plan review application process for food service …

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______________________________________________________________________________________________ Applicant Name (Print) Applicant Name (Signature) Date EH initials / Date

Food Safety Program

Mailing Address: 111 East 3rd

St.

Physical Address: 223 E. 4th

St.

Port Angeles, WA 98362

Phone: (360) 417-2328

Fax: (360) 417-2313

PLAN REVIEW APPLICATION PROCESS FOR FOOD SERVICE ESTABLISHMENT:

Carefully read the Plan Review Guideline Document before you begin.

The Washington State Retail Food Code, WAC 246-215 is a required resource for

all Food Establishments. It is available online or you may request a copy from the

Environmental Health office.

If the proposed facility is not currently permitted as a food establishment, research

zoning restrictions, public potable water source and waste water treatment system

before you begin.

Plan review fees are charged according to the proposed menu.

The Person in Charge of Food Safety must complete the Compliance Review list

and describe the Food Preparation Procedures. In order to demonstrate the

knowledge required for approval, you need to reference the exact sections in the

Washington State Retail Food Code.

Carefully review the application and make copies for your records.

Submit Plan Review fee and complete Application to Environmental Health

Division office in Clallam County Courthouse, 223 E. 4th

Street in Port Angeles,WA.

Complete applications will be reviewed by an Environmental Health Specialist.

Incomplete applications will be returned.

If approved you will receive a Plan Review Approval letter.

Pre-opening inspections are scheduled at least 5 days prior to the proposed open

date.

If the pre-opening inspection is satisfactory, then the purchase of a pro-rated

annual operating permit is required before opening (cost is dependent on FSE type). The permit year is October 1 to September 30 annually.

It is your responsibility to verify billing and contact information if there are any

changes.

Provide all sections of application at least 30 DAYS BEFORE your proposed

opening date.

Plan Reviews are processed in the order in which they are received. Plan for a 30 day turn

around beginning at time all documents are received.

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DOCUMENTATION CHECK LIST

Incomplete applications will be returned.

This application is designed for use in conjunction with the Plan Review Guidance Document. You do not need to print out and turn in the Plan Review Guidance Document. The following documents must be submitted along with this application:

Proof of Public Water Source and On-site Septic Food Establishment status approval unless on municipal water or municipal sewage treatment system.

Plans must be clearly drawn to scale (minimum 8 x 11 inches in size) and include. See page 7 of the Plan Review Document.

Food preparation, serving and seating areas, restrooms, office, storage, ware washing, janitorial and trash area. Include location of any outside equipment or facilities (dumpsters, well, septic system-if applicable). Provide equipment layout and specifications, clearly numbered and cross-keyed with the equipment list. Identify hand-washing, ware washing, food preparation and utility (mop) sinks. Provide plumbing layout showing the sewer lines, cleanouts, floor drains, floor sinks, vents, grease trap or grease

interceptor, hot and cold water lines, and direction of flow to sanitary sewer. Finish schedule showing floor, coved base, wall and ceilings for each area shown on the plans.

Proposed menu or complete list of food and beverages to be offered including final menu with Consumer Advisory if serving undercooked foods.

If proposed menu includes Special Processed Foods including smoking, curing, additives (e.g. vinegar in sushi rice) and reduced oxygen packaging, a Hazard Analysis Critical Control Point plan is required according to WAC 246-215.

Provide a copy of your Written Illness Policy identifying conditions of exclusion and restriction for food workers. See page 33 in the Plan Review Document. Post this policy at your establishment.

Approval from local building and fire officials (e.g. Department of Community Development, City building department).

Signed and Completed Application including all pages of this document.

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Plan Review Application for Food Establishments in Clallam County

TYPE OF APPLICATION:

New Establishment

Remodel

Change of Ownership

Change of Menu or Equipment

PROPOSED OPENING DATE:

RECEIVED BY:

Confirmed Complete and Date Entered:

Incomplete Application Returned Date:

FOOD ESTABLISHMENT INFORMATION

Name of Establishment: # of Seats or

Check stands:

Type of establishment: Restaurant Espresso Grocery (with Deli) Grocery (pre-packaged only) Catering Concession Bed & Breakfast Tasting Room Commercial Kitchen School

Establishment Physical Address: City: State: ZIP:

Establishment Email: Establishment Phone:

*Water Source:

Municipal / Group A

Well / Group B* *Application must include documentation of approved water system

*Sewage Disposal:

Municipal

On-Site Septic System* *Application must include documentation of approved On-site Septic System

BILLING / OWNERSHIP INFORMATION

Name of Owner:

Mailing Address: City: State: ZIP:

Billing / Owner Email: Phone Number:

MANAGER OR ON-SITE ESTABLISHMENT CONTACT INFOMATION

Name: Title:

Establishment Mailing Address: City: State: ZIP:

Email: Phone Number:

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By signing this document I certify that the information provided is true

and accurate to the best of my knowledge. I understand that:

1. Any changes to the menu, equipment, floor plan or services after submittal may result in

postponement of my application review.

2. Changes must be reviewed and approved by Clallam County Environmental Health;

additional paperwork and fees may be required.

3. The submitted proposed menu, equipment, floor plan and services meet the requirements

of Chapter 246-215 Washington Administrative Code.

4. It is my responsibility to immediately notify Clallam County Environmental Health of any

illness complaint received from a customer

_________________________________________________________ ____________________________________________________ _______________

Person in Charge (Print) Person in Charge (Signature) Date

Fee Type: ____________ Amount Collected: $_________________Check #______________ Receipt #:________________

□ $278.00 Complex Menu Any food service establishment which serves and/or prepares

potentially hazardous foods at least 6 hours in advance of serving or serves potentially hazardous

foods which require 2 or more of the following preparation steps: a) cook potentially hazardous

foods; b) cool potentially hazardous foods; c) reheat potentially hazardous foods; d) hot hold

potentially hazardous foods for 2 or more hours.

□ $159.00 Non-complex Menu Any food service establishment which serves and/or prepares

potentially hazardous foods, but does not meet the definition of a Complex Menu operation.

Establishments are limited to food that can be served immediately after preparation, i.e. espresso,

bakery, deli, etc.

□ $139.00 or $79.50 Change of Ownership with no other changes to the physical facilities

or the menu. This fee is 50% of your plan review fee for Complex or Non-complex menus,

respectively.

□ $93.00 Change in Food Service for changes in menu, increased seating or remodeling of

food establishment. All significant changes in service must be approved by an Environmental

Health Specialist.

□ $93.00 per hour Technical Assistance Fee Additional inspections and services beyond

those covered by The Plan Review fee or those that require services as a result of non-compliance

of County and State food safety codes. For example, if an Environmental Health Specialist must

make recurring visits to a food establishment whose employees do not have current food handler

cards, that establishment will be billed for each resulting follow-up inspection.

______

______

________

________

__

Ap

plican

t initial D

ate EH in

itial

CO

MP

LIA

NC

E R

EV

IEW

LIS

T

FO

OD

PR

EP

AR

AT

ION

PR

OC

ED

UR

ES

FO

OD

HA

ND

LIN

G

1.

Wh

o is resp

on

sible fo

r Co

mp

liance w

ith th

e Retail F

oo

d C

od

e, WA

C 2

46

-21

5 an

d w

here is th

at info

rmatio

n fo

un

d in

WA

C 2

46

-21

5? T

here

mu

st be o

ne P

erson

in C

harge d

urin

g all ho

urs o

f op

eration

.

2.

Wh

at are the sp

ecific du

ties of th

e Perso

n In

Ch

arge iden

tified in

WA

C 2

46

-21

5?

3.

Wh

at section

of W

AC

24

6-2

15

iden

tifies emp

loyee restrictio

n o

r exclusio

n b

ased o

n sy

mp

tom

s of illn

ess? Attach

the Illn

ess Po

licy yo

u w

ill

use an

d p

ost it at th

e establish

men

t..

4.

Wh

at is the o

nly th

ing y

ou

are requ

ired to

do

wh

en a cu

stom

er no

tifies yo

u th

at they

may

have b

ecom

e ill at you

r Fo

od

Estab

lishm

en

t?

5.

Wh

at con

ditio

ns are co

nsid

ered an

Imm

inen

t Health

Th

reat and

requ

ire closu

re?

6.

Wh

at system w

ill you

create to m

on

itor em

plo

yee foo

d w

ork

er card statu

s?

______

______

________

________

__

Ap

plican

t initial D

ate EH in

itial

7.

Wh

at section

of W

AC

24

6-2

15

describ

es han

d w

ashin

g?

8.

Wh

at section

of W

AC

24

6-2

15

describ

es the p

rop

er use o

f single-u

se gloves?

9.

Describ

e wh

en an

d h

ow

to m

on

itor eq

uip

men

t temp

eratures.

10

. If un

derco

ok

ed an

imal p

rod

ucts w

ill be served

, wh

at section

of W

AC

24

6-2

15

app

lies to ad

vising th

e con

sum

er?

11

. WA

C 2

46

-21

5 0

35

35

iden

tifies smo

kin

g, curin

g, the u

se of fo

od

add

itives (su

ch as vin

egar for su

shi rice) an

d red

uced

oxygen

pack

aging

as

Special F

oo

d P

rocesses w

hich

requ

ire a Hazard

An

alysis Critical C

on

trol P

oin

t (HA

CC

P) P

lan su

bm

itted fo

r review

. Iden

tify any m

enu

items an

d in

clud

e HA

CC

P p

lan w

ith ap

plicatio

n.

FO

OD

DE

LIV

ER

Y

12

. Ho

w o

ften w

ill frozen

foo

ds b

e delivered

? □ D

aily □

Week

ly □ O

ther:

13

. Ho

w o

ften w

ill refrigerated fo

od

s be d

elivered? □

Daily

□ W

eekly □

Oth

er:

14

. Wh

at are you

r foo

d so

urces?

15

. Wh

ere are receipts k

ept fo

r all deliveries an

d fo

od

stored

on

-site?

16

. Wh

at receivin

g temp

eratures w

ill you

accept an

d h

ow

will yo

u m

on

itor th

em? W

ho

will m

on

itor th

em?

______

______

________

________

__

Ap

plican

t initial D

ate EH in

itial

INST

RU

CT

ION

S: Describ

e the fo

llow

ing w

ith as m

uch

detail as p

ossib

le. Please w

rite legibly an

d u

se add

ition

al pages if n

ecessary. Attach

you

r

com

plete m

enu

and

use th

e chart b

elow

or d

esign a flo

w d

iagram fo

r each item

. Describ

e receipt, sto

rage, prep

aration

, assemb

ly and

ho

ldin

g or

serving o

f items yo

u w

ou

ld lik

e to serve. B

e specific ab

ou

t pro

cesses you

wo

uld

like to

use.

PR

OC

ES

S

IDE

NT

IFY

FO

OD

ITE

MS

IN

DIC

AT

E L

OC

AT

ION

A

ND

EQ

UIP

ME

NT

M

EE

TS

CR

ITE

RIA

(E

H to

circle a

nd

Initia

l)

Wa

shin

g

WA

C 2

46

-21

5 0

33

18

Y

ES/N

O

Th

aw

ing

W

AC

24

6-2

15

03

51

0

YE

S/NO

Co

ok

ing

W

AC

24

6-2

15

03

40

0, 0

34

05

, 0

34

10

, 03

41

5, 0

34

20

YE

S/NO

Ho

t Ho

ldin

g

Ho

t foo

d m

aintain

ed at 1

35F

0

35

25

YE

S/NO

Co

ld H

old

ing

C

old

foo

d m

aintain

ed at 4

1F

0

35

25

YE

S/NO

Pre

ve

ntin

g C

ross

Co

nta

min

atio

n d

urin

g fo

od

sto

rag

e o

r disp

lay

Sep

aration

by

species 0

33

06

YE

S/NO

Asse

mb

ly o

r pre

pa

ratio

n o

f fo

od

s tha

t will n

ot b

e co

ok

ed

.

Y

ES/N

O

Co

olin

g

Tim

e/Tem

peratu

re Co

ntro

l for

Safety foo

d w

ill be co

oled

to

41F

with

in 6

ho

urs; 1

35F

to

70 in

2 h

ou

rs

YE

S/NO

______

______

________

________

__

Ap

plican

t initial D

ate EH in

itial

Re

he

atin

g

Fo

od

mu

st be reh

eated to

a tem

peratu

re of 1

65 fo

r 15

seco

nd

s with

in 2

ho

urs

YE

S/NO

F

INIS

H S

CH

ED

UL

E

INST

RU

CT

ION

S: Ind

icate wh

ich m

aterials (qu

arry tile, stainless steel, fib

erglass reinfo

rced p

anels (F

RP

), 4” p

lastic coved

mo

ldin

g, etc.).

RO

OM

/A

RE

A

FL

OO

R

FL

OO

R/

WA

LL

JU

NC

TU

RE

W

AL

LS

C

EIL

ING

M

EE

TS

CR

ITE

RIA

(R

A to

circle a

nd

Initia

l)

Fo

od

Pre

pa

ratio

n

YE

S/NO

Dry

Fo

od

Sto

rag

e

YE

S/NO

Wa

rew

ash

ing

Are

a

YE

S/NO

Wa

lk-in

Re

frige

rato

rs a

nd

Fre

eze

rs

Y

ES/N

O

Se

rvice

/M

op

Sin

k

*RE

QU

IRE

D

YE

S/NO

Re

fuse

Are

a

YE

S/NO

To

ilet R

oo

ms a

nd

D

ressin

g R

oo

ms

YE

S/NO

Oth

er: In

dica

te

YE

S/NO

Ide

ntify

clea

nin

g fre

qu

en

cy o

f ph

ysica

l facility

inclu

din

g fo

od

an

d n

ot fo

od

con

tact e

qu

ipm

en

t, floo

rs, wa

lls an

d ce

iling

s.

______

______

________

________

__

Ap

plican

t initial D

ate EH in

itial

PH

YS

ICA

L F

AC

ILIT

IES

IN

STR

UC

TIO

NS: E

xplain

the fo

llow

ing w

ith as m

uch

detail as p

ossib

le. Ind

icate No

t Ap

plicab

le (NA

) as app

rop

riate.

TO

PIC

M

INIM

UM

CR

ITE

RIA

M

EE

TS

CR

ITE

RIA

C

ircle a

nd

Initia

l)

Ha

nd

wa

shin

g fa

cilities

Id

entify n

um

ber o

f the h

and

wash

ing sin

ks in

foo

d p

reparatio

n an

d w

arewash

ing areas:

______Fo

od

Prep

aration

_______ Warew

ashin

g Area ________ Service A

rea/W

ait Statio

n

M

inim

um

temp

erature o

f han

d w

ashin

g water:_____________

A

re han

d sin

ks cen

trally located

, easily accessib

le to h

igh u

se areas, with

in lin

e of site

from

foo

d p

reparatio

n o

r service areas, no

t ob

structed

by

do

ors o

r equ

ipm

ent?

YE

S/NO

Te

mp

era

ture

Mo

nito

ring

D

ev

ices

D

o all refrigeratio

n u

nits h

ave a th

ermo

meter? _____________________

H

ow

man

y T

herm

om

eters are availab

le to m

on

itor fo

od

? _________

W

hat ty

pe o

f therm

om

eters will yo

u u

se? ___________________________

W

here w

ill you

store th

ermo

meters? ________________________________

YE

S/NO

Se

wa

ge

Disp

osa

l *O

nsite

Se

ptic A

pp

rov

al m

ust

be

atta

che

d o

r ap

plica

tion

w

ill be

retu

rne

d.

Is th

e sewage system

pu

blic o

r no

n-p

ub

lic/priv

ate? pu

blic

no

n-p

ub

lic/priv

ate

o

If priv

ate, has th

e sewage system

been

app

roved

? Yes

* No

o

Will grease trap

s/intercep

tors b

e pro

vided

? Yes

No

Id

entify lo

cation

on

plan

.

o

YE

S/NO

Wa

ter Su

pp

ly

If usin

g a

we

ll, ap

pro

va

l of

wa

ter sy

stem

with

curre

nt

tests m

ust b

e a

ttach

ed

or

ap

plica

tion

will b

e re

turn

ed

Is th

e water su

pp

ly pu

blic o

r no

n-p

ub

lic/priv

ate? pu

blic

no

n-p

ub

lic/priv

ate

o

If priv

ate, has so

urce b

een ap

pro

ved? Y

es * N

o

o

Attach

cop

y o

f written

app

roval an

d/o

r perm

it.

YE

S/NO

______

______

________

________

__

Ap

plican

t initial D

ate EH in

itial

Wa

re-w

ash

ing

Fa

cilities

MA

NU

AL

DIS

HW

AS

HIN

G

Is a h

and

sink

availab

le at ware w

ashin

g area?

□ Y

es □ N

o

Id

entify th

e length

, wid

th, an

d d

epth

of th

e com

partm

ents o

f the 3

-com

partm

ent sin

k:

__________________________________________

W

ill the largest p

ot/ p

an fit in

to each

com

partm

ent o

f the 3

-com

partm

ent sin

k?

□ Y

es □ N

o If N

o, w

hat w

ill be th

e pro

cedu

re for m

anu

al cleanin

g and

sanitizin

g of

items th

at will n

ot fit in

to sin

k co

mp

artmen

ts? ______________________________________

D

escribe size, lo

cation

and

typ

e (drain

bo

ards, w

all-mo

un

ted o

r overh

ead sh

elves,

station

ary or p

ortab

le racks) o

f air dryin

g space:

____________________________________________________________________________________________

W

hat ty

pe o

f sanitizer w

ill be u

sed? □

Ch

emical T

ype:____________ □

Ho

t Water

ME

CH

AN

ICA

L D

ISH

WA

SH

ING

Id

entify th

e mak

e and

mo

del o

f the m

echan

ical dish

wash

er:______________________

W

hat ty

pe o

f sanitizer w

ill be u

sed? □

Ch

emical T

ype:____________ □

Ho

t Water

A

re temp

erature o

r chem

ical test strips av

ailable? Y

es N

o

W

ill ventilatio

n b

e pro

vided

? Yes

No

YE

S/NO

Ba

ckflo

w P

rev

en

tion

Will all p

otab

le water so

urces b

e pro

tected fo

r back

flow

? Yes

No

A

re all floo

r drain

s iden

tified o

n th

e sub

mit flo

or p

lan? Y

es N

o

YE

S/NO

To

ilet F

acilitie

s

Iden

tify locatio

ns an

d n

um

ber o

f toilet facilities: _____________________________

H

ot an

d co

ld w

ater pro

vided

? Yes

No

YE

S/NO

Po

ison

ou

s/C

lea

nin

g

Sto

rag

e

Id

entify th

e locatio

n an

d sto

rage of p

oiso

no

us o

r toxic m

aterials

W

here w

ill cleanin

g and

sanitizin

g solu

tion

s be sto

red at w

ork

station

s?

_____________________________________________________________________

H

ow

will th

ese items b

e separated

from

foo

d an

d fo

od

-con

tact surfaces?

______________________________________________________________________

1.

Iden

tify the lo

cation

of th

e facilities for clean

ing o

f mo

ps an

d o

ther clean

ing

equ

ipm

ent?

YE

S/NO

______

______

________

________

__

Ap

plican

t initial D

ate EH in

itial

Pe

st Co

ntro

l

Will all o

utsid

e do

ors b

e self-closin

g and

rod

ent p

roo

f? □ Y

es □ N

o □

NA

W

ill screens b

e pro

vided

on

all entran

ces left op

en to

the o

utsid

e? □ Y

es □ N

o □

NA

W

ill all op

enab

le win

do

ws h

ave a m

inim

um

#1

6 m

esh screen

ing? □

Yes □

No

□ N

A

W

ill insect co

ntro

l devices b

e used

? □ Y

es □ N

o □

NA

W

ill air curtain

s be u

sed? If yes, w

here? ___________________________

No

te: All p

ipes an

d electrical co

nd

uit ch

ases mu

st be sealed

to p

reven

t rod

ent access.

YE

S/NO

Re

fuse

, Re

cycla

ble

s, an

d

Re

turn

ab

les

W

ill refuse/garb

age be sto

red in

side? □

Yes □

No

If yes, wh

ere __________________

Id

entify h

ow

and

wh

ere garbage can

s and

floo

r mats w

ill be clean

ed?

______________________________________________________________________________________________

W

ill a du

mp

ster or a co

mp

acter be u

sed? □

Du

mp

ster □ C

om

pacto

r

Id

entify lo

cation

s of grease sto

rage con

tainers:_________________________________

W

ill there b

e an area to

store recyclab

les? □ Y

es □ N

o

If yes, wh

ere _____________________________________________________________

W

ill there b

e an area to

store retu

rnab

le dam

aged go

od

s? □ Y

es □ N

o

If yes, wh

ere _____________________________________________________________

W

ill surp

lus fo

od

be d

on

ated to

foo

d reco

very pro

grams? □

Yes □

No

If yes, w

here _____________________________________________________________

YE

S/NO

______________________________ Applicant initial Date EH initial

plan review application process for food service …

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