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HS REVIEW //Cog 2 /fir 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: r j "' Physical Address: ' 1 ' City: t ' State: Zip: Phone (if available): Fax Website: Applicant: Address: City: State: (. Zip: Phone: ci 111 ,'` ' Z; Fax: Email:: 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 .. f ,Vt' atiedai . , , Date: (Applicant or Responsible Representative) • r , Page 2 of 9 Hours of Operation: Mon '' ' Tues 11 - ! r ‘ Wed ' Thurs II ' Ir Fri II - '^ 1" Sat II OP ` Sun I) Number of Seats: I f Facility total square feet: , , r A - . Projected start date of construction / change of ownership: 0 / p Food Safety Knowledge: Do any members of management have current ServSafe or equivalent food service certification? 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): 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: t 4 1 r IC '.. ��`' �- tV��. . - 4 r� r t � <�l k tt" ' �t; ± i - _ t � —. " 114 t'' _ {C r n , . . A 1 ' ' :1 ` .-` CI f : ' Y . . VP', i e t ' t ,I.. r fr b ' V t a M " dr Indicate any of the following highly susceptible populations that will be catered to or served: � ( /A 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 ra Community/Municipal ❑ Non - transient, non - community ❑ Transient, non - community Is an annual water sample required of your establishment? (check one) ❑ Yes si No Wastewater System: Type of wastewater system: (check one) ig Public sewer ❑ On -site septic system Number of current seats: Number of seats applying for: 1 1 51 e C l "'r C Wl t� Water Heater: j t I G Manufacturer and Model: I'1 p ow " i J) n. elf' ? + L =r Storage Capacity: � ¢ gallons • Electric water heater: kilowatts (kW) • Gas water heater: ' t : _ `. "� st IBTU's Water heater recovery rate (gallons per hour at 100F rise): ; 0, 7 If tankless, GPM ; Number of heaters: , *Water heater calculator on the Plan Review Unit web page at www dettemstatc.nc.us/chs/food/plan3.htm Page 4 of 9 HOT HOLDING E that will be held hot before serving: , ! ))en y t i d ) cji redd (,) h r k4- 11 r.. ) COLD HOLDING - .t Foods that will be held cold before serving: 41.- r I 1.)C NI) Ire; 11 b owY e t) tel 4111 0 1 ) 7:11 ' d Je ci Aileeve DRY STORAGE Frequency of deliveries per week: , Square feet shelf space: ft2 Is a separate room designated for dry storage? FINISH SCHEDULE Floor, wall and ceiling finishes (vinyl tile, acoustic tile, vinyl baseboards, FRP, etc.) AREA FLOOR BASE WALLS CEILING • 1 Kitchen -rde ft r)t-rr Bar t 1 ie (eve \)a te.1010 t Lc ( • Food Storage Dry Storage tell CY . ,;( t? erri ' e 7. Ll Toilet Rooms Ile— _ 14, I Lit ) p 4 As. e t To tic Garbage & Can Wash Areas CMV ie i nt y6, br Other Other Page 5 of 9 FOOD PREPARATION FA Number of food prep sinks: 2. Are separate sinks provided for vegetables and meats? ' , - Size of sink drainboards (inches): How will sinks be sanitized after use or between meat species? l w? e'. 4 e.. -re +- c 1 t Y' e- Y DISHWASHING FACILITIES Hand Dishwashing Number of sink compartments:...,-' ft Size of sink compartments (inches): Length ";. Width Depth Length of drainboards (inches): Right Id 'Left ° .�.1 Are the basins large enough to immerse your largest utensil? / e r> What type of sanitizer will be used? Chlorine Quaternary ammonium Hot water Other (specify) Mechanical Dishwashing Will a dshmachine be used? Yes - No Dishmachine manufacturer and model: f% S ;20 0 (? 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? CC F. l `�Q ;Al , y ,,.. r.. ..w t 1'l0 , �� c r Y �t- j ,- How many air drying shelves will you have? Calculate the square feet of total air drying space: 5 etz # 171111, ft HANDWASHING Indicate number and locations of hand sinks in the establishment: (0' )- k- . : ' •� 4 : l 4 4 4 t ° r • (1...1 Page 6 of 9 EMPLOYEE AREA Indicate location for storing employees' personal items: • , y g . (), % "' ! , !' ,e, j A ) y { - '•_, P. .i. Ync... : ;, f "v 1 rect 03` e/ e.10 1 as o vt ty . GARBAGE, REFUSE AND OTHER Will trash be stored in the restaurant overnight? Yes No F. _ If so, how will it be stored to prevent contamination? Location and size of can wash facility: S e e 1" 1 t y� Are hot and cold water provided as well as a threaded nozzle? r 14 Will a dumpster be provided? y ?• r, Do you have a contract with the dumpster provider for cleaning? • How will used grease be handled? ✓! a m a , 1 r ,6 ' w re ( et ) Net a u ' 4(. . Is there a contract for grease trap cleaning? t - 1 ,1 m d ((4 h 2_ r 1E 4 t !' cl ti'v ct? 0 v Q.! Are doors self - closing? '1/4/9_5 Fly fans provided? N 0 Where will chemicals be stored? C ^ ,' r• f i' ? »r ,' ` r ' 1 .1 'J Where will clean linen be stored? 1 Y y t Yiec fi•. •Y t` Where will dirty linen be stored? I% A !E' oY1 ■ ` \ ` uf` q Vi c. Cct 1 S 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 FOOD PRODUCT ( )1;r f=, 1 ge'.pF< + ). . 1f ed - .hi?' v' ! Cr ttir i !! a 7 fr?Q' I + e 'F er f t . r 1A 1 ! .1 f r c j * , . r t c. ' r .1(11 r7 r ; t0 +f N c -i I ✓ e 1. (r t leer ' Yhf 4 c oY ,hc '� 1 , 7 f 1& y p � � , T f d t `X t .a 4 1t ,i v .1y ,ic ti, : :. wJi -t 'h C,i '"1!e Y t- alit TC, f ,.s i 7'.y Y/' ‘w. 4 l ! , ei t ' I "ci F. r e Y ' , ;? . d:' i- e J :' f ., 4f beg!' 4 4 o 1 (te ye' • V t- 1 1 ..; a 4_:, 4 -,Y Li", :7 r'r7e(yi! - 11 e '�- 'i. 441 ..7 I r? -r` -a: # r, , - i ' }tlre : t:'4 t rl ts , e , lL � 5 " � t t- -6r0 "'r't1 E' . ' V °. 5 to '«:.W elte .'( t -t -I < y - /f;. c3 FOOD PRODUCT :T .1 h t cm 1r% 1 .J J. s c f 2 { :it d t , r 4 r' ✓t. 4 h a p J 4 , rl 7 e .. r 7..E9°` „" 1 1 + r I yf €1 r 1 t..; '1'r ii +'hP UJed tiv !iv cit..; -1 y i,lY'r et ,c> c t"t i V., 11nr 0 t1Cr? ,.' rJ e i• 5 .4 .et 4 - 1 4 v 110.4 r _ i 1 /)rc Y ^f1,,�'t.- - I ' r ' i tre d 'r' Page 8 of 9 FOOD PRODUCT / / ,// /JJ.7 �S v 1 1e.f. e s'i, r2 d eep f ;n Pv, • 4 c'dt ke r la reel Yur1 'n4e -} P 15 hgeK * ter! 'b, w eV' * ,epee 4— te. r• e'2r an 5QY,re IL. F OOD PRODUCT (Svcs) � r .p(.2 '( rat vile 4 e I"l (2 yen if (J e V e n z e ve n A , " Alf; �r✓�' re K. t 0 ' t nr `t2t t- ?:1t n vi- } h ?". ,'`nY+ , YPeka,i ^0 1 0c... fietuse ce4,7 !c, (4 Orel F e11 ter cite to ere K 1lvttil 'j}' ig re 'tdy " pet merc i , u °,.. - ;trill "'e tYt %- C L; . v tJ , I k y t fcr , i i € y ..I & &U' o Y' r 1 4 . A,- YP" YPC 4.ct d ►DTh ore :\ •td. ¥ iP `''t<¢'er.t! -H t' FV1/�Q . a fi D ln� } Gi * FOOD PRODUCT h illJt)1Y.IO r �' 4I e$ ( 1 I + :�� e ((_ ' ' (t 1 r !' r' r . � N `, N 4 1 t ` P "�. ire Y .'( 1 f Y- • 0 .:' W it: d I e* e7 m a' b h e Yee..' 7' 21( a N i I k "1,'_ (` n r ,�� g en. ** *ADDITIONAL SHEETS ARE AVAILABLE Page9of9 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 1 FOOD PRODUCT i'`;! t..) < -' ;/ Q . C, o C r)i+I e, rch and. I.` j '0+ on khF Y I P'I 4, k 'i \I] U fr t " r i. r,: q :ir: yd 4 . r-ye r 6.1 - r: - ' ) T f i ' iM t � 4? 4 ✓n 7� ° cut ` i vl +a to t`t c cite�K 4vcj l,N :�vt��US�.KIE�� «�rc�, e 1✓1 t, F'I,.. 140 0 eV, 104Ck '} 'f'l1P it eeter ; fir S L' Fret f ;'o,`?e pi err - e. rt ;,,.r P. I e gt 't 1.5t ✓ t :t`. t! C4 =:c� 4-0 be.. SAPi 1Yl red oii sty! - r E • r 4, +nt.e +11P. 1- +- (!Je TYCO C't CI r.,Jg C.. a FOOD PRODUCT C 461 4 IC" iYO Zen .re e,-I.. -rr v; chi. Yr _uJ\"l e.rt 11? ve. Y'y -kb paw w .laYe J t5 fQk +o kh0. a k• 'r I Ypt•Y fl?e1 ! i C_rsnk -p d. r�JV� bar4- 40 ttr ey 4'4 ., gtie i v&,iemied.. t'c' b ;J P 7`/ P Page 8 of 9 FOOD PRODUCT f t t, C e' 2 fy- l.'. I. vl r '""' ..:'' it M, f lro V c., ..�.':.. COO i''f W ae i . " 1 , -q h t c' 1 e 9e . . r - A:1 e \ ^ PSe 3- if Ht (I% ., ')A. , -'k '('(leA .. Vic 4; ! ' Y'ctCe }o <ce!�GY` «%\ et AD Le. C) ^k.8..+ l er6ty\ #1V hlrt_K-e.* '- °t �1_ f oolc- }et e...' ![et-x>. VA r. 0-1ra.0eV (c w 'et ■ ti 6-Y iheq (1' 1 I#! 4 12'- 1 - A Ye .' Y2 • Ye 'he's( 4 r i., c , 1H. , I, w ^ 2 7 ' (-7,$ FOOD PRODUCT � !. e ft' 1 'l ; - -' r l R',avtc' ^. T't F_� 14 :.st Y� 0 xeet 7 =. 4-ke3 e Yv . % 04 !t) ! re i ' °e 'f - 1; em 4- tte., I -he. nYe. + Ve N -1-',;' 4-v1ty I )E'.q:�={-g191Q (f / j.. +`Isle! No fir; `t' o Ice, ti C.� t «. L.,, y e#10, l o? e d cf r1 et of ! ri c, I y i) E: y Crt Ott t1^,_ .&Y?, 41+rn;I Afr I the'_ )1 Y e lei? ± 10P I !et e: s„! V.- g PY3.It -d. Y FOOD PRODUCT .. J ,^ IL/ fl /;n C r , ,13,. " e; t?<Y "" i ki A 9 o ' in Cne it)" ti. 1 ° t o . } � 174e '� t 1C ! '. ,t '' “,. - ft) jtevc A 4 r le . Of ,.. f !�' "t,t , j 4aYt 6 tit A4. ^Y ` C1l,e , et d en d i <^ )a- ` ,,,,e i! ' I OA fel O 'e 4. 4he1+ -4+ In t e )Yrp iM blE. t ki ” ^._cn ** *ADDITIONAL SHEETS ARE AVAILABLE Page 9 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 FOOD PRODUCT yY 1 ! ri [Iv ko be r\ e d 1 fit' :. • ync -�- 11 � YC e r n A � c � �p •� 4 1'3 �` � �' n` i h "'�- )) P C4 YtPY- c -, \ VAll +� r r !t n Y' w Y' \r t1 ti_ 114, ..__ ,tr e v� , ^r+-tm, I(e,e co 4ci i v1e ttl t 3e o h 4o a i y;re f + €,Mk +© be, cos Ice. .&_ :5t-se ve d. , FOOD PRODUCT ° + .c' :.% C 4 "�, lh' 4 I 1"1 )4.1H . 4 bMC Ivt. [tYP. ' ^t1 he.. . C. ,. E" kit A r, to "? • 6t.. . _jit e s �, ;x,, eir+�t, `' I`7 cif L �'�? to le le 4t- +'bte'v1 -}n fli 1 fl? !l *T jb le. -1"o be ter K r t1. t. !r, e <-0 C. r;t,, Page 8 of 9 FOOD PRODUCT o !me 4 iv, bey..t?-2..? i P. N CI I V cure Keep 44- 0 rim +e 1 04.!..c , 9„41.).c 1 .. t sb et v (?....t hey erre , - 15 - v 0e: t ot flle CtYP (h e -1)le tor 5 5 rpo nit o re 141,9 , 0; ekve ce t doe, leyet-t e fo f1c veop±ekble. +-i- /e \-,./ he- Ye. he. 1 1 4 - e .7 Oren ci e / (on Le. ( 4-11 - yer,7` , 4 00 te rttcb t a :91-74 +he Cvoceccie$ rto qC4o •Ir L,u lie. 0. t re4 dy a o e f ke i orc t o k, i`c e 1) trer'ed FOOD PRODUCT I c•-t '(.. _) I "The, 19 e ev), 9 tani vle if roale.s r•r qe 4 41E. 9U - yr"? let #7..)0 t Iie v.) o tr I- c o 0 e y- 4 14y Ept tcae,i c eh,' cr.! lel ac r 4re tCP dr dr id r -Fe PIA ly e 11 1 4 1 e vt e f Ln: 1;•'‘)/ tOCaCit- +o con 1 i re 'II +.d. #O erve; ei r:Tc, Qv? j - 1 - ,hr, rei n.” I1C Set FOOD PRODUCT k-. c 4-14e., r‘i ye C 91-7 r t i 'rte /0 . 11 - "1 , 7 r d r. 1<ee, 1. , 3/4A i- 01V t _ft a et r t .1 re V , •AP - I mK t 7r.t (t - &€ -1 t1 1fr1 - 1 1- 5 JO& f� -eep citea 4 .?,. 77,9(V e 3 1t fee kJ,/ f f- c 01 ti w cc 1 peg kc, ,Cu-h4 e +tie .2, c 4 ir nrp. f 4 kit ■. er re; n kAt g*eve L.q E (p at avt,(.7b (c&eci_. 1 +tie eet -.? ecea vt.1( f `le 4 i - c d 1-h ev A y .,,e rb+ CiePac pen.t; 4.7" rtnr kA r..11,1ti they) Col- ill ry,04 rr otpy a YlAcill Octm Tcl.) 0 .0 Oen,vt--; +c, e 4 r, fre , ***ADDITIONAL SHEETS ARE AVAILABLE anct 9 �t 1 rot'. Lt7 1-q Keee 1- fecody to lie c)er,ied. Page 9 of 9 10t