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F:\Dept_Docs\FOOD\Plan Review Application\FOOD SERVICE PLAN Review Application Packet REV-01-29-20.doc
FOODSERVICE
PLAN
REVIEW
Application Requirements
& Guidelines
The Bethel Health Department is concerned about your time and
expense in building or remodeling a foodservice establishment.
We would like to make the plan review process as quick and
trouble free as possible. To help assure a timely review process,
please read and follow the Plan Review Guidelines attached.
Failure to submit complete and required information will cost you
time and may result in additional fees and delays.
This application is your checklist of everything you will need to
submit to us to insure a timely approval.
2
BETHEL HEALTH DEPARTMENT
Clifford J. Hurgin Municipal Center, 1 School Street,
Bethel, Connecticut 06801
(203) 794-8539
FOODSERVICE ESTABLISHMENT PLAN REVIEW APPLICATION
Application # ________________
Application Date _____________
Initial Plan Review: Class 1 ($150) Class 2 ($200) Class 3 ($300) Class 4 ($300)
Revised Plan Review: $100.00
Establishment Name: ___________________________________ Phone: _______________
Establishment Address: ________________________________________________________
Owner / Operator Name: ________________________________ Phone: _______________
Owner / Operator Address: _____________________________________________________
Contractor: ___________________________________________ Phone: _______________
Contractor Address: ___________________________________________________________
Date of Planned Opening: _________ Seating Capacity: ________ # Employees: ________
Type of Water Supply: Public Water Well If Well, yield __________gpm
Type of Sewage Disposal: Sewer Septic System
Is owner / operator a certified food manager? Yes No
Type of Establishment
Restaurant Market Caterer Vendor School Corporate Cafeteria
Hours of Operation: Sun _______ Mon _______ Tue _______ Wed _______ Thu _______
Fri _______ Sat _______
Total square feet of facility _______________
My signature below certifies that I have read all of the requirements and information contained in
this application:
Signature of Owner / Operator: _____________________________ Date _______________
Instructions for use of this form: Please write in the information where spaces have been
provided. If question does not pertain to your particular establishment, write N/A.
3
BETHEL HEALTH DEPARTMENT
Clifford J. Hurgin Municipal Center, 1 School Street,
Bethel, Connecticut 06801 - (203) 794-8539
Please submit with this application: Application # __________
1. Q.F.O. certificates for all new Q.F.O. staff Licensing Year ________
2. A current copy of your menu, if changed Date ________
3. Tax Collectors Approval
FOOD SERVICE LICENSE APPLICATION
Pursuant to the Code of the Ordinances of the Town of Bethel and the State Public Health Code, application is hereby made
for a license to operate a food establishment in the Town of Bethel. By this application, it is hereby agreed that the food
establishment will comply with the provisions of these regulations. Licenses are not transferable.
Check One: Amt. Due Amount Pd Cash/Ck# Recipt #
213.1 Annual Renewal Fee - Class 1 $175.00
213.2 Annual Renewal Fee – Class 2 $350.00
213.3 Annual Renewal Fee – Class 3 $350.00
213.4 Annual Renewal Fee – Class 4 $375.00
212.1 New Business /Change of Owner – Class 1 $175.00
212.2 New Business /Change of Owner – Class 2 $350.00
212.3 New Business /Change of Owner – Class 3 $350.00
212.4 New Business /Change of Owner – Class 4 $375.00
215 Reinspection Fee $75.00
Name of Business
Location of Business (Street #) (Street)
Business Phone
24 Hr. Emergency Contact Name (REQUIRED) Phone:
Type of Business: Restaurant Market/Grocery Store Deli/Convenience Store Caterer
Vendor Corporate Cafeteria School/ Day Care Health Care Institute Other
Owner or Operator ______________________________________________________________
If partnership or more than one owner, please complete page 2 of this application with a list of all names,
titles,
Home addresses and phone numbers and their signatures.
Home Address (No PO Boxes) ______________________________________________________
Home Phone ____________________________________________________________________
Qualified Food Operator _____________________________ Cert. #________________________
Alternate Qualified Food Operator __________________________ Cert. #_____________________
Continue on page 2
4
Page 2
Check All Applicable Boxes
Water: public well not applicable
Sewage Disposal: sewer septic system not applicable
Grease Trap: internal external heat assisted not applicable
Liquor Served: yes no (If yes, please submit a copy of liquor license.)
Seating Capacity: _________
Hours of operation: Mon ______ Tues ______ Wed ______ Thu ______ Fri ______ Sat ______ Sun______
Example: Mon: 11-9 Tues11-9 Wed 11-9 Thu 11-9 Fri 11-10 Sat 11-10 Sun closed
Signature of Licensee _________________________________________ Date ________________
Note: Establishments on private water supply wells must submit a complete water analysis report from a state certified
laboratory prior to the issuance of an annual license.
Licenses are sissued after tax collector approval
5
Bethel Health Department
Page 2, Food Service License Application:
The following information is required when the business is owned by a partnership or
Corporation. Please complete the necessary information for each partner.
Name of Business:
Business Partners:
Name (emergency person – 24 hr. availability)
Home Address (No PO Boxes)
Home Phone
Signature of Licensee _________________________________________ Date ________________
Name
Home Address (No PO Boxes)
Home Phone
Signature of Licensee _________________________________________ Date ________________
Name
Home Address (No PO Boxes)
Home Phone
Signature of Licensee _________________________________________ Date ________________
Name
Home Address (No PO Boxes)
Home Phone
Signature of Licensee _________________________________________ Date ________________
Name
Home Address (No PO Boxes)
Home Phone
Signature of Licensee _________________________________________ Date ________________
6
BETHEL HEALTH DEPARTMENT
Clifford J. Hurgin Municipal Center, 1 School Street,
Bethel, Connecticut 06801
(203) 794-8539
APPLICATION FOR INSTALLATION OF A COMMERCIAL
KITCHEN VENTILATION HOOD
NEW INSTALLATION REPLACEMENT
Food Establishment _____________________________________________________________
Address _______________________________________________________________________
Fabricator/Manufacturer of Hood* ___________________________________________________
Address _______________________________________________________________________
City ____________________ State __________ Zip __________ Phone ___________________
*If fabricator is custom building unit detailed plans and installation instructions are required. If using production model,
manufacturer’s name, address, model number, spec sheets and installation instructions are required.
I hereby certify that I will conform with the following requirements:
1. The hood and ventilation system shall be stainless steel, will meet NFPA Standard #96 and
will be NSF listed and approved by the building department.
2. The wall behind the cooking equipment will be covered with stainless steel and shall extend
from the hood to the floor in a manor that will prevent grease build up and facilitate
cleaning.
3. Detailed plans shall be submitted to the Health Department, the Building Department and
the Fire Marshall for approvals prior to the start of construction.
4. Any additions, deletions or modifications to the plans shall be submitted to the above offices
for approval prior to making changes.
5. The Health Department reserves the right to require modifications should unexpected
conditions arise.
6. The exhaust system shall be installed in accordance with the manufacture’s instructions or
the building or fire codes, whichever is most restrictive.
Signature of Contractor __________________________________ Date ____________________
Business Name ________________________________________Contact Name _____________
Business Address ______________________________________Telephone ________________
7
BETHEL HEALTH DEPARTMENT
Clifford J. Hurgin Municipal Center, 1 School Street,
Bethel, Connecticut 06801
(203) 794-8539
To: The Department of Liquor Control
165 Capitol Avenue
Hartford, CT 06106
I certify that: __________________________________________________
Name of Permittee
__________________________________________________
Name of Establishment
__________________________________________________
Street
__________________________________________________
Town
complied with the requirements of the State Public Health Code of places dispensing food and
beverages at the time of inspection.
____________________ _______________________________
Date Signature of Director of Health
or Authorized Agent
8
PLAN REVIEW GUIDELINES
1. Plans must be complete, to scale (¼ inch = 1 foot), and must include the following:
a. A sample menu.
b. Name, seal and signature of architect who did plans (if applicable) and date of
plan.
c. Equipment layout.
d. Equipment list by manufacturer and model number.
All equipment must be NSF approved or equivalent.
Use of non-commercial equipment is prohibited.
e. Manufacturers equipment specification sheets (cut sheets).
f. Mechanical diagrams, including plumbing, electrical, heating and ventilation.
g. Interior finish schedule.
2. Fill out application for plan review and include application fee Initial Plan Review: Class
1 ($150) Class 2 ($200) Class 3 ($300) Class 4 ($300) Revised Plan Review:
($100.00) made payable to the ‘Town of Bethel’.
3. You will be notified in writing after your plans are reviewed and approved.
4. Required inspections:
a. After plumbing roughed in.
b. After wall, floor and ceiling finishes are in.
c. After hood is installed.
d. After equipment is installed and establishment is ready to open.
5. DO NOT BEGIN ANY FORM OF RENOVATION, REMODELING OR CONSTRUCTION
ACTIVITY WITHOUT WRITTEN CONSENT FROM THIS OFFICE.
6. A complete water analysis must be submitted by a state certified laboratory if the
establishment is served by a well.
7. A pre-operational inspection must be conducted by this office and a license obtained
before you can open for business.
8. Sign-off on a liquor permit will not occur until after the pre-operational inspection.
If there are any equipment changes, building modifications, etc. after the original plans have
been approved, you must notify us for our approval.
Thank you for your cooperation.
9
CONTENTS AND FORMAT OF PLANS AND SPECIFICATIONS
1. Plans shall be a minimum of 11 x 14 inches in size and the layout of the floor plan
accurately drawn to a minimum scale of ¼ inch = 1 foot. This is to allow for ease in
reading plans.
2. Information accompanying the plan shall include: the proposed menu, seating capacity,
projected daily meal volume for food service operations.
3. The plan shall show the location and when requested elevated drawings of all food
service equipment. Each piece of equipment shall be clearly labeled on the plan
with a number that will be the same on the plan, on the schedule/list of equipment
and on the each spec sheet that will be submitted with the plan.
4. Adequate rapid cooling including ice baths and refrigeration, and hot-holding facilities for
potentially hazardous foods shall be clearly designated on the plan.
5. When menu dictates, separate food preparation sinks shall be labeled and located to
preclude contamination and cross-contamination of raw and ready-to-eat foods.
6. Adequate hand washing facilities used for no other purpose shall be designated for each
toilet room and in the immediate area of food preparation, food dispensing, and utensil
washing.
7. The plan layout shall contain room size, space between and behind equipment and
placement of the equipment on the floor.
8. Auxiliary areas such as storage rooms, garbage rooms, toilets, basements and/or cellars
used for storage or food preparation shall be represented on the plan and all features of
these rooms shown as required by these standards.
9. The plan and specifications shall also include:
a. Entrances, exits, loading/unloading areas and docks;
b. Complete finish schedules for each room to include floors, walls, ceilings and
covered juncture bases;
c. Plumbing schedule to include location of floor drains, floor sinks and water supply
lines, overhead waste waterlines, hot water generating equipment with capacity
and recovery rate, back flow prevention, waste water line connections;
d. Lighting schedule with protectors;
Food contact surfaces = 50 foot candles (540 lux)
All other areas = 20 foot candles (220 lux)
During periods of cleaning = 10 foot candles (110 lux)
10
e. Equipment schedule to include make and model numbers and National Sanitation
Foundation (NSF) or equivalent listing (when applicable) of all food service
equipment;
f. Source of water supply and method of sewage disposal. The location of these
facilities shall be shown and evidence submitted that state and local regulations
are to be complied with;
g. A color-coded flow chart demonstrating flow patterns for:
- food (receiving, storage, preparation, service)
- food and dishes (portioning, transport, service)
- dishes (clean, soiled, cleaning, storage)
- utensil (storage, use, cleaning)
- trash and garbage (service area, holding, storage)
h. Ventilation schedule for each room;
i. A mop sink with facilities for hanging wet mops;
j. Garbage can washing area/facility;
k. Cabinets for storing toxic chemicals;
l. Dressing rooms, locker areas, employee rest areas and/or coat rack as required;
m. Completed checklist;
n. Site plan (plot plan).
11
FOOD PREPARATION REVIEW
Check categories of Potentially Hazardous Foods (PHF’s) to be handled, prepared and
served.
CATEGORY YES NO
1. Thin meats, poultry, fish, eggs
2. Thick meats, whole poultry
3. Cold processed foods
(salads, sandwiches, vegetables)
4. Hot processed foods
(soups, stews, chowders, casseroles)
5. Bakery goods
(pies, custards, creams)
6. Other: _______________________________________________________________
* A generic HACCP plan for each category of food should be obtained for reference from
the health department.
PLEASE CHECK / ANSWER THE FOLLOWING QUESTIONS
FOOD SUPPLIES:
1. Is adequate and approved freezer and refrigeration available to store frozen foods at 0F
and below, and refrigerated foods at 41F (5C) and below? Yes No
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? Yes No
Number of refrigeration units: __________
Number of freezer units: __________
4. Is there a bulk ice machine available? Yes No
12
THAWING:
Please indicate by checking the appropriate boxes how potentially hazardous foods (PHF’s) in
each category will be thawed. More than one method may apply.
THICK THIN COLD HOT BAKED
MEATS MEATS FOODS FOODS GOODS
Refrigeration
Running Water
Less than 70F (21C)
Microwave
Cooked Frozen
(indicate wt.)
Other
(describe)
COOKING:
1. Will food product thermometers (0 - 212F) be used to measure final cooking reheating
temperatures of PHF’s? Yes No
Minimum cooking time and temperatures of product utilizing convection and conduction
heating equipment:
beef roast 130F 121 minutes
seafood 145F 15 seconds
pork 155F 15 seconds
eggs 145F 15 seconds
comminuted meats 155F 15 seconds
poultry 165F 15 seconds
other PHF’s 145F 15 seconds
* reheated PHF’s 165F 15 seconds
2. List type of cooking equipment:
13
HOT/COLD HOLDING:
1. How will hot PHF’s be maintained at 140F (60C) and above during holding for service?
Indicate type and number of hot holding units.
______________________________________________________________________
______________________________________________________________________
2. How will cold PHF’s be maintained at 41F (5C) and below during holding for service?
Indicate type and number of cold holding units.
______________________________________________________________________
______________________________________________________________________
COOLING:
THICK THIN COLD HOT BAKED
MEATS MEATS FOODS FOODS GOODS
Shallow Pans
Ice Baths
Reduce Volume
Rapid Chill
Other
(describe)
PREPARATION:
1. Please list categories of food prepared more than 12 hours in advance of service.
______________________________________________________________________
______________________________________________________________________
2. Will employees be trained in good food sanitation practices using a certified food service
sanitation course? Yes No
Name of course ________________________________________________________
3. Will disposable gloves and/or utensils and/or food grade paper be used to minimize
handling of ready-to-eat foods? Yes No
14
4. Is there an established policy to exclude or restrict food workers who are sick or have
infected cuts and lesions? Yes No
Please describe briefly: ___________________________________________________
______________________________________________________________________
______________________________________________________________________
5. 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
6. 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?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
7. Will all produce be washed prior to use? Yes No
Is there an approved location used for washing produce? Yes No
8. Describe the procedure used for minimizing the length of time PHF’s will be kept in the
temperature danger zone (41F - 140F) during preparation.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
9. Provide a HACCP plan for each category of vacuum packaged food item.
15
FINISH SURFACES REVIEW
I FLOORS
Floors must be smooth, impervious, non-absorbent, easily cleanable and commercial
grade. Quarry tile, commercial vinyl tile or a seamless poured epoxy floor is acceptable.
II WALLS
Walls must be smooth, impervious, non-absorbent, light colored and easily cleanable.
All food prep, warewashing or other areas subject to abuse or splashing must be either
FRP (Fiberglass Reinforced Polyester), ceramic tile, commercial marble or stainless
steel. Exposed waterlines, waste lines, gas lines or conduits are prohibited.
A 4-inch cove molding must be supplied on all walls. Indicate type of coving:
vinyl base quarry tile base
III CEILINGS
Ceilings must be smooth, impervious, non-absorbent and easily cleanable. Painted
sheetrock or vinyl faces suspended ceiling tiles are acceptable. Porous tiles are
acceptable only in customer seating areas. Exposed waterlines, waste lines, gas lines or
conduits are prohibited.
Material
Finish
Color
Kitchen
Floors
Walls
Ceilings
Prep Area
Floors
Walls
Ceilings
Warewashing
Floors
Walls
Ceilings
Storage Rooms
Floors
Walls
Ceilings
Restrooms
Floors
Walls
Ceilings
Bar
Floors
Walls
Ceilings
Locker Room
Floors
Walls
Ceilings
16
IV DOORS AND WINDOWS
All doors and windows must be tight fitting to exclude the entrance of insects and
rodents. Doors and drive-thru windows must be self-closing. Screening material shall
not be less than 16 mesh to the inch.
Windows that open: screened self-closing
Outside doors: screened self-closing
V LIGHTING
50-foot candles of light must be provided on all working surfaces and equipment in food
preparation, food storage, utensil washing and hand washing areas.
20-foot candles of light must be provided in toilet rooms measured at a distance of 30
inches from the floor.
Protective shielding must be provided for all light fixtures in food and clean equipment
areas. Shatterproof bulbs such as “tuff-skin” or “shat-r-shield” may be used in place of
plastic shields.
VI VENTILATION
Ventilation must be adequate so that all areas are kept reasonably free from excessive
heat, steam, condensation, vapors, fumes or objectionable odors. Exhaust hoods must
be designed to prevent grease or condensate from dripping into the food and the filters
or baffles must be readily removed for cleaning. Make-up air must be of adequate size,
design and properly located. Fire protection equipment must be installed so that it does
not create a cleaning problem or compromise the integrity of the original hood design.
Intake air ducts must be designed and located to prevent the
Hoods shall meet National Fire Protection Act Standard #96, be constructed of
stainless steel, and shall be NSF approved.
Cubic feet of air per minute exhausted through hood _______________
Cubic feet per minute of make-up air _______________
VII TOILET FACILITIES
Toilet facilities available to the public and employees are required. (Check with the
Building Official to confirm restroom requirements for your food service establishment.)
Facilities must be available to the public without passing through the kitchen.
Must be located within 500 feet if facility is located in multi-purpose building.
# of water closets for Men __________ Women __________
# of lavatories for Men __________ Women __________
# of urinals ________
17
Toilet facilities must be available and accessible all times establishment open.
Sanitary napkin receptacles must be provided in female restrooms.
(covered waste container)
Restrooms vented to outside by mechanical fan.
Restrooms must have self-closing doors.
VIII HANDWASHING FACILITIES
Handwashing facilities shall be provided for each food preparation area, food dispensing
area, utensil washing area, and toilet rooms.
All handwashing facilities provided with hot and cold water under pressure.
Each hand washing station provided with liquid soap dispenser and appropriate hand
drying
paper towels electric dryer
Faucet type to be used ________________________________________________
Note: Any self-closing or metering faucet must be capable of providing a flow of water for
at least 15 seconds.
IX FOOD PREP SINK
All raw fruits and vegetables shall be washed thoroughly before being cooked or served. A
separate sloped backsplash sink shall be provided for these food preparations.
X CHEMICAL STORAGE
All toxic materials including cleaning compounds, pesticides, sanitizers, etc. must be
stored in an area away from food preparation, and in a locked cabinet.
Location _________________________________________________________
XI CLEANING EQUIPMENT STORAGE
Cleaning equipment (mops, brooms, etc.) shall be stored in a room completely
separate from food storage or prep, utensil storage areas or utensil washing.
Slop sink with backflow preventer provided.
XII DRESSING ROOMS
Are separate dressing rooms provided? yes no
Are lockers provided? yes no
If not, describe storage facilities for employees’ personal belongings (purse, coat,
shoes, etc.) ___________________________________________________________
18
XIII LAUNDRY FACILITIES
Are laundry facilities located on premises? yes no
If yes, what will be laundered?
Washing Machine yes no
Dryer yes no
Location of clean linen
Location of dirty linen
XIV GARBAGE AND REFUSE
Interior
Will refuse be stored inside? yes no
If so, where
Is there a garbage can cleaning sink or area yes no
Exterior
Will dumpster be used? yes no
Number _______________ Size
Frequency or pick up
Contractor
Will a compactor be used? yes no
Number _______________ Size
Frequency of pick up
Contractor
Note: Dumpsters must be on concrete pad construction and screened or fenced from
view. See Process and Guidelines to be followed for Food Service Plan Reviews. All
dumpsters and compactors must be leak proof and have tight fitting lids.
Will garbage cans be stored outside? yes no
Describe surface and location where dumpster / compactor / cans are to be stored
Type and location of grease storage receptacle
Is there an area to store recycled containers? yes no
Describe
19
XV DISHWASHING FACILITIES
The Building Department requires detailed information on the use of the sinks noted on
plans to determine what plumbing connections are necessary
A 3-compartment sink must be provided with compartments that are large enough to
submerse the largest piece of equipment used.
Size of each compartment: L __________ W __________ D __________
Drain board at least 24 inches provided at each end of sink. Wall mounted drain shelving
may be substituted. (Wire shelves over sink.)
Will a dishwasher be used? yes no
NSF Approved yes no
Make _________________________ Model _________________________
Type of machine high temp chemical
Hot water requirements: __________ gallons per hour of __________ degree F water.
Booster Heater: Make _____________________ Model ___________________
Indirect waste line provided: yes no Ventilation required: yes no
XVI HOT WATER SUPPLY
Hot water heater: Make ____________________ Model ____________________
Fuel Type oil gas electric Size __________ gallons
Hot water requirements of establishment are __________ gallons per hour, based on
usage requirements of all fixtures.
XVII GREASE TRAPS
Applicants are required to plan for the construction of a grease trap/interceptor in
accordance with the treatment requirements of the Water Pollution Control Authorities.
Information is available through the WPCA and the Building Department.
XVIII EQUIPMENT – DESIGN, CONSTRUCTION, INSTALLATION
All foodservice equipment and utensils must be NSF approved or equivalent
Deli case refrigerators must meet CRMA standards
Equipment including ice machines and ice storage equipment shall not be located
under exposed sewer lines, waste lines or other sources of contamination.
Equipment used for food preparation or storage shall be installed so as to facilitate
cleaning around and beneath each unit.
For all floor mounted equipment, the space between adjoining units, and between a unit
and a wall must be either closed or sealed if exposed to seepage, or sufficient space
provided to facilitate easy cleaning between, behind and beside equipment.
20
Equipment, which is placed on tables or counters, must either be readily moveable,
sealed thereto, or mounted on legs at least 4 inches high to facilitate easy cleaning.
Cooking equipment (ranges, stoves, fryolators, etc.) shall be mounted on lockable
castors and supplied with a flexible reinforced AGA listed Z21.69-97 gas connection
hose. Spacing requirements listed below are not applicable in this instance.
Floor mounted cooking equipment, which is not able to be mounted on castors, must be
installed on and sealed to a non-absorbent masonry pad having a minimum thickness
of 6 inches.
Space Requirements:
If equipment is less than 24 inches wide, the space between equipment and wall must
be at least 6 inches.
If equipment is more than 24 inches but less than 72 inches wide, the space between
equipment and wall must be at least 12 inches.
If equipment is more than 72 inches wide, the space between equipment and wall must
be at least 18 inches.
XIX REFRIGERATION AND FREEZER STORAGE
WALK IN REFRIGERATORS WALK IN FREEZERS
Floors __________ __________ __________ __________
Walls __________ __________ __________ __________
Ceilings __________ __________ __________ __________
Size __________ __________ __________ __________
Interior finishes must be smooth, non-absorbent and easily cleanable.
Floors can be pre-fabricated from manufacturer or may be quarry tile.
A floor drain must be provided in the walk-in refrigerator with the floors pitched to the
drain. If this is not possible, a drain must be provided immediately outside the walk-in
door.
REACH-IN REFRIGERATORS AND FREEZERS
# of refrigerators_______________ capacity _______________ cubic feet
# of freezers _______________ capacity _______________ cubic feet
Thermometers must be provided in all refrigeration units in a location where they
can be seen easily.
XX FACILITIES TO PROTECT FOOD
21
All utensils and equipment must be stored at least 12 inches off the floor, and must be
clean, dry and protected from splash and dust.
Hot holding units must be capable of maintaining food at an internal temperature of 140
degrees F or above, during display, service or holding periods.
If food is transported to another location off premises, food must be protected from
contamination and held at proper holding temperatures. List equipment and procedures:
Appropriate thermometers required to monitor temperatures.
Are you having a salad bar? yes no
Type of foods: cold hot
Method of keeping foods cold: ice electric cold plate
Method of keeping hot food: ______________________________
Permanent drain installed yes no
Adequate sneeze guards provided
Are frozen deserts being portioned and dispensed? yes no
Running water dipper provided? yes no
Separate food preparation area provided for Sushi bar?
yes no not applicable
XXI DRY STORAGE
The dry storage space required depends on menu, number of meals, quantity purchased
and frequency of delivery.
Room free of overhead sewer and waste line pipes.
Adequate metal shelving provided. (Bottom shelves 12 inches above floor.)
Adequate metal or durable dunnage racks provided.
Adequate food containers with tight fitting covers and dollies provided.
Food dispensing scoops provided.
22
XXII PLUMBING AND CROSS CONNECTION CONTROL
You must hire a professional plumber with permits issued
through the Building Department. Plumbing code regulations
must be adhered to.
The Building department requires detailed information on
use of the sinks noted on plans to determine what plumbing
connections are necessary.
23
********************
********************
STATEMENT: I hereby certify that the above information is correct, and I fully understand
that any deviation from the above without prior permission from this Health Regulatory Office
may nullify this approval.
Signature(s):
_________________________________________________________________
_________________________________________________________________
owner(s) or responsible representative(s)
Date: ______________________
********************
I have provided/will provide the plumbing contractor with the information on pages 20-22.
Signed: _______________________________________ Date: __________________
********************
Approval of these plans and specifications by this Health Regulatory Authority
does not indicate compliance with any other code, law or regulation that may be
required – federal, state or local. It further does not constitute endorsement or
acceptance of the completed establishment (structure or equipment). A pre-
opening inspection of the establishment with equipment will be necessary to
determine if it complies with the local and state laws governing food service
establishme ts.
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FillableFOOD SERVICE PLAN Review Application Packet REV-02-26-2020 Template for Review of Engr plans memo

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Completed 11 July 2020

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