EnvHealthFoodPermitAppFSEstabM

PERMIT APPLICATION FOR FOOD SERVICE

ESTABLISHMENTS AND MOBILE/EXTENDED

FOOD SERVICE BASE OPERATIONS

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Revised 12/5/2017

NOTICE

THIS PERMIT APPLICATION PACKET IS COMPOSED OF THREE PARTS: ADMINISTRATIVE

INFORMATION; OPERATIONAL INFORMATION; AND PLAN REVIEW INFORMATION.

ADMINISTRATIVE INFORMATION: THIS INFORMATION WILL BE USED TO ESTABLISH

COMMUNICATION BETWEEN THE LOCAL HEALTH AUTHORITY AND THE PERMIT

APPLICANT/PERMIT HOLDER. IT WILL ALSO BE USED TO ADMINISTER THE PERMITTING

AND ESTABLISHMENT INSPECTION PROCESSES.

OPERATIONAL INFORMATION: THIS INFORMATION WILL BE USED TO ENABLE THE

LOCAL HEALTH AUTHORITY TO BECOME FAMILIAR WITH THE QUESTIONS OF WHAT

TYPES, WHEN, HOW MUCH, AND WHERE FOOD WILL BE PREPARED AND SERVED BY

THE PROPOSED FOOD SERVICE ESTABLISHMENT.

PLAN REVIEW INFORMATION: IN ACCORDANCE WITH DPH CHAPTER 511-6-1-.02(4), THIS

INFORMATION WILL BE UTILIZED BY THE LOCAL HEALTH AUTHORITY IN ITS REVIEW

AND APPROVAL PROCESS OF SUBMITTED PLANS AND SPECIFICATIONS FOR

PROPOSED NEW CONSTRUCTION, OR REMODELING AND CONVERSION OF EXISTING

BUILDINGS FOR PROPOSED FOOD SERVICE ESTABLISHMENTS. ADDITIONALLY, THIS

INFORMATION WILL BE UTILIZED BY THE LOCAL HEALTH AUTHORITY TO ACCESS THE

LEVEL OF COMPLIANCE STATUS OF EXISTING FOOD SERVICE ESTABLISHMENTS

DURING THE OCCURRENCE OF A CHANGE IN PERMIT HOLDER.

AS PER DPH CHAPTER 511-6-1-.02(1)(c), IN ORDER TO QUALIFY FOR A PERMIT TO

OPERATE A FOOD SERVICE ESTABLISHMENT, THE PERMIT APPLICANT MUST 1) BE AN

OWNER OF THE PROPOSED FOOD SERVICE ESTABLISHMENT (OR AN OFFICER OF THE

LEGAL OWNERSHIP), 2) AGREE TO ALLOW THE HEALTH AUTHORITY ACCESS TO THE

FOOD SERVICE ESTABLISHMENT, 3) PROVIDE ALL REQUIRED INFORMATION

REQUESTED BY THE HEALTH AUTHORITY AND PAY ALL APPLICABLE FEES; AND 4)

PROVIDE EVIDENCE OF SATISFACTORY COMPLIANCE WITH THE PROVISIONS OF THE

CHAPTER AND ALL OTHER PROVISIONS OF LAWS THAT APPLY TO THE LOCATION,

CONSTRUCTION AND MAINTENANCEE OF FOOD SERVICE ESTABLISHMENTS AND THE

SAFETY OF PERSONS THEREIN.

AT THE HEALTH AUTHORITY’S INITIAL INSPECTION OF THE COMPLETED FOOD SERVICE

ESTABLISHMENT AND PRIOR TO THE ISSUANCE OF A PERMIT BY DEMONSTRATING

SATISFACTORILY COMPLIANCE WITH THE PROVISION OF DPH CHAPTER 511-6-1; AND

PROVIDING WRITTEN DOCUMENTATION INDICATING SATISFACTORY COMPLIANCE WITH

ALL OTHER PROVISIONS OF LAWS THAT APPLY TO THE FOOD ESTABLISHMENT’S

LOCATION, CONSTRUCTION AND MAINTENANCE, AND THE SAFETY OF PERSONS

THEREIN.

INSTRUCTIONS: COMPLETE THE FOLLOWING APPLICATION DOCUMENT IN DUPLICATE

AND FORWARD THE ORIGINAL COMPLETED DOCUMENT TO THE LOCAL HEALTH

AUTHORITY (COUNTY HEALTH DEPARTMENT), IN WHICH THE FOOD SERVICE

ESTABLISHMENT IS TO BE LOCATED AND OPERATED. GO TO THE DEPARTMENT’S

ENVIRONMENTAL HEALTH WEBPAGE AT

http://dph.georgia.gov/sites/dph.georgia.gov/files/related_files/site_page/EnvHealthContactInformation2015-

10.pdf FOR COUNTY HEALTH DEPARTMENT CONTACT INFORMATION.

http://dph.georgia.gov/sites/dph.georgia.gov/files/related_files/site_page/EnvHealthContactInformation2015-10.pdf http://dph.georgia.gov/sites/dph.georgia.gov/files/related_files/site_page/EnvHealthContactInformation2015-10.pdf

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ADMINISTRATIVE INFORMATION

Name of Establishment:_______________________________________________________

Food Service Address:________________________________________________________ Street # and Name Suite/Unit # City Zip Code

Email address: _________________________Business Phone Number: ________________

1. Reason for plan review (Check appropriate block)

New Application Change of Ownership:

Will there be any changes to the previous menu, equipment or facility structure? ______ Renovation of Existing Establishment

2. Method of Operation: (Check All Appropriate Blocks)

Food Service Establishment Food Service/Wholesaler – requires a Georgia Dept. of Agriculture permit in addition to food service permit Catering Operation Mobile Base – please complete a mobile food unit application for each mobile unit Extended Food Service Institution (e.g. school, hospital, nursing home, etc.)

Incubator Establishment A (one shared space) – VARIANCE REQUIRED Incubator Establishment B (cubicle/build out units)- VARIANCE REQUIRED Incubator Establishment B member (cubicle/build out units) – VARIANCE REQURIED

FOR HEALTH AUTHORITY USE ONLY:

Applicable Fees Paid? ___ YES ___ NO If NO, explain: ______________________

Is Proposed Menu attached? _____YES ____ NO If NO, Explain: ________________

Thawing Method

Refrigeration

Running Water Less than 70ºF

Microwave (as part of cooking process)

Cooked from Frozen state

Other (describe)

COOLING

METHOD

THICK

MEATS

THIN

MEATS

THIN SOUPS/

GRAVY

THICK

SOUPS/

GRAVY

RICE/

NOODLES

Shallow Pans

Ice Baths

Reduce Volume or Size

Rapid Chill

Thawing Method

*THICK FROZEN FOODS

*THIN FROZEN FOODS

Refrigeratio

Shallow Pans

Ice Baths

Reduce Volume or Size

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ADMINISTRATIVE INFORMATION continued

Ownership By: Individual Corporation Partnership LLC

Association Other _____________________________

If Corporation, Partnership, LLC, Association, or Other Legal Entity, please provide a listing of all persons comprising the legal ownership to include the name(s), title(s), address and phone numbers, including owners and officers. Please attach additional page, if necessary.

Legal business name to appear on permit (the business owner’s name or corporation name as it appears on the business license):

Person who functions as the immediate supervisor of the management for the food service establishment such as zone, district, or regional supervisor:

Name: _____________________________________ Title:__________________________

Mailing Address:

Street City State Zip Code

Telephone Number: ( ) _____________ Email Address: _________________________

If Applicable, identify all counties that in which Mobile Unit(s) will operate:

Please attach separately, a detailed a business plan (which includes a DESCRIPTION OF YOUR BUSINESS MODEL, OPERATIONS PLAN (i.e. how you plan to operate), IDENTIFY MARKET/CONSUMERS, and SERVICES PROVIDED, etc).

Chapter 511-6-1-.03(2)(n) allows for continued operations in the event of an interruption of electrical or water service for two or more hours ONLY if the Health Authority has approved a plan prior to the occurrence of such an event. Please indicate whether or not you would like to continue operations in the event of an interruption of electrical or water service for two or more hours:

YES – I will provide an Emergency Operation Plan to the Health Authority prior to opening that will address adequate control of Risk Factors such as, but not limited to:

Ensuring availability (including alternate sources if necessary) of safe water

Adequate access to functioning toilets

Length of time capable of operating with no water and/or electricity

Other information as necessary dependent upon my type of operation

NO – I do NOT plan to continue operations if there is an interruption in electrical service or water for more than 2 hours. I understand that any future decision to operate under such conditions will require a PRE-APPROVED Emergency Action Plan by the Health Authority PRIOR to such incident.

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OPERATIONAL INFORMATION

1. Is water supply: Public or Private ?

2. If private, has source been approved? YES NO PENDING

Please attach copy of written approval and/or permit.

3. Please answer the following based on your operation (check all that apply):

❑ Establishment does not cook any raw animal foods; only reheat commercially precooked ingredients

❑ Establishment cooks raw animal foods and reheats cooked foods that are prepared onsite

❑ Establishment conducts a specialized process which requires an approved HACCP plan

❑ Establishment serves raw or undercooked animal foods in a ready to eat form (i.e. rare steaks/burgers, sashimi, etc)

4. Check Appropriate Block(s) for any proposed specialized processes for your establishment.

❑Curing* ❑ Smoking for preservation* ❑Sprouting seeds or beans*

❑Reduced Oxygen Packaging+ ❑ Operating a molluscan shellfish life-support system

❑Using food additives or adding components to render food non-TCS or for preservation*

❑Not Applicable ❑Other

* Requires a variance, HACCP plan, and written procedures + May require a variance and HACCP plan depending on the procedures

Please identify Hours of Operation for each day of the week Sun _________ Tues _________ Thurs _________ Sat _________

Mon _________ Wed _________ Fri_________

Number of Seats: ________ Number of Staff (Maximum per shift): ________

Total Square Feet of Facility: ________ Number of Floors on which operations are conducted: ______

Maximum Meals to be served (approximate number):

Breakfast _________ Lunch _________ Dinner _________

Projected Date for Start of Project: ______________

Projected Date for Completion of Project: _____________

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Type of Service (check all that apply):

Sit Down Meals Drive-thru Take Out Catering

Mobile unit Delivery Online

Other___________________

Total number of Managers (have supervisory/management responsibility) which are certified in Food Safety _________

Please enclose the following documents:

Proposed Menu (including seasonal, off-site and banquet menus)

Manufacturer Specification sheets for each piece of equipment shown on the plan (include hot water heater specifications

Site plan showing location of business in building; location of building on site including alleys, streets; and location of any outside equipment (dumpsters, well, septic system - if applicable)

Plan (drawn to scale) of food establishment showing location of equipment, plumbing, electrical services and mechanical ventilation

Equipment schedule

Water supply

Complies with all other provisions of laws that apply to the location, construction and maintenance of food service establishments and the safety of persons therein

(USE ADDITIONAL PAPER AS NEEDED)

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DO NOT WRITE BELOW THIS LINE – HEALTH DEPARTMENT USE ONLY

You may obtain a copy of the Rules and Regulations for Food Service by visiting our website at http://dph.georgia.gov/food-rules-and-regulations

THE FOLLOWING DOCUMENTS ARE ENCLOSED:

❑ Business Plan Attached ❑ Equipment List Attached

❑ Plans Attached ❑ Menu Attached

❑ Plan Review Checklist ❑ Food Preparation Review

❑ Construction Review ❑ Water Supply Public/Approved

❑ Vomitus/Diarrheal Clean-up Plan ❑ Wastewater/Septic System Approval

❑ Notarized Verification of Residency

For Public Benefits Application

WHEN APPLICABLE:

❑ Pets in outside dining procedures

❑ Variance/HACCP plan/procedures

❑ Emergency Action Plan for water/electrical interruptions

FOOD SERVICE RISK CATEGORIZATION:

❑ Risk Type I - do not cook any foods may reheat commercially precooked ingredients

❑ Risk Type II – cook and/or hold and reheat foods that are prepared onsite

❑ Risk Type III/HAACP Plan - requires an approved HACCP plan http://dph.georgia.gov/food-rules-and-regulations

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OPERATIONAL INFORMATION Continued

FOOD PREPARATION REVIEW:

Check categories of Time/Temperature Control for Safety Food (TCS) to be handled, prepared and served.

CATEGORY (YES) (NO)

1. Thin meats, poultry, fish, eggs (hamburger; sliced meats; fillets)

2. Thick meats, whole poultry (roast beef; whole turkey, chickens, hams)

3. Cold processed foods (salads, sandwiches, vegetables)

4. Hot processed foods (soups, stews, rice/noodles, gravy, chowders, casseroles)

5. Bakery goods (pies, custards, cream fillings & toppings)

6. Fresh produce

7. Specialty foods (i.e. acidification, curing, drying, reduced oxygen packaging, etc)

8. Other ________________________________________________________

PLEASE CHECK THE BOX/ANSWER THE FOLLOWING QUESTIONS

FOOD SUPPLIES:

1. Are all food supplies from inspected and approved sources? YES NO

Please list suppliers:

2. What are the projected frequencies of deliveries for:

Day of week AM/PM Key Drop Delivery

Frozen foods _________ ____ Yes ___ No ___ Refrigerated foods __________ ____ Yes ___ No ___

Dry goods __________ ____ Yes ___ No ___

3. Provide information on the amount of space (in cubic feet) allocated for:

Dry storage ___________ Refrigerated Storage ___________

Frozen storage ___________

4. How will dry goods be stored off the floor?

5. Will foods be transported after preparation (delivery or catering)? Yes No

Please describe equipment used to transport hot/cold foods and provide spec sheets:____________________________________________________________________

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OPERATIONAL INFORMATION continued

6. Please describe delivery radius (in time/distance traveled):

COLD STORAGE:

1. Is adequate and approved freezer and refrigeration available to store frozen foods frozen, and refrigerated foods at 41º F (5 º C) and below? YES NO

Provide the method used to calculate cold storage requirements.

2. Will raw meats, poultry and seafood be stored in the same refrigerators and freezers with cooked/ready-to-eat foods? YES NO

If yes, how will cross-contamination be prevented?

3. Does each refrigerator/freezer have a thermometer in the warmest part of the unit? YES NO

Number of refrigeration units: _______ Number of freezer units: ________

4. Is there a bulk ice machine available? YES NO

5. Please describe the cleaning schedule for the bulk ice machine:

THAWING FROZEN TIME/TEMPERATURE FOR SAFETY (TCS) FOOD:

Please indicate by checking the appropriate boxes how frozen time/temperature for safety foods (TCS) in each category will be thawed. More than one method may apply. Also, indicate where thawing will take place.

Thawing Method *THICK FROZEN FOODS *THIN FROZEN FOODS

Refrigeration

Running Water Less than 70ºF

Microwave (as part of cooking process)

Cooked from Frozen state

* Frozen foods: approximately one inch or less = thin, and more than an inch = thick.

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COOKING:

1. What type of Temperature measuring device (thermometer) will be used to measure final cooking/reheating temperatures of TCS foods?

2. Will meat, poultry, eggs, or fish be offered raw or undercooked on the menu? If yes, which items?

NO YES ___________________________________________________________

Minimum cooking time and temperatures of product utilizing convection and conduction heating equipment:

Beef roasts-------------------------------------------------------- 130 º F (121 min) Solid seafood pieces -------------------------------------------- 145 º F (15 sec) Other PHF’s ---------------------------------------------------- 145 º F (15 sec) Eggs:

Immediate service ------------------------------------- 145 º F (15 sec) Pooled* ------------------------------------------------- 155 º F (15 sec) (*pasteurized eggs must be served to a highly susceptible population)

Pork -------------------------------------------------------------- 145 º F (15 sec) Comminuted meats/fish --------------------------------------- 155 º F (15 sec) Poultry ----------------------------------------------------------- 165 º F (15 sec) Reheated for hot holding of cooked and cooled TCS foods--165 º F (15 sec)

2. List types of cooking equipment.

HOT/COLD HOLDING:

1. How will hot TCS food be maintained at 135ºF (57ºC) or above during holding for service?

Indicate type and number of hot holding units.

2. How will cold TCS food be maintained at 41ºF (5ºC) or below during holding for service?

Indicate type and number of cold holding units.

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COOLING:

Please indicate by checking the appropriate boxes for how TCS foods will be cooled to 41 º F (5 º C) within 6 hours (135 º F to 41 º F in 6 hours; provided the food reaches from 135°F to 70 º F in 2 hours). Also, indicate where the cooling will take place.

COOLING

METHOD

THICK

MEATS

THIN

MEATS

THIN SOUPS/

GRAVY

THICK SOUPS/

GRAVY

RICE/

NOODLES

Shallow Pans

Ice Baths

Reduce Volume or

Size

Rapid Chill

1. Please describe how the cooling process for TCS food from 135ºF to 70ºF within 2 hours and 135ºF to 41ºF within 6 hours will be monitored to ensure that cooling parameters are met.

Indicate cooling strategy, and the monitoring procedures (frequency, type of temperature measuring equipment used, written policies/procedures you intend to follow, etc).

REHEATING FOR HOLDING:

1. How will TCS foods that are cooked, cooled, and reheated for hot holding be reheated so that all parts of the food reach a temperature of at least 165 º F for 15 seconds. Indicate type and number of units used for reheating foods.

SAFE PRACTICES:

1. Please indicate how and when employees will be trained on employee health policy, food safety, and allergens? Method of training and tracking mechanism:

2. Which barriers (such as disposable, single-use gloves, utensils, food grade paper, etc.) do you plan to utilize to prevent handling of ready-to-eat foods with bare hands?

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3. Is there a written policy to exclude or restrict food workers who are sick or have infected cuts and lesions? YES NO Please describe briefly or attach a copy:

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 sanitized?

Chemical Type: _______________ Concentration: ________________ Test Kit: YES NO

5. Will ingredients for cold ready-to-eat foods such as tuna, mayonnaise and eggs for salads and sandwiches be pre-chilled before being mixed and/or assembled? YES NO If not, how will ready-to-eat foods be cooled to 41ºF?

6. Are raw fruits and vegetables served on the menu or ingredients in dishes? YES NO If yes, is a dedicated sink provided for washing raw fruits and vegetables prior to their preparation?

YES NO

7. Will the facility be serving food to a highly susceptible population? YES NO If yes, how will the temperature of foods be maintained while being transferred between the kitchen and service area?

8. Are there any other locations besides the main kitchen area is which food is planned to be held or stored prior to being served?

The undersigned hereby applies for a permit to operate a Food Service Establishment pursuant to O.C.G.A. 26-2-371-373 and hereby certifies that he has received a copy of the Rules and Regulations for Food Service, Chapter 511-6-1, Georgia Department of Public Health. Further and if granted a permit by the Health Authority to operate a food service establishment, the undersigned agrees to comply with all provisions contained with the Rules and Regulations of Chapter 511-6-1.

Signed: ______________________________ Date: ________________________________ Print Name: ___________________________ Title: _________________________________ (State Whether Business Owner or Authorized Agent)

NOTE: ANY CHANGES IN THE EXISTING FOOD SERVICE ESTABLISHMENT FACILITY WILL

REQUIRE THE OWNER OR AGENT TO CONTACT THE LOCAL HEALTH AUTHORITY. IT IS

ILLEGAL FOR FOOD SERVICE ESTABLISHMENTS TO BEGIN OPERATION TO SERVE FOOD

TO THE PUBLIC WITHOUT FIRST OBTAINING A VALID FOOD SERVICE PERMIT FROM THE

LOCAL HEALTH AUTHORITY.

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PLAN REVIEW INFORMATION

A. FINISH SCHEDULE

Applicant must indicate which materials (quarry tile, stainless steel, 4" plastic coved molding, etc.) will be used in the following areas.

FLOOR COVING WALLS CEILING

Kitchen

Bar

Food Storage

Other Storage

Toilet Rooms

Dressing Rooms

Garbage &

Refuse Storage

Mop Service

Basin Area

Warewashing

Area

Walk-in

Refrigerators

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B. INSECT AND RODENT CONTROL

APPLICANT: Please check appropriate boxes.

YES NO NA

1. Will all outside doors be self-closing and rodent proof ?

2. Are screen doors provided on all entrances left open to the outside?

3. Do all openable windows have a minimum #16 mesh screening?

4. Is the placement of electrocution devices identified on the plan?

5. Will all pipes & electrical conduit chases be sealed; ventilation systems exhaust and intakes protected?

6. Is area around building clear of unnecessary brush, litter, boxes and other harborage?

7. Will air curtains be used?

If yes, where? ________________

C. GARBAGE AND REFUSE

Inside

8. Do all containers have lids?

9. Will refuse be stored inside?

If so, where? ____________________________

10. Is there an area designated for garbage can or floor mat cleaning?

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Outside

11. Will a dumpster be used?

Number ________ Size ________ Frequency of pickup ___________ Contractor ___________________

12. Will a compactor be used?

Number ________ Size ________ Frequency of pick up ___________ Contractor ______________________

13. Will garbage cans be stored outside?

14. Describe surface and location where dumpster/compactor/garbage cans are to be stored:

15. Describe location of grease storage receptacle

16. Is there an area to store recycled containers?

Describe

Indicate what materials are required to be recycled;

Glass Metal Paper

Cardboard Plastic

17. Is there any area to store returnable damaged goods?

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D. PLUMBING CONNECTIONS (Write NA if not applicable)

AIR GAP AIR

BREAK

*INTERAL

TRAP

*P

TRAP

VACUUM

BREAKER

CONDENSATE

PUMP

18. Toilet

19. Urinals

20. Dishwasher

21. Garbage Grinder

22. Ice Machines

23. Ice storage bin

24. Sinks

a. Mop sink

b. Janitor sink

c. Handwash sink

d. 3 Compartment sink

e. 2 Compartment sink

f. 1 Compartment sink

g. Water Station

25. Steam Tables

26. Dipper Wells

27. Refrigeration condensate/drain lines

28. Hose connection

29. Potato peeler

30. Beverage Dispenser w/carbonator

31. Other __________

* TRAP: A fitting or device which provides a liquid seal to prevent the emission of sewer gases without materially affecting the flow of sewage or waste water through it. An integral trap is one that is built directly into the fixture, e.g., a toilet fixture. A “P” trap is a fixture trap that provides a liquid seal in the shape of the letter “P”. Full “S” traps are prohibited.

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32. Are floor drains provided & easily cleanable, if so, indicate location:

E. WATER SUPPLY

35. Is ice made on premises or purchased commercially?

If made on premise, are specifications for the ice machine provided? YES NO Describe location and method for ice scoop storage:__________________________________

Provide location of ice maker or bagging operation

36. What is the capacity of the hot water generator?_______________________________________

37. Is the hot water generator sufficient for the needs of the establishment? YES NO Please provide the Water Heater:

Make _____________ Model _________________ Storage Capacity ______

BTU or KW ________

38. Is there a water treatment device? YES NO

If yes, how will the device be inspected & serviced?

39. How are backflow prevention devices inspected & serviced?

F. SEWAGE DISPOSAL

40. Is building connected to a municipal sewer? YES NO

41. If no, is private disposal system approved? YES NO PENDING Please attach copy of written approval and/or permit.

42. Are grease traps provided? YES NO If so, where? ____________________________________________________________

Provide schedule for cleaning & maintenance______________________________________

LOCATION

FILTER &/OR

EXTRACTION

DEVICES

SQUARE

FEET

FIRE

PROTECTION

AIR CAPACITY

CFM

AIR MAKEUP

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G. DRESSING ROOMS

43. Are dressing rooms provided? YES NO

44. Describe storage facilities for employees' personal belongings (i.e., purse, coats, boots, umbrellas, etc.)

GENERAL

45. Are insecticides/rodenticides stored separately from cleaning & sanitizing agents?

YES NO

Indicate location:

46. Are all toxics for use on the premise or for retail sale (this includes personal medications), stored away from food preparation and storage areas? YES NO

47. Are all containers of toxics including sanitizing spray bottles clearly labeled? YES NO

48. Will linens be laundered on site? YES NO If yes, what will be laundered and where?___________________________________________________________________

If no, how will linens be cleaned?

49. Is a laundry dryer available? YES NO

50. Location of clean linen storage:

51. Location of dirty linen storage:

52. Are containers constructed of safe materials to store bulk food products? YES NO Indicate type:

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53. Indicate all areas where exhaust hoods are installed:

LOCATION FILTERS &/OR

EXTRACTION

DEVICES

SQUARE

FEET

FIRE

PROTECTION

AIR

CAPACITY

CFM

AIR MAKEUP

54. How is each listed ventilation hood system cleaned?

I. SINKS

55. Is a mop sink present? YES NO If no, please describe facility for cleaning of mops and other equipment:

56. If the menu dictates, is a food preparation sink separate from a dedicated raw fruit and vegetable sink present? YES NO

J. DISHWASHING FACILITIES

57. Will a dishwasher be used for warewashing in addition to the required three compartment sink?

YES NO

58. Dishwasher Type of sanitization used (if applicable):

Hot water (temp. provided) ___________ Booster heater_____ Chemical type _________

Is ventilation provided? YES NO

59. Do all dish machines have templates with operating instructions? YES NO

60. Do all dish machines have temperature/pressure gauges as required that are accurately working? YES NO

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61. Does the largest pot and pan fit into each compartment of the pot sink? YES NO If no, what is the procedure for manual cleaning and sanitizing?

62. Are there drain boards on both ends of the pot sink? YES NO

63. What type of sanitizer is used? Chlorine Quaternary ammonium Other _____________

64. Are test papers and/or kits available for checking sanitizer concentration? YES NO

K. HANDWASHING/TOILET FACILITIES

65. Is there a hand washing sink in each food preparation and warewashing area? YES NO

66. Do all hand washing sinks, including those in the restrooms, have a mixing valve or combination faucet? YES NO

67. Do self-closing metering faucets provide a flow of water for at least 15 seconds without the need to reactivate the faucet? YES NO

68. Is hand soap available at all hand washing sinks? YES NO

70. Are hand drying facilities (paper towels, blowers) available at all handwash sinks? YES NO

71. Are covered waste receptacles available in each restroom? YES NO

72. Is hot and cold running water under pressure available at each hand washing sink? YES NO

73. Are all toilet room doors self-closing? YES NO

L. EMERGENCY ACTION PLAN

74. If at any time your operation experiences an electrical or water interruption, do you have an Emergency Action Plan (EAP)? YES NO

…If your answer is YES, please ATTACH plan to this application along with all other documents requested.

If your answer is NO, please EXPLAIN your operation’s alternative to an EAP (such as, a temporary closure). *Note: Information provided in this blank is for informational purposes ONLY. Providing an alternative to an EAP is not an approval for such activity from Georgia Department of Public Health. It is recommended to discuss any alternatives with your local EHS for verification of whether your operation is in compliance with Chapter 511-6-1.

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STATEMENT: I hereby certify that the above information is correct, and I fully understand that any deviation from the above information and approved food service plans and specifications without prior permission from the local health authority may nullify this approval. Approval of these plans and specifications by the local health authority DOES NOT indicate compliance with any other code, law or regulation that may be required – federal, state, or local. It DOES NOT constitute endorsement or acceptance of the completed establishment (structure or equipment). A final inspection of each completed establishment with the necessary equipment will be necessary to determine if it complies with the Georgia Rules and Regulations Governing Food Service Establishments. A food Service permit from the local health authority must be secured before this establishment can operate as a food service establishment.

Signed: _______________________________________ Date ______________________________

Print Name: __________________________________ Title:______________________________ (State Whether Business Owner or Authorized Agent)