HomeMy WebLinkAbout- Miscellaneous - 127 WAVERLY ROAD 6/28/2024 FDA/CFP: Food Establishment Plan Review Guide - Sections I Page 1 of 19
Food and Drug Administration and Conference for Food Protection
FOOD ESTABLISHMENT PLAN REVIEW GUIDE
2000
SECTION I
FOOD ESTABLISHMENT PLAN REVIEW APPLICATION TO BE
COMPLETED BY THE OPERATOR AND SUBMITTED TO THE
REGULATORY AUTHORITY
Regulatory Authority
JUN 13 2008
,-J3 Z)
TOWN OF NORT Ai�DOV�k
Date: 6 /l i HEALTH DEPARTMENT
FOOD ESTABLISHMENT PLAN REVIEW APPLICATION ,
NEW REMODEL CONVERSION
Name of Establishment: PA71 F/2 2"—' I A
Category: Restaurant , Institution , Daycare , Retail Market , Other P� z Z�������
Address: j �� �� j=Z�� '1 4)tL,F1A �� � c,�L I�� d i I}
Phone if available: / 7 `3 7,9 933 �p
Name of Owner:
Mailing Address: 1 7 Jvaae/' � ro YaA 01 �YS
i
Telephone:
Applicant's Name: O ��
Title (owner, manager, architect, etc.): �
Mailing Address:
Telephone:
I have submitted plans/applications to the following authorities on the following dates:
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FDA/CFP: Food Establishment Plan Review Guide - Sections I Page 2 of 19
Governing Board of Council Plumbing,
Zoning Electric.
Planning Police
Building Fire.
Conservation Other( )
Hours of Operation: Sun /' Thurs PO'
din
Mon i/- IV Fri ///;��►- j �',,,t
Tues /�f/Vl Sat GlPI'^
Wed A%- qPM
Number of Seats:_
Number of Staff: ;k
(Maximum per shift)
Total Square Feet of Facility:
Number of Floors on which
operations are conducted P
Maximum Meals to be Served: Breakfast_
(approximate number) Lunch
Dinner
Projected Date for Start of Project:
Projected Date for Completion of Project: �T
Type of Service: Sit Down Meals
(check all that apply) Take Out
Caterer
Mobile Vendor
Other /7-e4 v c v�
Please enclose the following documents:
__zProposed 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)
J Plan drawn to scale of food establishment showing location of equipment, plumbing, electrical services and
mechanical ventilation
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FDA/CFP: Food Establishment Plan Review Guide - Sections I Page 3 of 19
Equipment schedule
CONTENTS AND FORMAT OF PLANS AND SPECIFICATIONS
1. Provide plans that are a minimum of 11 x 14 inches in size including the layout of the floor plan accurately drawn to
a minimum scale of 1/4 inch= 1 foot. This is to allow for ease in reading plans.
2. Include: proposed menu, seating capacity, and projected daily meal volume for food service operations.
3. Show the location and when requested, elevated drawings of all food equipment. Each piece of equipment must be
clearly labeled on the plan with its common name. Submit drawings of self-service hot and cold holding units with
sneeze guards.
4. Designate clearly on the plan equipment for adequate rapid cooling, including ice baths and refrigeration, and for
hot-holding potentially hazardous foods.
5. Label and locate separate food preparation sinks when the menu dictates to preclude contamination and cross-
contamination of raw and ready-to-eat foods.
6. Clearly designate adequate handwashing lavatories for each toilet fixture and in the immediate area of food
preparation.
7. Provide the room size, aisle space, space between and behind equipment and the placement of the equipment on the
floor plan.
8. On the plan represent auxiliary areas such as storage rooms, garbage rooms, toilets,basements and/or cellars used for
storage or food preparation. Show all features of these rooms as required by this guidance manual.
9. Include and provide specifications for:
a. Entrances, exits, loading/unloading areas and docks;
b. Complete finish schedules for each room including floors, walls, ceilings and coved juncture bases;
c. Plumbing schedule including location of floor drains, floor sinks, water supply lines, overhead waste-water
lines, hot water generating equipment with capacity and recovery rate, backflow prevention, and wastewater line
connections;
d. Lighting schedule with protectors;
(1) At least 110 lux(10 foot candles) at a distance of 75 cm (30 inches)above the floor, in walk-in
refrigeration units and dry food storage areas and in other areas and rooms during periods of cleaning;
(2) At least 220 lux(20 foot candles):
(a) At a surface where food is provided for consumer self-service such as buffets and salad bars or
where fresh produce or packaged foods are sold or offered for consumption;
(b) Inside equipment such as reach-in and under-counter refrigerators;
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FDA/CFP: Food Establishment Plan Review Guide - Sections I Page 4 of 19
(c)At a distance of 75 cm (30 inches)above the floor in areas used for handwashing, warewashing,
and equipment and utensil storage,and in toilet rooms; and,
(3) At least 540 lux(50 foot candles) at a surface where a food employee is working with food or working
with utensils or equipment such as knives, slicers, grinders, or saws where employee safety is a factor.
e. Food Equipment schedule to include make and model numbers and listing of equipment that is certified or
classified for sanitation by an ANSI accredited certification program(when applicable).
f. Source of water supply and method of sewage disposal. Provide the location of these facilities and submit
evidence that state and local regulations are complied with;
g. A color coded flow chart demonstrating flow patterns for:
-food(receiving, storage,preparation, service);
-food and dishes(portioning, transport, service);
-dishes (clean, soiled, cleaning, storage);
-utensil (storage,use, cleaning);
-trash and garbage (service area, holding, storage);
h. Ventilation schedule for each room;
i. A mop sink or curbed cleaning facility with facilities for hanging wet mops;
j. Garbage can washing area/facility;
k. Cabinets for storing toxic chemicals;
1. Dressing rooms, locker areas, employee rest areas, and/or coat rack as required;
m. Completed Section 1;
n. Site plan(plot plan)
FOOD PREPARATION REVIEW
Check categories of Potentially Hazardous Foods (PHF's) to be handled, prepared and served.
CATEGORY* (YES) (NO)
1. Thin meats,poultry, fish, eggs(hamburger; sliced meats; fillets) (vj ( )
2. Thick meats, whole poultry (roast beef; whole turkey, chickens, hams) (Vc ( )
3. Cold processed foods (salads, sandwiches, vegetables) )
4. Hot processed foods (soups, stews, rice/noodles, gravy, chowders, casseroles) ( ( 01
5. Bakery goods (pies, custards, cream fillings&toppings) ( ) ( 4<
6. Other F/%Z t C ALMt1L:S
* A generic HACCP plan for each category of food may be available from the regulatory authority for
reference.
PLEASE CIRCLE/ANSWER THE FOLLOWING QUESTIONS
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FOOD SUPPLIES:
1. Are all food supplies from inspected and approved sources? S /NO
2. What are the projected frequencies of deliveries for Frozen foods �JC£
Refrigerated foods tX and Dry goods (��' cJct ie
3. Provide information on the amount of space (in cubic feet) allocated for:
Dry storage 5k e-I r k
Refrigerated Storage ypp 611. , and
Frozen storage 3® t.F,
4. How will dry goods be stored off the floor?
5Ae/veS ,i- Sk%mod
COLD STORAGE:
1. Is adequate and approved fr9gzer and refrigeration available to store frozen foods frozen, and refrigerated foods
at 41°F (5°C) and below?� NO
Provide the method used to calculate cold storage requirements.
2. Will raw eats, poultry and seafood be stored in the same refrigerators and freezers with cooked/ready-to-eat
foods? "/NO
If yes, how will cross-contamination be prevented? j
;-,,'1 � S`` ,
3. Does each refrigerator/freezer have a thermometer? S I NO
Number of refrigeration units: j
Number of freezer units: .2-
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.
Thawing Method *THICK FROZEN FOODS *THIN FROZEN FOODS
Refrigeration
Running Water Less than 70°F(21°
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C)
Microwave(as part of cooking
process)
Cooked from Frozen state
Other(describe)
*Frozen foods: approximately one inch or less=thin,and more than an inch=thick.
COOKING:
1. Will food product thermometers be used to measure final cooking/reheating temperatures of PHF's? Ell/NO
What type of temperature measuring device: //►1 1��/�( exuom� iv
Minimum cooking time and temperatures of product utilizing convection and conduction heating equipment:
beef roasts 130°F (121 min)
solid seafood pieces 145*F(15 sec)
other PHF's 145°F (15 sec)
eggs:
Immediate service 145T(15 sec)
pooled* 155T (15 sec)
(*pasteurized eggs must be served to a highly susceptible
population)
pork 145T (15 sec)
comminuted meats/fish 155T(15 sec)
poultry 165T (15 sec)
reheated PHF's 165T(15 sec)
2. List types of cooking equipment.
HOT/COLD HOLDING:
1. How will hot PHF's be maintained at 140T (60°C) or above during holding for service?Indicate type and number of
hot holding units.
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FDA/CFP: Food Establishment Plan Review Guide - Sections I Page 7 of 19
2. How will cold PHF's be maintained at 41°F (5°C) or below during holding for service?Indicate type and number of
cold holding units.
C� d
COOLING:
Please indicate by checking the appropriate boxes how PHF's will be cooled to 41°F (5°C) within 6 hours (140°F to 70'
F in 2 hours and 70°F to 41°F in 4 hours). Also, indicate where the cooling will take place.
COOLING THICK THIN MEATS THIN SOUPS/ THICK RICE/
METHOD MEATS GRAVY SOUPS/ NOODLES
GRAVY
Shallow Pans
Ice Baths
Reduce Volume
or Size ✓/
Rapid Chill
Other p K � � S �i r�}V'J �; .
- X"
(describe) 0
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°F for 15 seconds. Indicate type and number of units used for reheating foods.
2. How will reheating food to 1650F for hot holding be done rapidly and within 2 hours?-
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PREPARATION:
1. Please list categories of foods prepared more than 12 hours in advance of service.
2. Will food employees be trained in good food sanitation practices?b//NO
Method of training:
5-Aft, � �
Number(s) of employees:
Dates of completion: '�'S)lr - 7
ill disposable gloves and/or utensils and/or food grade paper be used to prevent handling of ready-to-eat foods?
t's",
NO
4. Is there a written policy to exclude or restrict food workers who are sick or have infected cuts and lesions? SAES'/NO
Please describe briefly:
Will employees have paid sick leave?YES/ 10
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?
Chemical Type: /o v r
Concentration: J-47 few
Test Kit YES'/NO
6. Will ingredients for cold ready-to-eat foods.su as tuna, mayonnaise and eggs for salads and sandwiches be pre-
chilled before being mixed and/or.assembled?Q'E/NO
If not,how will ready-to-eat foods be cooled to 41°F?
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7. Will all produce be washed on-site prior to use? ES/NO
Is there a planned location used for washing produce? ES I NO
Describe aAlltl, All-, VLa �� ;i
If not, describe the procedure for cleaning and sanitizing multiple use sinks between uses.
, Ele Lore A2c� cz,� - t 7�
ire S4
8. Describe the procedure used for minimizing the length of time PHF's will be kept in the temperature danger zone
(41 T - 140T)during preparation.
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9. Provide a HACCP plan for specialized processing methods such as vacuum packaged food items prepared on-site or
otherwise required by the regulatory authority. /v A I/ e
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?
A. FINISH SCHEDULE
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Applicant must indicate which materials(quarry tile, stainless steel, 4" plastic coved molding, etc.)will be used ill the
following areas.
Kitchen FLOOR COVING WALLS CEILING
Bar
Food Storage �� 1 /vl r Ck OC�`g�l�r
✓ v
Other Storage
Toilet Rooms
/ � c
Dressing Rooms
Garbage & Refuse OC/ t
Storage J
Mop Service Basin Ger c v�
Area
Warewashing V �� A'
Area S
Walk-in
Refrigerators and
Freezers
B. INSECT AND RODENT CONTROL
APPLICANT: Please check appropriate boxes.
YES NO NA
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y
1. Will all outside doors be self-closing and rodent proof?
2. Are screen doors provided on all entrances left open to the outside?
3. Do all openable windows have a minimum#16 mesh screening? (J? O ( )
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? II,�
7. Will air curtains be used?If yes, where? �fy!I 'OCLI'tjs� ( ( )
C. GARBAGE AND REFUSE
Inside
8. Do all containers have lids?
9. Will refuse be stored inside?
If so, where?
10. Is there an area designated for garbage can or floor mat cleaning?
Outside
11. Will a dumpster be used? r ( ( ) ( )
Number_�Size e;l &U 41 r{e( \/q 0
Frequency of pickup P
Contractor %
12. Will a compactor be used? 1
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
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15. Describe location of grease storage receptacle
16. Is there an area to store recycled containers?, O O
Indicate what materials are required to be recycled;
( ) Glass
( ) Metal
( ) Paper
( ) Cardboard
( ) Plastic
17. Is there any area to store returnable damaged goods?
D. PLUMBING CONNECTIONS
AIR GAP AIR *INTEGRAL *"P" VACUUM CONDENSATE
BREAK TRAP TRAP BREAKER PUMP
18. Toilet
19. Urinals
20. Dishwasher
21. Garbage
Grinder
22. Ice machines
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FDA/CFP: Food Establishment Plan Review Guide - Sections I Page 13 of 19
23. Ice storage
bin
ti.
24. Sinks
a. Mop
b. Janitor
c. Handwash
d.
3 Compartment
e. 2
Compartment
f. 1
Compartment
g. Water Station
25. Steam tables
26. Dipper wells
27. Refrigeration
condensate/
drain lines
28. Hose
connection
29. Potato peeler
30. Beverage
Dispenser
w/carbonator
31. Other
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FDA/CFP: Food Establishment Plan Review Guide - Sections I Page 14 of 19
* 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:
"zi
E. WATER SUPPLY
33. Is water supply public (vor private ( ) ?
l34. If private,has source been approved? YES ( )NO ( ) PENDING
Please attach copy of written approval and/or permit._ r►�
35. Is ice made on premises ( ) or purchased commercially ( ) ? 14K
If made on premise, are specifications for the ice machine provided? YES ( )NO ( )
Describe provision for ice scoop storage: /j `4
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 Part 5 & Part 9 Under Section III in this manual) '
38. Is there a water treatment device?YES ( )NO
If yes, how will the device be inspected& serviced?
39. How are backflow prevention devices inspected& serviced?
sib
F. SEWAGE DISPOSAL
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FDA/CFP: Food Establishment Plan Review Guide - Sections I Page 15 of 19
40. Is building connected to a municipal sewer? YES (\�/NO ( )
41. If no, is private disposal system approved?YES ( )NO ( ) PENDING O l
Please attach copy of written approval and/or permit.
42. Are grease traps provided? YES M NO ( )
If so, where? ' V LJ !" U ti+-(�
Provide schedule for cleaning& maintenance LT�� ct- 6�
G. DRESSING_ROOMS
43. Are dressing rooms provided? YES ( )NO (iK
44. Describe storage facilities for employees'personal belongings (i.e.,purse, coats, boots, umbrellas,etc.)
&AA
H. GENERAL
45. Are insecticides/rodenticides stored separately from cleaning& sanitizing agents?
YES ('4N0 ( f
Indicate location: 4CV� � )�� i�=l 'f-&0,7e�l
0 W J, e
46. Are all toxics for use on the premise r for retail sale (this includes personal medications), stored away from food
preparation and storage areas? YES,( O ( )
47. Are all containers of toxics including sanitizing spray bottles clearly labeled?
YES(✓<0 ( )
48. Will linens be laundered on site? YES ( )NO (\4/
If yes, what will be laundered and where?
If no, how will linens be cleaned? L,CC" _�e of 1Li F Oy�'�✓ l � eo�
49. Is a laundry dryer available?YES ( )NO (�
50. Location of clean linen storage: Ova
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�'51. Location of dirt ylinen storage: fl�f
i J
52. Are containers constructed of safe materials to store bulk food products?YES (v)NO ( )
Indicate type: r Tf�s�C ✓�� [Q � — -r' �vU���
53. Indicate all areas where exhaust hoods are installed:
LOCATION FILTERS SQUARE FIRE AIR AIR
&/OR FEET PROTECTION CAPACITY MAKEUP
EXTRACTION CFM CFM
DEVICES
above
54. How is each listed ventilation hood system cleaned?
I. SINKS
55. Is a mop sink present? YES (vf<o ( )
If no, please describe facility for cleaning of mops and other equipment:
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56. If the menu dictates, is a food preparation sink present?YES ( )NO ( )
J. DISHWASHING FACILITIES
57. Will sinks or a dishwasher be used for warewashing?
Dishwasher( )
Two compartment sink
Three compartment sink( )
58. Dishwasher
Type of sanitization used:
Hot water(temp. provided)
Booster heater
Chemical type
Is ventilation provided?YES ( )NO ( )
59. Do all dish machines have templates with operating instructions?YES ( )NO O
60. Do all dish machines have temperature/pressure gauges as required that are accurately working? YES ( )N ( )
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 (y
W
63. What type of sanitizer is used?
Chlorine (v7
Iodine
Quaternary ammonium ( )
Hot Water ( )
Other ( )
64. Are test papers and/or kits available for checking sanitizer concentration?YES (�O ( )
K. HANDWASHING/TOILET FACILITIES
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FDA/CFP: Food Establishment Plan Review Guide - Sections I Page 18 of 19
65. Is there a handwashing sink in each food preparation and warewashing area?YES(vTO ( )
66. Do all handwashing sinks, including those in the restrooms,have a mixing valve or combination faucet?YES
NO( )
67. Do self-closing metering faucet Provide a flow of water for at least 15 seconds without the need to reactivate the
faucet?YES ( )NO ( ) /U C)/VZ:�
68. Is hand cleanser available at all handwashing sinks?YES (,41NO
69. Are hand drying facilities(paper towels,air blowers,etc.)available at all handwashing sinks?YES (vyNO( )
70. Are covered waste receptacles available in each restroom? YES (VY<0( )
71. Is hot and cold running water under pressure available at each handwashing sink?YES (v)INO ( )
72. Are all toilet room doors self-closing? YES (- NO ( )
73. Are all toilet rooms equipped with adequate ventilation?YES (v10 ( )
74. If required, is a handwashing sign posted in each employee restroom?YES (,)'NO( )
L. SMALL EQUIPMENT REQUIREMENTS
75. Please specify the number, location, and types of each of the following:
Slicers W, 6-e-oteW-
Cutting boards
Can openers
Mixers
Floor mats
Other t�,� ✓ (� ( C�6� •C r 5
�C�CXX�fXXKXXX�C
STATEMENT: I hereby certify that the above information is correct, and I fully understand that any deviation
from the above ut r mission from this Health Regulatory Office may nullify final approval.
Signature(s)
7 - ---
owner(s)or responsible representative(s)
Date: ' / ,
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FDA/CFP: Food Establishment Plan Review Guide - Sections I Page 19 of 19
Approval of these plans and specifications by this 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 preopening inspection of
the establishment with equipment in place & operational will be necessary to determine if it complies with the
local and state laws governing food service establishments.
florae I Plan Review: Table of Contents
Hypertext updated by dms/ces 2000-MAR-30
http://www.cfsan.fda.gov/—dms/prev-1.html 3/24/2008
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