HomeMy WebLinkAboutEHPR-2-10-4013.TIF
Catawba County Public Health Department
Division of Environmental Health
a
FOOD ESTABLISHMENT PLAN REVIEW APPLICATION
For submission with full set of signed and sealed plans produced by an architect or engineer.
Type of Construction: NEW REMODEL CONVERSION
County in which Located: C 61
Name of Establishment: -1~0-r/9 L (~o r~vev, I e pica. May- el--
Establishment's Address: ~ 7 U S 14 ul u -7 0 S (A)
City: N i C k o ►"y Zip Code: 2.9 G 0 2
Owner's Current Physical MQ I y-6 ,4Ue- 0o,4v-4- S'IJ
Mailing Address: City: 0. c ko V- Zip Code: 2 ~f'w Z
24 I
Phone if available:
) - ( 320 - 5M Fax: 30B
)
I have submitted plans/application to the following:
(Please note date phone number and contact person on application line)
Plumbing ~n e a fl,"' o, C -
Contact Person "It o,naQ,t~ S VA e
Phone Number 04 - 3( qsl
Electrical ro u e.. ~I P C 4K z'C-
Contact Person b e O-A S{v-tL 'j2 e,
Phone Number 10 - (3q3__ - X13-7
Building 1- R o -Z P- I e,.(4 T✓tC -
Contact Person ✓
Phone Number 0"133
)
Hours 7Mon eration
Sun Tue ✓ Wed Thu Fri Sat
Number of Seats 10
Number of Staff 3 (Maximum per shift) S~ n
Facility Total Sq. Ft. P oo
Projected Number of Meals to be Served: (Approximate number)
Breakfast j 0 Lunch 6 0 Dinner '30
Projected Start Date of Construction 1" 0 V- 0&r S-/ 2.01 O
Projected Completion Date of Project J u' 14 155 2-0
I O
l
Type of Service (Check all that apply)
Sit Down Meals
Take Out
Caterer
Mobile Food Unit
Push Cart _
Limited Food Service
Temporary Food Stand
Single Service Utensil Only
Multi-Use Utensil Service Only
Both Multi-Use and Single Service Utensils
Other
Please Enclose the Following Documents
® Proposed menu items (including seasonal variations in the menu).
® Manufacturer specification sheets for each piece of equipment shown on plans.
® Site plan showing location of business in building, location of building on site including alleys,
streets and location of any outside facility (dumpster, walk-ins, etc.).
Plan of facility drawn to scale showing location of equipment, plumbing, electrical service and
mechanical ventilation, including location of all electrical panels.
2
ITEMS TO DE 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 the 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 standards as specified according to 15A NCAC 18A
.2600, Rule .2617 paragraph (d).
6. As specified according to 15A NCAC 18A .2600, Rule .2632 "Storage Spaces". All items stored
in rooms where food or single-service items are stored shall be at least 12 in. (30.48 cm.) above
the floor when placed on stationary storage units or 6 in. (15.24 cm.) above the floor when
placed on portable storage units or otherwise arranged so as to permit thorough cleaning.
7. Acceptable materials for walls, ceilings and coved juncture bases in food preparation, handling
and storage areas include quarry tile, ceramic tile, sealed concrete, commercial linoleum,
fiberglass reinforced panels, stainless steel, wall board painted with washable, nonabsorbent
paint, vinyl coated ceiling tiles: brick, cinder blocks, slag blocks, or concrete blocks, if used,
must be glazed, tiled, plastered or filled so as to provide a smooth surface. If plans specify the
use of a material not on this list, include a sample of the material for evaluation.
3
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.) V'
Thick meats, whole poultry (whole roasts, pork, chicken, meat loaf, etc.)
Hot processed foods (soups, stews, chowders, casseroles)
Bakery goods (pies, custards, creams)
Other:
PLEASE CHECK BOX FOR THE FOLLOWING QUESTIONS
FOOD SUPPLIES /
I. Are all food supplies from inspected and approved sources? Yes i/ 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 45° F (7° C) and below? Yes ✓ No
Pro ;N((0'W de the method used to calculate cold storage requirements:al-e-
V 61t-h r ;rt c 0 VIAM PE-h a v-~ G it re c~ s
Provide total footage of space dedicated to walk-in cold storage S T-
Provide total footage of space dedicated to reach-in cold storage 1 17 CA4
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-cont inatio be prevented? r'i vt God as
Z ct10 o JL C 0ds ro'j _A" 4s 0" 65~kP i )
4. Does each refrigerator/freezer have a thermometer? Yes No
Number of refrigeration units: Number of freezer units: 2-
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 Process Thick Meats Thin Meats Fish Seafood Poultry Products Baked Goods
Refrigeration
-Running Waterless than 70° F (210C)
Cooked Frozen (indicate wt. lbs.)
Microwave
Other (describe): _
4
COOKING PROCESS
Item #1 - Will food product thermometers (0° - 212° F) be used to measure final coo ing/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 1309F (121 min) Comminuted meats 155° F (15 sec
Seafood 145 F 15 sec Poultry 165 F 15 sec
Port 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 140° F (60° C) or above during holding
for service? Indicate type and number of hot holding units.
s e e a 4-+,-a C~ 4 z (v + 3 fi
Item #3 - Cold Holding
How will cold PHI` (potentially hazardous food) be maintained at 45° F (7° C) or above during holding
for service? Indicate type and number of hot holding units.
s e e 6 C tl e4( i2ta-15 ^ e Z ~f
Item 44 - Cooling
Please indicate by checking the appropriate box how PHF (potentially hazardous food) will be cooled to
45° F (7° C) within 6 hours (140° 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
Ice Baths
.Rapid Chill
Other (describe):
5
FOOD PREPARATION
I . Please list categories of foo prepared more than 12 hours in advance of service.
i C ,Aa S "k ( k
2. Will disposable gloves and/or utensils and/or food grade paper be used to minimize handling of
ready-to-eat foods? Yes ✓ No
3. Is there an established policy to exclude or restrict food workers who are sick or have infected
cuts and lesions? Yes e/ No
Please describe procedure: J 4AJ ev'Ao/ l Uy-ec A ooh e- -mo o dA•,
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: Vv~ I C V-n c Ua S a n f' L/ tev-
5. How will ingredients for cold ready-to-eat foods such as tuna, mayonnaise a eggs for salads r
Ic~✓
and sandwiches be pre-chilled before mixed and/or assembled? u g y ui a ~k4yl C.0 0
6
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.
1. Produce Preparation Procedures
a. Will produce be washed or rinsed prior to use? Yes ✓ No
b. Is there an approved location used for washing or rinsing produce? Yes L/ No
c. Will it be used for other operations? Yes No
Please indicate location of produce washing equipment and describe the procedures. Include time of day
and freq=for washing or rinsing the produ eat this location:
(.c) - see a ~fo c~ 3 O
ova
, ,r
CPlease 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:
~ ~ a ~J C y~ ~~o wt ✓►1 ~n~s
rvxU, t' LA o J!?=4d0&((5 -d 0V-b0 (A e e 4"t
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:
- -
4-r) od
7
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
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 f/ 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 w shing or rin$in the seafood at this location:
e Q C~t (e
an
- -_Y►~~~41 I ✓l G1 " ~ ~ S Gl i rt 6 -1r f I S i ~n G -
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 t this location:
4. Pork and/or Red Meat Preparation Procedures
a. Will pork and red meats be washed or rinsed prior to use? Yes t~ 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 washin or rinsing the seafood at this location:
!3e-e G cA, a 0lah.s x. 30 le
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: ,
S' e a,,~GIiLd y ~6r y7 S t 3 O of l le ~
SQL, ff c oNr`l f{ t sa r~,' j 1. ,~r7 `r7r- o Ut S c=
8
DESIGN INFORMATION
1. DRY GOODS STORAGE
1. Is appropriate dry good storage space provided for based upon menu, meals and frequency
of deliveries? Yes No
Provide information on the frequency of deliveries and the expected gross volume that is to be
delivered each time. 1
vPir'►~S - ~ l.p C~ L~
II. WATER SUPPLY /
I. Please check one: Is water supply Community? Yes NoMunicipal? 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 t Z No
If yes, please attach copy of written approval and/or permit. /
3. Is ice made on premises or purchased commercially? Yes Z No
Please specify: 1 e ✓ \ a~4'~A 4 eg,Uir►ti, J vA -44a G~6J n fa~,S
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 No N/A_
Number _ Size Frequency of Pickup
Contractor Service: if,,, j ; c ,(Or-14
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. /
6. Is the dumpster to be cleaned by an off site contracted cleaning service? Yes V No
9
If yes, please provide name and ddress oft e firm contracted for this service.
Name: ) 0 ~j 2 P~~,► ►v~i'+1
Mailing Address:
City: State: Zip Code:
Telephone: Fax:
7. W ill a compactor be used? Yes No ✓ N/A
Number Size Frequency of Pickup
Contractor Service:
8. Will the compactor be cleaned on site? Yes No N/A
If the compactor is to be cleaned on site, then the waste water from the cleaning operation
will be required to be discharged to the sanitary sewer system. /
9. Is the compactor to be cleaned by an off site contracted cleaning service? Yes ✓ No
If yes, please provide name and address of the firm contracted for this service.
Name: ~J P~~ ~e ~~rr►ti►`n P.G~
Mailing Address:
City: State: Zip Code:
Telephone: Fax:
10. Describe surface and location where dumpster/compactor/cans are to be stored:
fez a'4*ach iati,S
11. Will trash containers be stored outside? /Yes/ No
If yes, please describe location: S~ ' ~4 Cat
12. Type and location of waste cooking grease storage receptacle: 5e L cz ~4Adl cl n 6*1.9
13. Is there an area to store recycled containers? Yes No
Describe:
14. Location and size of grease trap: $e Gt - ~;1~ ytr
10
X. SEWAGE DISPOSAL /
1. Is building connected to a municipal sewer? Yes No
2. If no, is private disposal system approved? Yes No Pending
If yes, please attach a copy of the written approval and/or permit.
XI. GENERAL.
I. Are insecticides/rodenticides if used stored separately from cleaning and sanitizing agents?
Indicate location: bo dx- o0.n1 1i'k, v-00 Yes ✓ No
2. Are all cleaning materials and toxicants stored away from food preparation/storage areas? This
includes items used on premises, retail sales and ersonal edications. Yes ✓ No
Please Describe Location: Q ~ ,~-i < < V'V 0
3. Are all containers of toxic/cleaning material including sanitizing spray bottles clearly labeled?
Yes ✓ No
4. Are laundry facilities located on premises? Yes No_Le~
If yes, what will be laundered?
5. Is a laundry dryer available? Yes_ No
If yes, please describe location:
6. Location of clean linen storage: 'i ZA
7. Location of dirty linen storage: ZA-
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)
~ e- o l Or► /a
Own r(s) or Responsible Representative(s)
Date: 2 / d
11
FOOD PREPARATION®RKSIIEE SUPPLEMENT
Food Item:
Will the food item be washed or rinsed prior to use? If yes please indicate location of equipment and
describe the washing procedures. Include time of day and frequency for washing or rinsing the product
at this location:
Location of equipment:
Time of day and frequency:
Procedure used to wash or rinse food item:
Please describe the preparation procedures for the food items described above and indicate location of
equipment to support this operation. The preparation procedure should include dishes in which the
product will be used, and should include time of day and frequency of preparation for the food item at
this location:
Location and type of equipment of equipment:
Time of day and frequency:
Food item preparation procedures:
12
TOTAL, Convenience Market
MENU
Primary Food Items
Fried Chicken
Trot Dogs
Pizza
Assorted Fresh Sandwiches : Turkey, Roast Beef, Ham, Salami, Bologna
Sandwich 'T'oppings : American, Swiss, Cheddar, Provolone Cheese and Lettuce,
Tomato, Onion, Green Peppers, Jalapeno Peppers, Banana Peppers, Olives
Side Items
French Fries
Onion Rings
Fried Zucchini
Fried Mushrooms
Green Beans
Broccoli & Carrots
Pinto Beans
Blackeyed Peas
Mashed Potatoes
Macaroni & Cheese
Biscuits
A C~ CATAWBA COUNTY, NC.
100-A South West Blvd PLAN RECEIPT
Q+ a Newton, NC 28658-
(828)465-8399 Wednesday, February 24, 2010
r ~
j84'Z sM www.catawbacountync.gov
Plan Case: EHPR-2-10-4013 Invoice Number: INV-2-10-259826
Environmental Health Plan Review Invoice Date: 02/24/2010
Site Address: 327 SW HWY 70, Hickory, NC
APPLICANT OWNER
F.A. FOODMART CONVENIENCE STORE FRANCESCO APOLLONIO
1340 SW 14TH AVE CT
HICKORY NC 28602
Fee Name Fee Amount
Food and Lodging Review Fee Fixed $200.00
Total Fees Due: $200.00
PAYMENTS
Date Pay Type Check Number Amount Paid Change
02/24/2010 Check 101 $200.00 $0.00
Total Paid: $200.00
Payer: FRANCESCO APOLLONIO
Total Due: $0.00
i.
~lanreceipt;~iuacl=10~-'_903--tc(.~c-S1?7 it~1?St~bS'.d>';.rpt 02/24/2010 14:05