Tooele Health Department
             
Tooele County Health Department
151 N. Main Street, Suite 140 - Tooele, UT 84074
Phone (435) 277-2440 Fax (435)277-2444

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 Poulty (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
Indirect Waste - (Floor Sink), (Hub Drain), (Floor Drain)
Direct Waste
Plumbing Fixture - Garbage Grinder
Indirect Waste
Direct Waste
Indirect Waste - (Floor Sink), (Hub Drain), (Floor Drain)
Direct Waste
Plumbing Fixture - Ice Machine
Indirect Waste
Direct Waste
Indirect Waste - (Floor Sink), (Hub Drain), (Floor Drain)
Direct Waste
Plumbing Fixture - Ice Storage
Indirect Waste
Direct Waste
Indirect Waste - (Floor Sink), (Hub Drain), (Floor Drain)
Direct Waste
Plumbing Fixture - Food Prep Sinks
Indirect Waste
Direct Waste
Indirect Waste - (Floor Sink), (Hub Drain), (Floor Drain)
Direct Waste
Plumbing Fixture - Utensil/Pot Wash
Indirect Waste
Direct Waste
Indirect Waste - (Floor Sink), (Hub Drain), (Floor Drain)
Direct Waste
Plumbing Fixture - Hand Wash
Indirect Waste
Direct Waste
Indirect Waste - (Floor Sink), (Hub Drain), (Floor Drain)
Plumbing Fixture - Steam Tables
Indirect Waste
Direct Waste
Indirect Waste - (Floor Sink), (Hub Drain), (Floor Drain)
Direct Waste
Plumbing Fixture - Dipper Wells
Indirect Waste
Direct Waste
Indirect Waste - (Floor Sink), (Hub Drain), (Floor Drain)
Direct Waste
Plumbing Fixture - Refrigeration
Indirect Waste
Direct Waste
Indirect Waste - (Floor Sink), (Hub Drain), (Floor Drain)
Direct Waste
Plumbing Fixture - Potato Peeler
Indirect Waste
Direct Waste
Indirect Waste - (Floor Sink), (Hub Drain), (Floor Drain)
Direct Waste
Other
Indirect Waste
Direct Waste
Indirect Waste - (Floor Sink), (Hub Drain), (Floor Drain)
Direct Waste
BLACKFLOW PREVENTION: Indicate type(s) of backflow prevention for all plumbing fixtures.
Dishwasher
Air Gap
Air Break
Vacuum Breaker
Garbage Grinder
Air Gap
Air Break
Vacuum Breaker
Ice Machines
Air Gap
Air Break
Vacuum Breaker
Ice Storage Bin
Air Gap
Air Break
Vacuum Breaker
Sinks-Mop
Air Gap
Air Break
Vacuum Breaker
Sinks-3 Compartment
Air Gap
Air Break
Vacuum Breaker
Sinks-2 Compartment
Air Gap
Air Break
Vacuum Breaker
Steam Tables
Air Gap
Air Break
Vacuum Breaker
Dipper Wells
Air Gap
Air Break
Vacuum Breaker
Refrigeration Condensate Drain Lines
Air Gap
Air Break
Vacuum Breaker
Hose Bibb Connection
Air Gap
Air Break
Vacuum Breaker
Beverage Dispense W/Carbonator
Air Gap
Air Break
Vacuum Breaker
Other
Air Gap
Air Break
Vacuum Breaker
DISHWASHING FACILITIES

Manual Dishwashing
Identify the length, width, and depth of the compartments of the 3-compartment sink
Will the largest pot and pan fit into each compartment of the 3-compartment sink
If no, what will be the procedure for manual cleaning and sanitizing of items that will not fit?
*Describe size, location and type.
*Drainboards, wall-mounted or overhead shelves, stationary or portable racks) of air drying space for dishes, utensils, equipment, etc.
What type of sanitizer will be used?
Chlorine
Quaternary Ammonia
*What type of sanitizer will be used when washing dishes & equipment in the 3-compartment sink?
Mechanical Dishwashing (is applicable)
Identifiy the make and model of the mechanical dishwasher
What type of sanitizer will be used?
Chemical
Hot Water
Will ventilation be provided?
DRESSING ROOMS
Describe storage facilites for employees' personal belongings.
Other
Identify the location for the storage of poisonous or toxic materials (cleaning chemicals, etc.)
Will cleaning and sanitizing solutions be stored at workstations?
If yes, how will these items be separated from food and food contact surfaces?
Will linens be laundered on site?
If yes, where?
If no, how and where will linens be cleaned?
Identify location of clean and dirty linen storage:
How often will linens be delivered and picked up?
OTHER PROCESSES
Please indicate below any process or service that this establishment will conduct:
         Sushi or other raw or undercooked fish or seafood product.
         Catering, delivery, preparation or service of food outside of the listed establishment address.
If you check either of the boxes above, you must submit the appropriate review forms.

I hereby certify that the above information is correct, and I fully understand that any
deviation from the above without prior permission from the Tooele County Health Department may nullify
final approval.
Signature
Date

Approval of these plans and specifications by the Tooele County Health Department 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 and operational will be necessary to determine if it complies with the regulations governing food service establishments.

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