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HomeMy WebLinkAboutEHPR-08-2022-42078.TIF ENVIRONMENTAL HEALTH Catawba County Government Center 25 Government Drive ' P.O. Box 389 I Newton, NC 28658 C a t a w b a county Phone: (828) 465-8270 I Fax: (828) 465-8276 public health •,urc rw:rn nnn f:�!ua: EtiF,:li.:lf!. Cale wbcCw.ai yNC.go'J 6,14Pt -DS-)D ) 4,)D Food Establishment Plan Review Application for Ownership Chancre (Note:If the establishment has been closed for more than one year, then applicant must fill out short form instead of this form) Name of Existing Establishment: _ t "(Al 1 4 (.501 -0 6 Li.z( Name of New Establishment: 1T4 . TA: 'il. 6.01e 44&-/,2 Establishment's Address: /"7 7(, c A City: /-HCICC/(4 State: /LAC, ZIP: ,,?hi ,C,?, Phone: W2,9 - 3c 4- 5:1`l( fax: _ New Owner's Name: (6 p.a�. 7"re� l' Sfh�v/,,e , (Auto G1,C. R iirC DIVE D A U G 2 5 2022 Please Enclose the Following Documents • Proposed menu items (including seasonal variations in the menu). Environmental Health • 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. .olli's of Operation Number of Seats: Gal Sun ,I`' /4(t Maximum Number of Staff per Shift: 6 Mon `( /-IlL Facility Total Square Feet: IiP/1C.X Tue 1�� Wed 7 I-4/t- Projected Start Date: 8/61) Thu `/i (it , Fri :›"1' /4/1 Projected Number of Meals to be Served (Approximate number): Sat i fL Breakfast 7.S lunch 7 i Dinner /S6) Type of Service (Check all that apply) [ Sit Down Meals ! ) Push Cart Take Out ❑ Limited food Service ❑ Caterer L Single Service Utensil Only ❑ Mobile Food Unit [-_J Multi-Use Utensil Service Only " Other Vier u/ 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. Existing Finish Schedule Floor,wall and ceiling finishes(vinyl tile,aco stic tile,vinyl baseboards, FRP, etc.) Area Floor Base Walls Ceiling Kitchen 41' Bar L— ri Food Storage �� ��� 4-r Dry Storage T Lt. :Tit-6Restrooms �' f2,— Garbage & Can Wash Areas 7 f,__ -ria, , I _Al- Wait Station Areas Other T-i LL 4 1 Other 1/46 /Itp �� 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.) [] Yes hC No Thick meats,whole poultry(whole roasts,pork, chicken, meat loaf,etc.) Yes No Hot processed foods(soups, stews,chowders,casseroles) Yes No Bakery goods(pies,custards,creams) Other: Supplies & Storage Food Supplies Are all food supplies from inspected and approved sources? , Yes No Cold Storage Are adequate and approved freezer and refrigeration available to store frozen foods at 00 F and below, and refrigerated foods at 450 F (700C)and below? k' Yes No Provide the method used to calculate cold storage requirements: F4 't "i-t11 c A. .5rT-ZIn/&,449J Space dedicated to walk-in cold storage: 6( ft2 Space dedicated to reach-in cold storage: `i'C) ft2 Will raw meats,poultry and seafood be stored in the same refrigerators or freezers with cooked/ready-to-eat foods? Yes X No If yes, how will cross-contamination be prevented? 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 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 Water less than 700 F(210 C) Cooked Frozen(indicate wt.lbs.) Microwave Other(describe): (- it���c f tfi- //-" A4.tat-4 fKl1 l&.'4-/4 ,< -C cc Kt% 0.1/0-j' Cooking Process 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°F115 sec) Pork 155° F (15 sec) Other PHF 14 F (15 sec) Eggs 145°F (15 sec) * reheating PHF 165°F (15 sec) 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. PLt A 4 CAS i L/ 11-6)(_,At/, CI,I4S%i i( ) f16•1 1- 0...9l t& &,-' Ct1 iC/J CL •zii/ Cold Holding How will cold PHF (potentially hazardous food) be maintained at 450 F (70 C)or below during holding for service? Indicate type and number of cold holding units. S acJof-( ",(AAA 4-- 67- ui¢ /'�,� t(t./`�"1-K�✓ .(3 1 OTC,.,i �IJ Cooling Please indicate by checking the appropriate box how PHF(potentially hazardous food)will be cooled to 450 F(70 C)within 6 hours (1350 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 _ I Rapid Chill Other (describe): CA!.."--4( Food Preparation Please list categories of food prepared more than 12 hours in advance of service. ,//4 Will disposable gloves and/or utensils and/or food grade paper be used to minimize handling of ready-to-eat foods?X Yes A No Is there an established polity to exclude or restrict food workers who are sick or have infected cuts and lesions? Yes ❑ No Please describe procedure: 5 el 4-r'.(C +.E.D G c ccI r t4 f ; O,i% /cry 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: ,4-rri44-ik4- 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? AJ/4 Indicate any specialized process that will take place: ri Curing n Acidification(sushi, etc.) n Smoking n Reduced Oxygen Packaging (e.g.vacuum packaging, sous vide,cook-chill, etc.) Explain checked processes: f 4 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. Produce Preparation Procedures Will produce be washed or rinsed prior to use? Yes I I No Is there an approved location used for washing or rinsing produce? XI Yes ; ! No Will it be used for other operations? [ 1 Yes 54No 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: f W9 /Pill/4, - /,�.,;4c.(, f4 /-fcV,cl S./1 f.1 /IUD Li S aJC, , L[/7u&J •/_‘,ir T I Z✓� /�/Tfil [I 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: Seafood Preparation Procedures 7/1 Will seafood be washed or rinsed prior to use? I 1 Yes i I No Is there an approved location used for washing or rinsing seafood? I 1 Yes I_ I No Will it be used for other operations? I I Yes I j 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: s cc/ t cc`/-/! ,y(ete ZZ.-r 771 ritY 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: Poultry Preparation Procedures Will poultry be washed or rinsed prior to use?Will ❑No Is there an approved location used for washing or rinsing poultry? l _] Yes L.1No Will it be used for other operations? O Yes r INo 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: ()rt/Ls'i U$/ / iiiici44 ' frfus-r- is fr(4/l,,.r 7 /'<r r, -Z44 774-4.✓ 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: N/4 Pork and/or Red Meat Preparation Procedures Will pork and red meats be washed or rinsed prior to use? ikif,, Li Yes ❑No Is there an approved location used for washing or rinsing pork and red meats? ❑ Yes ❑No 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: 0/A.4 U�� CC— CC-t)/( / j 4Cj4 G.2ue_ Design Information Dry Goods Storage 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. Water Supply Water supply: Li Well (community) %Municipal If the water supply is other than a Municipal supply, it will be required to be registered with Public Water Supply. If water supply is from a Community Water Supply system is it registered and approved as public water supply? xi Yes ❑No Yes If yes, please attach copy of written approval and/or permit. Ice: Made on premises ❑Purchased commercially If made on premises, then specification for the ice machine will need to be provided. C J/..L/Z,! '7z ,Q/LI ci 7- Describe provision for ice scoop storage: T,✓ 1-h ca -f cY- /44 Garbage and Recyclables Will a dumpster be used? Yes ❑No Number of Dumpsters: Sire: Pickup Frequency: Will the dumpster be cleaned on site? Li Yes krilo 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. Is the dumpster to be cleaned by an off site contracted cleaning service? [i Yes ®"No If yes, please provide name and address of the firm contracted for this service. Name: Mailing Address: City: State: Zip Code: Telephone: Fax: Will trash containers be stored outside? 'Yes [J No If yes, please describe location: f!✓2/ 4,1-ic to$1- Recycling Type of waste cooking grease storage receptacle: Location of waste cooking grease storage receptacle: S7U <.,h 4 14 Is there on area to store recycled containers? ❑ Yes ® No Size of grease trap: Ake C_V:Liu'J CAM cIVY Location of grease trap: -JLY,S i, <1... 1JZJ G/1<vt1 2 ,/ LJ/t Sewage Disposal Is building connected to a municipal sewer? M Yes ❑ No If no, is private disposal system approved (septic system)? ❑Yes ❑ No El Pending If yes, please attach a copy of the written approval and/or permit. I hereby certify that the above information is correct, and I fully understand that any deviation from the above without p ' r approval from this Health Regulatory Office may nullify this approval. Signature: Date: q,) V,/2- Owner or Responsible Representative . JackIn The-Box;tore Cookiing.Equipment - • -_ Suppl1r_ - • • _Model Number' car • • _ .._ _ --. •_ .. . ^fig 072T IBX • .__ .; Kitchen Fryer _ . - Fryrmaster HDI50G Kitchen Sink 3 Compartment - Qualsery •BK832006 Kitchen Protein Holding Unit. • Prince Cate DHB BK3C • -Kitchen .Ki chen High Speed Toaster ;Antunes VCT2000CS Kitchen • Coffee.Machine(can be used for Tea) •Bunn ITCB: - /gohen. _ Reach In Refrigerator TRUE „T 23,'T49,T72 IG Under Counter Freezer - Silver King _ SKUCF-7FBK Kitchen Under Counter Refrigerator 'Silver King. bMdtfple; Kitchen,multiple' Under Counter Shelf Refrigerator •_ Silver King SKSR' Kitchen Stand Up Refrigerator&Freezer . . TRUE Multiple Kitchen,-multiple Welkin Cooler - Kolpak._.. •Kitthen Walkin.Freezer - ' Kolpak ° •Kitchen Ice Bin(560 Ibs) • Manitowoc_ C730S Kitchen. ice;Machine Manitowoc 1B0824YC • ,'Kitchen- Microwave Amana HDCI8SD Kitchen Shake Machine _ - ' Sanisery ''601 _ - Kitchen BEVERAGES OLD-FASHIONED THICK SHAKES •rarer.- -•QI COOKIE REGI $3.39 LI $3.89 E00d 050d :. .5 ••CHOCOLATE -VANILLA REGI $3.39 I Ll $3.89 li •STRAWBERRY 7801620R60d TDORE0R090d PREMIUM ROAST COFFEE ICED `— t:i ••ORIGINAL REGI $2.49 I L 1 $3.19 I ice4 EL g/,tt _ •MOCHA HOT REGL $1.69 e L $2.19 J ad ad FRESH BREWED ICED TEA S77t1t •UNSWEETENED Si $1.79 'µI $1.99 ,LI $2.19 - � 1Ot Od _ 10(aOi4— tOr30Od __ FOUNTAIN DRINKS Sul 260 al Sal 280d nod 25O01 Od nod 160d Sal 260d 270d 40d Habra 390al Sul 420d 410d 370d Od +ad 250d Sul 390d 410d 1EOd Liit S20o1 Sul S50d SSOat 490d Od 56001 300d Sul '590d S50d 260d it $1.79 IMI $1.99 IL( $2.19 i_ BBOOTTLED [ $1.79-j MAIID !I 2.29 MILK r $2.29 I WATER ORANGE'ma- ttO4"`— BREAKFAST SERVED ALL DAY UPGRADE YOUR COMBO or• Aar*MAW wow jams to:L.110w^ ill . 21SUPREMECROISSANT imbo. $5.39 Sandwich. $3.59 .. COMMwr/o laro.ncN • "ae 650•71001-::450d 22 GRANDE BURR TOSAUSAGE 44 COMIC, Combo: $5 69 Burrito: $3.89 d rhoul . 23 MEATRR IOVERSltO_ - BU • p h.,,,T°e..., #111.1 . Combo: $5.69 Burrito: $3.89 910-IBOa174.4 • 24 SAUSAGE,EGG& CHEESE BISCUIT ��,„ • Ctiallel" °',AINOwKN Combo: $4.29 Sandwich: $2.49 `**PI' swp 7l08d0d sxcii a../614&1044 a1Ci `".* ., . 25 SPICY CHICKEN BISCUIT Combo: $5.69 Sandwich: $3.89 C04410 S11/9MKM Eye •i 75348041 55001 26 LOADED BREAKFAST 10,0voCO0 Combo: $5.69 Sandwich: $3.99 1111, vIDllcwa Mal 27 EXTREMESAUSAGE• `°"'° °" " Combo: $5.39 Sandwich: $3.59 28 ULTIMATE BREAKFAST COr.O SaNDWKH 1 Combo: $5.59 Sandwich: $3.79 • �' 29 IED SOURDOUGH SWISS co .O SNKIM,CM .i Combo: $5.69 Sandwich: $3.99 Aimilo mryz ,4 seat; 3O JUMBO PUTTER cores n.nn •i Combo: $5.59 Platter: $3.79 BIM T46.s»�I s4o:r . °!_ 6 4 COM.O SWDWiCPt BREAXJACK*FAST •I �^ ,,M, -- Du! ISa:4 Combo: $3.59 Sandwich: $1.79 fw T p v• o x nn ' D3. 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'`' aEouua r$1.19 , e,;` 340a1 ��"�" C CATAWBA COUNTY �� 100A SOUTHWEST BLVD ,� NEWTON,NORTH CAROLINA 28658 RECEIPT U :y y PHONE:828.465.8399 �► Thursday,August 25,2022 j 8 4 2 sM www.catawbacountync.gov PAYOR: Cedar Tree Restaurant Group LLC Cedar Tree Restaurant Group LLC(Yablun,Jeff) PAYMENTS TRANSACTION NUMBER: TRC-45990777-25-08-2022 PAYMENT DATE: 08/25/2022 PAYMENT TYPE: Credit Card 294263312 INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT 08-22-411108 110-580200-663000 Food and Lodging Review Fee $75.00 TOTAL PAYMENTS: $75.00 EHPR-08-2022-42078 CASE TYPE: Environmental Health Plan Review WORK CLASS: Other FLI SITE ADDRESS: 1776 CATAWBA VALLEY BLVD SE,HICKORY NC 28602 Establishment JACK IN THE BOX 6823, 1776 CATAWBA VALLEY BLVD,HICKORY NC 28601 Paid By CEDAR TREE RESTAURANT GROUP LLC,, B:8133341830 JEFYABLUN@CEDARTREERG.COM **NO PEOPLESOFT ACCOUNT ASSIGNED** receipt 08/25/2022 16:47 Page 1 of 1