Plan Review Application for Food Service Establishments (2023)

10 JOHNSTON COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 309 East Market Street , Smithfield , NC 27577 Phone 919 - 989 - 5180 Fax 919 - 989 - 5190 Email ehapplications @ johnstonncgov PLAN REVIEW APPLICATION FOR A FOOD SERVICE ESTABLISHMENT Procedure for Application and Plan Submission 1 Fully complete this plan review application , make sure to include a phone number for the contact person 2 Provide a drawing of the establishment showing location and description of all equipment This must be drawn to scale suchas ¼ " 1 ' 3 Provide a menu Please include an explanation of unique dishes 4 Provide equipment spec sheets on all equipment 5 The fee for this plan review is 25000 The completed Application , Menu , Drawing of the Facility , Equipment Spec Sheets and Fee should be returned to our office at the above address If emailed to us at the email address above , the fee can be paid over the phone with a card by calling 919 - 989 - 5180 Attached is an Employee Health Policy and a Vomit & Diarrhea clean up Policy Print both and keep for your records Type of Facility Check One Restaurant Food Stand Meat Market Catering Only Cafeteria Commissary Facility Information Name of Establishment ______________________________________________________________________ Establishment's Address _____________________________________________________________________ Phone if Available __________________________________________________________________________ Owner's Information Name of Owner __________________________Corporation Name LLC , Inc , DBA _________________________ Owner's Phone # ______________________________________Email _______________________________Mailing Address ___________________________________________________________________________ Contact Person's Information Name of Contact Person _____________________________________________________________________ Contact Person Phone # _________________________________ Email _______________________________ Mailing Address ____________________________________________________________________________ Operational Information Days and Hours of Operation Mon Tue Wed Thu Fri Sat Sun Will the Food Service have Buffet Customer Self Service Number of Seats ____________________________ Number of Staff _ ________________________________ Total Square Footage of the Facility ____________________________________________________________ Indicate any of the following Highly Susceptible populations that will be catered to or served Nursing Home Child Care Center Health Care Facility Assisted Living Center School with pre - school age childrenPageFood Preparation and Storage 1 Which of the following will be prepared in your facility Check all that apply Chicken - will you be using Cutting raw Whole raw Processed breasts Cooked from frozen state Raw hamburger - will you patty YES NO Raw shrimp - will you be cleaning YES NO Raw fish - will you be cleaning YES NO Raw beef or pork - will you be cutting YES NO Raw oysters - will they be served raw YES NO Raw vegetables - will you be washing YES NO 2 If any of the above has been checked , please indicate where these items will be washed and prepared or if they will be purchased pre - processed _______________________________________________________________ ___ ____________________________________________________________ Note If meats or vegetables are washed and prepared , separate prep sinks maybe required 3 Will you be cooling any item s Please describe the item s and indicate your procedure for cooling _______________________________________________________________ ___ ____________________________________________________________ ___ ____________________________________________________________ 4 Will any item s be pre - cooked and hot held Describe the item s and indicate how temperature will be maintained _______________________________________________________________ ___ ____________________________________________________________ ___ ____________________________________________________________ 5 Will any item s be thawed Describe the item s and indicate your procedure for thawing _______________________________________________________________ ___ ____________________________________________________________ 6 Indicate any specialized processes that will take place Curing Acidification sushi , etc Reduced Oxygen Packaging Vacuum Smoking Sprouting Beans Other _ _______________________ Explain the Specialized Process __________________________________________________________ _______ _____________________________________________________________________________Page7 Will food product thermometers be provided YES NO 9 Will food contact equipment be indirectly plumbed YES NO ie ice machine , prep sink s , drink machine , etc __________________________________________________________________________________________ Dishwashing Facilities 1 Do you plan to use multi - use dishes or glasses YES NO Check all that apply plates glasses silverware mugs If using only Single service disposable items , skip to questions # 4 2 How will your dishes and utensils be cleaned and sanitized Dishwasher Three compartment sink 3 If you are using a dishwasher , please answer the following Make and Model _ ____________________________________________________________________ How does it sanitize __________________________________________________________________ Water consumption per hour or per rack __________________________________________________ Do you have a prewash sink YES NO If no , how will you pre - clean , pre - flush , or pre - soak _________________________________________ _______ _____________________________________________________________________________ 4 In addition , what other dish washing facilities do you have Two compartment sink Three compartment sink 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 cleaned and sanitized ____________________________________________________________________________________ _______ _____________________________________________________________________________ _______ _____________________________________________________________________________ 6 Please describe your procedure to ensure all dishes and or pans will air dry ____________________________________________________________________________________ _______ _____________________________________________________________________________ 7 What is the size of the sink vats _____________ x _____________ x _____________ Drainboard Dimensions ______________ x _______________ 8 What type of sanitizer is going to be used for food contact surfaces Chlorine Quaternary ammonia Other Please describe _ ______________________________________ 9 Will test strips for testing sanitizer be provided YES NO __________________________________________________________________________________________PageHandwashing 1 Indicate Number and Location of the Handwashing Sinks _____________________________________ _______ _____________________________________________________________________________ _______ _____________________________________________________________________________ Water Heater 1 Water heater storage capacity _________________ Gallons Storage 2 Water heater recovery rate in gallons per hour at a 70F temperature rise _____________ GPH See Water Heater Calculations Worksheet 3 Are laundry facilities located on premises YES NO Water Supply & Sewage Disposal 1 Type of water supply public water well water 2 Wastewater Disposal municipal sewer on - site septic system Storage 1 How much dry storage do you have __________________________________________ square feet 2 Please indicate location of the following in your facility Dry food storage _ ____________________________________________________________________ Single service storage _ ________________________________________________________________ Paper products _ _____________________________________________________________________ Chemicals cleaning products _ __________________________________________________________ Personal & office items ________________________________________________________________ Linen if applicable __________________________________________________________________ Garbage and Refuse 1 Will the facility have Dumpster s with lids YES NO Trash can s with lids YES NO Grease storage receptacle YES NO Can wash cleaning facility YES NO Off - site contracted cleaning service YES NO 2 Location where dumpster s compactor can s will be stored _ ________________________________ _______ _____________________________________________________________________________ _______ _____________________________________________________________________________PagePage pageNumber5Pest Control 1 Do you have a pest control company YES NO 2 If no , please explain pest management procedures __________________________________________ _______ _____________________________________________________________________________ 3 Are outside doors self - closing YES NO 4 Do you have a fly fan YES NO 5 If no , please explain procedure for controlling flies in the facility _______ ________________________ _______ _____________________________________________________________________________ Finish Schedule Examples Tile , FRP , Sheet Metal , Concrete , Painted Sheetrock , etc FLOOR BASE WALLS CEILING Kitchen ______________ ______________ _______________ ______________ Bar ______________ ______________ _______________ ______________ Food Storage ______________ ______________ _______________ ______________ Toilet Rooms ______________ ______________ _______________ ______________ Dressing Rooms ______________ ______________ _______________ ______________ Refuse Storage ______________ ______________ _______________ ______________ Mop Area ______________ ______________ _______________ ______________ STATEMENT I hereby certify that the above information is correct , and I fully understand that any deviation from the above without prior approval from this Health Regulatory Office may nullify the approval Signature s ________________________________________________ Date __________________________ Owner s or Responsible Representative s 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 state laws governing food service establishments PagePage pageNumber6Example of a set of plans drawn to scale Include the location and description of equipment in the facility This should be drawn to scale such as ¼ " 1 ' Include location of panel box , water heater , air handling unit , drink machines , sinks , hand sinks , restrooms , coolers , freezers , ice machines , cooking equipment , prep areas and stations , etc PagePage pageNumber7Water Heater Calculation Worksheet Equipment Quantity Size GPH One Comp Sink _______ x __ ______ by ___ _____ by ____ ____ __________ Two Comp Sink _______ x ___ _____ by ________ by____ ____ __________ Three Comp Sink _______ x ________ by ________ by _ _______ __________ Four Comp Sink _______ x ___ _____ by ________ by ___ _____ __________ One Comp Prep Sink _______ x 5 GPH __ ________ Two Comp Prep Sink __ _____ x 10 GPH __________ Three Comp Prep Sink _______ x 15 GPH __________ Three Comp Bar Sink _______ x __ ______ by ___ _____ by ________ __________ Four Comp Bar Sink _______ x ________ by ___ _____ by ___ _____ __________ Hand sink _______ x 5 GPH __________ Pre - Rinse _______ x 45 GPH _ _________ Can Wash _______ x 10 GPH __ _________ Mop Sink _______ x 5 GPH _ __________ Dish machine _______ x Note # 1 __________ Cloth washer _______ x Note # 2 _ __________ Hose Reel _______ x Note # 3 _ __________ Other Equipment _______ x _______________ _ __________ ___ ____________________ TOTAL ___ ________ Note # 1 Dishwasher Calculations ______gals hr Final Rinse x 70 _________ Note # 2 Cloth Washer Calculations Limited Use Washer used 1 to 2 times per day GPH 60GPH x 25 Intermediate Use Washer used every 4 hours GPH 60 GPH x 45 Heavy Use Washer used once every 2 hours GPH 60 GPH x 80 Continuous Use Washer used every hour GPH 60 GPH x 100 Note # 3 Hose Reel Calculations 20 GPH for first reel and 10 GPH for each additionalPagePage pageNumber81 Vomit & Diarrhea Clean - up Plan PURPOSE In accordance with 2 - 50111 of the FDA Food Code , " A food establishment must have written procedures to implement a plan for employees to follow when responding to vomiting or diarrheal events that involve the discharge of vomitus or fecal matter onto surfaces in the food establishment " ASSEMBLE A CLEAN - UP KIT You can buy a kit from a supplier or assemble your own Clean - up kits should contain personal protective equipment and cleaning supplies Disinfectant • If using concentrated bleach shown as 825 on the label , add 3 4 cups of bleach to 1 gallon of water • If using regular bleach , shown as 525 on the label , add 1 cup of bleach to 1 gallon of water • Commercially prepared disinfectants effective against Norovirus can be used The US Environmental Protection Agency has a list of approved commercial disinfectants for reference Basic Personal Protective Equipment Recommended Personal Protective Equipment • Single - use gloves • 1 disposable mask or other effective face covering • 1 pair of goggles • 1 disposable gown with sleeves • 1 disposable hair cover • 1 pair of disposable shoe covers Basic Cleaning Supplies Recommended Cleaning Supplies • Plastic garbage bags with seal or twist tie • Paper towels • Absorbent powder solidifier such as kitty litter or baking soda • Disinfectant • 1 scoop scraper • Drop cloth • Caution tape for marking contaminated area • Dedicated mop and bucket disposable mop heads recommended BEFORE CLEAN UP BEGINS • Promptly remove ill customers , workers , and others from areas of food preparation , service , and storage • Contain a 25 - 30 feet area from the epicenter of the event to keep anyone not involved in clean up out of the area • Put on personal protective equipment Anyone cleaning up vomit or diarrhea should at a minimum wear single - use gloves and a face mask or other effective covering PagePage pageNumber92 CLEANING UP SURFACES HARD SURFACES STEP 1 Cover • Cover the vomit or diarrhea with paper towels or an absorbent powder such as cat litter to soak up liquids STEP 2 Remove • Remove the soaked paper towels or hardened powder with a scoop scraper and careful ly place them in a plastic bag STEP 3 Wash • Prepare a solution of soapy water • Wash all surfaces contaminated with vomit or diarrhea with this solution Include all nearby surfaces possibly splashed by vomit or diarrhea , such as chair legs , tables , walls , shelves , or counters within the containment area • Rinse the soapy water from all surfaces with clean water STEP 4 Disinfect • Using paper towels or a mop with a washable or disposable mop head , saturate all washed surfaces with disinfectant The disinfectant can be an approved commercially prepared solution , or a solution prepared in - house see " Assemble a Clean - Up Kit " • If using a disinfectant prepared in house , allow a minimum 10 minute contact time If using a commercially prepared disinfectant , follow the manufacturer ' s instructions • Rinse all food - contact surfaces with clean water after they have been disinfected Wash , rinse , and sanitize these surfaces prior to using for food preparation • Non - food contact surfaces do not need to be rinsed CARPET AND UPHOLSTERED FURNITURE STEP 1 Cover • Cover the vomit or diarrhea with paper towels or an absorbent powder such as cat litter to soak up liquids Page03 LINENS , TOWELS , AND CLOTHING STEP 1 Contain • Carefully place all washable contaminated items in a disposable bag to transport them to be laun - dered STEP 2 Wash • Machine wash soiled items in a washing machine using hot water , laundry detergent and disin - fectant • Wash with an effective disinfectant , bleach or other chemical , in accordance with manufacturer ' s in - structions STEP 3 Dry • Dry the freshly - washed items in a dryer on the high - heat setting AFTER CLEAN UP STEP 1 Remove • Remove all personal protective equipment and place in the plastic bag Do not touch any of the surfaces that were just cleaned as they can be re - contaminated All personal protective equipment must be taken off before leaving the area that has just been cleaned • Place all used cleaning supplies , such as paper towels and disposable mop heads , in the plastic bag Seal the bag with a twist tie or other effective method • Throw away all uncovered food in the contained area , as well as any food handled by the person who was sick • Remove all waste from the facility immediately following local , state , or federal rules STEP 2 Remove • Carefully remove the saturated paper towels or hardened powder with the scoop scraper and place in a plastic bag • Never vacuum STEP 3 Wash • Prepare a solution of soapy water • Wash all surfaces contaminated with vomit or diarrhea with this solution Include all nearby surfaces possibly splashed by vomit or diarrhea , such as chair legs , tables , walls , shelves , or counters within the containment area • Rinse the soapy water from all surfaces with clean water STEP 4 DisinfectPage14 Please keep this document in the facility where it can be readily available for em - ployees and the Regulatory Authority to reference TRAINING WORKERS ON CLEAN - UP PROCEDURES • Identify who will be in charge of cleaning up after vomit and diarrhea events • Train selected workers on how to use personal protective equipment , wash and disinfect surfaces , and dispose of vomit and diarrhea • Training should take place when - the vomit and diarrhea clean - up procedures are first written and put in place ; - new workers are hired ; - periodically as a review ; - and as vomit and diarrhea procedures are changed • Monitor clean - up employees for illness at least 48 hours after the incident Exclude clean - up employees if they become symptomatic STEP 3 Wash hands • Wash hands thoroughly before performing any other duties food - handlers double - wash hands • Wash and disinfect mop handles and other reusable cleaning supplies , such as scoops scrapers , using the same steps used for hard surfaces STEP 2 Cleaning Mops and ScoopsPage2Food Employee Reporting Agreement Reporting Symptoms of Illness I agree to report to the Person in Charge PIC when I have 1 Diarrhea 2 Vomiting 3 Jaundice yellowing of the skin and or eyes 4 Sore throat with fever 5 Infected cuts or wounds , or lesions containing pus on the hand , wrist , an exposed body part such as boils and infected wounds , however small Note The PIC must report to the Health Department when an employee is jaundiced Reporting Diagnosed Illnesses I agree to report to the Person in Charge PIC when I have been diagnosed with 1 Norovirus 2 Hepatitis A virus 3 Shigella spp infection shigellosis 4 Shiga Toxin - Producing Escherichia coli O157 H7 or other STEC infection 5 Typhoid fever caused by Salmonella Typhi 6 Salmonella nontyphoidal Note The PIC must report to the Health Department when an employee has one of these illnesses Reporting Exposure of Illness I agree to report to the PIC when I have been exposed to any of the illnesses listed above through 1 An outbreak of Norovirus , typhoid fever , shigellosis , E coli O157 H7 or other STEC infection , or Hepatitis A 2 A household member with Norovirus , typhoid fever , shigellosis , illness due to STEC , or Hepatitis A 3 A household member attending or working in a setting experiencing a confirmed outbreak of Norovirus , typhoid fever , shigellosis , E coli O157 H7 or other STEC infection , or Hepatitis A Exclusion and Restriction from Work If you have any of the symptoms or illnesses listed above , you may be excluded or restricted from work If you are excluded from work you are not allowed to come to work If you are restricted from work you are allowed to come to work , but your duties may be limited Returning to Work If you are excluded from work for having diarrhea and or vomiting , you will not be able to return to work until 1 more than 24 hours have passed since your last symptoms of diarrhea and or vomiting , or 2 provide written medical documentation from a health practitioner indicating that the symptoms are from a noninfectious condition If you are excluded from work for exhibiting symptoms of Norovirus , Salmonella Typhi , nontyphoidal Salmonella , Shigella spp infection , E coli O157 H7 or other STEC infection , and or Hepatitis A , you will not be able to return to work until approval from the Health Department is granted I have read or had explained to me and understand the requirements concerning my responsibilities under the Food Code and this agreement to comply with 1 Reporting requirements specified above involving symptoms , diagnoses , and exposure specified ; 2 Work restrictions or exclusions that are imposed upon me ; and 3 Good hygienic practices I understand that failure to comply with the terms of this agreement could lead to action by the food establishment or the fo od Regulatory Authority that may jeopardize my employment and may involve legal action against me Employee Name please print _______________________ Signature of Employee _______________________ Date ___________ PIC Name please print _____________________________ Signature of PIC ____________________________ Date ___________Page3E Coli Overview A bacterium that can produce a deadly toxin and causes an estimated 70,000 cases of foodborne illnesses each year in the US Sources Meat , especially undercooked or raw hamburger , produce and raw milk Incubation period 2 - 10 days Symptoms Severe diarrhea , cramping , dehydration Prevention Cook implicated food to 155F , wash hands properly and frequently , correctly wash rinse and sanitize food contact surfaces Shigella Overview Shigella is a bacterium that causes an estimated 450,000 cases of diarrhea illnesses each year Poor hygiene causes Shigella to be easily passed from person to person Sources Salad , milk , dairy products , and unclean water Incubation period 1 - 7 days Symptoms Diarrhea , stomach cramps , fever , chills and dehydration Prevention Wash hands properly and frequently , especially after using the restroom , wash vegetables thoroughly Salmonella nontyphoidal Overview Salmonella is a bacterium responsible for millions of cases of foodborne illnesses a year The elderly , infants , and individuals with impaired immune systems are at risk for severe illness Death can occur if the person is not treated promptly with antibiotics Sources Raw and undercooked eggs , undercooked poultry and meat , dairy products , seafood , fruits and vegetables Incubation period 5 - 72 hours up to 16 days has been documented for low doses Symptoms Nausea , vomiting , cramps , and fever Prevention Cook all food to proper temperatures , chill food rapidly , and eliminate sources of cross - contamination ie proper meat storage , proper washing , rinsing , and sanitizing procedures Salmonella Typhi Typhoid fever Overview Salmonella Typhi is the bacterium that causes Typhoid fever and is responsible for an estimated 430 cases each year This illness is caused by eating or drinking food or water contaminated with feces from an infected person Incubation period Generally 1 to 3 weeks , but may be as long as 2 months after exposure Sources Ready to eat food , water , and beverages Symptoms High fever , from 103 ° F to 104 ° F ; lethargy ; gastrointestinal symptoms , including abdominal pains and diarrhea or constipation ; headache ; achiness ; loss of appetite A rash of flat , rose - colored spots sometimes occurs Symptoms typically last 2 to 4 weeks Prevention E xcluding sick food workers , practicing good personal hygiene , preventing cross - contamination , and cooking food to the required final cook temperatures Hepatitis A Overview Hepatitis A is a liver disease caused by the Hepatitis A virus Hepatitis A can affect anyone In the United States , Hepatitis A can occur in situations ranging from isolated cases of disease to widespread epidemics Incubation period 15 - 50 days Symptoms Jaundice , nausea , diarrhea , fever , fatigue , loss of appetite , cramps Prevention Wash hands properly and frequently , especially after using the restroom Norovirus Overview This virus is the leading cause of diarrhea in the United States Any food can be contaminated with norovirus if handled by someone who is infected with the virus This virus is highly infectious Incubation period 6 - 48 hours Symptoms Nausea , vomiting , diarrhea , and cramps Prevention Wash hands properly and frequently , especially after using the restroom obtain food from a reputable food source and wash vegetables thoroughly Common Foodborne Illnesses 1 Handwashing is the MOST CRITICAL control step in prevention of disease Invest 20 seconds to follow these 6 simple steps 1 Wet your hands and arms with warm running water 2 Apply soap and bring to a good lather 3 Scrub hands and arms vigorously for 10 to 15 seconds clean under nails and between fingers 4 Rinse hands and arms thoroughly under running water 5 Dry hands and arms with a single - use paper towel or warm - air hand dryer 6 Use the towel to turn off faucets and open door handles so you don't re - contaminate your hands 2 Don't go to work when you are sick 3 No bare hand contact with ready - to - eat foods Prevention of Contamination by HandsPage