HomeMy WebLinkAboutEHPR-09-2022-42393.TIF (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 Q.-`,,L S ` V l EY-+ cClA+e-• . ,
Nome of New Establishment c' r"'--+Y`^b S c.ck.n Ci..ak S�ram•
Establishment's Address: 02 L AS
City: t�k.cs'r State: f`K ZIP: 266,c)
Phone: F 2 8 — 5c.42l - k4 Sd(4 Fax: NlA
New Owner's Name: '4Q1 r1;o Ate,
• 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 34"m 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.
Number of Seats: 44' -
Sun 11461 - `f rill Maximum Number of Staff per Shift C'
Mon G to Se-d Facility Total Square Feet 2 l Go
Tue ( 4o 5 e d
-k.
Wed 11 Avv‘ - q-r M Projected Start Date: ' ( Z02Z
Thu 11 A-vsN - -4-10nn
Fri I I taw\ 8 P""' Projected Number of Meals to be Served(Approximate number):
Sat 11 Aft‘- sew% Breakfast Lunch 5 0 Dinner Sd
Will poultry be washed or rinsed prior to use? L��/Tes ❑No
Is there an approved Iocotioe used for washing or rinsing poultry? �✓f sus ❑N°
Will it be used for other operations? ❑ Yes g.."
Please indicate location of poultry washing equipment and describe the procedures. ladede time of day and frequency for washing or
rinsing the seafood at this location:
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Please desaibe tie poultry preparutios procedures and Whole locetien of equipment to support this operatics. The prspsrolios
procedure should Weds dishes(proposed men items)in which the poultry will be used,and should indede time of day and
fr
equency
of preparatiau for the poultry att.thiss location: \ r�I
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Will pork and red meats be washed or rinsed prier to use? ❑ Yes 214
Is there cm approved location used for washing or rinsing pork and red meats? [J Yes 2fetlo
Will it be used for other operations? Yes L‘
Please indicate location of seafood washing equipment and describe the procedures. laded.time of day aid frequency for washing or
rinsing the seafood at this localise:
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Please describe the pork and red meats preparation procedures aid indicate location of equipment to support this operation. The
preparation procedure*add Weds dishes(proposed memo items)in which the pork aid red meats will be used,aid shoeW laded.
time of day and frequency of preparatioi for the pork aid red meats at this location:
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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.
Will produce be washed or rased prior to use? [Ies ❑ No
Is there on approved locatboa used for woshiug or rinsing produce? g'fes ❑ No
Will it be used for other operations? [ Yes ❑ No
Please indicate bcatior of produce washing egoipneut and describe the procedures. lndude time of day and frequency for washing or
rinsing the produce at this locatia:
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Phase describe the produce prepucotiee procedures and indicate Iocatior of equipment to support this operation. The preparatioe
procedure should iodide dishes(proposed meus items)in which the produce will be used,cad should Wade time of dap and beggary
of preparation for the produce at this localism
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Will seafood be washed or timed prior to use? ❑Yes (7fNe
Is there on approved lentil's used for washing or dnsing seafood? ❑Yes LEilo
Will it be used for other operations? ❑Yes I4 o
Please indicate fondles of seafood washing equipment and describe the procedures. Iwcbde time of day aid fregiary for washing or
rinsing the seafood at this locaiiom:
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Please describe the seafood preparation procedures and indicate location of equipment to support this operation. The preparation
procedure should boded'dishes(proposed maw items)fa which the seafood will be used,and should ladede time of day and frequency
of preparation for the seafood at this location:
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Will food product thermometers(0'— 2121)be used to measure final cookiaareheating temperatures of PHF(potentially hazardous food)?
Yes ❑ Ho
Minimum cooking time and temperature of product utilizing convection and conduction heating
equipment:
Product Time&Temperature Product Time&Temperature
Beef roast 130e F(121 min) Comminuted meats 155°F(15 sec)
Seafood 145e F(1S 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)
How will hot PHF(potentially hazardous food)be maintained at 135°F(S70 C)or above dories holding for service? hdicste type and
umber of trot holdinsg[writs.
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How will cold PHF(potentially hazardous food)be maintained at 450 F(70 C)or below during holding for service? ladkate type sod
number of cold holding nits.
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Please indicate by eheddag the appropriate box how PHF(potentially hazardous food)will be cooled to 450 F(70 C)within 6 boon(1350 F
to 700 F in 2 boors and 70°F to 45°F in 4 boon).
Cooling Process Thick Meats Thin Meats Piah Seafood Poultry Products Baked Goods
Shallow Pass Et R F - l l
Ice Baths
Rapid Chill _�- Cc/' l✓
Other(describe): ^�1
Please list categories of food prepared more than 12 hours in advance of service.
Will disposable gloves and/or steusils and/or food grade paper be used to minimize lamdUug of ready-to-oat foods?lJ Yes ❑ No
Is there an established polity to exclude or restrict food workers who are sick or bow Wetted cuts aid lesion?{ I1es ❑ Ne
Please descrthe procedure:
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How will cooking equipment,cutting boards,cornier tops and other food contact'effaces which carrot be submerged is sinks or put
through a dishwasher be clamed and sanitized?Please describe procedure:
Hew will ingredients for cold ready-to-eat foods such as tuna,mayoiialse aid eggs for salads aid sandwiches be pro-chilled before mixed
asd/or assembled?
Indicate any specialized process that will take place:
Curb% ❑Addiflcatiei(sushi,etc.) ❑ Smahisg
❑Reduced Oxygen Packaging(e.g.vacuum packaging,sous vide,cook-chill,etc.)
Explain checked processes:
(Check all that apply)
it Down Meals El Push Cart
LAY Take Out ❑Limited Food Service
El/Caterer ❑Single Service Utensil Only
LI/Mobile Food Unit ❑Multi-Use Utensil Service Only
❑ Other
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 fadiities for potentially hexardoes food
(PNF)should be dearly designated on the plan.
3. When mesa 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 1SA 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.
Floor,wall and ceiling finishes(vinyl tile,acoustic tile,vinyl baseboards,PRP,etc.)
Area Floor Base Walls Ceiling
Kitchen
Bar f N� )14 q1
Food Storage +-t�� v` t �� P „, G
Dry Storageeisvl Gf1G412,
Restrooms r� Vi r►�l F
Garbage 8 Can Wash Areas _C ,cr rOn c
,�9 G
Wait Station Areas CTCl%tr— F P
Other 14‘.-ett.t544-4.
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Other �I ���-
Check categories of Potentially Hazardous Food(PHF)to be handled prepared and served.
Ries ❑No This meats,poultry,fish,eggs(hamburgers,chicken breast,fish filet,etc.)
[g'Yes ❑ No Thidc meats,whole poultry(whole roasts,pork,thicken, meat loaf,etc.)
[Rios ❑No Hot processed foods(soups,stews,chowders,casseroles)
2n to.
Bakery goods(pies,custards,creams)
Other.
Are all food supplies from inspected aid approved sources? ✓ces No
Are adequate and approved freezer aid refrigeratiou available to store frozen foods at 00 F aid below,and refrigerated foods at ISO F
(70OC)aid below?Oes No
Provide the method used to calculate cold storage regeiremeits:
Space dedicated to walk-in cold storage: ft2 Space dedicated to reach-in cold storage: ft2
Will raw meats,poultry and seafood be stored is the same refrigerators or freezers with caked/ready-to-eat feeds? Eves No
If yes,how will cress-coatomiaatiom be prevented? w twe-“As. QYs. •,c a- rvN•e-4 f°""
144
Does each refrigerator/freezer have a thermometer? Rites No
Number of refrigeration wits: 3 Number of freezer units: - -
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
Ruuiag Waterless than 700 F(210 C)
Cooked Frozen(-Indicate wt.lbs.) 1 1 I I
Microwave l__.l _ U ❑
Other(desalt):
Is appropriate dry good storage space provided for based span moue,meals and frequency of deliveries? �{es ❑ No
Provide information or the heresy of deliveries and the expected gross volume that is to be delivered each time.
Water supply: ❑ Well(community) Rienhipal
If the water supply is other than a Mrridpal supply,D will be required b be registered with Public Water Supply.
If water supply is from a Cammrrity Water Supply system is it registered and approved as public water supply? ❑Yes ❑No
Yes If yes,--, please attach copy of written approval and/or permit.
IV Ice: Mode on premises ❑Purchased commercially
If made oa premises,thee specificatioa for the ice machine will need to be provided.
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Describe provision for he scoop storage: `-
MI a dumpster be tried? [?i Yes ❑No
Number of Dumpsters: 2- She: �rc1S Pic*Frequency: L.Je ,kt
Will the drmpster be deemed an site? Yes ❑No
If the clunpsier is to be defined of site,them the waster water from the dealing operation will be required to be discharged to the
sanitary sewer system.
Is the derrpster to be deemed by an off site cockaded deeming service? ❑Yes ❑No
If yes,please provide name and address of the firm contracted for this service.
Name:
Nahum;Address:
City: State: Zip Code:
Teleph000: Fax:
Will trash containers be stored outside? dyes 0 No
If yes,please describe location:
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Type of waste cooking grease storage receptacle: `�`-"'44"``e ram' 1�4�`a�- Q .
Location of waste cooking grease storage receptacle: NeAC.4 -cc$L. tr►1'P`,.skrQii CrvAtta coo"c-)
Is there en area to store recycled containers? ❑Yes 216
Size of grease trap:
Location of grease trap:
Is bedding coeeected to a meeidpal sewer? E Yes ❑No
If ao,is private disposal system approved(septic system)? 0 Yes 0 No ❑ Pending
fF yes,please attack 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 prior approval from Health Regulatory Office may nullify this
approval. {
Signature: ! /t� r Date: / W e2DYy
i
Owner or Responsible Representative