HomeMy WebLinkAboutEHPR-08-2016-24574.TIF A
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COUNTY • Catawba County Public Health Department
Division of Environmental Health
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FOOD ESTABLISHMENT PLAN REVIEW APPLICATION FOR OWNERSHIP CHANGE j ,,
(Note that if the establishment has been closed for over one year then applicant must fill out short form instead of this form)
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Name of Existing EsIdbiishment: —- f' C1(Cr
Name of New Establishment Unless the Same: 94 '1 A/y,Q-e /7 O27(.4 7-G
Establishment's Address: pi i�� M_,
�5Lo 14-1 1111AeI 1 Sfi City: c Co Zip Code: �6(
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New Owner's Name:
Mailing Address: PO 8' /g5 City://emu«, f Zip Code: 2eta3
Phone Number: (c2 ' ) —(3ZZ - 2‘V0) Fax: (tf) --( 72V
Please Enclose the Following Documents
OD Proposed menu items (including seasonal variations in the menu).
▪ Manufacturer specification sheets for each piece of equipment that may be added or replaced.
• Plan of facility drawn to scale (min 1/4" = 1') showing location of equipment,plumbing, electrical
service and mechanical ventilation, including location of all electrical panels only if complete
remodel and/or replacing, adding/moving equipment. That will be determined by plan
reviewer.
Hours f peration � /."d%),�
Sun Mon( -00 Tue `f Wed s/ Thu Fri 17 Sat
Number of Seats e0
Number of Staff 2— (Maximum per shift)
C.
Facility Total Sq. Ft. 20Od
Projected Number of Meals to be Served: (Approximate number)
Breakfast e Lunch �S Dinner
Projected Start Date:
1
Type of Service (Check all tltatpply)
Sit Down Meals
Take Out -
Caterer
Mobile Food Unit
Push Cart
Limited Food Service
Single Service Utensil Only
Multi-Use Utensil Service Only
Other
ITEMS THAT NEED TO BE ADDRESSED
1. Information plans should include; the proposed menu, seating capacity, projected daily meal
volume for food service operation.
2. Adequate rapid cooling including ice baths and refrigeration, and hot-holding facilities for
potentially hazardous food (PHF) should be clearly designated on the plan.
3. When menu dictates, separate food preparation sinks should be labeled and located to preclude
contamination and cross-contamination of raw and ready to eat foods.
4. Auxiliary areas such as storage rooms, garbage rooms, toilets, basements and/or cellars used for
storage or food preparation should be represented on a plan.
5. Insure that all food service/kitchen equipment is National Sanitation Foundation International
(NSF) listed, Underwriters Laboratories Inc., Classified for Sanitation or if not NSF or UL
listed/classified, be constructed to meet NSF/ANSI standards as specified according to 15A
NCAC 18A .2600, Rule .2654 and 2009 NC Food Code Manual Chapter 4.
6. As specified according to 2009 NC Food Code Manual 4-4 all items stored in rooms where food
or single-service items are stored shall be at least 6 in. (15.24 cm.) above the floor when placed
on stationary storage units or when placed on portable storage units or otherwise arranged so as
to permit thorough cleaning.
FINISH SCHEDULE
Floor,wall and ceiling finishes(vinyl tile,acoustic tile,vinyl baseboards,FRP,etc.)
AREA FLOOR BASE i WALLS CEILING
Kitchen F Y v,
Bar
Food Storage
Dry Storage
Restrooms
Garbage&Can Wash Areas
Wait Station Areas
Other
Other
2
FOOD PREPARATION REVIEW
Check categories of Potentially Hazardous Food (PHF) to be handled prepared and served.
CATEGORY Yes No
Thin meats, poultry, fish, eggs (hamburgers, chicken breast, fish filet, etc.)
Thick meats,whole poultry (whole roasts, pork, chicken, meat loaf, etc.)
Hot processed foods (soups, stews, chowders, casseroles)
Bakery goods (pies, custards, creams) .7
Other:
PLEASE CHECK Box FOR THE FOLLOWING QUESTIONS
FOOD SUPPLIES
1. Are all food supplies from inspected and approved sources? Yes No
COLD STORAGE
2. Are adequate and approved freezer and refrigeration available to store frozen foods,F and
below, and refrigerated foods at 45°F (7° C) and below? Yes No
Provide the method used to calculate cold storage requirements:
-'rk e r v y n 4TH ra.
Provide total footage of space dedicated to walk-in cold storage
Provide total footage of space dedicated to reach-in cold storage
3. Will raw meats, poultry and seafood be stored in the same refrigerators and freezer with
cooked/ready-to-eat foods? Yes ) No
If yes, how will cross-contamination be prevented? C R.ecov-t- e4 `5' . 4.4e_
4. Does each refrigerator/freezer have a thermometer? Yes No
Number of refrigeration units: Number of freezer units:
THAWING
Please indicate by checking the appropriate box how PFIF (potentially hazardous food) in each category
will be thawed. More than one method may apply.
Thawing Process Thick Meats Thin Meats Fish Seafood Poultry Products Baked Goods
Refrigeration " :021 C p fi g= iTm.
Running Water less than 70°F(21°C) EN qal d�'i,..a:.ti� WOW j iE - ii3T
Cooked Frozen(indicate wt.lbs.) r v 1SS q Ys• ' `r' 'S•"` ° 'e 20-.1r:a
Microwave i ' '`•°'�"' ' rx';" fsal� � �s�a +
Other (describe):
3
COOKING PROCESS
Item#1 - Will food product thermometers (0°–212°F) be used to measure final cooking/reheating
temperatures of PHF (potentially hazardous food)? Yes No
Minimum cooking time and temperature of product utilizing convection and conduction heating
equipment:
Product Time& Temperature Product Time & Temperature
Beef roast 130° F (121 min) Comminuted meats 155°F (15 sec)
Seafood 145°F(15 sec) Poultry 165°F (15 sec)
Pork 155°–F(15 sec) Other PHF 145°F (15 sec)
Eggs 145°F(15 sec) * reheating PHF 165°F(15 sec)
Item#2 - Hot Holding
How will hot PHF(potentially hazardous food) be maintained at 135°F (60° C) or above during holding
for service? Indic to type and number of hot holding units.
51- ec, -tc,te, e_
Item#3 - Cold Holding
How will cold PHF (potentially hazardous food) be maintained at 45° F (7° C) or below during holding
for service? Indicate type and number of cold holding units.
TC 1—GA 11 I
Item #4- Cooling
Please indicate by checking the appropriate box how PHF (potentially hazardous food) will be cooled to
45°F (7° C)within 6 hours (135° F to 70°F in 2 hours and 70° F to 45°F in 4 hours).
Cooling Process Thick Meats Thin Meats Fish Seafood Poultry Products Baked Goods
Shallow Pans sV al co' E:av,_27, _D.7,rigtf.;�_�As-±:,AM
Ice Baths C�k • 51.7--_4A P' "n.717,Oi:aq-.,
Rapid Chill ' /r.7 l �•�:
EI„ it` fig
Other(describe):
4
1
FOOD PREPARATION
1. Please list categor'e f food prepared more than 12 hours in advance of service.
2. Will disposable gloves and/or utensils and/or food grade paper be used t 4 nimize handling of
ready-to-eat foods? Yes No
3. Is there an established polity to exclude or restrict food workers who are sick or have i ected
cuts and lesions? Yes No
Please describe procedure:
4. How will cooking equipment, cutting boards, counter tops and other food contact surfaces which
cannot be submerged in sinks or put through a dishwasher be cleaned and sanitized?
Please describe procedure:
5. How will ingredients for cold ready-to-eat foods such as tuna, mayonnaise and eggs for salads
and sandwiches be pre-chilled before mixed and/or assembled?
6. 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:
5
l
•
THE FOLLOWING 4 QUESTIONS DEAL WITH FOOD PREPARATION PROCEDURES FOR FACILITIES.
Food preparation procedures are needed to obtain information on how the food is prepared and to help
determine that adequate facilities are available. The food preparation procedures should include types
offood prepared,time of day and equipment used for service in the facility.
(Attached is Food Item Preparation Worksheet Supplement for additional food items prepared in
the facility.)
If your company has food preparation procedures already developed, these can be submitted as part of
the plan review approval process.
1. Produce Preparation Procedures �f
a. Will produce be washed or rinsed prior to use? Yes �`r No
b. Is there an approved location used for washing or rinsing produce? Yes ?C No
c. Will it be used for other operations? Yes No X.
Please indicate location of produce washing equipment and describe the procedures. Include time of day
and frequency for washing or rinsing the produce at this location:
Please describe the produce preparation procedures and indicate location of equipment to support this
operation. The preparation procedure should include dishes (proposed menu items)in which the produce
will be used,and should include time of day and frequency of preparation for the produce at this location:
2. Seafood Preparation Procedures
a. Will seafood be washed or rinsed prior to use? Yes No
b. Is there an approved location used for washing or rinsing seafood? Yes No
c. Will it be used for other operations? Yes No
Please indicate location of seafood washing equipment and describe the procedures. Include time of day
and frequency for washing or rinsing the seafood at this location:
•
6
Please describe the seafood preparation procedures and indicate location of equipment to support this
operation. The preparation procedure should include dishes(proposed menu items)in which the seafood
will be used, and should include time of day and frequency of preparation for the seafood at this location:
3. Poultry Preparation Procedures t.".1-'
a. Will poultry be washed or rinsed prior to use? Yes No_
b. Is there an approved location used for washing or rinsing poultry? Yes No
c. Will it be used for other operations? Yes No
Please indicate location of poultry washing equipment and describe the procedures. Include time of day
and frequency for washing or rinsing the seafood at this location:
Please describe the poultry preparation procedures and indicate location of equipment to support this
operation. The preparation procedure should include dishes (proposed menu items)in which the poultry
will be used,and should include time of day and frequency of preparation for the poultry at this location:
4. Pork and/or Red Meat Preparation Procedures
a. Will pork and red meats be washed or rinsed prior to use? Yes No
b. Is there an approved location used for washing or rinsing pork and red meats? Yes No
c. Will it be used for other operations? Yes No
Please indicate location of seafood washing equipment and describe the procedures. Include time of day
and frequency for washing or rinsing the seafood at this location:
Please describe the pork and red meats preparation procedures and indicate location of equipment to
support this operation. The preparation procedure should include dishes (proposed menu items) in which
the pork and red meats will be used,and should include time of day and frequency of preparation for the
pork and red meats at this location:
7
1
DESIGN INFORMATION
I. DRY GOODS STORAGE
1. is appropriate dry good storage space provided for based upon menu, meals frequency
of deliveries? Yes No
Provide information on the frequency of deliveries and the expected gross volume that is to be
delivered each time.
II. WATER SUPPLY
1. Please check one: Is water supply a well (community)? Yes No Municipal? Yes' No
If the Water supply is other than a Municipal supply,it will be required to be registered
with Public Water Supply.
2. If water supply is from a Community Water Supply system is it registered and approved as
public water supply? Yes No
If yes, please attach copy of written approval and/or permit.
3. Is ice made on premises or purchased commercially? Yes No
Please specify:
If made on premised than specification for the ice machine will need to be provided. Describe
provision for ice scoop storage:
III DUMPSTER
4. Will a dumpster be used? Yes >1 No N/A
Number Size Frequency of Pickup
�Contractor Service: )j w r ke
5. Will the dumpster be cleaned on site? Yes No
If the dumpster is to be cleaned on site,then the waster water from the cleaning operation
will be required to be discharged to the sanitary sewer system.
8
6. Is the dumpster to be cleaned by an off site contracted cleaning service? Yes No
If yes, please provide name an d, f.the firm contracted for this service.
Name: ////
Mailing Address:
City: State: Zip Code:
Telephone: ( )-( - ) Fax: (
7. Will trash containers be stored outside? Yes No Y-
If yes, please describe location: •
8. Type and location of waste cooking grease storage receptacle:
9. Is there an area to store recycled containers? Yes No
Describe:
10. Location and size of grease trap:
X. SEWAGE DISPOSAL 'N?{.1. Is building connected to a municipal sewer? Yes l No
2. If no, is private disposal system approved(septic system)? Yes No Pending
If yes, please attach a copy of the written approval and/or permit.
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STATEMENT: I hereby certify that the above information is correct, and I fully understand that any
deviation from the above without prior approval from this Health Regulatory Office may nullify this
approval.
Signature(s) � ,,/
Owner(s) or Responsible 1presentative(s)
Date: s//7/2‘2/�
9
�,A Co CATAWBA COUNTY
�' �� 100A SOUTHWEST BLVD
! NEWTON,NORTH CAROLINA 28658 RECEIPT
PHONE: 828.465.8399
E: t,: Tuesday,August 23, 2016
18 4'- sM www.catawbacountync.gov
PAYOR: SHERRILL FURNITURE CO
SHERRILL FURNITURE CO
PAYMENTS
TRANSACTION NUMBER: TRC-797481-23-08-2016
PAYMENT DATE : 08/23/2016
PAYMENT TYPE: Check 334786
application and check left at Hickory, spoke with Pat
INVOICE NUMBER FEE NAME FEE AMOUNT
08-16-331943 Food and Lodging Review Fee $75.00
TOTAL PAYMENTS : $75.00
EHPR-08-2016-24574
CASE TYPE: Environmental Health Plan Review WORK CLASS: Other FLI
SITE ADDRESS: 856 HIGHLAND AVE SE, HICKORY NC 28602
Applicant HICKORY WHITE, 856 HIGHLAND AVE SE, HICKORY NC 28602
Paid By SHERRILL FURNITURE CO, PO BOX 189, HICKORY NC 286030189
**NO PEOPLESOFT ACCOUNT ASSIGNED **
receipt 08/23/2016 16:55 Page 1 of 1