
Are doors self - closing? Li ' Fly fans provided? E5 Where will chemicals be sto UNDE- Cam/ s Gt•ES
Where will clean linen be stored? (,!'/tick{'/, COtitnet -7A"✓L JS4EL I/t3
Where will dirty linen be stored? AR+ 4ts 54cA Poott /IJ fr/TC Welk/
Page 7 of 9
MENU
Dinners (All Platters served w /Hushpuppies and choice of 2 sides.)
Old Timers $ 5.50 BBQ w /Slaw & Hushpuppies
BBQ Platter $ 7.25
Chicken Platter Dark $ 6.50 Thigh & Leg
Chicken Platter White $ 7.00 Breast & Wing
Combo Dark Platter $ 7,50 BBQ w/Thigh
Combo White Platter $ 8.00 BBQ w /Breast
3 Wing Snack w /Frys $ 6.00
Sandwiches
Combo (Includes Fries & Drink)
BBQ Sandwich $ 3.65 $ 6.00
Hot Dog $ 1.75 $ 6.00 (2 Hot Dogs)
Breast Sandwich $ 3.50 $ 6.00
2 Leg Sandwich $ 3.50 $ 6.00
Sides
French Fries $ 2.00
Hush Puppies (1 /2 Dozen) $ 1.00
Boiled Potatoes
Green Beans
Cole Slaw
Brunswick Stew
Potato Salad
Sweets
Banana Pudding $ 1.50
Brownie $ 1.50
Kid's Meals
Grill Cheese, FF & Sm. Drink $ 3.50
Cheese Quesadilla, FF & Sm. Drink $ 3.50
Hot Dog , FF & Sm. Drink $ 3.50
Leg or Wing, FF & Sm. Drink $ 3.50
Sub Apple Sauce or Mandarin Oranges N/C
Beverages
Fountain Drink (16oz) $ 1.75
Tea (16oz) $ 1.50
Kid's $ 1.00
Coffee $ 1.25
TAKE OUT
Half
Pint BBQ $ 9.00 $ 5.00
4 Piece Chicken $ 5.50
8 Piece Chicken $ 10.00
12 Piece Chicken $ 14.50
16 Piece Chicken $ 19.00
BBQ Pack $ 11.00
Chicken Pack $ 12.00
Family Pack $ 18.00
Value Pack $ 21.50
Half
Pint Potato Salad $ 3.00 $ 1.75
Pint Boiled Potatoes $ 3.00 $ 1.75
Pint Green Beans $ 3.00 $ 1.75
Pint Cole Slaw $ 3.00 $ 1.75
Pint Brunswick Stew $ 4.50 $ 2.50
Hushpuppies (Per Dozen) $ 1.50 $ 1.00
Tea (Gallon) $ 4.25 $ 2.50
i -
Food Handling Procedures: White Swan Express
Pork Barbeque:
1) Product is vacuum packaged in 5 lb. packs in a USDA approved and monitored
facility. It is shipped to the restaurant in refrigerated trucks.
2) Product is stored in reach -in refrigerators.
3) The product is fresh, never frozen.
4) Product is heated by submerging in water on the steam table. It is removed from
package and transferred to a stone pot on the steam table once it has been heated.
5) Product is handled as needed.
6) Leftover product deemed usable is transferred to plastic containers to be reheated
and used the next day.
7) Product is cooled in the reach -in refrigerator.
Chicken:
1) Product arrives, via Food Distributor, raw, in wax box cases. The 8 piece
chickens are individually packaged in sealed plastic bags.
2) The cases are stored in reach -in refrigerators.
3) The product is fresh, never frozen.
4) Product is opened and drained in the prep sink located in the prep kitchen. It is
then placed in a clear plastic tub and breaded. Tub with breading is stored in
reach -in refrigerators until needed. Product is then deep fried in the deep fat
fryers and served.
5) Product not consumed immediately is stored in a food warmer with both bottom
and top heating elements. This equipment is designed to maintain proper holding
temperatures.
6) Product is handled as needed.
7) Product is not reused.
Hot Dogs:
1) Product arrives fully cooked in wax cardboard boxes.
2) Product is stored in reach -in refrigerators.
3) The product is fresh, never frozen.
4) Product is made to order and heated by deep frying in the deep fat fryer.
5) Product is handled as needed.
6) This product is made to order, so there are no leftovers.
Chicken Breast for Chick Filet Sandwiches:
1) Product arrives frozen, via Food Distributor,
2) Product is stored in reach -in freezer.
3) Product is deep fried in the deep fat fryer from a frozen state and never thawed
prior to cooking.
4) Product is handled as needed.
5) This product is made to order, so there are no leftovers.
1
French Fries:
1) Product arrives frozen, via Food Distributor
2) Product is stored in a reach -in freezer.
3) Product is deep fried in the deep fat fryer from a frozen state and never thawed
prior to cooking.
4) Product is handled as needed.
5) This product is made to order, so there are no leftovers.
Hushpuppies:
1) Product arrives in 25 lb. bags in powder form, via Food Distributor.
2) Product is stored in Dry Storage area.
3) Product is mixed with hot water to form a batter.
4) Product is deep fried in the deep fat fryer and served.
5) Product not consumed immediately is stored in a food warmer with both bottom
and top heating elements. This equipment is designed to maintain proper holding
temperatures.
6) Product is handled as needed.
7) This product is made to order, so there are no leftovers.
Boiled Potatoes:
1) Product arrives raw in 501b. bags via Food Distributor
2) Product is stored in Dry Storage area.
3) Product is washed, cut to proper proportions, and boiled until done on the 6
burner range.
4) Product is then placed on the steam table to maintain proper holding temperatures
for service.
5) Product is handled as needed.
6) Leftover product deemed usable is transferred to plastic containers to be reheated
and used the next day.
7) Product is cooled in the reach -in refrigerators.
Green Beans:
1) Product arrives fully cooked in #10 cans via Food Distributor.
2) Product is stored in the Dry Storage area on a can rack.
3) Product is seasoned and heated on the 6 burner range.
4) Product is then placed on the steam table to maintain proper holding temperatures
for service.
5) Product is handled as needed.
6) Leftover product deemed usable is transferred to plastic containers to be reheated
and used the next day.
7) Product is cooled in the reach -in refrigerators.
2
y
Cole Slaw:
1) Product arrives fully prepared in 101b. plastic containers via Food Distributor.
2) Product is stored in a reach -in refrigerator.
3) Product is transferred to a refrigerated cooler on the steam table for service.
4) Product is handled as needed.
5) Leftover product deemed usable is transferred to the reach -in refrigerator to be
used the next day.
Potato Salad:
1) Product arrives fully prepared in 81b. containers via Food Distributor.
2) Product is stored in a reach -in refrigerator.
3) Product is transferred to a refrigerated cooler on the steam table for service.
4) Product is handled as needed.
5) Leftover product deemed usable is transferred to the reach -in refrigerator to be
used the next day.
Brunswick Stew:
1) Product is stored in the Dry Storage area on a can rack.
2) Product is seasoned and heated on the 6 burner range.
3) Product is then placed on the steam table to maintain proper holding temperatures
for service.
4) Product is handled as needed.
5) Leftover product deemed usable is transferred to plastic containers to be reheated
and used the next day.
6) Product is cooled in the reach -in refrigerators.
Banana Pudding:
1) Product ingredients arrive fully cooked via Food Distributor.
2) Product ingredients are combined in the prep kitchen to create product and stored
in reach -in refrigerators.
3) Product is pre - packaged in individual servings as part of the preparation.
4) Product is handled as needed.
Brownie:
1) Product arrives fully cooked and pre - packaged for individual sale via Food
Distributor.
2) Product requires no refrigeration.
3) Product is handled as needed.
Bread/Buns:
1) Product arrives fully cooked in bread racks via Food Distributor.
2) Product is stored in cooking area in bread racks on dolly.
3) Product requires no refrigeration.
4) Product is handled as needed.
3