Limited Operations Retail Food Establishment Application

Transcription

1 DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT 1555 North 17 th Avenue Greeley, CO Web: Health Administration Vital Records Tele: Fax: Public Health & Clinical Services Tele: Fax: Environmental Health Services Tele: Fax: Communication, Education & Planning Tele: Fax: Emergency Preparedness & Response Tele: Fax: Our vision: Together with the communities we serve, we are working to make Weld County the healthiest place to live, learn, work and play. Limited Operations Retail Food Establishment Application Dear Plan Review Applicant: At times, the comprehensive Retail Plan Review and Application packet doesn t fit the operations of a potential retail food establishment because the scope of the business is limited. Examples of this type of business include bakeries, catering operations, freezer meats, and the sales of burritos that are prepackaged at a commissary. To that end, the Weld County Department of Public Health and Environment has developed a simplified packet. If you do not fit into the categories listed above, please refer to the other plan review application links on our website. In all cases, please call our office for consultation as to whether it is suitable to utilize the abbreviated paperwork. If your operation is approved to use the limited operations application, the following information must be completed and returned to the Weld County Department of Public Health & Environment, Environmental Health Services Division, at least thirty (30) days prior to the beginning of construction, remodel or intended use of a commissary. Please use the following checklist to assure that you submit all required information: Applicable section (note: all pages may not be necessary) - I. Limited Operations - II. Bakeries and Related - III. Caterers Plan Review Application Fee with checks payable to WCDPHE ($100.00) Owner Information Form License Application Photocopy of the Colorado State Sales Tax License (obtained from Department of Revenue*) Commissary Letter (if applicable) Affidavit- Restrictions on Public Benefits (if applicable)** Non-profit applicants must submit documentation of 501(c)(3) designation A pre-opening inspection is required prior to operation. Please call to schedule the pre-opening inspection at least 5 (five) working days before you are ready for the inspection. This will allow us to better meet your needs. Final review and license fees will be collected during the pre-opening inspection. The fees include a $50.00 per hour charge for review and inspection activities (e.g. evaluation of plan review, walk-through and pre-opening inspections, etc.) and Retail Food Establishment license fee (fee varies depending upon license type and facility size). *Department of Revenue Phone: (303) (Denver) (970) (Fort Collins) Website: Within twenty-one (21) days of the receipt of the plan review information, a response will be mailed to you. The letter either will approve your plans or will require changes to the existing plans in order to comply with the Colorado Retail Food Establishment Rules and Regulations 6 CCR **Colorado Revised Statute requires that this Affidavit and appropriate identification be provided to verify that all sole proprietors and individual applicants for retail food establishment licenses are lawfully present in the United States prior to the issuance of the license. Appropriate types of identification are described on the Affidavit.

2 Application I. Limited Operations: Prepackaged burritos, ice cream vendor, freezer meats, etc. Please provide your answers on a separate sheet of paper Prepackaged potentially hazardous foods (burritos, salads, kraut burgers, etc.): 1) Provide a menu or list of items that will be sold (flavors/types). 2) Where will the product be prepared? 3) At what time will they be prepared? What time is packaged? 4) How will a safe temperature be maintained while food is being sold? a. Can the unit holding maintain a temperature of 135 degrees or above? 41 degrees and below? b. If the unit cannot hold temperatures above 135 degrees or below 41 degrees then time as a public health control may be used (please request form from the Department). 5) How will food items be packaged? 6) Attach copies of policies or describe procedures that will be used to prevent bare hand contact with ready-to-eat foods. 7) Attach copies of policies or describe procedures that will be used to exclude or restrict workers who are ill. The policies or procedures need to describe when ill workers will be excluded or restricted due to illness or infection, need to outline when exclusions and restrictions are to be lifted, and the controls that will be implemented when workers return to work. Ice cream freezer (located in a store): 1) Provide a menu or list of items that will be sold. 2) Provide the make and model number of the freezer. Note: The freezer must have a commercial certification; it cannot be a household model 3) Provide the supplier name of the ice cream for your business. 4) Provide a floor plan of the building where the freezer will be located. Freezer Meats/ Mobile Ice Cream Operations: 1) Provide a menu or list of items that will be sold. 2) Provide the make and model number of the freezer. Note: The freezer must have a commercial certification; it cannot be a household model 3) If applicable provide a floor plan of the building where the freezer will be located. Note: If the freezer is located at a residence, it must be in a separate location such as a garage or shed and a separate entrance must be provided so that our inspectors do not access your living area. 4) Where will food be obtained? 5) How often will temperatures be checked? How will temperatures be taken? 6) What will happen if food product is found off temperature? 7) Where will food product be sold at? (days, times, locations) 8) How will food product be held frozen if sold at another location from where stored? 2

3 II. Small Bakery Operations (brownies, pies, cookies): 1. Submit Menu. 2. Please describe how the temperature of potentially hazardous foods will be monitored. Detail frequency of temperature checks, what foods and/or equipment will be monitored. Please attach copies of logs that will be used to help manage proper food temperatures. 3. Describe how frozen foods will be thawed. In a refrigerator, under running water, cooking process, or microwave? 4. Attach copies of policies or describe procedures that will be used to exclude or restrict workers who are ill. The policies or procedures need to describe when ill workers will be excluded or restricted due to illness or infection, need to outline when exclusions and restrictions are to be lifted and the controls that will be implemented when workers return to work. 5. Attach copies of policies or describe procedures that will be used to address restrictions and management of workers that have cuts, burns or other open sores on their hands and arms. 6. Attach copies of policies or describe procedures that will be used to prevent bare hand contact with ready-to-eat foods. 7. Where will foods be prepared? What facility will be used as the commissary? (see commissary agreement on page 10) 8. Please describe where raw ingredients and finished product will be stored at the commissary. How will your food products be marked? 9. If your finished product is potentially hazardous (pumpkin pie, pies with meringues) please describe how these foods will be cooled. How will the cooling process be monitored? 3

4 III. Caterers: A. Submit Menu. Include appetizers, entrees, lunches, dinners, sides, salads and beverages. B. Are there SOPs, a Hazard Analysis Critical Control Point (HACCP) plan or a Food Handling Procedure Manual available that describes preparation, cooling, reheating, cooking of foods and the handling of leftovers? YES/NO If yes, please submit with plans. C. Please describe how the temperature of potentially hazardous foods will be monitored. Detail frequency of temperature checks, what foods and/or equipment will be monitored. Please attach copies of logs that will be used to help manage proper food temperatures. D. List the foods that will be prepared more than 12 hours in advance of service. Include foods that are made from scratch such as soups, sauces, potato salad, pasta salads, chili, pasta noodles, roasts, casseroles, etc. E. Will potentially hazardous foods be cooled to 41ºF (5ºC) or below? YES/NO If yes, please explain how they will be cooled: Technique: Indicate the size of and the material of the containers in which food will be placed during cooling. Are foods covered during the cooling process? YES/NO Please describe how cooling processes are going to be monitored. F. Will potentially hazardous foods be reheated and then held hot before being served? YES/NO. If yes, please explain how they will be reheated to above 165ºF (74ºC): List the equipment that will be used for reheating: Please describe how reheating processes are going to be monitored. 4

5 Please list the foods that are to be held hot at or above 135ºF (57ºC). G. Describe how frozen foods will be thawed. In a refrigerator, under running water, cooking process, or microwave? H. Attach copies of policies or describe procedures that will be used to exclude or restrict workers who are ill. The policies or procedures need to describe when ill workers will be excluded or restricted due to illness or infection, need to outline when exclusions and restrictions are to be lifted and the controls that will be implemented when workers return to work. I. Attach copies of policies or describe procedures that will be used to address restrictions and management of workers that have cuts, burns or other open sores on their hands and arms. J. Attach copies of policies or describe procedures that will be used to prevent bare hand contact with readyto-eat foods. K. Will raw meats, poultry, or seafood be stored/displayed in the same refrigerator(s) and freezer(s) with cooked, ready-to-eat foods? YES/NO If yes, please indicate on the plans which refrigerator(s) and freezer(s) will be used for this storage. L. Please list the equipment that will be provided to maintain food at proper temperatures during transport. M. Will the produce used in the operation be washed in the establishment, or will all produce be received prewashed? Please describe washing process if done at the establishment. 5

6 N. Will vacuum packaging or reduced atmospheric packaging be conducted in the establishment? YES/NO If yes, please provide specifications sheets for the equipment that will be used and a copy of the required HACCP plan for each category of food to be processed in this manner. O. Will the establishment prepare foods that will be sold wholesale? YES/NO If yes, does the establishment currently have a wholesale license? YES/NO If yes to either question, please list the foods that are intended for wholesale. P. What is the greatest number of people you will serve? Q. How many employees will you have? If employing temporary staff for larger events, how are those staff members to be trained as it relates to food safety? R. Where will foods be prepared? What facility will you be using as your commissary? (see commissary agreement on page 10) S. Please describe where raw ingredients and finished product will be stored at the commissary. How will your food products be marked? 6

7 RETAIL FOOD ESTABLISHMENT INFORMATION FORM FOR OFFICE USE ONLY IN# ACCT. I.D. # SR# OWNER INFORMATION 1. Owner(s) Name 2. Corporation Name (as it appears on Sales Tax License) 3. Owner Address City State Zip 4. Home Phone No. ( ) Work Phone No. ( ) 5. Owner Mailing Address City State Zip 6. Address ESTABLISHMENT INFORMATION 1. Establishment Name 2. Site Address City State Zip 3. Mailing Address City State Zip 4. Phone Number: ( ) Manager/Contact Person 5. State Sales Tax Number: Seating Capacity 6. Hours of Operation: Days Su M T W Th F Sa Business Hours to / to (circle all that apply) 7. Water Supply (check one) Community / Public Name of District Non-Community / Private PWSID # Well Depth 8. Sewage Disposal (check one) Municipal / Public Individual Sewage Disposal System Name of District Permit # 9. SEND LICENSE/RENEWALS TO: (check one) Owner Mailing Address Establishment Site Address Establishment Mailing Address Or: 10. CHANGE OF OWNERSHIP ONLY Previous Establishment Name Date of change of ownership : Has facility been closed for more than 2 weeks? Yes No Has Menu Changed? Yes No Has equipment changed? Yes No Has layout of kitchen changed? Yes No Date 7

8 All licenses, certifications, and registrations issued to individual owners or sole proprietors by the Weld County Department of Public Health and Environment must be accompanied by verification of citizenship. This requirement does not apply to you if you are not an individual owner or sole proprietor. Verification includes completing the affidavit and providing a notarized copy of an approved identification. Approved identification includes: A valid Colorado driver s license or a Colorado identification card; A United States military card or a military dependent s identification card; A United States Coast Guard Merchant Mariner card; A Native American Tribal Document, In addition to the above listed forms of identification, the following will be allowed. A certificate verifying naturalized status issued by an authorized agency of the United States bearing applicant s intact photograph impressed with the raised embossed seal of the issuing agency; A certificate verifying United States citizenship issued by an authorized agency of the United States bearing applicant s intact photograph impressed with the raised embossed seal of the issuing agency, or; Other approved State s driver s license or identification card. Not all states verify lawful presence prior to issuing license. Therefore, only those States listed below are deemed acceptable. 1 1 Alabama, Arizona, Arkansas, California, Connecticut, Delaware, District of Columbia, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Minnesota, Mississippi, Missouri, Montana, Nevada, New Hampshire, New Jersey, New York, North Dakota, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, South Dakota, Virginia, West Virginia, and Wyoming; AFFIDAVIT - RESTRICTIONS ON PUBLIC BENEFITS I,, swear or affirm under penalty of perjury under the laws of the State of Colorado that (check one): I am a United States citizen, or I am a Permanent Resident of the United States, or I am lawfully present in the United States pursuant to Federal law. I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute and it shall constitute a separate criminal offense each time a public benefit is fraudulently received. Signature Date Firm s Legal Name: Firm s Site Address: Street Unit City Zip 8

9 If individual owner/owners, attach copy of your approved document here. Subscribed and sworn to before me this day of, 201 By. Witness my hand and official seal. Date My commission expires: Notary Public 9

10 COMMISSARY AGREEMENT I, of, (Owner/Operator) (Commissary Name) located at (Address of Commissary) do hereby give my permission to (Name of Business Using Commissary) to use my kitchen facilities to perform the following: Preparation of foods such as vegetables or fruits, Ware washing cutting meats, cooking, cooling, reheating. Filling water tanks Storage of foods, single service items, and cleaning supplies Dumping waste water Service and cleaning of the equipment Other: Commissary Water Supply? Municipal Well Commissary Sanitary Sewer Service? Municipal Septic Indicate hours facility is open for use: Sun to Mon to Tues to Wed to Thurs to Fri to Sat to Sun to Indicate the equipment available at the commissary for the proposed uses: Hand sink Prep Sink Mop sink Three bay sink Dish machine Refrigeration Cooling equipment Dry Storage Other Owner/Operator of Commissary Date Phone Number This Commissary Agreement is valid for the calendar year only. 10

11 For Agency Use Only September 1, August 31, 2018 Incomplete applications, or applications without payment (if required), will not be processed. Ownership type: Individual (must complete affidavit of residency) Corporation (LLC, LLP, S-Corp, etc.) Non-profit (includes government) Other Full legal name of owner, corporation, or non-profit: Trade name (DBA): Contact name (on site): CO Sales Tax Acct. No. Physical address of business: City: State: Zip: County where business is located: Phone number: Other contact number (mobile, fax, etc.): Mailing address (if different from above): City: State: Zip: Date you started the business: Seasonal? Mark each month you operate: JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC In consideration thereof, I do hereby certify that I have complied with all items of sanitation as listed in the Colorado Retail Food Establishment Rules and Regulations (6 CCR ), and that I have complied with all orders given me by authorized inspectors of the Colorado Department of Public Health & Environment, or local board of health. I also agree that in the event sanitation items are not complied with, I will discontinue serving food until such time as requirements are met. Signature: Title: Date: Calendar Year: Check the appropriate license type from the list below. This is your license fee. License Type Code Fee No fee license (K-12 schools, non-profits) 1000 $0.00 Limited food service (convenience, other) 2000 $ Restaurant (0 100 seats) 3000 $ Restaurant ( seats) 3100 $ Restaurant (> 200 seats) 3200 $ Grocery store (0 15,000 sq.ft.) 4000 $ Grocery store (> 15,000 sq.ft.) 4150 $ Grocery store w/ deli (0 15,000 sq.ft.) 5000 $ Grocery store w/ deli (> 15,000 sq.ft.) 5150 $ Mobile unit (prepackaged) 6200 $ Mobile unit (full food service) 6300 $ Oil & Gas Temporary 7000 $ Special Event 8000 Set locally Total Due: $