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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 2 ] --

______________________________________________________________________________________

The undersigned hereby applies for a permit to operate a Food Service Establishment pursuant to the OCGA 26-2-371-373 and hereby certifies that he has received a copy of the Rules for Food Service, Chapter 290-5-14, Georgia Department of Human Resources.

Signed: __________________________________________ Date ______________________________

Title: ____________________________________________

(State Whether Business Owner or Authorized Agent)

NOTE: ANY CHANGES IN THE EXISTING FOOD SERVICE ESTABLISHMENT FACILITY WILL

REQUIRE THE OWNER OR AGENT TO CONTACT THE LOCAL HEALTH AUTHORITY. IT IS

ILLEGAL FOR FOOD SERVICE ESTABLISHMENTS TO BEGIN OPERATION WITHOUT FIRST

OBTAINING A VALID FOOD SERVICE PERMIT FROM THE LOCAL HEALTH AUTHORITY.

–  –  –

2. Are screen doors provided on all entrances left open to the outside?

3. Do all openable windows have a minimum #16 mesh screening?

4. Is the placement of electrocution devices identified on the plan?

5. Will all pipes & electrical conduit chases be sealed; ventilation systems exhaust and intakes protected?

6. Is area around building clear of unnecessary brush, litter, boxes and other harborage?

7. Will air curtains be used?

If yes, where? ________________

–  –  –

Outside

11. Will a dumpster be used?

Number ________ Size ________ Frequency of pickup ___________ Contractor ___________________

12. Will a compactor be used?

Number ________ Size ________ Frequency of pick up ___________ Contractor ______________________

13. Will garbage cans be stored outside?

14. Describe surface and location where dumpster/compactor/garbage cans are to be stored

15. Describe location of grease storage receptacle __________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

16. Is there an area to store recycled containers?

Describe __________________________________________________________________________________

__________________________________________________________________________________________

–  –  –

Document K-5 Page 12 of 17 Georgia Department of Community Health

PERMIT APPLICATION FOOD SERVICE ESTABLISHMENTS

AND MOBILE FOOD SERVICE OPERATIONS

* TRAP: A fitting or device which provides a liquid seal to prevent the emission of sewer gases without materially affecting the flow of sewage or waste water through it. An integral trap is one that is built directly into the fixture, e.g., a toilet fixture. A “P” trap is a fixture trap that provides a liquid seal in the shape of the letter “P”. Full “S” traps are prohibited.

32. Are floor drains provided & easily cleanable, if so, indicate location: ______________________________

__________________________________________________________________________________________

E. WATER SUPPLY

–  –  –

34. If private, has source been approved? YES NO PENDING Please attach copy of written approval and/or permit.

35. Is ice made on premises or purchased commercially?

–  –  –

Describe provision for ice scoop Storage:___________________________________________________

Provide location of ice maker or bagging operation___________________________________________

36. What is the capacity of the hot water generator? _____________________________________________

37. Is the hot water generator sufficient for the needs of the establishment?

Provide calculations for necessary hot water. (See Section 9 of the Food Service Manual for Design, Installation and Construction for more information)

–  –  –

If yes, how will the device be inspected & serviced? ____________________________________________

______________________________________________________________________________________

39. How is backflow prevention devices inspected & serviced? ______________________________________

______________________________________________________________________________________

–  –  –

40. Is building connected to a municipal sewer? YES NO

41. If no, is private disposal system approved? YES NO PENDING Please attach copy of written approval and/or permit.

42. Are grease traps provided? YES NO If so, where? _________________________________________________________________________

Provide schedule for cleaning & maintenance_______________________________________________

G. DRESSING ROOMS

–  –  –





44. Describe storage facilities for employees' personal belongings (i.e., purse, coats, boots, umbrellas, etc.)___________________________________________________________________________

_______________________________________________________________________________________

GENERAL

45. Are insecticides/rodenticides stored separately from cleaning & sanitizing agents? YES NO Indicate location: _____________________________________________________________________

____________________________________________________________________________________

46. Are all toxics for use on the premise or for retail sale (this includes personal medications), stored away from food preparation and storage areas? YES NO

47. Are all containers of toxics including sanitizing spray bottles clearly labeled? YES NO

48. Will linens be laundered on site? YES NO If yes, what will be laundered and where?____________________________________________________

______________________________________________________________________________________

If no, how will linens be cleaned? ___________________________________________________________

–  –  –

50. Location of clean linen storage: _____________________________________________________________

Document K-5 Page 14 of 17 Georgia Department of Community Health

PERMIT APPLICATION FOOD SERVICE ESTABLISHMENTS

AND MOBILE FOOD SERVICE OPERATIONS

51. Location of dirty linen storage: _____________________________________________________________

_______________________________________________________________________________________

52. Are containers constructed of safe materials to store bulk food products? YES NO Indicate type: ___________________________________________________________________________

______________________________________________________________________________________

53. Indicate all areas where exhaust hoods are installed:

–  –  –

54. How is each listed ventilation hood system cleaned? ____________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

I. SINKS

55. Is a mop sink present? YES NO

If no, please describe facility for cleaning of mops and other equipment:

_____________________________________________________________________

_____________________________________________________________________

56. If the menu dictates, is a food preparation sink separate from a dedicated raw fruit and vegetable sink present? YES NO

J. DISHWASHING FACILITIES

–  –  –

59. Do all dish machines have templates with operating instructions? YES NO

60. Do all dish machines have temperature/pressure gauges as required that are accurately working?

YES NO

61. Does the largest pot and pan fit into each compartment of the pot sink? YES NO If no, what is the procedure for manual cleaning and sanitizing?

_____________________________________________________________________________________

_____________________________________________________________________________________

62. Are there drain boards on both ends of the pot sink? YES NO

–  –  –

64. Are test papers and/or kits available for checking sanitizer concentration? YES NO

K. HOT WATER GENERATING EQUIPMENT

65. For information on sizing water heating equipment see attachment “A”

L. HANDWASHING/TOILET FACILITIES

66. Is there a hand washing sink in each food preparation and warewashing area? YES NO

67. Do all hand washing sinks, including those in the restrooms, have a mixing valve or combination faucet?

YES NO

68. Do self-closing metering faucets provide a flow of water for at least 15 seconds without the need to reactivate the faucet? YES NO

–  –  –

70. Are hand drying facilities (paper towels, air blowers, etc.) available at all hand washing sinks? YES NO

71. Are covered waste receptacles available in each restroom? YES NO

72. Is hot and cold running water under pressure available at each hand washing sink? YES NO

73. Are all toilet room doors self-closing? YES NO ************ STATEMENT: I hereby certify that the above information is correct, and I fully understand that any deviation from the above information and approved food service plans and specifications without prior permission from the local health authority may nullify this approval.

Approval of these plans and specifications by the local health authority DOES NOT indicate compliance with any other code, law or regulation that may be required – federal, state, or local. It DOES NOT constitute endorsement or acceptance of the completed establishment (structure or equipment). A final inspection of each completed establishment with the necessary equipment will be necessary to determine if it complies with the Georgia Rules and Regulations Governing food Service Establishments.

A food Service permit from the local health authority must be secured before this establishment can operate as a food service establishment.

Signature(s) _____________________________________________________ Date: ____________

Owner or responsible representative

–  –  –



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