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Home My WebLink AboutEast Coast Wings & Grill Application.TIF Catawba County Public Health Department Division of Environmental Health FEPRA OOD STABLISHMENT LAN EVIEWPPLICATION For submission with full set of signed and sealed plans produced by an architect or engineer. ä Type of Construction: NEW _______ REMODEL _______ CONVERSION _______ ùÛÈÛÅÚÛ County in which Located: ____________________________________________________________ ÷ÛÉÈùÍÛÉÈåÓÎÕÉõÊÓÐÐ Name of Establishment: ____________________________________________________________ ôåã é÷ Establishment’s Address: ____________________________________________________________ ôóùñíêã City: _________________________________ Zip Code: ___________ ðíå÷éöííøøêóæ÷ Owner’s Current Physical ____________________________________________________________ ð÷åóéæóðð÷ Mailing Address: City: _________________________________ Zip Code: ___________ Phone if available: (_____) – (_____ - _______) Fax: (_____) – (_____ - _______) **************************************************************************************************** I have submitted plans/application to the following: (Please note date, phone number and contact person on application line) Plumbing __________________________________________________________________ Contact Person __________________________________________________________________ Phone Number (_____) – (_____ - _______) Electrical __________________________________________________________________ Contact Person __________________________________________________________________ Phone Number (_____) – (_____ - _______) ùûèûåúûùíçîèã Building __________________________________________________________________ úóððêíõ÷êé Contact Person __________________________________________________________________ Phone Number (_____) – (_____ - _______) Hours of Operation Sun_______ Mon_______ Tue_______ Wed_______ Thu_______ Fri_______ Sat_______ Number of Seats _______ Number of Staff _______ (Maximum per shift) Facility Total Sq. Ft. _______ Projected Number of Meals to be Served: (Approximate number) î û Breakfast_______ Lunch_______ Dinner_______ îíæ Projected Start Date of Construction ________ ö÷ú Projected Completion Date of Project ________ 1 Type of Service (Check all that apply) ä Sit Down Meals _______ ä Take Out _______ ä Caterer _______ Mobile Food Unit _______ Push Cart _______ Limited Food Service _______ Temporary Food Stand _______ Single Service Utensil Only _______ Multi-Use Utensil Service Only _______ ä 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 I TEMS 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 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, If plans specify the must be glazed, tiled, plastered or filled so as to provide a smooth surface. use of a material not on this list, include a sample of the material for evaluation . 3 FPR OOD REPARATION EVIEW Check categories of Potentially Hazardous Food (PHF) to be handled prepared and served. CYesNo ATEGORY Thin meats, poultry, fish, eggs (hamburgers, chicken breast, fish filet, etc.) _______ _______ ä Thick meats, whole poultry (whole roasts, pork, chicken, meat loaf, etc.) _______ _______ ä Hot processed foods (soups, stews, chowders, casseroles) _______ _______ ä Bakery goods (pies, custards, creams) _______ _______ ä Other: ______________________________________________________ _______ _______ ä PCBFQ LEASE HECK OX FOR THE OLLOWING UESTIONS FS OODUPPLIES 1. Are all food supplies from inspected and approved sources? Yes_____ No_____ ä CS OLDTORAGE 0 2.Are adequate and approved freezer and refrigeration available to store frozen foods at 0 F and 00 below, and refrigerated foods at 45 F (7 C) and below? Yes_____ No_____ ä Provide the method used to calculate cold storage requirements: __________________________ îùê÷öêóõ÷êûè÷øéèíêûõ÷ ______________________________________________________________________________ ùûðùçðûèóíîìêíõêûï Provide total footage of space dedicated to walk-in cold storage ________________________ ùçöè Provide total footage of space dedicated to reach-in cold storage ________________________ ùçöè 3.Will raw meats, poultry and seafood be stored in the same refrigerators and freezer with cooked/ready-to-eat foods? Yes_____ No_____ ä If yes, how will cross-contamination be prevented? ____________________________________ ìðûù÷øíîé÷ìûêûè÷éô÷ðöûîøéèíê÷øóî ______________________________________________________________________________ é÷ìûêûè÷ûììêíæ÷øùíîèûóî÷êéíêìûùñûõóîõ 4.Does each refrigerator/freezer have a thermometer? Yes_____ No_____ ä Number of refrigeration units:_______ Number of freezer units:_______ T HAWING 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 ääää 00 Running Water less than 70F (21C) Cooked Frozen (indicate wt. lbs.) úãíêø÷ê Microwave Other (describe): _____________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ 4 P C OOKINGROCESS 00 Item #1 - Will food product thermometers (0 – 212 F) be used to measure final cooking/reheating temperatures of PHF (potentially hazardous food)? Yes_____ No_____ ä Minimum cooking time and temperature of product utilizing convection and conduction heating equipment: Product Time & Temperature Product Time & Temperature 00 Beef roast 130 F (121 min) Comminuted meats 155 F (15 sec) 00 Seafood 145 F (15 sec) Poultry165 F (15 sec) 00 Port 155 F (15 sec) Other PHF 145 F (15 sec) 00 Eggs 145 F (15 sec) * reheating PHF 165 F (15 sec) Item #2 - Hot Holding 00 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. ____________________________________________________________________________________ óè÷ïùííñé÷êæ÷ ____________________________________________________________________________________ óè÷ïöííøåûêï÷ê ____________________________________________________________________________________ óè÷ï ôíðøóîõéèûèóíî ____________________________________________________________________________________ óè÷ï öèíæ÷êô÷ûøåûêï÷ê ____________________________________________________________________________________ Item #3 - Cold Holding 00 How will cold PHF (potentially hazardous food) be maintained at 45 F (7 C) or above during holding for service? Indicate type and number of hot holding units. ____________________________________________________________________________________ óè÷ï øêçîø÷êùíçîè÷êê÷öêóõóè÷ï øêåêùô÷öéúûé÷ ____________________________________________________________________________________ óè÷ï øêåíêñèíìê÷öêóõ ____________________________________________________________________________________ óè÷ïøê çìêóõôèê÷öêóõ ____________________________________________________________________________________ óè÷ïøêåê éûîøåóùô éûðûøê÷öêóõ ____________________________________________________________________________________ óè÷ï øêåê éûîøåóùô éûðûøê÷öêóõ Item #4 - Cooling Please indicate by checking the appropriate box how PHF (potentially hazardous food) will be cooled to 000000 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 ää Ice Baths ää Rapid Chill Other (describe): _____________________________________________________________________ èôóîï÷ûèéûê÷ùííñ÷øèííêø÷êöóéôé÷ûöííøûê÷ùííñ÷øèííêø÷ê ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ 5 P F OODREPARATION 1.Please list categories of food prepared more than 12 hours in advance of service. ______________________________________________________________________________ èôóùñï÷ûèéêóúé ______________________________________________________________________________ ìûéèûéûðûø ______________________________________________________________________________ ùíð÷éðûå ______________________________________________________________________________ ______________________________________________________________________________ 2.Will disposable gloves and/or utensils and/or food grade paper be used to minimize handling of ready-to-eat foods? Yes_____ No_____ ä 3.Is there an established policy to exclude or restrict food workers who are sick or have infected cuts and lesions? Yes_____ No_____ ä Please describe procedure: ________________________________________________________ éóùñùûððíçèíêïûîûõ÷êíîéèûööåóððé÷îøãíçôíï÷ ______________________________________________________________________________ ùçèéíêð÷éóíîéïûîûõ÷êåóðð÷æûðçûè÷ì÷êóîøóæóøçûðùûé÷é÷îø÷ïìðíã÷÷ôíï÷óöúûîøûõ÷åóèôõðíæ÷é ______________________________________________________________________________ ûê÷îíèéçööóùó÷îè÷îíçõô ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 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: ________________________________________________________ éìêûãåóèôéûîóèóâ÷êûîøåóì÷ùð÷ûî ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 5.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?___________________________ éèíê÷øóîåûðñóîùííð÷êèô÷î ______________________________________________________________________________ èêûîéö÷êê÷øøûóðãèíöííøìê÷ìéèûèóíîöíêûéé÷ïúð÷úãíêø÷ê ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 6 4. T HE FOLLOWING 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 The food preparation procedures should include types determine that adequate facilities are available. 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_____ ä b.Is there an approved location used for washing or rinsing produce? Yes_____ No_____ ä c.Will it be used for other operations? Yes_____ No_____ ä 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: ____________________________________________________________________________________ óè÷ïûððìê÷ìóéøíî÷íîù÷øûóðãóîèô÷ïíêîóîõ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 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: ____________________________________________________________________________________ ûððóéøíî÷óîìê÷ìûê÷ûíîù÷øûóðãóîèô÷ïíêîóîõçéóîõùíðíê÷øùíø÷øùçèèóîõúíûêøéñîóæ÷éûîøùûïúêí ____________________________________________________________________________________ úçùñ÷èéûîøùíîèûóî÷êéèô÷ûê÷ûóéùð÷ûî÷øåóèôéûîóèóâ÷êûððñîóæ÷éûîøùçèèóîõúíûêøéûê÷êçîèôêíçõô ____________________________________________________________________________________ èô÷øóéôåûéô÷êûóêøêó÷øûîøéèíê÷øçîèóðî÷äèçé÷ ____________________________________________________________________________________ ï÷îçóè÷ïééûîøåóùô÷ééûðûøéúçêõ÷êéåêûìéûìì÷èóâ÷êé ____________________________________________________________________________________ 2. Seafood Preparation Procedures a.Will seafood be washed or rinsed prior to use? Yes_____ No_____ ä b.Is there an approved location used for washing or rinsing seafood? Yes_____ No_____ ä c.Will it be used for other operations? Yes_____ No_____ ä 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: ____________________________________________________________________________________ óè÷ï øíî÷íîù÷øûóðãóîèô÷ïíêîóîõéûîóèóâ÷èô÷ï÷ûèéóîñûîøåûéô êóîé÷éôêóïìùð÷ûîûîøéûîóèóâ÷èô÷ ____________________________________________________________________________________ ï÷ûèéóîñöíððíåóîõ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 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: ____________________________________________________________________________________ óè÷ï øíî÷íîù÷øûóðãóîèô÷ïíêîóîõéûîóèóâ÷èô÷ï÷ûèéóîñûîøåûéô êóîé÷éôêóïììðûù÷óîéïûððùûïúêí ____________________________________________________________________________________ úçùñ÷èåóèôðóøùð÷ûîûîøéûîóèóâ÷èô÷ï÷ûèéóîñöíððíåóîõúçööûðíéôêóïìåêûìééûðûøé ____________________________________________________________________________________ ____________________________________________________________________________________ 3. Poultry Preparation Procedures a.Will poultry be washed or rinsed prior to use? Yes_____ No_____ ä b.Is there an approved location used for washing or rinsing poultry? Yes_____ No_____ ä c.Will it be used for other operations? Yes_____ No_____ ä 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: ____________________________________________________________________________________ î û ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 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: ____________________________________________________________________________________ ûððöêö÷éôìíçðèêãóéìûùñûõ÷øúãïûîçöûùèçê÷ûîøéèíê÷øóîåûðñóîùííð÷êçìíîø÷ðóæ÷êãóèåóððèô÷îú÷ ____________________________________________________________________________________ ìðûù÷øóîéôûððíåìûîéûîøïíæ÷øèíóè÷ï ùô÷öéúûé÷øûóðãúçööûðíåóîõéöóîõ÷êééûðûøééûîøåóùô÷éåêûìé ____________________________________________________________________________________ ûððöêíâ÷îìíçðèêãóéìûùñûõ÷øúãïûîçöûùèçê÷ûîøéèíê÷øóîåûðñóîöê÷÷â÷êóèåóððèô÷îú÷ìðûù÷øóîùûïúêí ____________________________________________________________________________________ úçùñ÷èéûîøïíæ÷øèíóè÷ïåíêñèíìöê÷÷â÷êøûóðãúíî÷ð÷ééåóîõé 4. Pork and/or Red Meat Preparation Procedures a.Will pork and red meats be washed or rinsed prior to use? Yes_____ No_____ ä b.Is there an approved location used for washing or rinsing pork and red meats? Yes_____ No_____ ä c.Will it be used for other operations? Yes_____ No_____ ä 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: ____________________________________________________________________________________ î û ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 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: ____________________________________________________________________________________ ìÍÊÑÛÎØ ÍÊê×Ø ï×ÛÈêóúéûê÷ø÷ðóæ÷ê÷øóîïûîçöûùèçê÷øìûùñûõóîõéèíê÷øóîåûðñóîöê÷÷â÷êûîøèôûå÷øóîåûðñóîùííð÷ê ____________________________________________________________________________________ èô÷îìðûù÷øóîìíèíöôíèåûè÷êöíê ôêéìðûù÷øóîéôûððíåìûîéùííð÷øóîåûðñóî ____________________________________________________________________________________ ùííð÷êíêóù÷úûèôèô÷îåêûìì÷øóîùð÷ûêåêûìûîøéèíê÷øóîåûðñóîùííð÷êèóððíêø÷ê ____________________________________________________________________________________ 8 DESIGN INFORMATION I.DRY GOODS STORAGE 1.Is appropriate dry good storage space provided for based upon menu, meals and frequency of deliveries? Yes_____ No_____ ä Provide information on the frequency of deliveries and the expected gross volume that is to be delivered each time. ______________________________________________________________________________ ø÷ðóæ÷ê÷øèåóù÷ûå÷÷ñ ûå÷÷ñ ______________________________________________________________________________ çé÷øèô÷îùøêãéèíêûõ÷ùûðùçðûèóíîìêíõêûï ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ II.WATER SUPPLY 1.Please check one: Is water supply Community? Yes___ No___ Municipal? Yes___ No___ ä 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_____ No_____ If yes, please attach copy of written approval and/or permit. 3.Is ice made on premises or purchased commercially? Yes_____ No_____ ä Please specify: _________________________________________________________________ óè÷ïïûîóèíåíùóù÷ïûùñ÷êúóî If made on premised than specification for the ice machine will need to be provided. Describe provision for ice scoop storage: ____________________________________________________ ðõéùííìùíæ÷ê÷øôíðø÷êïíçîè÷øíî÷äè÷êóíêíöóù÷éèíêûõ÷úóî ______________________________________________________________________________ ______________________________________________________________________________ III DUMPSTER 4.Will a dumpster be used? Yes______ No______ N/A______ ä Number __________ Size __________ Frequency of Pickup __________ ùçãø Äå÷÷ñ Contractor Service: ___________________________________________________________ õøé ê÷ìçúðóùé÷êæóù÷é ___________________________________________________________________________ 5.Will the dumpster be cleaned on site? Yes_____ No_____ ä 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_____ No_____ ä 9 If yes, please provide name and address of the firm contracted for this service. Name: ______________________________________________________________________ õøé ê÷ìçúðóùé÷êæóù÷é Mailing Address: ______________________________________________________________ ìíúíä City: _____________________________ State: _______ Zip Code: ______________ ùíîíæ÷êîù Telephone: (____)-(____-_______) Fax: (____)-(____-_______) 7.Will a compactor be used? Yes______ No______ N/A______ ä Number __________ Size __________ Frequency of Pickup __________ Contractor Service: ____________________________________________________________ ____________________________________________________________________________ 8.Will the compactor be cleaned on site? Yes______ No______ N/A______ ä 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: ______________________________________________________________________ Mailing Address: ______________________________________________________________ City: _____________________________ State: _______ Zip Code: ______________ Telephone: (____)-(____-_______) Fax: (____)-(____-_______) 10.Describe surface and location where dumpster/compactor/cans are to be stored: ____________________________________________________________________________ øçïìéè÷êíîðãåóððú÷ðíùûè÷øûèê÷ûêíöúçóðøóîõð÷ûé÷éìûù÷íîûéìôûðèéçêöûù÷ 11.Will trash containers be stored outside? Yes_____ No_____ ä If yes, please describe location: __________________________________________________ ____________________________________________________________________________ 12.Type and location of waste cooking grease storage receptacle: __________________________ õûððíîéèíêûõ÷ùíîèûóî÷êé ____________________________________________________________________________ íîåô÷÷ðéðíùûè÷øûèê÷ûêíöúçóðøóîõíîûéìôûðèéçêöûù÷ 13.Is there an area to store recycled containers? Yes_____ No_____ ä Describe: ____________________________________________________________________ ÷ûùôõðûééíîðãìðûéèóù ûðçïóîçïðíùûè÷øûèê÷ûêíöúçóðøóîõíîûéìôûðèéçêöûù÷ ____________________________________________________________________________ õûððíîùíîèûóî÷êéíîåô÷÷ðé 14.Location and size of grease trap: __________________________________________________ õûððíîðíùûè÷øûèê÷ûêíöúçóðøóîõéìûù÷ _____________________________________________________________________________ _____________________________________________________________________________ 10 X.SEWAGE DISPOSAL 1.Is building connected to a municipal sewer? Yes_____ No_____ ä 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 1.Are insecticides/rodenticides if used stored separately from cleaning and sanitizing agents? Indicate location: _________________________________ Yes_____ No_____ íîéô÷ðæóîõóîùûîåûéôêííï ä 2.Are all cleaning materials and toxicants stored away from food preparation/storage areas? This includes items used on premises, retail sales and personal medications. Yes_____ No_____ ä Please Describe Location: ________________________________________________________ ùð÷ûîóîõíîéô÷ðæóîõóîùûîåûéôêííï _____________________________________________________________________________ ê÷èûóðéûð÷éóîíööóù÷ øóéìðûãùûé÷÷ïìðíã÷÷ï÷øéåóððú÷óîðíùñ÷êéðíùûè÷øóîéèíêûõ÷ûê÷û 3.Are all containers of toxic/cleaning material including sanitizing spray bottles clearly labeled? Yes_____ No_____ ä 4.Are laundry facilities located on premises? Yes_____ No_____ ä If yes, what will be laundered? ____________________________________________________ _____________________________________________________________________________ 5.Is a laundry dryer available? Yes_____ No_____ ä If yes, please describe location: ___________________________________________________ _____________________________________________________________________________ 6.Location of clean linen storage: ___________________________________________________ ðûçîøêãìêíæóø÷øúãæ÷îøíêø÷ðóæ÷ê÷øóîùð÷ûêìðûéèóùúûõéûîøéèíê÷ø _____________________________________________________________________________ íîúíèèíïéô÷ðöíöêûùñðíùûè÷øóîéèíêûõ÷ _____________________________________________________________________________ 7.Location of dirty linen storage: ____________________________________________________ æ÷îøíêìêíæóø÷øôûïì÷êðíùûè÷øóîéèíêûõ÷ _____________________________________________________________________________ _____________________________________________________________________________ **************************************************************************************************** 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) _________________________________________________________________ ùúÊÛØÐ×ÃôÍÎ×ÃÙÇÈÈ øÓÕÓÈÛÐÐÃÉÓÕÎ×ØÚÃùúÊÛØÐ×ÃôÍÎ×ÃÙÇÈÈ øîÙÎÿùúÊÛØÐ×ÃôÍÎ×ÃÙÇÈÈÍÍÇ×ÏÛÓÐÿÚÊÛØü×ÛÉÈÙÍÛÉÈÅÓÎÕÉÙÍÏÙÿçé øÛÈ× _________________________________________________________________ Owner(s) or Responsible Representative(s) Date: ___________________________ ø÷ù÷ïú÷ê 11 FPWS OOD REPARATION ORKSHEETUPPLEMENT 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