Tooele Health Department

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Tooele County Health Department

151 N. Main Street, Suite 140 - Tooele, UT 84074

Phone (435) 277-2440 Fax (435)277-2444

www.tooelehealth.org

Food Establishment

Plan Review Application

Please put N/A for any fields that are not applicable

Establishment Information

Organization Name:
Address:
Address:
City:	State/Province:	ZIP/Postal Code:
Phone:
Email:

Contact Name
Mailing Address
Email Address
Street Address/P.O. Box/City/State/Zip Code
City/State/Zip
Contact Email
Architect/Designer (New Construction)
Phone Number

Check One

	New Facility
	Remodel/Modification of an Existing Facility

Fee Schedule: Fees are based on risk assessment. Fees will be due after the risk level assessment is conducted.

**Please Note: Prior to commencing food service operations, the owner/operator must apply for a separate food service permit and pass a final inspection.**

**Any food establishment level 2 or higher require managers to pass a food safety manager course and register with the health department.

Food Property Risk: Check those items listed below which are prepared at the establishment.

		Raw Meats (beef, pork, and lamb)
		Raw comminuted meats (ground beef, pork, or fish)
		Raw Poultry (chicken, turkey, etc.)
		Raw shelled or unpasteurized eggs
		Raw fish
		Sashimi (sushi), ceviche or other raw fish dishes
		Raw shellfish or crustacean (lobster, shrimp, clams, oysters, mussels, etc.
		Stuffed fish, stuffed meat, stuffed pasta, stuffed poultry, or ratites
		Game birds (duck, pheasant, etc.)
		Game animals (elk, venison, etc.
		Raw liver, tongue, heart, tripe (menudo)
		Potato salad, pasta salad, other prepared salads or dressings.
		Beans (refried, baked) cooked rice, cooked pasta
		Vegetables cooked for hot/cold holding (including potatoes, cooked salsa, greens, tofu)
		Garlic and oil mixture combined in-house
		Soup, sauces, gravy
		Seed sprouts, melon,cut tomatoes, fresh salsa, cut leafy greens
		Pre-cooked animal products (cold cuts, pre-cooked chicken or beef, canned fish, hot dogs, salami, pastrami, pepperoni, krab, pasteurized, eggs, etc.
		Dairy (milk, cheese, custard, cream dessert, ice cream)

Food Operation Risk: Check those processes or events that occur at the establishment for PHF.

		(4) Cold holding/storage
		(4) Hot Holding
		(4) Cooling hot food
		(1) Thawing
		(4) Cooking (grill, bake, fry) of raw animal products
		(2) Reheating for hot holding (ex. hot dog, soup, anything that has been cooled)
		(4) Buffet Service
		(4) Time, as a public health control (in lieu of temperature control)
		(3) Lapse of 24 hours or more between preparation and service
		(3) Contact with raw meats
		(2) Produce washing
		(3) Transportation/delivery/catering
		(3) Highly susceptible population served exclusively
		(4) Parasite destruction/record keep (for sushi, sashimi, ceviche)
		(4) Processes where HACCP or written plan required: partial cooking, reduced oxygen packaging, Ph modified rice.

4 Critical Control Point 3 High Probability of Contamination/Risk

2 Medium Probability of Contamination/Risk 1 Low Probability of Contamination/Risk

Signature of Applicant

Population Risk: Average daily volumne of meals in the establishment is:

Manager/PIC

Date

Payment Information:

Method of Payment:
Update Name from Personal/Organizational Information

Name on Account:
Routing Number:
Account Number:
Institution:

Name on Card:
Account Number:
Expiration Date:
Billing Street Address:
Billing ZIP/Postal Code:

Change Payment Method

NOTE: PHF/TCS in this document stands for Potentially Hazardous Food / Time Temperature Control for Safety. This is food that requires temperature or time control to ensure food safety.

Food Supply & Storage

Are food supplies from inspected and approved sources

How often will frozen foods be delivered?

How often will refrigerated foods be delivered?

How often will dry goods be delivered?

What type(s) of containers will be used to store bulk food products such as rice, flour, sugar, etc.

Identify the materials and finishes of cabinets, countertops, and shelving:

FOOD PREPARATION PROCEDURES

Explain the handling/preparation procedures for the following categories of food. Describe in detail the processes from receiving to service including:

		How the food will arrive (frozen, fresh, raw, pre-cooked, packaged, etc.)
		Where the food will be stored
		Where (prep table, sink, counter, etc.) the food will be washed, cut, marinated, breaded, cooked, etc.
		When (time of day and frequency/day) food will be handled/prepared.

Produce

Poultry (chicken, turkey, eggs, etc.)

Meat (beef, pork, lamb, etc.)

Seafood (fish, shellfish, shrimp, crab, lobster, etc.)

Ready-To-Eat Food (Portion & serve foods such as prepared salads, cold cuts, cheese)

Will disposable gloves and/or utensils and/or food grade papers be used?

Is there an established policy to exclude/restrict food workers who are sick or have infected cuts?

Please discribe briefly policy to exclude or restrict food workers who are sick or have infected cut

Thawing Frozen PHF/TCS (Potentially Hazardous Food/Time Temperature Control for Safety):

Thawing method(s) (check all that apply and indicate where thawing will take place):

Under Refrigeration

Running Water less than 70 Degrees F (21 Degrees C)

Microwave (as part of cooking process)

Cooked from frozen state

Other (describe)

COOKING AND REHEATING

List all foods that will be cooked and served

List all foods that will be held hot prior to service (i.e. steam table, warmer)

List all foods that will be cooked and cooled.

List all foods that will be cooked, cooled and reheated.

List all foods that will be heated and served.

*Provide a separate written HACCP plan for specialized processing methods of foods such as Reduced Oxygen

Packaging (vacuum packaging, cook-chill, etc.), use of additives to render a food non-PHF (TCS) food, curing and smoking for preservation, and molluscan shellfish tanks

REHEATING

How and where will PHF (TCS) foods 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 Degrees for 15 seconds within 2 hours.

Reheating

PEST CONTROL

Will all outside doors be self-closing and rodent proof?

Will screens be provided on all entrances, openings and vents left open?

Will all openable windows have a minimum #16 mesh screening

Will electrical insect control devices be used?

Will air curtains be used?

If yes, where?

Identify how all pipes and electrical conduit chases will be sealed.

How will the area around building be kept clear of unnecessary brush, littler, boxes & harbage?

REFUSE, RETURNABLES, AND SEWAGE DISPOSAL

Will garbage/refuse be store inside?

If so, where?

Identify how and where garbage cans and floor mats will be cleaned

Will a dumpster or a compactor be used?

Number

Size

Frquency of pickup

SEWAGE DISPOSAL

Is the sewage system?

If private, has the sewage system been approved?

Will grease traps/interceptors be provided?

If so where?

WATER SUPPLY

Is the water supply

If private, has source been approved?

Is ice

What is the capacity of the water heater?

SURFACE FINISHES

Applicants must fill in materials (i.e. quarry tile, stainless steel, 6" plastic coved molding, etc.)

Kitchen (Floor, Base, Walls, Ceiling)

Bar (Floor, Base, Walls, Ceiling)

Food Storage (Floor, Base, Walls, Ceiling)

Other Storage (Floor, Base, Walls, Ceiling)

Toilet Rooms (Floor, Base, Walls, Ceiling)

Dressing Rooms (Floor, Base, Walls, Ceiling)

Garbage and Refuse Storage (Floor, Base, Walls, Ceiling)

Mop Service Basin Area (Floor, Base, Walls, Ceiling)

Other (Floor, Base, Walls, Ceiling)

PLUMBING

Plumbing Fixture - Dishwash

		Indirect Waste
		Direct Waste