HomeMy WebLinkAboutEHPR-06-2023-44566.tif G) ENVIRONMENTAL HEALTH
Catawba County Government Center
C a t a w b a county 25 Government Drive I P.O. Box 389 I Newton, NC 28658
public health Phone: (828) 465-8270 I Fax: (828) 465-8276
IIMIING "Y1116_MIR Email: EHAdministrativeAssistants@CatawbaCountyNC.gov
Food Establishment Plan Review Application
Type of Construction: New 0 Remodel 0 Existing E' RTAP*❑
*Ibvisioas to Approved Plow Provide a ist of al flanges to the previously approved plans.Revise appl arhon as related 6 14 r ik.b&-)D)3 -'I N Slob
For REMODEL, specify the scope of work:
Name of Establishment: C I t-h1 k b!r ma d e A l41 E Z.tc r e...Kurcl1
If existing, please give name of old establishment if known: Stnti.4.. as ("bate_
Address: ` c c C al(1`i.t,i - k;--1.` t 1 ! .‘
City: -1*i C n' \ State: NC ZIP Code: c9 2
Phone (if available): 82- -3D'1-O 107_ Fax (if available):
Owner or Owner's Representative: °conk- O ,
Address:
City: State: NC ZIP Code:
Phone(if available): Fax(if available):
E-mail Address:
Submitter: Oim nu-A t tr r i 1 i
Company: Li I N-bm Tc1�er t kicl e-
Contact Person: .—t.r 1 V i-1._ Ske r +', 1 I
Address: )ii4 I L h
City: 14 tC4C\Y State: NC ZIP Code: 47(p
Phone (if available): ___....) -!" Fax (if available):
E-mail Address: vm YY1 --[Y r '\\1 ei114,0airlr.i k .C !
Title (owner, manager,architect, e .
I certify that the information in this application is correct, and I understand that any deviation
without prior approval from this Health Regulatory Office may nullify plan approval.
(0 er or Responsible Representative)
...„--,---
Signature & Date: I 1 Y r , ‘\
Daily Hours of Operation:
Sun Li Mon Tue Wed Thu Fri Sat 5
Projected number of meals served daily:
Breakfast: Lunch: Dinner:
Number of food deliveries received per week:
Number of seats: Facility total square feet:
Projected start date of construction: Projected completion date:
Type of food service: (Select all that apply)
❑ Restaurant ❑ Sit-down meals
,_,/Food Stand ❑ Take-out meals
Ly Drink Stand ❑ Catering / ❑ Delivery
❑ Commissary ❑ Custom Self-Service Area
❑ Meat Market
❑ Other (explain):
Type of utensils used:
[Si gle-service ( Isposable): Multi-use (reusable):
Plates Glassware Silverware ❑ Plates ❑ Glassware ❑ Silverware
Will specialize processes be used as specified in Section 3-502.11 of the North Carolina Food Code?
❑ Yes No
If YES, indicate which processes will be used:
❑ Curing ❑ Acidification (sushi, etc.) ❑ Reduced Oxygen Packaging (eg: Vacuum)
❑ Smoking ❑ Sprouting Beans ❑ Other
Explain checked processes:
Indicate any of the following highly susceptible populations that will be catered to or served:
❑ Nursing Home ❑ Child Care Center ❑ Health Care Facility
❑ ssisted Living Center ❑ School with pre-school aged children
RI/N/A
Will any virtual brands be provided?
❑ Yes L 'No
If YES, list brand names:
Menu to be served:
Estimated number of meals per week:
North Carolina Department of Health&Human Services • Division of Public Health • Environmental Health Section • Food Protection Program
5605 Six Forks Rd • 1632 Mail Service Center • Raleigh, NC 27699
Page 2 Revised 01/2023
Cold Storage:
How was the volume of cold storage indicated below determined to be adequate?
Reach-in cold storage (in cubic feet): Walk-in cold storage (in cubic feet):
Reach-in refrigerator storage:�3c..rb.c.ft3 Walk-in refrigerator storage: ft3
Reach-in freezer storage: &3c4Abicft' Walk-in freezer storage: ft3
Number of reach-in refrigerators: A
Number of reach-in freezers: J_
Cold Holding:
List foods that will be held cold: (include equipment used)
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Fish
Hot Holding:
List foods that will be held hot: (include equipment used)
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Cooling:
Indicate by checking the appropriate boxes how cooked food will be cooled to 41°F (7°C) within 6 hours.
If"Other"is checked indicate the type of food:
Cooling Process Meat Seafood Poultry Other
Shallow Pans ❑� ❑❑ ❑
Ice Baths [
Rapid Chill** ❑ Cl ❑ ❑
("Check only if rapid chill equipment such as blast chillers are provided.)
Thawing:
Indicate by checking the appropriate boxes how food in each category will be thawed.
If"Other" is checked indicate type of food:
Thawing Process Meat Seafood Poult Other
Refrigeration ❑ _ ❑
Running Water less than 70°F (21°C) L ❑ 0 ❑
Cooked Frozen ❑ ❑ ❑ CI
Microwave ❑ ❑ ❑ ❑
North Carolina Department of Health&Human Services • Division of Public Health • Environmental Health Section • Food Protection Program
5605 Six Forks Rd • 1632 Mail Service Center • Raleigh, NC 27699
Page 3 Revised 01/2023
Dry Storage:
Provide information on the frequency of deliveries and the expected gross volume that is to be delivered each time:
Where will dry goods be stored? f t 11-6 f
Square feet of dry storage shelf space: Lai{ ft2
Finish Schedule:
Indicate floor, wall and ceiling finishes (e.g., quarry tile, stainless steel, vinyl coated acoustic tile)
Area Floor Base Walls Ceiling
Kitchen 111 L. V>,finy ! act4eci
Bar f •
Food Storage � V1 Ary( C t 4-
Dry Storage 11 n Y� Tee} YtX
Toilet Rooms +I Le, 3hes4 (TX C
Dressing Rooms ,..�
Garbage& Refuse Storage
Service Sink L i by 1✓ G ,4 cA
Other:
Other:
Water Supply and Sewage:
Water supply: ff Municipal ❑ Well Sewer: Etillunicipal ❑ Septic
Will ice be: Illade on premises El Purchased
Water heater(s):
Tank type: A
a. Manufacturer and model: . O, *'n t*h Cy c,lo>g
b. Storage capacity: 64.) gallons
Electric water heater: kilowatts (kW) Gas water heater: t5accx., BTU's
c. Water heater recovery rate(gallons per hour at 80°F temperature rise): 1 1. GPH
Tankless:
a. Manufacturer and model:
b. Quantity of tankless water heaters:
c. Water heater recovery rate (gallons per minute at 80°F temperature rise): GPM
(See Water Heater Calculators on the Plan Review Unit website to calculate recovery rate needed)
North Carolina Department of Health&Human Services • Division of Public Health • Environmental Health Section • Food Protection Program
5605 Six Forks Rd• 1632 Mail Service Center • Raleigh,NC 27699
Page 5 Revised 01/2023
Check the appropriate box indicating equipment drains:
Indirect Waste Direct Waste
Plumbing Fixtures Floor sink Hub Drain Floor Drain
Warewashing Sink ❑ [ Li ❑
Prep Sinks ❑ [ LJ ❑
Handwashing Sinks ❑ ❑ El
Warewashing Machine 0 ❑ ❑
Ice Machine ❑ ❑ [r 0
Garbage Disposal ❑ ❑ ❑ ❑
Dipper Well ❑ El ❑ ❑
Refrigeration ❑ ❑ ❑
Steam Table El El ❑ ❑
Other: ❑ ❑ ❑ ❑
•
Other: ❑ El ❑ ❑
Warewashing Equipment:
Manual Warewashing:
Size of each sink compartment(inches): Length: Width: Depth:
Whgt,type of sanitizer will be used? Er
hlorine ❑ Iodine ❑ Quaternary Ammonium LrJ Not Water ❑ Other(specify)
Mechanical Warewashing:
Will a warewashing machine be used? es Ei4o
Warewashing machine manufacturer and moael:
Type of sanitization: ❑ Hot water (180°F) ❑ Chemical
General:
Describe how cooking equipment, cutting boards, slicers, counter tops, other food contact surfaces and clean in place
equipment that cannot be submerged in sinks or put through a dishwasher will be cleaned and sanitized:
ttb rne.iCCa i n St r..)
Describe location and type (drainboards, wall-mounted or overhead shelves, stationary or portable racks)of air-drying
Space: totier h ea
Square feet of air drying space: ode ft2
North Carolina Department of Health&Human Services • Division of Public Health • Environmental Health Section • Food Protection Program
5605 Six Forks Rd• 1632 Mail Service Center • Raleigh,NC 27699
Page 6 Revised 01/2023
Handwashing:
Indicate number and location of handwashing sinks:
t Aen't 4'rcrn)
KrIcnen •— 1
Employee Accommodations:
Indicate location for storing employees' personal items (ex. coats, purses, medication, etc.):
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Refuse and Recyclables:
Will refuse be stored inside? ❑ Yes ENo
If yes, where:
Provision for refuse disposal: umpster ❑ Compactor
Will a contract for off-site cleaning of the dumpster/compactor be obtained? ❑ Yes �lo
If yes, indicate name of cleaning contractor:
Will the dumpster/compactor be cleaned at the establishment? ❑ Yes ❑ No
Describe location for storage of recyclables (cooking grease, cardboard, glass, etc.):
Service Sink:
Location and size of service(mop) sink/can wash: ar'CL ac&6a.r.,-tfA-1,but fa t r •
Describe location for storage of cleaning implements (e.g:-'mops, brooms, hoses, etc.):
aD -5k natt r4 C.orr�rxar(�,c4 ryTh op buC.ts iAAf-t"h Vklrirlers
Insect and Rodent Control:
Ho is protection provided on all outside doors?
Self-closing door ❑ Fly Fan ❑ Screen Door
How is protection provided on windows (including drive-thru windows) or other openings to the outer a ?
❑ Self-closing ❑ Fly Fan ❑ Screening {a'N/A
Linen:
Indicate location of clean and dirty linen storage: ❑ N/A (no linen storage on site)
l lien f, �'� .A t'1 lr\< "544t; 11-4•1
Poisonous and Toxic Material:
Indicate location of poisonous and/or toxic materials (chemicals, sanitizers, etc.) storage:
•
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North Carolina Department of Health&Human Services • Division of Public Health • Environmental Health Section • Food Protection Program
5605 Six Forks Rd • 1632 Mail Service Center • Raleigh, NC 27699
Page 7 Revised 01/2023
Food Handling Procedures: (Should be provided by owner/owner's representative)
Explain the following with as much detail as possible. Provide descriptions of the specific areas of the kitchen
and corresponding items on the plan where food will be handled.
Explain the handling procedures for the following categories of food. Describe the process from receiving to service
including:
• How the food will arrive (frozen, fresh, packaged, etc )
• Where the food will be stored
• Where (specific pieces of equipment with their corresponding equipment schedule numbers) and how the food
will be handled (washed, cut, marinated, breaded, cooked, hot held, etc.)
• When (time of day and frequency/day) food will be handled
1. Ready to eat foods: Edible without additional preparation necessary. e.g., salads, cold sandwiches, raw molluscan shellfish
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2. Produce; grains and pasta: e.g.. beans. rice, macaroni
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v`1►ur� �4� Needec1
3. Poultry:
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4. Meat:
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5. Seafood:
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W ile N - f ,, raced rd
North Carolina Department of Health&Human Services • Division of Public Health • Environmental Health Section • Food Protection Program
5605 Six Forks Rd • 1632 Mail Service Center • Raleigh, NC 27699
Page 4 Revised 01/2023
$A • CATAWBA COUNTY
Eg'' 4 100A SOUTHWEST BLVD
NEWTON.NORTI I CAROLINA 28658 RECEIPT
111 4c( PHONE:828.465.8399
J Thursday,June 8,2023
/8 . 5M www.catawbacountyncgov
PAYOR: CLINTON TABERNACLE AME ZION CHURCH
CLINTON TABERNACLE AME ZION CHURCH
PAYMENTS
TRANSACTION NUMBER: 'FRC-65857341-08-06-2023
PAYMENT DATE: 06/08/2023
PAYMENT TYPE: Check 10745
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
06-23-423734 110.580200.663000 Food and Lodging Review Fee $250,00
TOTAL PAYMENTS: $250.00
EHPR-06-2023-44566
CASE TYPE: Environmental Health Plan Review WORK CLASS: Other FLI
SITE ADDRESS: 480 CATAWBA VALLEY BLVD SE,HICKORY NC 28602
Applicant CLINTON TABERNACLE AME ZION CHURCH,PO BOX 2862,HICKORY NC 28603
**NO PEOPLESOFT ACCOUNT ASSIGNED**
receipt 06108R023 10:32 Page 1 of 1