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HomeMy WebLinkAboutEHPR-04-2023-43944.tif • (i) ENVIRONMENTAL HEALTH Catawba County Government(enter c a i a w b a county 25 Government Drive I P.Q. Box 389 1 Newton, NC 28658 public health Phone:{828)465.8270 f Fax:" (828) 465-8276 •.,.,,ui+�� arrr+�. Email:EfHAdmla@Catawi� o(auntytlC.gav Food Establishment Plan Review Application ���� C� ange (Note:If the establishment has been dosed for more than oneyear, K n applicant muswnership t out short form instead of this form) plett _use to .D CI'U I u e4 O Nome of Existing Establishment: C DOkS V Hie 6 rill f LLC Name of New Establishment: C DO(. S✓+'1 le Cj r'l i or va 1 e, ',Lc Establishment's Address: Le f Old .she(b`j 1'vac/ 1 1 F rj i!`^1t)ujd /r1A City: V D+ P. Stale: C ZIP: gf g Phone:4'1 V L-6 40440 Fax: NJA New Owner's Name: �G'tiCV i e God StirlfTi fr Dam r°roil Please Enclose the Following Documents • 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'"a 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 of Operation Number of Seats: 5 0 San C 1 0 S ed Maximum Number of Staff per Shift: 5 _ Mon C I o S ed Facility Total Square Feet: 11 I 00 St1: (oppr. .� Tue L 1 a rr1- CI p M. Wed A M - Ctdr% Projected Start Date: 14-U/- a a 3 Thu I I A✓Y1 g p1 Fri 1 1 at nA. Projected Number of Meals to be Served (Approximate number): Sat C j o S eU Breakfast n a lunch y 0 (D5- 70 Dinner • Food Preparation Review Check categories of Potentially Hazardous Food(PHF)to be handled prepared and served. Category [Yes Li Ha Thin meats,poultry,fish,eggs(hamburgers,chicken breast,fish filet,etc.) v"Yes 0 No Thick meets,whole pouhry(whole roasts,pork,chicken,meat loaf,etc.) ©Yes ❑No Not processed foods(soaps,stews,chowders,casseroles) [Yes ffNo Bakery goods(pies,custards,creams) Other: Supplies & Storage Food Supplies Are all food supplies from inspected and approved sources? I✓Yes No Cold Storage Are adequate and approved freezer and refrigeration available to stare frozen foods at 00 F and below,end refrigerated foods at 45°F (700C)and below?!T Yes No `` • Provide the method used to calculate cold storage requirements: m u 1-Y t p Li,r p os e C o(d S-4-o,r a se Spare dedicated to walk-in cold storage: N)A ft' Space dedicated to reach-in cold storage: 3a'3 l.P ft2 Will row meats,poultry cod seafood be stored in the same refrigerators or freezers with cooked/ready-to-eat foods? Yes PNo If yes,bow will cross-contamination be prevented? Does each refrigerator/freezer haver a a�thermometer? Id Yes Li Na 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 • •` --. i; , s t; •�rrzPn�77rP GS " ; zr , Wr 3r 00 r r� a Uir rsF 1' -Running Water less thus 70 F(21 {� * = ::; 1 Cooked Frozen(indicate wt.16s.?1 D l�)b � , V li.i r'Xr } ` + '�'.,N ,1 --- t, _'---. ; � of Fr'��rH g.'Ui. C Y+-^ "'�� �y Microwave ' ; t, '� x `: s+ c Other(describe): Food Preparation Please list categories of food prepared more than 12 hours in advance of service. assero(es7 MAC +-cAeCic, 7Por7aasfs/ tfEa IJ°afsrlipelley- ocs a4c/SfPcv gene. nr'y 4'h,ng 4► ft-i- s bP ctSSErnbi_e / and 1-i r bA4 ed �1 � ldSGtg iIy be mod", I�p,4i -t-s,e pain} a f bald;ng And ±k•er re-fr4se�a-{fd ( Cpvered ai,rTdpfed)/n a� v C� I -I- I a ht9c,crs ate( 2v�n --I-c,P nt r 7rq rn1).5-/ mea(S ( opr72 sf-s,Twl_t,i?vastse-Fe--) be+weep -1- 3 AaciSi4 re-Prisera-1-&21 ` O°(orCvlder. label Con4eA+5 ,ctflake— CooiL w;4- 3 c(a-CS. Will disposable gloves and/or utensils and/or food grade paper be used to minimize handling of ready-to-eat foods? Yes n No Is there an established polity to exclude or restrict food workers who are sick or hove infected cuts and lesions?L Yes Li No Please describe procedure: �e5 - F:Obd Repor-:i-i'ns ll recinen4', l rnp)ave hlea/101 cold Pe16c6 / }f 4j i en e. Form I- c4nrl. Joi 4- a"ci 1) Arc ken e.1 PAO-ip ?too. shared -Pae45 e�bo� � �u✓�d Iq- ,�,rY� Cele,soriCoronaviri-eJ - ,Lis- i# Gsimmun coodbpr,P -XIl(-Ness - Or emp,04.e es any rnanaaer. How will cooking equipment,cutting boards,counter tops and other food contact surfaces which cannot he submerged in sinks or put through a dishwasher be cleaned and sanitized?Please describe procedure: ). Scrape Or I,V:Pe 54..“--f ACC ee.leQn o-flanui clebrrs a- ►4pp1 -Food fir- e 012n- a.bYassive GJPara,r s��-- and walk 3. erase +hP Ss r-c4Ce y. Sc?_f); 2� -A-Ne Sur.cacr° Iblfar), if & r) S. sL4r-1-ace4o Atr- dr3- 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? ('oIr1 —COCA such A,s_ie- duce -1-oma.40e5 df'ced on'oasi 5)icecl ( eese. and mays are Kep+ a f LiD° r or Colder invele indi✓rduc,l pa (P`as-hc N%5) abore -!-he vp-c-c",5era,4-44 bt e of -11,e Sandwich t`�r p1 LE`1 e r;gerq.-1-or• -1-e-r a.re gPp4-Co✓ereed ldn-I-a r4)ac(j Or Se_rv"4e, WOr-t6;ne h 4-t baciL—up QroduC+S Qre in rP r, sere -l-ecl base_ labe.lfra t rya-+ed Ico✓e'ed6 Indicate any specialized process that will take place: U Curing Acidification (sushi, etc.) n Smoking l._.. Reduced Oxygen Packaging(e.g.vacuum packaging, sous vide, cook-chill,etc.) Explain checked processes: Nlo►vk 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 1 Product Time&Temperature Beef toast 130°F 121 min I Comminuted meats 1-5 F{i5 sec) Seafood 14 F115 sec) 1 _ _ Poultry __ 165e F415 sec _...___ Perk 155°F(15 se() T Other PHF _ i45°F(15 sec) - — Eggs 145°F(15 sec) *reheating PHF 1b5°Fj15 sec) Hot Holding Haw will hot PHI(potentially hazardous food)be maintained at 1350 F(570 C)or above during holding for service? Indicate type and number al hot holding units. I. .rr S-1•andjn9 3 -DraWer \AGy lk Iee-tr'c� o). (fC of S-FPam ``able — 4 SPc+lon w1 pan Capa.c -j+j Cold Holding How will cold PHF(potentially hazardous food)be maintained at 450 F(70 C)or below daring holding for service? Indicate type and number of cold holding units. Cooling Please indicate by checking the appropriate box bow PHF(potentially hazardous food)will be coaled to 450 I(70 C)within b hours(1350 f to 700 F in 2 hours and 700I to 450 F in 4 hours). Cooling Process Thick Meats Thin Meats Pis. Seafood Poultry Products Raked oods Shallow Pons / d Ice Baths _ } �e{ �5.kt Rapid Chill Other(describe): OLt - fish is Flash VrozertC &F)+hawed + n .ce, . rr,ed +0 oteler- S i -- 5 nCver pc 4 of our GoOliAs- Will trash containers be stored outside? ❑Yes [l7No If yes,please describe location: Recycling ( Type of waste cooking grease storage receptacle:�)Ue— Iil1_gQ I�-Y�,telsOrta5e, Disposal l7u,rcnp5-tfr location of waste cooking grease storage receptacle: Dk.(45 i de it e- --- o 0-ctib4Se -D,.tcrs+er Is there on area to store recycled containers? ❑Yes [Viso Size of grease trap: N111 Location of grease trap: In ic1 e Sep-41cTan --Pc.(m p d 4- t C e Q . f Sewage Disposal Is building connected to a municipal sewer? ❑Yes LIS no If no,is private disposal system approved (septic system)? [-ales ❑ No ❑ Pending If yes,please attach a copy of tke written approval and/oi permit. is Pump-ecl a year b "-" i ..its 5-ep-lCT4nlC Se ivcceS. I hereby certify that the above information is correct, and 1 fully understand that any deviation from the above without prior approval from this Health Regulatory Office may nullify this approval. (� 2 Signature: ii/i�]ylyI' /C�(� Date: I / j �+ J Owner or Responsible Representative CATAWBA COUNTY 100A SOUTHWEST BLVD NEWTON,NORTH CAROLINA 28658 RECEIPT -44 c.)71 O PHONE:828.465.8399 Tuesday,April 11, 2023 /8 4 2 sM www.catawbacountync.gov PAYOR: Dameron,Summer PAYMENTS TRANSACTION NUMBER: TRC-61623019-1I-04-2023 PAYMENT DATE: 04/11/2023 PAYMENT TYPE: Credit Card 303595826 --_- - ---_---_ INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT 04-23-421040 110-580200-663000 Food and Lodging Review Fee $75.00 TOTAL PAYMENTS: $75.00 EHPR-04-2023-43944 CASE TYPE: Environmental Health Plan Review WORK CLASS: Other FLI SITE ADDRESS: 6861 OLD SHELBY RD,VALE NC 28168 Owner JACKIE DAMERON RENTALS LLC,6861 OLD SHELBY RD,VALE NC 28168 B:704-462-4040 Paid By SUMMER DAMERON,206 WELLINGTON DR,LINCOLNTON NC 28092 SUMMERCURTIS87 tr GMAIL.COM **NO PEOPLESOFT ACCOUNT ASSIGNED** receipt 04/11/2023 09:58 Page 1 of 1 Case# FLI-04-2023-193088 j' CATAWBA COUNTY HEALTH DEPARTMENT 1 ® Environmental Health Section 18 42 5M 04/05/2023 WATER SAMPLE FIELD REPORT Cooksville Grill 6861 OLD SHELBY RD, VALE NC 28168 Site Address: 6861 OLD SHELBY RD,VALE NC 28168 Parcel Number: 266701299279 Sample Collected by: Date/Time Sampled: Sampling Point: Is well head accessible? Yes No Reason for inaccessibility Well New or Existing? New Existing Type of Well: Drilled Bored Hand Dug Punch Does well meet adequate construction standards from what can be observed: Yes No Items of non-compliance: Evidence of improper grouting or no grouting Well does not meet a required setback(comment) Improperly constructed sanitary well seal Well head not term at>= 12" above finished grade Well head missing vent Well head does not have a threadless tap Well missing identification plate or pump tag Wire conduit opening not sealed Other(comment) Comment: rsamfeldreport 04/05/2023 09:03 Page I of 2 CO Case# FLI-04-2023-193088 t CATAWBA COUNTY HEALTH DEPARTMENT Environmental Health Section /8 4 22 sM 04/05/2023 WATER SAMPLE TEST RESULTS Cooksville Grill 6861 OLD SHELBY RD, VALE NC 28168 Site Address: 6861 OLD SHELBY RD,VALE NC 28168 Parcel Number: 266701299279 Lab Coliform Analysis Results: Total Coliforms: Fecal/E.Coli: No Collection Date Over 30 hours old Invalid Results: Excessive turbidity Excessive Chlorine Lab Accident Lab Tech Initials Date/'Time Received Date/Time Completed rsamfieldreport 04/05/2023 09.03 Page 2 of 2