Food Establishment Application Guide

( ) Nursing Home ( ) Water Supply : Public Water ( ) Private Well ( ) Sewage: Public Sewage ( ) Septic Tank ( ) Aerobic Treatment Unit ( ) Grease Trap ( ) Laundry Tank ( ) Owner Information : Name of Owner: ____________________________________________________________ Name of Applicant: (if different from owner) _____________________________________ Mailing Address: ____________________________________________________________ City: ___________________________________ Zip Code: _________________________ Owner Home:____________________________ Cell:______________________________ Page 2 of 5 Hours of Operation: Sun _____________ Thurs _____________ Mon _____________ Fri _____________ Tues _____________ Sat _____________ Wed _____________ Food Service Questionnaire: To better determine the type of permit required for your food service establishment, please answer the following questions: Number of Licensed Residents/Clients ( if applicable ): ________ Total Number of Food Workers: ________ Maximum Number per Shift: ________ Maximum Meals to Serve: Breakfast _____________ ( Estimate ) Lunch _____________ Dinner _____________ Snacks _____________ Type of Service: Sit Down ( ) Mobile Food Unit ( ) ( Check all that apply ) Take Out ( ) Other ( ) specify: ___________________________ Caterer ( ) ************************************************************************************ YES NO 1. Will you be serving only pre-packaged snacks and/or drinks? ( ) ( ) 2.<br><br> Will you be washing dishes, utensils, and/or wares? ( ) ( ) 3. Will you be using only single-use/ single-service utensils?<br><br> ( ) ( ) 4. Will you be portioning prepared, catered meals, or snacks? ( ) ( ) 5.<br><br> Will you be cooking or warming using the stove, oven, or microwave? ( ) ( ) 6. Will you be warming or preparing infant bottles?<br><br> ( ) ( ) 7. Will you be cooking at home and bringing food to your facility? ( ) ( ) 8.<br><br> Are all food supplies from inspected and approved sources? ( ) ( ) Foods to be Handled, Prepared, and Served : YES NO 1. Thin Meats, poultry, fish, eggs (hamburger, sliced meats, fillets) ( ) ( ) 2.<br><br> Thick meats, whole poultry (roast beef, whole turkey, chicken, hams) ( ) ( ) 3. Cold Processed foods (salads, sandwiches, vegetables) ( ) ( ) 4. Hot processed foods (soups, stews, rice/noodles, gravy, casseroles) ( ) ( ) 5.<br><br> Baked goods (pies, cakes, cookies, brownies) ( ) ( ) 6. Other __________________________________________________________________________ Food Service Manager Certification Name/Number (if applicable _____________________________ Food-supplies and deliveries : What are the projected frequencies and times of deliveries for: Frozen foods: Frequency ________________ Time ________________ Refrigerated foods: Frequency ________________ Time ________________ Dry goods: Frequency ________________ Time ________________ Page 3 of 5 FLORIDA DEPARTMENT OF HEALTH FLORIDA DEPARTMENT OF HEALTH Food Service Plan Review Check List : Fee: $40.00 per hour non-refundable fee made payable to Escambia County Health Department Complete below and check all that apply : Location of Food Establishment: City limits ( ) County limits ( ) YES NO Pending N/A Zoning: Date Submitted: ______________ Approved ( ) ( ) ( ) ( ) Planning: Date Submitted: ______________ Approved ( ) ( ) ( ) ( ) Building: Date Submitted: ______________ Approved ( ) ( ) ( ) ( ) Plumbing: Date Submitted: ______________ Approved ( ) ( ) ( ) ( ) Fire Authority: Date Submitted: ______________ Approved ( ) ( ) ( ) ( ) Other: ______________________________________________________________________ Plans/Applications have been submitted to the required authorities on the following dates: Square Footage of Food Area/ Kitchen: ____________ Square Footage of the Facility: ____________ **************************Please Submit the Following Documents************************** Required Food Establishment Plans: (no larger than 11x17 inches) 1.____ Proposed Menu - To include all snacks/meals served on a weekly basis 2.____ Floor Plan - Floor plan to scale must include all that apply : a) Identify location of each piece of equipment clearly labeled with its common name (fridge, freezer, oven, stove, warming units, microwaves, dishwasher, fire suppression system, ventilation hoods, steam tables, etc&) b) Identify location of all food preparation areas and indicate if they will be used for raw foods and/or ready to eat foods. Include location of 2-compartment food preparation sink.<br><br> c) Identify location of all hand wash only sinks. d) Label and locate all restrooms, and include all toilets, urinals, and rest room hand wash sinks) e) Locate and identify the dishwashing area. i.<br><br> If manual dishwashing, identify location of 3-compartment sink and label as wash, rinse, and sanitize ii. If automatic dish washing, label and locate machine, indicate method of sanitization, and provide any equipment specifications. iii.<br><br> Identify areas for drying clean dishes and utensils. f) Identify dining rooms, storage rooms, pantries, garbage rooms, janitorial rooms, etc& g) Identify location of mop sink and facilities for hanging wet mops 3.____ Site Plan - Site plan to scale must include all that apply : a. Identify location of building on property and include the following: (Location of irrigation/ drinking wells, septic system, dumpster, play ground area, parking lot, building exits, fences, sheds, bodies of water, and any other outdoor equipment.) Page 4 of 5 Food Service Plan Review (continued) Please indicate the type of equipment that will be utilized in the food service establishment.<br><br> Ensure all equipment specified as cyes d below are labeled on the floor plan and/or site plan. Check all that apply: Food Service Equipment : Other Equipment Not Listed : ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ Garbage and Rubbish Disposal : YES NO County/ City Public Garbage Can----------------------------- ( ) ( ) Garbage Compactor--------------------------------------------- ( ) ( ) Dumpster stored on smooth non-absorbent material-------- ( ) ( ) Other: (specify)_________________________________ Chemicals, Pest Control, Cleaning and Ventilation : How often will pest control/pesticides be sprayed? (Please list agent who will be applying pesticides) _____________________________________________________________________________________ Where will cleaning supplies and household chemicals be stored?<br><br> ________________________________ _____________________________________________________________________________________ How will dry storage be kept 6 inches off the floor? ___________________________________________ _____________________________________________________________________________________ What are the floors, walls, ceiling constructed from? __________________________________________ Is this material smooth, non-absorbent, and cleanable surface?<br><br> Yes ( ) No ( ) How is the food establishment ventilated? (central air/heat, window unit, fans, air filtration system) _____________________________________________________________________________________ Thank You from the Escambia County Health Department Tradition-Service-Leadership " Protecting You Since 1821 Questions: Call (850) 595-6700 Page 5 of 5 YES NO Stove------------------------------------ ( ) ( ) Approved Exhaust Hood------------- ( ) ( ) Microwave----------------------------- ( ) ( ) Freezer--------------------------------- ( ) ( ) Refrigerator---------------------------- ( ) ( ) Ice Machine---------------------------- ( ) ( ) Dishwasher---------------------------- ( ) ( ) Hand Wash Sink---------------------- ( ) ( ) Food Prep Sink------------------------ ( ) ( ) 2-Compartment Sink----------------- ( ) ( ) 3-Comopartment Sink---------------- ( ) ( ) Slanting Drain Board----------------- ( ) ( ) Mop/ Janitorial Sink------------------ ( ) ( ) Floor Drains--------------------------- ( ) ( )

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