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«Address of Facility: Ga. (Street, Highway, or RFD) (City) (County) (Zip Code) Physical Location of Mobile Unit(s) if Applicable:_ (Counties in which ...»

-- [ Page 1 ] --

Georgia Department of Community Health

PERMIT APPLICATION FOOD SERVICE ESTABLISHMENTS

AND MOBILE FOOD SERVICE OPERATIONS

=======================================================================================

Complete in duplicate and forward the original to the County Health Department in which the facility is located.

Name of Facility: ___________________________________________________________________________

Check Appropriate Block(s): ❑ Mobile food Service ❑ Food Service Establishment Catering Operation New Change of Owner Renovation of Existing Establishment Plans Attached Equipment List Attached Menu Attached Supporting Documentation: Plan Review Checklist Food Preparation Review Construction Review Food Service Risk Categorization: Risk Type I Risk Type II Risk Type III/HAACP Plan Address of Facility: ______________________________________________________________________Ga.

(Street, Highway, or RFD) (City) (County) (Zip Code) Physical Location of Mobile Unit(s) if Applicable:_________________________________________________

(Counties in which mobile units will operate) Facility Owner’s Name: ________________________________________ Phone Number: _______________

Facility Owner’s Address: ___________________________________________________________________

(Street, Highway, or RFD) (City) (County) (State) (Zip Code) Business Ownership: ________________________________________________ Phone (______) __________ (Individual, Association, Partnership, Corporation or legal Entity) If Association, Partnership, Corporation or Legal Entity, give names, title, address and phone number of persons involved, including owners and officers. Otherwise indicate N/A Name________________________ Address ______________________City ___________Phone __________ Name________________________ Address ______________________City ___________Phone __________ Name________________________ Address ______________________City ___________Phone __________ Name________________________ Address ______________________City ___________ Phone __________

(USE ADDITIONAL PAPER IF NEEDED)

Document K-5 Page 1 of 17 Georgia Department of Community Health

PERMIT APPLICATION FOOD SERVICE ESTABLISHMENTS

AND MOBILE FOOD SERVICE OPERATIONS

===================================================================

OPERATIONAL INFORMATION

Hours of Operation: Sun ______ Th

–  –  –

Please enclose the following documents:

_____ Proposed Menu (including seasonal, off-site and banquet menus) _____ Manufacturer Specification sheets for each piece of equipment shown on the plan _____ Site plan showing location of business in building; location of building on site including alleys, streets; and location of any outside equipment (dumpsters, well, septic system - if applicable) _____ Plan drawn to scale of food establishment showing location of equipment, plumbing, electrical services and mechanical ventilation _____ Equipment schedule The undersigned hereby applies for a permit to operate a food service establishment pursuant to O.C.G.A. 26-2et seq. and hereby attests to the accuracy of the information provided in on the application and affirms to comply with the Rules and Regulations for Food Service, Chapter 290-5-14, Georgia, DHR.

Applicant’s Name: ______________________________________________ Phone Number: ______________

–  –  –

1. Thin meats, poultry, fish, eggs (hamburger; sliced meats; fillets)

2. Thick meats, whole poultry (roast beef; whole turkey, chickens, hams)

3. Cold processed foods (salads, sandwiches, vegetables)

4. Hot processed foods (soups, stews, rice/noodles, gravy, chowders, casseroles)

5. Bakery goods (pies, custards, cream fillings & toppings)

6. Other ________________________________________________________________

PLEASE CIRCLE/ANSWER THE FOLLOWING QUESTIONS

FOOD SUPPLIES:

–  –  –

1. Is adequate and approved freezer and refrigeration available to store frozen foods frozen, and refrigerated foods at 41º F (5 º C) and below? YES NO Provide the method used to calculate cold storage requirements.

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: _____

–  –  –

4. Is there a bulk ice machine available? YES NO

THAWING FROZEN POTENTIALLY HAZARDOUS FOOD:

Please indicate by checking the appropriate boxes how frozen potentially hazardous foods (PHF's) in each category will be thawed. More than one method may apply. Also, indicate where thawing will take place.





–  –  –

1. Will food product thermometers be used to measure final cooking/reheating temperatures of PHF's?

YES NO What type of temperature measuring device:__________________________

Minimum cooking time and temperatures of product utilizing convection and conduction heating equipment:

–  –  –

(See Rule 290-5-14-.04 (5) pages 60 through 62 of the Chapter for more information.)

2. List types of cooking equipment.

_______________________________________________________________________________________

_______________________________________________________________________________________

HOT/COLD HOLDING:

1. How will hot PHF's be maintained at 135 º F (57 º C) or above during holding for service? Indicate type and number of hot holding units.

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________

2. How will cold PHF's be maintained at 41 º F (5 º C) or below during holding for service? Indicate type and number of cold holding units.

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

–  –  –

Please indicate by checking the appropriate boxes how PHF's will be cooled to 41 º F (5 º C) within 6 hours (135 º F to 70 º F in 2 hours; then, 70 º F to 41 º F in 4 hours). Also, indicate where the cooling will take place.

–  –  –

REHEATING:

1. How will PHF’s 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 º F for 15 seconds. Indicate type and number of units used for reheating foods.

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

2. How will reheating cooked and cooled food to 165 º F for at least 15 seconds for hot holding be done rapidly and within 2 hours?

_______________________________________________________________________________________

_______________________________________________________________________________________

2. Will food employees be trained in good food sanitation practices? YES / NO

Method of training:

___________________________________________________________________________________

Number(s) of employees:_______________________________________________________________

Dates of completion:___________________________________________________________________

–  –  –

4. Is there a written 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?

–  –  –

6. 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 not, how will ready-to-eat foods be cooled to 41 º F?

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

7. Are raw fruits and vegetables indicated within the menu? YES NO If yes, is a dedicated sink provided for washing raw fruits and vegetables prior to their preparation?

YES NO (Note: Multi-compartmented sinks are considered as one unit. For example, a 2-compartment sink is one unit and not two separate sinks.) Describe________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Document K-5 Page 7 of 17 Georgia Department of Community Health

PERMIT APPLICATION FOOD SERVICE ESTABLISHMENTS

AND MOBILE FOOD SERVICE OPERATIONS

8. Describe the procedure used for minimizing the length of time PHF's will be kept in the temperature danger zone (41 º F - 135 º F) during preparation.

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

9. Providing a HACCP plan is required for specialized processing methods such as vacuum packaged food items prepared on-site or otherwise required by the regulatory authority. Attach a copy of HACCP plan if applicable. (See Rule 290-5-14-.02 (5) page 24 and Rule 290-5-14-.04 (6) (j) page 70 and 71 of Chapter.)

10. Will the facility be serving food to a highly susceptible population? YES NO If yes, how will the temperature of foods be maintained while being transferred between the kitchen and service area? ____________________________________________________________________________

______________________________________________________________________________________



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