Transitional Permit Application (2023)

10 JOHNSTON COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 309 East Market Street , Smithfield , NC 27577 Phone 919 - 989 - 5180 Fax 919 - 989 - 5190 Emailehapplications @ johnstonncgovTransitional Permit Application Application Submittal This completed Application with the Floor Plan drawing and a proposed Menu must be submitted to the Johnston County Environmental Health Office prior to permitting This packet can be submitted in person or by mail at the address listed above It can also be submitted via email to the email address listed above There is not a fee for this application process General Information New Name of Establishment _________________________________________________________________________________ Address _________________________________________________________________________________________________ City ____________________________________________________________ Zip Code ________________________________ New Owner Name _________________________________ Corporation Name LLC , Inc , DBA ________________________________Phone Number _______________________________________ Email _______________________________________________ Mailing Address ___________________________________________________________________________________________ City ______________________________ State _________________________________ Zip Code ________________________ Contact Person Name ______________________________________________________________________________________ Phone Number _______________________________________ Email _______________________________________________ Previous Name of Establishment ______________________________________________________________________________ Previous Owner Name ___________________________________________ Phone Number _____________________________ Projected Date of Purchase _ _________________________________________________________________________________ Projected Date to Open under New Ownership __________________________________________________________________ Signature _ __________________________________________________________ Date ________________________________ New Owner or Owner's Representative Hours of Operation Sun _________ Mon _________ Tues ____ _____ Wed _________ Thurs ____ _____ Fri __ _______ Sat ____ _____ Type of Food Service Restaurant Food Stand no seats provided Drink Stand no food , multiuse cups only Commissary Meat Market Lodging Catering Only Other ___________________________________________________PageSeating and Type of Service Total Number of Seats if applicable __________________ Buffet or Self Service Yes No Service Items that will be used _____ Single Service Items all items disposable _____ Plates _____ Cups _____ Utensils _____ Multi Use Items wash & sanitize between users _____ Plates _ ____ Cups _____ Utensils Water Supply and Sewage Disposal Water Supply ______ Municipal ___ ___ Well Sewer ______ Municipal ______ Onsite Septic System Proposed Changes Include a Brief Description of any proposed changes for this facility Include any equipment changes , remodels , and expansions or additions _________________________________________________________________________________________________________ __ _______________________________________________________________________________________________________ __ _______________________________________________________________________________________________________ __ _______________________________________________________________________________________________________ __ _______________________________________________________________________________________________________ __ _______________________________________________________________________________________________________ __ _______________________________________________________________________________________________________ __ _______________________________________________________________________________________________________ Proposed Menu List the items that will be offered on your menu below a copy of the menu can also be attached to this application _________________________________________________________________________________________________________ __ _______________________________________________________________________________________________________ __ _______________________________________________________________________________________________________ __ _______________________________________________________________________________________________________ __ _______________________________________________________________________________________________________ __ _______________________________________________________________________________________________________ __ _______________________________________________________________________________________________________ __ _______________________________________________________________________________________________________ __ _______________________________________________________________________________________________________PageDrawing of the floor plan Include locations of sinks , dish machines , cooking equipment , coolers , freezers , can wash mop sinks , prep stations , serving areas , storage areas , outside storage or serving areas , beverage and bar areas If changes are going to be made , please indicate that as well on this plan Page