TENNESSEE DEPARTMENT OF AGRICULTURE
CONSUMER & INDUSTRY SERVICES
ATTN: FOOD & DAIRY
P.O. BOX 40627 Packages to: 436 HOGAN ROAD
NASHVILLE, TN 37204 NASHVILLE, TN 37220
PHONE# 615-837-5193 NEWFOOD.BUSINESS@TN.GOV
PLEASE CHECK ALL THAT APPLY:
MANUFACTURER ____
WAREHOUSE
____
C
OLD STORAGE
____
____
NEW ____ REMODEL ____ CONVERSION ____
SUPPLIERS
___________________________
(Upload copy of well water or spring approval from local environmental
FOOD MANUFACTURER / WAREHOUSE PLAN REVIEW QUESTIONNAIRE
Food Manufacturer plan review questionnaire to be completed by the Owner/Operator and submitted to Consumer & Industry.
Please refer to the Tennessee Statutes Title 53. Food, Drug and Cosmetic Act, 21 CFR Part 117 CURRENT GOOD
MANUFACTURING PRACTICES, HAZARD ANALYSIS AND RISK-BASED PREVENTIVE CONTROLS FOR HUMAN FOOD for
the basic requirements and more information.
BUSINESS NAME Include any dba _________________________________________________________________________________________
______________________________________________________________________________________________________________________
ADDRESS ________________________________________________________ CITY _________________________ ZIP CODE _____________
COUNTY _________________________________
PHONE NUMBER
PHONE ___________________________ CELL PHONE
NAME OF BUSINESS OWNER(S) _________________________________________
MAILING ADDRESS _______________________________________
CITY
_________________________
NAME OF CONTACT _____________________________________________________
DISTRIBUTION ___________________________
CHECK ONE:
WELL WATER ____ CITY WATER ____ SPRING ____
f
ield office or from the TN Dept of Environment & Conservation)
CHECK ONE: PUBLIC SEWAGE ____ SEPTIC TANK ____
TYPE OF PRODUCT(Choose all that apply to your operation):
Shelf Stable _____; Refrigerated _____; Frozen _____;
PRODUCT CATEGORY(S) that best describe your products: (Check all that apply)
Dressing/Condiments ___; Deer Processing ___; Bottled Water ___; Refrig Bakery Item ____; Non-Refrig Bakery Item ____;
Ready to Eat Salads ____; Honey/Sorghum ____; Snack Foods ____; Jam/Jelly ____; Meat Based ____; Custom Slaughter ____;
Alcoholic Beverage ____; Juice ____; Chocolate/Candy ____; Fish/ Seafood ____; Dry Mixes ____; Multi Foods ____; Other ____;
LIST ALL PRODUCTS that will be manufactured, prepared or processed?
BUILDING SIZE _________________________ NUMBER OF EMPLOYEES _________________________
HOURS OF OPERATION _________________ DAYS OF OPERATION _______________________ DATE OF OPENING _________________
DO YOU HAVE?
RECALL PROGRAM _____; HAZARDOUS ASSESSMENT _____; PREVENTIVE CONTROL QUALIFIED INDIVIDUAL _____
TRAINING PROGRAM ______; SANITATION PROGRAM _____; DOCUMENTED PROCESSES _____; FDA REG # _______________________
CITY
ZIP CODE
EMAIL ADDRESS
_______________________________________________________
PHONE NUMBER ___________________________
Ellington Agricultural Ctr, Box 40627, Nashville, TN 37204; Phone (615) 837-5193; newfood.business@TN.gov
Form AG0738 Rev. 07/21/2021
RDA 10178
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