Fillable Cleveland County Health Department Food Establishment Plan Review Application (City of Norman)

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Cleveland County Health Department Food Establishment Plan Review Application (City of Norman)

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Plan Review Application
Cover Page
Please return application along with fee to:
Cleveland County Health Department
250 12th Ave. NE
Norman, OK 73071
Phone: (405) 321-4048
Fax: (405) 329-1273
Web: cleveland.health.ok.gov
Oklahoma State Department of Health ODH Form 824
Consumer Health Service Page 1 of 16 (Rev./)
PLAN REVIEW APPLICATION
Establishment Type (select one): Food
Name of Establishment: County:
Street Address:
City: State: Zip Code:
APPLICANT INFORMATION:
Applicant’s Name / Title:
Primary Phone #: Secondary Phone #:
Street Address:
City: State: Zip Code:
E-Mail Address:
CONTACT INFORMATION IF DIFFERENT FROM APPLICANT:
Contact’s Name / Title:
Primary Phone #: Secondary Phone #:
Street Address:
City: State: Zip Code:
E-Mail Address:
Type of Ownership: Individual Partnership Corporation LLC
(if applicable) State Tax ID #: and/or Federal ID #:
Type of Construction:
New Construction (includes seasonal/mobile establishments) Remodel of existing food establishment
Existing establishment changing the type of operation Conversion of existing structure
Change of ownership with no changes in operation
NOTE: Temporary food establishments are exempt from plan review and will be evaluated for compliance on site.
HEALTH DEPARTMENT USE ONLY
Date Copy of Rules Received:
OAC 310:225 Owner
OAC 310:240
OAC 310:25 Manager
OAC 310:260
OAC 310:285
OSDH License #:
OSDH Receipt # / Date:
All facilities must be inspected and licensed prior to operation.
SUBMITTING THIS FORM DOES NOT CONSTITUTE
AUTHORIZATION TO OPEN AN ESTABLISHMENT.
Applicant’s Title
Applicant’s Signature / Date of Signature
Submit fully completed form with
$425
.00
nonrefunda
ble
fee (NO CASH) & plans to the address listed on cover page.
Lodging
Med. Marijuana
click to sign
signature
click to edit
Oklahoma State Department of Health ODH Form 824
Consumer Health Service Page 2 of 16 (Rev.)
PLAN REVIEW APPLICATION GUIDELINES
(Please complete all applicable sections)
SECTION I) ESTABLISHMENT INFORMATION
a) Name of Establishment:
b) Street Address of Establishment:
c) Type of Operation (check all that apply):
Frozen Food Locker Food Service Establishment Bar
Food Service Establishment w/Bar Combination Retail Food Mobile Food Svc.
Health Facility Retail Food Store School
Seasonal Food Non Profit Institution Food Processor
Privately Owned Prison Food Wholesaler Salvage Food
Water Bottling Facility Drug Manufacturer Drug Warehouse
Hotel and Motel Other (specify):
d) Type of Construction:
New Remodel  Conversion  Other (specify):
SECTION II) ESTABLISHMENT OPERATING INFORMATION
a) Daily Operating Hours
Sunday: Monday: Tuesday: Wednesday:
Thursday: Friday: Saturday: Seasonal (Months):
b) Seating Capacity (indicate number/amount)
Indoor Dining Seats: Outdoor Dining Seats:
c) Number of Staff (maximum per shift):
d) Area (indicate in # of total square feet)
Facility: Kitchen Area:
e) Maximum Meals to be Served (approximate)
Breakfast: Lunch: Dinner:
f) Project Dates: Start of Project: Completion of Project:
g) Type of Service (check all that apply)
Sit-Down Meals Take-Out Caterer
Single-Use Utensils Multi-Use Utensils Other (specify):
Oklahoma State Department of Health ODH Form 824
Consumer Health Service Page 3 of 16 (Rev.
SECTION III) ADDITIONAL DOCUMENTATION (Please include ALL of the following with the packet)
Proposed menus, including:
Seasonal
Off-site
Banquet
Plan of food establishment (should be drawn to scale or show dimensions), showing location of:
Equipment
Plumbing services
Electrical services
Mechanical services
Equipment schedule including:
Location
Plumbing
Drain connections
Electrical connections
Manufacturer specification sheets for each piece of equipment used. (Include custom fabricated equipment.)
Site plan showing location of establishment and location of building on site including:
Alleys
Streets
Location of any outside equipment or facilities (dumpsters, well, septic system - if applicable)
Completed Affidavit of Lawful Presence
Copy of valid ID of individual owner (prior to licensure)
Copy of Certificate of Incorporation if owned by LLC, INC, etc. (prior to licensure)
Copy of Oklahoma Sales Tax ID (prior to licensure)
SECTION IV) CONTENTS AND FORMAT OF PLANS AND SPECIFICATIONS
It is recommended that plans be drawn to scale or have dimensions indicated. Plans should be submitted on a minimum
of an 8.5” x 11” sheet of paper. The following should be indicated in these documents:
Location of all food equipment. Each piece of equipment must be clearly labeled, marked, or identified on the
floor plan.
Food equipment schedule which includes:
Make and model numbers and listing of equipment certified or classified for sanitation by an ANSI-accredited
certification program (when applicable).
Elevations may be necessary for equipment and storage (i.e., height of storage from floor).
Provisions for adequate rapid cooling, including ice baths and/or refrigeration, and hot-holding and cold-holding
of “Potentially Hazardous Foods.”
Sinks:
Hand-washing
Warewashing
Food preparation
Auxiliary areas:
Storage rooms
Garbage rooms
Toilets
Basements and/or cellars used for storage or food preparation
Entrances, exits, loading/unloading areas and delivery docks
Oklahoma State Department of Health ODH Form 824
Consumer Health Service Page 4 of 16 (Rev.12/16)
Complete finish schedules for each room, including:
Floors
Walls
Ceilings
Covered juncture bases
Plumbing schedule, including location of:
Floor drains
Floor sinks
Water supply lines
Overhead waste-water lines
Hot water-generating equipment: capacity/recovery rate, backflow prevention, wastewater line connections
Location of lighting fixtures
Source of water and method of sewage disposal
Ventilation schedule, if required, for mechanical warewashing, ventilation hoods, etc.
Service sink or curbed cleaning facility with:
Facilities for hanging wet mops; or
Similar wet cleaning tools and for disposal of mop water and similar liquid waste
Storage location of poisonous and/or toxic materials
Areas for storage of employee personal care items
Location of refuse, recyclable, and/or returnable containers
SECTION V) FOOD ESTABLISHMENT OPERATIONAL PLAN
Please allow up to two (2) weeks after the completed application has been submitted to your county health department for
review and approval. Please answer every question that applies to your food service operation. If it does not apply,
indicate “N/A” next to the question. Submitting incomplete plans will delay the plan review process.
Every section must be filled out by the operator and submitted prior to licensing. Add additional pages or documents
as needed to describe your operation.
The Oklahoma Food Code, Chapter 257 Title 310, can be obtained online at http://food.health.ok.gov (Adobe PDF reader
required).
a) Type of service that best describes your operation:
Cook and Serve Cook, Hold Hot and Serve
Cook, Chill, Reheat, Hold Hot and Serve Hold Cold and Serve
Commercially prepackaged food only (except beverage) Other (specify):
b) Will food be transported to another location as with a catering operation or satellite kitchen? Yes No
SECTION VI) FOOD PREPARATION
Check categories of Time/Temperature Control for Safety (TCS) Foods to be handled, prepared and served:
a) Thin meats, poultry, fish, eggs (hamburger; sliced meats; filets): Yes No
b) Thick meats, whole poultry (roast beef, whole turkeys, chickens, hams): Yes No
c) Cold processed foods (salads, sandwiches, vegetables): Yes No
d) Hot processed foods (soups, stews, rice/noodles, gravy, chowders, casseroles): Yes No
e) Bakery goods (pies, custards, cream fillings and toppings): Yes No
f) Other (specify):
Oklahoma State Department of Health ODH Form 824
Consumer Health Service Page 5 of 16 (Rev.12/16)
SECTION VII) FOOD PREPARATION PROCEDURES
Explain the handling/preparation procedures for the following categories of food. Describe the processes from
receiving to service including:
How the food will arrive (frozen, fresh, packaged, etc.)
Where the food will be stored
Where (prep table, sink, counter, etc.) the food will be washed, cut, marinated, breaded, cooked, etc.
When (time of day and frequency/day) food will be handled/prepared
a) Produce:
b) Poultry:
c) Meat:
d) Seafood:
SECTION VIII) FOOD SUPPLIES
a) Are all food supplies from inspected and approved sources? (check one) Yes No
b) List all food distributors for your facility:
c) List food from animals that you will serve raw or partially cooked (i.e., sushi, steak tartar, oyster shooters):
Oklahoma State Department of Health ODH Form 824
Consumer Health Service Page 6 of 16 (Rev.12/16)
d) If serving raw fish (i.e., sushi, lox, ceviche), will parasite destruction be done on-site or by the supplier? (See
310:257-5-49) Check one of the following:
On-site: Provide your procedure for parasite destruction. (A freezer used for parasite destruction must maintain -
4°F for 7 days. Measure and record temperature of freezer unit daily.)
Supplier: Provide the name of your supplier and documentation to show parasite destruction. (Each invoice
received from the supplier shall state the specific fish by species that has been frozen to meet the parasite destruction
requirements under 3-402.11.)
e) List your food suppliers for the following (310:257; Chapter 5)
Category
Supplier(s)
Game meats (i.e., emu, ostrich, elk):
Raw or partially cooked fish products
(i.e., lox, ceviche, raw oyster, sushi):
Fresh or live shellfish:
Wild mushrooms:
f) What are the projected frequencies of deliveries for:
1. Frozen foods:
2. Refrigerated foods:
3. Dry goods:
g) Provide information on the amount of space (in cubic feet) allocated for:
1. Frozen storage:
2. Refrigerated Storage:
3. Dry storage:
h) Describe how will dry goods be stored off the floor:
SECTION IX) COLD STORAGE
a) Is adequate and approved freezer and refrigeration available to keep frozen foods frozen, and store refrigerated foods
at 41°F (5°C) or below? Yes No
Provide the method used to calculate cold storage requirements:
b) Will raw meat, poultry or seafood be stored in the same refrigerators or freezers as cooked or ready-to-eat food?
Yes* No
*If Yes, how will cross-contamination be prevented?
c) Does each refrigerator/freezer have an ambient thermometer? Yes No
Number of refrigeration units: Number of freezer units:
d) Is ice: made on premises? or purchased commercially?
e) Will there be an ice bagging operation? Yes No
Oklahoma State Department of Health ODH Form 824
Consumer Health Service Page 7 of 16 (Rev.12/16)
SECTION X) THAWING FROZEN POTENTIALLY HAZARDOUS FOOD
Please indicate by checking the appropriate boxes how frozen time/temperature control for safety (TCS) foods in each
category will be thawed. More than one method may apply. (See 310:257-5-56.) Specify where thawing will take place.
Thawing Method
Thin Frozen Foods
(less than one [1] inch thick)
Refrigeration
Specify Location
Running water less than 70°F (21°C)
Specify Location
Microwave (as part of cooking process)
Specify Location
Cooked from frozen state
Specify Location
Other (describe)
Specify Location
SECTION XI) COOKING
a) Will food product thermometers be used to measure final cooking and reheating temperatures of TCS
(Time/Temperature Control for Safety) foods? Yes No
b) What type of temperature measuring device(s) will be available?
c) List types of cooking equipment.
SECTION XII) HOT/COLD HOLDING
a) How will hot TCS foods be maintained at 135°F or above during holding for service? Indicate type and number of hot
holding units.
b) How will cold TCS foods be maintained at 41°F or below during holding for service? Indicate type and number of
cold holding units.
c) Will time (4hr) be used as a control for TCS foods? Yes* No
*If Yes, a written procedures for all foods that will be held via time rather than temperature shall be prepared in
advance and submitted to the county health department for approval. See Attachment A of this packet for a guidance
document (310:257-5-62).
Oklahoma State Department of Health ODH Form 824
Consumer Health Service Page 8 of 16 (Rev.12/16)
SECTION XIII) COOLING
Please indicate by checking the appropriate boxes how TCS foods will be cooled to 41°F (5°C) within 6 hours (135°F to
70°F in 2 hours and 70°F to 41°F in 4 hours). Also, specify where the cooling will take place. (310:257-5-57 & 5-58)
Cooling Method
Thick Meat
Thin Meat
Thin Soup/Gravy
Thick Soup/Gravy/
Refried Beans
Rice/Pasta
Shallow Pans
(Specify location)
(Specify location))
(Specify location)
(Specify location)
(Specify location)
Ice Baths
(Specify location)
(Specify location))
(Specify location)
(Specify location)
(Specify location)
Reduce Volume/Size:
(Specify location)
(Specify location))
(Specify location)
(Specify location)
(Specify location)
Rapid Chill
(Specify location)
(Specify location))
(Specify location)
(Specify location)
(Specify location)
Other:
(Specify location)
(Specify location))
(Specify location)
(Specify location)
(Specify location)
(Specify location)
SECTION XIV) REHEATING
a) 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°F within two (2) hours? Indicate type/number of units used for reheating foods.
SECTION XV) PREPARATION
a) Please list categories of foods prepared more than twelve (12) hours in advance of service.
b) 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 washed, rinsed and sanitized?
c) 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 No, how will ready-to-eat foods be cooled to 41°F?
d) Will all produce be washed on-site prior to use? Yes No
1. Where is the planned location to be used for washing produce?
2. Describe the procedure for cleaning and sanitizing these sinks before use.
Oklahoma State Department of Health ODH Form 824
Consumer Health Service Page 9 of 16 (Rev.12/16)
e) Describe the procedure used to minimize the length of time TCS foods will be kept in the temperature danger zone
(41°F - 135°F) during preparation.
f) Will the facility be serving food to a highly susceptible population? Yes* No
*If Yes, how will temperature of foods be maintained while being transferred between kitchen and service area?
g) Will facility use specialized processing methods that require a HACCP plan? (see below) Yes No
HACCP (310:257-15-8 & 15-9) - Processes include but not limited to:
Packaging food using a reduced oxygen packaging method
Using food additives or adding components such as vinegar as a method of food preservation rather than as a
method of flavor enhancement
Smoking food as a method of preservation
Curing foods such as hams, sausages
Sprouting seeds or beans
h) Will there be any foods partially cooked before service? Yes* No
If Yes*, a written procedure is required to be submitted with application for review and approval, see (Attachment B,
Non-continuous cooking or Partial Cooking (310:257-5-48.1); complete all sections on written procedure sheet.
SECTION XVI) FINISH SCHEDULE
a) Indicate which materials will be used in the following areas. Materials such as (but not limited to):
quarry tile
stainless steel
Fiberglass Reinforced Panels [FRP]
ceramic tile
4" plastic-covered molding
You must indicate the wall color or provide a color sample with this application packet.
(Table continues next page.)
Area
FLOOR
FLOOR/WALL
JUNCTURE
WALLS
CEILING
Kitchen
Bar
Food Storage
Garbage/Refuse Storage
Other Storage
Mop Service Sink
Warewashing Area
Oklahoma State Department of Health ODH Form 824
Consumer Health Service Page 10 of 16 (Rev.12/16)
Dressing Rooms
Walk-in Refrigerators
and Freezers
Other (specify):
b) Identify the finishes of cabinets, countertops, and shelving: (i.e. sealed wood, formica, painted, etc.)
SECTION XVII) INSECT AND RODENT CONTROL
a) Will all outside doors be self-closing and rodent proof? Yes No N/A
b) Are screen doors provided on all entrances left open to the outside? Yes No N/A
c) Do all opening windows have a minimum of #16 mesh screening? Yes No N/A
d) Are electrical insect control devices identified on the plan? Yes No N/A
e) Will all pipes and electrical conduit chases be sealed? Yes No N/A
f) Will all ventilation systems exhaust and intakes be protected? Yes No N/A
g) Is area around building clear of unnecessary brush, litter, boxes
and other harborage? Yes No N/A
h) Will air curtains be used? If Yes, where? Yes No N/A
SECTION XVIII) GARBAGE AND REFUSE
a) Inside:
1. Do all garbage containers have lids? Yes No N/A
2. Will refuse be stored inside? Yes No N/A
If Yes, where?
3. Is there area designated for garbage can or floor mat cleaning? Yes No N/A
b) Outside:
1. Will a dumpster be used? Yes No N/A
If Yes: Number: Size: Frequency of pickup:
Contractor:
2. Will a compactor be used? Yes No N/A
If Yes: Number: Size: Frequency of pickup:
Contractor:
3. Will garbage cans be stored outside? Yes No N/A
4. Describe surface and location where dumpster/compactor/garbage cans are to be stored:
5. Describe location of grease storage receptacle:
6. Is there an area to store recycled containers? Yes No N/A
7. Indicate which material(s) must be recycled: Glass Metal Plastic Paper Cardboard
Oklahoma State Department of Health ODH Form 824
Consumer Health Service Page 11 of 16 (Rev.12/16)
SECTION XIX) WATER SUPPLY
a) Is water supply: public? or private? If private, has source been approved?* Yes No Pending
*You must attach a copy of written approval and/or permit from the Oklahoma Department of Environmental Quality
(or provide prior to opening).
b) Describe provision for ice scoop storage:
c) Is the hot water generator sufficient for the needs of the establishment? Yes No
d) What is the capacity and location of the water heater?
e) Provide calculations for necessary hot water to verify needs are met:
SECTION XX) SEWAGE DISPOSAL
a) Is building connected to a municipal sewer? Yes No*
*If No, is private disposal system approved?** Yes No Pending
**You must attach a copy of written approval and/or permit from the Oklahoma Department of Environmental
Quality (or provide prior to opening).
b) Are grease traps/interceptors provided? Yes* No
*If Yes, indicate the location?
Provide schedule for cleaning & maintenance:
SECTION XXIII) DRESSING ROOMS/EMPLOYEE PERSONAL STORAGE
a) Are dressing rooms provided? Yes No
b) Describe storage facilities for employees' personal belongings (i.e., purse, coats, boots, umbrellas, etc.):
SECTION XXI) GENERAL
a) Where will all toxics for use on the premises or for retail sale (this includes personal medications) be stored so that
they are away from food preparation and storage areas?
b) How will all containers of toxics, including sanitizing spray bottles be clearly labeled?
c) Will linens be laundered on site? Yes* No**
*If Yes, what will be laundered and where?
**If No, how will linens be cleaned?
d) Is a laundry dryer available? Yes No
e) Location of clean linen storage:
f) Location of dirty linen storage:
g) Are containers constructed of safe materials to store bulk food products? Yes No
Indicate type:
h) How often is each listed ventilation hood system cleaned?
Whole system:
Filters:
Oklahoma State Department of Health ODH Form 824
Consumer Health Service Page 12 of 16 (Rev.12/16)
SECTION XXII) SINKS
a) Is a mop sink present? Yes No*
*If No, please describe facility to be used for cleaning of mops and other equipment:
SECTION XXIII) DISHWASHING FACILITIES
a) Identify methods that will be used for warewashing? (Check all that apply.)
Mechanical Dishwasher Two-compartment sink Three-compartment sink
b) If Mechanical Dishwashing:
1. Identify the make and model of the mechanical dishwasher:
2. Type of sanitization used:
Hot water with booster heater (indicate temperature):
Chemical (indicate type):
3. Do all mechanical dishwashers have an audible or visual alarm to signal that
detergent or sanitizer needs to be added? Yes No
4. Do all dish machines have accurately working temperature/pressure gauges? Yes No
5. Are test papers and/or kits available for checking sanitizer concentration? Yes No
c) If Manual Dishwashing (Two- or Three-compartment sink used):
1. Identify the dimensions of the compartments of the two- or three-compartment sink:
Length: Width: Depth:
2. Does the largest pot / pan fit into each compartment of the two- or three- compartment sink? Yes No*
*If No, what is the procedure for manual cleaning and sanitizing?
3. Are there drain boards on both ends of the pot sink? Yes No*
*If No, indicate location and type of air drying space for wet equipment ( i.e. wall-mounted or overhead shelves,
stationary or portable racks):
4. What type of sanitizer is used?
Chlorine Quaternary Ammonium Iodine Other (specify):
5. Are test papers and/or kits available for checking sanitizer concentration? Yes No
SECTION XXIV) HAND-WASHING/TOILET FACILITIES
a) Is there a hand-washing sink in each food preparation and warewashing area? Yes No
b) Do any of the hand-washing sinks, including those in the restrooms, have a mixing valve or combination faucet?
Yes* No *If Yes, where?
c) Do self-closing metering faucets provide a flow of water for at least 15 seconds without the need to reactivate the
faucet? Yes No
d) Is hand cleanser (soap) available at all hand-washing sinks? Yes No
e) Are hand-drying facilities available at all hand-washing sinks? Yes No
f) Is one covered waste receptacle available in the women’s restroom? Yes No
g) Is the hot & cold running water under pressure available at each hand-washing sink? Yes No
Oklahoma State Department of Health ODH Form 824
Consumer Health Service Page 13 of 16 (Rev.12/16)
h) Are all toilet room doors self-closing? Yes No
i) Are all toilet rooms equipped with adequate ventilation? Yes No
j) Is a hand-washing sign posted by every hand sink, including restrooms? Yes No
SECTION XXV) BACKFLOW PREVENTION
Please provide the following specifications:
AIR GAP
AIR BREAK
VACUUM BREAKER
OTHER
Dishwasher
Garbage Grinder
Ice Machines
Ice Storage Bin
Sinks
a) Mop
b) 3-Compartment
c) 2-Compartment
d) 1-Compartment
a)
b)
c)
d)
a)
b)
c)
d)
a)
b)
c)
d)
a)
b)
c)
d)
Steam Tables
Dipper Wells
Potato Peeler Lines
Hose Bib Connection
Refrigeration
Condensate / Drain
Beverage Dispenser
with Carbonator
Identify the locations of all floor drains, if provided:
SECTION XXVI) SMALL EQUIPMENT REQUIREMENTS
Please specify the following:
Number
Location
Types
Slicers
Cutting Boards
Can Openers
Mixers
Floor Mats
Other
Oklahoma State Department of Health ODH Form 824
Consumer Health Service Page 14 of 16 (Rev.12/16)
SECTION XXVII) EMPLOYEE TRAINING
a) How will food employees be trained* in good food sanitation practices?
b) Number(s) of employees:
c) Dates of training* completion:
*Contact your county health department to verify if a Food Handler Card is required in your county of licensure.
d) Below, please describe the Bare Hand Contact procedures your facility will follow. You may contact your
county health department if guidance documents are needed for Bare Hand Contact procedures. (310:257-5-21)
1. Will disposable gloves, utensils, and/or food grade paper be used to
prevent handling of ready-to-eat foods? Yes** No*
*If No, is a written Bare Hand Contact policy or procedure on file? Yes No
**If Yes, list method(s) to be used and on what foods:
2. Is there a written policy to exclude or restrict food workers who are sick or have infected cuts and lesions?
(310:257-3-4) Yes No
3. Please describe illness sick policy:
4. How will employees be trained in the seven (7) major allergen groups? [310:257-3-2 (3)(A)]
Oklahoma State Department of Health ODH Form 824
Consumer Health Service Page 15 of 16 (Rev.12/16)
Attachment A
TIME AS A PUBLIC HEALTH CONTROL PROCEDURE
As specified in Chapter 257 Food Code 310:257-5-62
ESTABLISHMENT NAME:
ESTABLISHMENT ADDRESS:
Time only, rather than time in conjunction with temperature control, up to a maximum of 4 hours, will be used as the
public health control for the following food item(s):
Food
Method (e.g., chart, time stamp)
1. Food shall have an initial temperature of 41ºF or less if removed from cold holding temperature control, or 135°F or
greater if removed from hot holding temperature control.
2. Food shall be marked or otherwise identified to indicate the time that is 4 hours past the point in time when the food is
removed from temperature control (Method used to identify food will be submitted with this sheet for review).
3. Food shall be cooked and served, served if ready-to-eat, or discarded, within 4 hours from the point in time when the
food is removed from temperature control.
4. Food in unmarked containers or packages, or marked to exceed a 4 hour limit shall be discarded.
PIC / CFM: (Print)
(Signature)
(Date)
RPS: (Print)
(Signature)
(Date)
Oklahoma State Department of Health ODH Form 824
Consumer Health Service Page 16 of 16 (Rev.12/16)
Attachment B
Oklahoma State Department of Health ODH Form 301
Protective Health Services February 18, 2014
AFFIDAVIT OF LAWFUL PRESENCE
BY PERSON MAKING APPLICATION FOR A LICENSE, PERMIT OR CERTIFICATE
I, the undersigned applicant, being of lawful age, state that one of the following statements is true and correct:
(Check only ONE of the following statements that apply)
I am a United States citizen.
I am an approved alien under the federal Immigration and Nationality Act and am approved to be
present in the United States. I understand this approval may or may not include approval for
employment. The issuance of a license, permit or certificate by the Oklahoma State Department of
Health is not authorization for employment in the United States.
Admission/Registration #
Authorizing Document: (Attach a copy of the authorizing document.)
I state under penalty of perjury under the laws of Oklahoma that the foregoing is true and correct and that I have
read and understand this form and completed it in my own hand.
Print Name: Date:
City: State:
Signature: _____________________________________________________________________
For RENEWAL license, permit or certificate, please write the number:
(Current license, permit or certificate number)
INSTRUCTIONS FOR USE OF THIS AFFIDAVIT OF LAWFUL PRESENCE FORM:
The person signing this form must read these instructions carefully.
1. If the person signing this form is receiving services and not making an application for a license, permit or certificate, this form
should not be used but rather, either the form titled, "Affidavit of Lawful Presence by Parent or Guardian of Person Receiving
Services" or the form titled "Affidavit of Lawful Presence by Person Receiving Services" should be used.
2. If the person signing this form is a citizen of the United States then that person should check the box to the left of the statement,
"I am a citizen of the United States." If the person signing this form is not a citizen of the United States but is an approved alien under
the federal Immigration and Nationality Act and is lawfully present in the United States then that person should check the box to the
left of the statement, "I am an approved alien under the federal Immigration and Nationality Act and am approved to be present in the
United States."
3. If an approved alien, write the identification number in the “Admission/Registration #” field and write the name of the authorizing
document in the “Authorizing Document” field. (Examples of authorizing documents are: INS Form I-551 or INS Form I-94)
4. The person signing this form should write today’s date in the space provided; write the city and state where they are actually located
when they sign this form print and sign their name in the space provided; and if only if applying for a renewal write the current
license, permit or certificate number in the space provided.
5. Within this form, the term "penalty of perjury" means the willful assertion of the fact of either United States citizenship or lawful
presence in the United States as a qualified alien, and made upon one's oath or affirmation and knowing such assertion to be false.
Making such a willful assertion on this form knowing it to be false is a crime in Oklahoma and may be punishable by a term of
incarceration of not more than five (5) years in prison. Additionally, one who procures another to commit perjury is guilty of the crime
of subornation of perjury and may be punished in the same manner, as he would be if personally guilty of the perjury so procured.
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Cleveland County Health Department Food Establishment Plan Review Application (City of Norman)

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Completed 14 July 2020

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