Remodel / Revision Plan Review Checklist Facility name: This checklist will help you prepare a complete plan review packet. Submit the completed plan review packet and signed checklist with the required application fee. Incomplete plan review packets will not be accepted. Make a copy of this plan review packet for your records prior to submittal. Plan review fees are non-refundable.. ***REQUIRED*** Office Use ITEM DESCRIPTION Only 1 Application Provide complete application. 2 Scope of work Provide a scope of work. 3 Fee Include application fee. Intake ITEM DESCRIPTION 4 Open During Remodel questionnaire ***REQUIRED ONLY IF APPLICABLE*** Provide complete Open During Remodel questionnaire. 5 Floor plan Provide proposed floor plan with original floor plan. OR Provide demolition plan. Office Use Only Intake 6 Equipment list Provide make and model numbers of all new equipment. Show location on floor plan. Only commercial grade, National Sanitation Foundation (NSF) or equivalent, equipment is acceptable. 7 Menu Provide a detailed menu of all the food and beverages you will be serving/selling. 8 Food preparation steps Provide description of how the new menu items will be prepared. Include how each menu item is obtained, stored, and prepared. Describe process of cooking, cooling, reheating, and hot holding, if applicable. 9 Supplemental questions Provide complete Supplemental Question form(s) if applicable. (catering and food processing) I understand I cannot make any changes to this food establishment until I have received written approval from this program, obtained all annual operating permits and have been inspected and approved by all applicable city, county and state agencies. Signature/Title Date FoodEstablishmentPlanReviewCheckLIst_EH_07_07_17_dlp
General Food Plan Review Application Application must be completed in full and submitted with fee and the items listed for processing: Reviewed for completeness by EHS Initials TYPE OF PLAN REVIEW (Check applicable box) $ 671 (PLU 333) New food service establishment $180 Base fee plus $180 per hour for each add l hour (PLU 311) $322 Base fee plus $180 per hour for each add l hour (PLU 311 & 301) $180 (PLU 335) Reopen food service establishment $180 (PLU 334) New Limited Grocery Remodel of existing food service establishment or revision of approved plan Change of ownership / conditional operating permit AND remodel of existing food service establishment or revision of approved plan $180 plus lab fees (PLU 385) HACCP when required by WAC for menu items $671 Base fee plus $160 for each add l permit (PLU 366) $180 (PLU 335) Preliminary site consultation ESTABLISHMENT INFORMATION Name: Site Address: New multiple permit food service establishment (large grocery store) City: OWNER INFORMATION Name: Address: ZIP: Phone: E-mail Address: City: State: Zip: CONTACT INFORMATION (if different than owner) Name: Address: Phone: E-mail Address: City: State: Zip: OTHER INFORMATION Type of Food Service Establishment: OFFICE USE ONLY Local Building Inspection Agency: Water District: Sewer District: Water Supply (check one): Private Well Public Sewage Disposal (check one): Onsite Sewage System Sewer Inspection is based upon requirements of WAC 246-215; Rules & Regulations of the State Board of Health for Food Service Sanitation. Other agency approvals requisite to your operation may include County or City Planning, Building, Plumbing and Fire Departments, Water and Sewer Utilities. APPLICANT SIGNATURE DATE General_Plan_Review_Application_EH_100317_dlp
Scope of Work Facility name: Check all that apply to your project: Remodel (closing kitchen) include checklist items 5 and 6 Remodel (remaining open for business) include checklist items 4, 5, and 6 Changing equipment include checklist item 5 and 6 Changing menu include checklist items 7 and 8 Changing of food process include checklist item 8 Adding catering include checklist item 9 If remodeling, provide a description of your proposed project. Be as detailed as possible. Vague or confusing descriptions may result in a prolonged review time. The scope of work is detailed on the floor plan or other attached document Example: Relocating three-compartment sink to southwest corner of kitchen, adjacent to the ice machine, to make space for the addition of a 6 X 6 walk-in refrigerator. The two-door refrigerator currently adjacent to the ice machine will be moved to the front service area by the soda fountain. A handwash sink will be installed near the left drainboard of the three-compartment sink, with a 16 stainless steel splash guard between the sinks. Current countertops at wait station will be replaced with new laminate countertops. Proposed work estimated to take 3 days. Scope_of_Work_07_17_EH_dlp
R Open During a Remodel Establishment Name: Address: City: State: Zip Code: All food service establishments, including grocery stores with multiple food service operations, wanting to continue operation during a remodel must submit written documentation stating the procedures that will be used to ensure food safety during the remodel. The documentation must include the following: a. Where and how handwash facilities will be set up b. What methods will be used for maintaining proper temperatures of all potentially hazardous foods c. Where produce and raw poultry or meats will be prepared d. Where dishwashing will occur e. What procedures will be followed if interruptions in water, power or sewage disposal occur f. What type of dust barriers will be used and where will they be used g. A floor plan of any temporary food preparation areas The items noted in the submitted documentation stating the procedures that will be used to ensure food safety during the remodel must be in place during all applicable phases of the remodel. Dust barriers must also be installed to ensure that food protection and safety is not compromised. I understand that the following information provided is accurate to the best of my knowledge. Any unapproved change without the consent of the Snohomish Health District will void this approval. Owner Name (Print): Signature: Date: OpenDuringRemodel_EH_7_2017_dlp
FoodEstablishmentPlanReviewCheckLIst_EH_05_2017_pac
Menu Provide copies of your menus. Include all food and beverages you will serve. If the facility is a grocery store serving only fruits, vegetables or commercially prepackaged food, a list of goods sold may be submitted in place of the menu. Be sure to include specials and seasonal items. Only food and beverages listed may be served. Submit copies of all breakfast, dinner, lunch, bar/lounge, happy hour, kids, catering, and online menus, fresh sheets, table tops or menu boards. If a menu board will be used, provide photographs of the menu showing all food and beverages listed. All menu items must be readable in photographs. A consumer advisory is required for all food of animal origin that is offered raw, undercooked or cooked to the customer s specification. Be sure all menu items requiring a consumer advisory are clearly identified and remind the patron that consuming these foods may result in foodborne illness. Consumer Advisory information may be found at Washington State Department of Health under Code Clarifications. The menu, food preparation steps, and the mode of operation may be restricted to protect public health (WAC 246-215). Sample Menu AAA #1 Drive In Breakfast Pancakes... $2.00 Eggs*, hash browns, bacon, toast... $3.00 Oatmeal... $2.00 Lunch Ham sandwich... $3.00 Pho soup*... $3.00 Rib eye steak*...$10.00 Dinner Prime rib*...$10.00 Shrimp pasta...$10.00 Deluxe cheeseburger*...$10.00 Chicken salad...$10.00 Salads Mixed greens... $3.00 Romaine... $3.00 Caesar*... $3.00 Beverages Fountain beverages Large... $3.00 Medium... $2.00 Small... $1.00 Coffee... $1.00 Tea... $1.00 * These menu items are served raw, undercooked or cooked to your specification. Consuming raw or undercooked food may increase your risk of foodborne illness. FoodEstablishmentPlanReviewMenu_EH_05_2017_pac 3020 Rucker Avenue, Suite 104 Everett, WA 98201-3900 fax: 425.339.5254 tel: 425.339.8730
Food Preparation Steps Provide the food preparation steps for all menu items. Include how each menu item is obtained, stored, prepared, cooked, cooled and kept hot before serving. Menu items that are prepared in an identical way may be grouped together. Menu, food preparation steps, and the mode of operation may be restricted to protect public health (WAC 426-215). Examples: BBQ beef/pork beef and pork are delivered frozen and stored in the walk-in refrigerator to thaw. After the beef and pork are thawed, they are marinated in our special sauce in the walk-in refrigerator overnight. Meats are then cooked on the smoker. After smoking, the beef and pork are shredded and mixed with our BBQ sauce and cooled in hotel pans at 2 food depth in the walk-in refrigerator. After meats are cooled to 41 F, they are covered with plastic wrap. Meats are reheated in the steamer as needed and kept in the front area steam table until served. Leftover items are cooled uncovered in the walk-in refrigerator at 2 food depth. All hamburgers patties are purchased frozen. Frozen patties are placed on grill once ordered. Hamburger patties are not cooked in advance. Pho soup beef bones are delivered and stored in the walk-in refrigerator. The beef bones are placed into a large pot, and water is added. The bones and water are brought to a boil and vegetables and spices are added. After soup is cooked half of the broth is held hot on the range at above 135 F and the remainder is cooled to 41 F uncovered in the walk-in refrigerator at 2 food depth. The remaining pho soup is reheated to over 165 F the next day before use. Chicken salad raw chicken is purchased frozen and thawed in the walk-in refrigerator. Chicken is marinated overnight in the walk-in refrigerator. Chicken is cooked on char-broiler, cut into small pieces and placed on sheet pan at 2 food depth to cool in the walk-in refrigerator. After chicken has cooled to 41 F, the chicken is portioned and wrapped. Portioned chicken is kept in the preparation refrigerator until ordered. Chicken is mixed with greens and salad toppings per order. All salad greens are rinsed each morning in the food preparation sink and stored in the preparation refrigerator. Ham/turkey/roast beef sandwiches ham, turkey and roast beef are purchased pre-cooked. Meat is sliced daily, portioned, and placed in the preparation refrigerator. All fruits and vegetables are rinsed each morning in the food preparation sink and stored in the preparation refrigerator. Sandwiches are made to order and served cold or heated on panini grill. Shrimp pasta shrimp is purchased pre-cooked and frozen. Shrimp is thawed in the walk-in refrigerator. Pasta is par-cooked on stove and cooled at 2 food depth uncovered in the walk-in refrigerator. Once cooled to 41 F, the shrimp and pasta are portioned, bagged and stored in the preparation refrigerator. When ordered by customer, portioned pasta and shrimp are sautéed on stove-top. FoodEstablishmentPlanReviewFoodPrepSteps_EH_07_2017_pac
Catering Questions Facility name: This application is only for offsite catering. This includes set-up or service of food items outside of the permitted food establishment. Please answer the following questions. Attach numbered responses if you need additional space. Check all the types of catering you will provide. Self-service buffet line Served buffet line (served by catering staff) Table service 1. Yes No Do you have a valid restaurant permit in Snohomish County? If no, provide the name, address and contact person of the approved establishment where food will be prepared, and a signed commissary use letter. (Note that commissaries must be within Snohomish County.) Approved establishment name: Address: Contact person: 2. The maximum number of catered meals served daily is. (The approved number will be included on your permit. This is the total number of customers you may serve in one day.) 3. The volume of food to be stored along with anticipated number of events to be catered per week and anticipated number of meals to be served must be submitted. Include whether or not more than one event may be catered on any day. 4. Provide a detailed catering menu that lists all food and beverages that may be catered. The catering menu must be separate from the restaurant menu. (Please attach.) 5. How will beverages be served? Catering_Questions _EH_071317_dlp 1
6. Will any beer, wine or mixed drinks from portable bars be served? If yes, provide specification sheets for portable bars and details of handwashing facilities. 7. Will any food of animal origin (i.e. meat, seafood, eggs) be offered raw, undercooked or cooked to customer specification? No, we do not offer raw or undercooked food items. Yes. I will provide a Consumer Advisory Warning for any menu item that will be served raw or undercooked. This includes raw meat, shellfish, such as oysters on a half shell, Caesar salad (dressing made with raw egg), sushi, steak tartare, eggs over easy, steaks cooked to order, etc. A Consumer Advisory Warning will be present on the catering menu and at the serving area. An example of the buffet line Consumer Advisory Warning, such as a table tent or placard, has been provided. (Please attach with menu.) 8. How often is food delivered to your establishment? Provide the quantity of food per delivery. 9. List any food that will be cooked at a catered event site: 10. List any food that will be prepared at a catered event site: Catering_Questions _EH_071317_dlp 2
11. Provide details of how food will be kept hot and kept cold before and during service at the event. 12. List what reheating equipment will be provided if hot food falls below 135 F: 13. A walk-in refrigerator is required for cooling. If any food will be cooled, is a walk-in refrigerator shown on the floor plans? Yes, walk-in provided. The dimensions are ft by ft. No, we do not cool food. 14. List any food that will be cooled. Include any leftover hot food that will be saved or food that will be cooked, cooled and reheated later. 15. Describe your policy for what happens to leftover food items at the end of each catered event. 16. Leftover food items set out for service must be discarded. Food that has warmed or cooled into the temperature danger zone (41 F to 135 F) must be discarded. Please acknowledge by initialing here: Catering_Questions _EH_071317_dlp 3
17. Provide details of what equipment will be used to transport hot and cold food to catered functions. Provide equipment specification sheets and identify the quantity of each type of equipment that you will have. 18. Provide the year, make and model number of all vehicles used to transport food to catered events. Include a picture of the vehicle with the license plate number identified. Vehicle make: Vehicle model: Vehicle license plate: 19. How will utensils, plates, linens and other equipment be transported? 20. Yes No Will you provide dishes, utensils or glassware at catered events? If yes, how will they be cleaned? 21. If linens, utensils and plates are provided by another service, provide name of company and contact number. 22. Handwash sinks are required at all serving locations including beverage service areas. Restroom handwash sinks do not meet this requirement. Provide details of all temporary handwash stations you will use at remote sites. At least one temporary handwash station must be provided. Catering_Questions _EH_071317_dlp 4
23. Yes No Will your handwash sink be stocked with soap, paper towels and warm water (between 100-120 F)? 24. Sneeze guards must protect any open food or condiments at the serving area. Provide dimension, elevation and material of sneeze guard protection for hot and cold entrees on the serving line. 25. What type of barriers will be used to prevent public access to the cooking/preparation/storage/service areas? 26. Provide a sample catering line showing how serving lines are set-up. Include location of handwash stations and sneeze guard protection for open food. (Please attach.) I agree to provide Snohomish Health District a monthly catering schedule. Please acknowledge by initialing here: Provide the name, email and phone number of person who will supply the catering schedule: Name: Phone: Email: Catering_Questions _EH_071317_dlp 5