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HomeMy WebLinkAboutSFPR-09-2017-27483.TIF CATAWBA Catawba County Public Health Department CUZ1tTY 'x Division of Environmental Health — � North Ci+rrlfno FOOD ESTABLISHMENT PLAN REVIEW APPLICATION FOR OWNERSHIP CHANGE (Note that if the establishment has been closed for over one year then applicant must fill out short form instead of this form) Name of Existing Establishment: r�stn a`r C-,t���` -- Name of New Establishment Unless the Same: Cqn�RaJ-C_ U669 Establishment's Address: S-11;_ �r,�cj f '06 71G-(l�fAVe -- City: —E-1LC_kC9.r - Zip Code: PlbroO ! New Owner's Name: M04100- ( &lief G(f'---f1 Mailing Address: -A ©octa Z c, Clrr---City: !Fmye-H(V4le Zip Code: 1 asl�3 Phone Number: (ice )-( Fax: ..,_ .-. ... -.'.•.wtiN`:.:•'k i v•w°:�:•.� .'•::•:-f.1:.:..,..:::'r:r:ru•�ss s:.+s::::,. :.: .: ...v exux:eY:9's Se tii Please Enclose the Following ]Documents ■ Proposed menu items (including seasonal variations in the menu). �j M 00 dad``s Ccxn Q Manufacturer specification sheets for each piece of equipment that may be added or replaced. Plan of facility drawn to scale (min I/4" = i') 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 of Operation Sun- '� Mon--V Tue '/ Wed-_ Thu Fri ✓ Sat v Number of Seats Number of Staff (Maximum per shift) Facility Total Sq. Ft. L-IS(Do 04 Projected Number of Meals to be Served: (Approximate number) Breakfast yL bi5tu,ts Lunch-3s kS- Dinner 30--V Projected Start Date: 1 Type of Service (Check all that apply) Sit Down Meals X Take Out Caterer Mobile Food Unit �( Push Cart Limited Food Service Single Service Utensil Only Multi-Use Utensil Service Only Other �C 61Ctnc1- Deli 1SdPCJ-r '.rk't: - 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. I 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. S. 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 . 600, 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. EXISTING FINISH SCHEDULE Floor,wall and ceiling finishes(vinyl tile,acoustic tile,vinyl baseboards,FRP,etc.) AREA FLOOR BASE WALLS CEILING Kitchen Bar Food Storage Dry Storage Restroo ms Garbage & Can Wash Areas Wait Station Areas Other Other 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.) r/ Hot processed foods (soups, stews, chowders, casseroles) Bakery goods (pies, custards, creams) Other: PLEASE CHECK BOX FOR TATE FOLLOWING QUESTIONS FOOD SUPPLIES I. Are all food supplies from inspected and approved sources?Yes X No COLD STORAGE 2. Are adequate and approved freezer and refrigeration available to store frozen foods at 0° F and below, and refrigerated foods at 450 F (7° C) and below? Yes X No Provide the method used to calculate cold storage requirements: Provide total footage of space dedicated to walk-in cold storage _ 100 s91jit. , c3c«►+F (y 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 as. If yes, how will cross-contamination be prevented? -Ilqis Gs -t- C ry sr Corr 4ACAM ION..J�+-- SC0.{NIOCL- 4. Does each refrigerator/freezer have a thermometer? Yes No Number of refrigeration units:_ Number of freezer units: t _ THAWING Please indicate by checking the appropriate box how PHF (potentially hazardous food) in each category will be thawed. More than one method may apply. Thawing Pro Cess Thick Meats Thin Meats Fish Seafood Poultry Products Baked Goods Refrigeration Running Water less than 701 F(211 C) Cooked Frozen(indicate wt. lbs.) Microwave Other (describe): COOKING PROCESS Item #1 - Wil I food product thermometers (00--212° F) be used to measure final cooking/reheating temperatures of PHF (potentially hazardous food)? es ,x No Minimum cooking time and temperature of product utilizing convection and conduction heating equipment: Product Time& Temperature Product Time& Temperature Beef roast 1300 F(121 min) Comminuted meats 1550 F (15 sec) Seafood 145°F (15 sec) Poultry 1650 F (15 sec) Pork 155°F (15 sec) Other PHF 1450 F (15 sec) Eggs 1450 F (15 sec) * reheatin;PHF 165° F (15 sec) Item #2 -Hot Holding How will hot PHF (potentially hazardous food) be maintained at 1350 F (570 C) or above during holding for service? Indicate type and number of hot holding units, nn-- �CflCc. J, 'JC. v o --- Item Item #3 - Cold Holding How will cold PHF (potentially hazardous food) be maintained at 450 F (7° C) or below during holding for service? Indicate type and number of cold holding units. - Met tV4atoeJ t',% &W (_U 14 c( Of-C( S jk'cc�cG (lei C -4j&%-C bailAy Item#4 - Cooling Please indicate by checking the appropriate boa how PHF (potentially hazardous food) will be cooled to 45° F (7° C)within 6 hours (135° F to 700 F in 2 hours and 700 F to 450 F in 4 hours). Cooling Process Thick Meats Thin Meats Fish Seafood Poultry Products Baked Goods Shallow Pans Ice Baths Rapid Chill Other (describe): FOOD PREPARATION 1. Please list categories of food prepared more than 12 hours in advance of service. Y 4 ?. Will disposable gloves and/or utensils and/or food grade paper be used to minimize handling of ready-to-eat foods? ��( No 3. Is there an established polity to exclude or restrict food workers who are sick or have infected cuts and lesions? (ID No Please describe procedure: szcK' iz - S- c-'e to �- te, -7o a^ e'A C1 vy"ck cwt Yt r.'SZ cc-tics- cSok�(a fid. -io l��l�.vi -ij dej?evtc< can -f Rett" SCVee:'_r 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: lq�p�y ly LkRo,Sec lnl "ek s0w'r +LeJ Cwt --Q�ou"O( 5arif_jr_+_sor► 0W_M,c�&� 'Z';'eAen't a{IoW'-c( _io c.,r �r�� pr I V'� +9 0 sc. 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 '71-_ r I)c t P61 e� -}- 1 S -4Cyr- a C��/ -EQ 2G��E. erot eIcC9`�er 4 Mr ao'y be.-e+e ~Eo C 611 -_- "0rC>0C hfy 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: 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 of food 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. I. Produce Preparation Procedures a. Will produce be washed or rinsed prior to use? Yes -,c No b. Is there an approved location used for washing or rinsing produce? Yes X No c. Will it be used for other operations? Yes X No 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: 5 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: s-eac 2. Seafood Preparation Procedures a. Will seafood be washed or rinsed prior to use? Yes x No b. Is there an approved location used for washing or rinsing seafood? Yes X No c. Will it be used for other operations? Yes X 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: 24Q c-►-a C l- n itiC�G< u!v4 (Df a u cLSCc�(� '1z'�Ski th ®car <>eac{'�oo� 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: �;`l �m� tOc iv1 Cc? iN1C�lt�. ,�{pwetl�rr, � i� x 1 0.d�IM-efn vk d� � l �/l�t��rccnCcl g'-CC�o' rrf S ct o��G�G.wIF l' C�c,�T�y nnS` ^vJG�Gt�C�J- -�' �C,St 3. Poultry Preparation Procedures a. Will poultry be washed or rinsed prior to use? No b. Is there an approved location used for washing or rinsing poultry? 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: all �4 v �`'-}— �S ���« �t..tL C�e�iJco► 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 -dayannd_ frequency of preparation for the poultry at this location: tx 4. Pork and/or Red Meat Preparation Procedures a. Will pork and red meats be washed or rinsed prior to use? No b. Is there an approved location used for washing or rinsing pork and red meats?� No c. Will it be used for other operations? No 6 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: C bye J s C• a+nC< 1A c ,�st S G c,-���t Ct a�✓.c� 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: ��Gse sCe C6 DESIGN INFORMATION I. DRY GOODS STORAGE 1. Is appropriate dry good storage space provided for based upon menu, meals and frequency of deliveries? es No Provide information on the frequency of deliveries and the expected gross volume that is to be delivered each time. t Cc1Y'c� 3 -E_',dol-s v�c e y J C-A, S-Aces II. WATER SUPPLY 1. Please check one: Is water supply a well (community)? Yes Irl Municipal?Q No If the Water supply is other than a Municipal supply, it will be required to be registered with Public Water Supplv. 2. If water supply is from a Community Water Supply system is it registered and approved as public water supply? C��Y i res No If yes, please attach copy of written approval and/or permit. 3. Is ice made on premises or purchased commercially? Yes ON Pleases eci �c�/�,-SA --pC�n ScJav►ySi CV 'ice Co. P fy 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? Cel No N/A 7 C,�C r- -k(�►e� Number Size Frequency of Pickup wa Contractor Service; Sorv,c-cs u(i C;t� 5. Will the dumpster be cleaned on site? Yes l�o 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. 6. Is the dumpster to be cleaned by an off site contracted cleaning service?Yes If yes, please provide name and address of the firm contracted for this service. Name: Mailing Address: City: State: Zip Code: Telephone: ��-�_- ; Fax: 7. Will trash containers be stored outside? Yes No If yes, please describe location: S. Type and location of waste cooking gr ase storage receptacle 9. Is there an area to store L:> 3cln%1Ck s-lor� a 0ltwxj '.r►) '�>ro,.lcdrd tc,, recycled containers? Yes Describe: 10. Location and size of grease trap ��O CAI100— .tc.s ADL' l^1�AC� '�H� s?}o.c C�C�dS 1 ctf:Mfr cam.t' !. l7c�a�'+(�aG� Vatk V V o-te cit 2�fPrY 3 If f10 n �1: X. SEWAGE DISPOSAL I. Is building connected to a municipal sewer? � No 2. If no, is private disposal system approved (septic system)? Yes No fending If yes, please attach a copy of the written approval and/or permit. •. ;etit:�i.•�.--ii+:ifV:li.:e if:T w=......:: ..;W,.,. ..:iW it it•:. w .. .. pie r.v sc... •,. ... ,.. . .- . .. .r .n n < >i... 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) or espc`�i'sz e Representative(s) Date: \V(a 6 1�- 8