Plan Review, Food Establishment, Frozen Dessert Applications With
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HEALTH AND HUMAN SERVICES DEPARTMENT City of Newton 1000 Commonwealth Avenue Newton, MA 02459 Telephone 617.796.1420 Fax 617.552.7063 TDD/TTY 617.796.1089 Ruthanne Fuller Mayor FOOD ESTABLISHMENT PLAN REVIEW APPLICATION Complete the Following Application(s). Please Print Legibly. Incomplete applications and missing documents may cause a delay in the decision-making process. Date: Type of Food Operation ☐ Restaurant ☐ Retail Market ☐ Frozen Dessert Manufacturer - Retail & Wholesale Complete Attachment A: Frozen Dessert License Application ☐ Institution ☐ Daycare ☐ Other (Specify): ☐ New ☐ Remodel ☐ Conversion Name of Establishment: Establishment Address: Newton, MA Zip: 024 Establishment Phone: Number: 617- Name of Owner: Owner’s Mailing Address: Owner’s Phone Number: Email: Applicant’s Name: Email: Title: ☐ Owner ☐ Manager ☐ Contractor ☐ Architect ☐ Other: Applicant’s Mailing Address: Applicant’s Phone Number: HOURS OF OPERATION Sun Mon Tue Wed Thu Fri Sat Will the establishment apply for seating? ☐ Yes ☐ No • Please Note: According to MA General Law Chapter 140 Section 2, Food Establishments that offers seating to the Public for consumption on the premises requires a Common Victualler (CV) License. Additionally, According to MA General Law, Food Service Establishments with 25 or more seats are required to have an employee trained in Anti-Choking procedures at all times the establishment is open to the public. 1 If known, number of Seats authorized by CV: ☐ NA (No seats) Will the establishment apply for an Alcohol License? ☐ Yes ☐ No FOOD ESTABLISHMENT Area of Facility (ft²): Number of Floors: Maximum # of Meals to be served (approximate): Breakfast: Lunch: Dinner: TYPE OF SERVICE(S) ☐ Sit Down Meals ☐ Take Out Only ☐ Caterer ☐ Single-Use Utensils ☐ Multi-Use Utensils Will the establishment have entertainment (music, television etc.)? ☐ Yes ☐ No Will the establishment have Sunday entertainment? ☐ Yes ☐ No Will there be outdoor dining? ☐ Yes ☐ No FOOD SUPPLY Food Sources (Company Name(s)): • Foods to be sold at a retail operations shall be purchased from licensed wholesale operations How often will refrigerated foods be delivered? How often will frozen foods be delivered? How often will dry goods be delivered? Provide the amount of space (cubic feet) allocated for: Refrigerator Storage: Freezer Storage: Dry Storage: Identify the location and containers that will be used to store bulk food products (rice, sugar etc.): 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 hot held prior to service: 2 Hot holding for service of TCS (Time / Temperature Control for Safety Food) Foods Maintained at 135°F and above Type of unit(s): Number of unit(s): Location: Cold holding for service of TCS Foods - Maintained at 41°F and below Type of unit(s): Number of unit(s): Location: Will any of the following Special Processing Methods be used? ☐ Yes ☐ No • Reduced Oxygen Packaging (ROP), Use of Additives to Render a Food Non-TCS (Acidification), Curing and Smoking for Preservation, Cook-Chill, Sous Vide, Live Molluscan Shellfish Tank, Sprouted Seeds, Fermenting Some Special Processes require a HACCP(Hazard Analysis Critical Control Point) Plan and / or a Variance Please Note: There is an additional $50.00 Fee for the Review of Special Processes / Variance Requests Will a HACCP Plan be submitted? ☐ Yes ☐ No • If yes, in addition to this application, complete the “Hazard Analysis Critical Point Plan Review Application”. Will a request for a Variance be requested? ☐ Yes ☐ No • If yes, complete the “Request for Variance Form” including the “Granted Variance” Section of the form Will the establishment partially cook Animal Foods? ☐ Yes ☐ No • If yes, a plan must be submitted for review and approval Will the establishment use Time as a Public Health Control? ☐ Yes ☐ No • If yes, complete “Time as a Public Health Control (TPHC) Request” form Explain the Handling / Preparation Procedures for the following categories of food. Describe the processes from receiving to service including: 1. How the food will arrive (frozen, fresh, packaged, etc.) 2. Where the food will be stored 3. Where the food will be washed, cut, marinated, breaded, cooked etc. (prep table, sink, counter etc.) 4. When food will be handled / prepared (time of day and frequency / day) Ready to Eat Foods (RTE) (e.g. salads, cold sandwiches, and raw molluscan shellfish): Produce: Poultry: Meat: 3 Seafood: Will the basement (if applicable) be used? ☐ Yes ☐ No What will the basement (if applicable) be used for: ☐ Food Preparation ☐ Storage Only Note: If the basement will be used for Food Preparation, the submitted plans shall include the layout and equipment specifications. Explain how the basement will be used for food preparation: PEST CONTROL Will all outside doors be self-closing and rodent proof? ☐ Yes ☐ No Will screens be provided on all entrances left open to the outside? ☐ Yes ☐ No Will all openable windows have mesh screening (minimum #16 mesh)? ☐ Yes ☐ No Will air curtains be used? ☐ Yes ☐ No • If yes, where will they be located? WATER SUPPLY What is the capacity and location of the water heater? Will an ice machine be installed? ☐ Yes ☐ No • If yes, where? WARE & DISHWASHING Will the largest pot & pan fit into each compartment of the 3-compartment sink? ☐ Yes ☐ No If No, describe the cleaning method that will be used: Describe the location & type of device used for air drying clean equipment: Will a dish / glass machine be used? ☐ Yes ☐ No • If yes, what will be the final rinse sanitizing cycle? ☐ Hot Water ☐ Chemical Will the dish / glass machine final rinse be under pressure? ☐ Yes ☐ No • If yes, will the machine have a pressure gauge? ☐ Yes ☐ No Will the machine be equipped to automatically dispense detergents and sanitizers? ☐ Yes ☐ No What type of device will be installed on the ware washing machine to verify that detergents and sanitizers are delivered or not delivered to the respective washing and sanitizing cycles? ☐ Visual ☐ Audible Please note: A ware washing machine shall be equipped to automatically dispense detergents and sanitizers and incorporate a visual means to verify that detergents and sanitizers are delivered or a visual or audible alarm to signal if the detergents and sanitizers are not delivered to the respective washing and sanitizing cycles. What type of sanitizer and the brand name will be used on food contact surfaces? ☐ Chlorine: ☐ Quaternary: 4 Will dressing rooms/ lockers be provided? ☐ Yes ☐ No • If no, where will employees store personal items? Identify the storage location for poisonous or toxic materials (chemical storage): Identify how grease will be disposed: How often will the grease trap(s) be cleaned? Identify the location of grease storage containers: REFUSE Will refuse / garbage be stored inside? ☐ Yes ☐ No • If yes, describe where: Identify how and where garbage cans and floor mats will be cleaned: Will a dumpster be used? ☐ Yes ☐ No • If yes, how many? Size: Frequency of pick-up: Name of company used for dumpster pick-up: Name of company used for grease pick-up: Note: All Waste Disposal Companies (Offals) must be licensed with the City of Newton Health and Human Services Department Describe the surface and location where the dumpster / garbage will be stored outside: Is there a Written Employee Health Policy for ALL Employees’? ☐ Yes ☐ No • If yes, provide a copy of the Written Employee Health Policy • If no, the FDA “Employee Health and Personal Hygiene Handbook” can be used to develop a Written Policy The Handbook can be obtained online http://www.in.gov/isdh/files/Employee_Health_Handbook.pdf or http://www.newtonma.gov/gov/health/enviro/permits_and_regulations.asp Projected Start Projected Completion Projected Establishment Opening Date: Date: Date: Please Note: After six (6) months if the work has not started or an extension has not been granted by the Newton Health and Human Services Department, your plan review application will be considered null and void. Fees will not be refunded. 5 FINISH SCHEDULE Indicate the materials that will be used in the following areas (example: Quarry Tile, Stainless Steel, Fiberglass Reinforced Panels (FRP), Ceramic Tile etc.). AREA FLOOR FLOOR / WALL JUNCTURE WALLS CEILING Kitchen Bar Food Storage Other Storage Toilet Room Dressing Room Garbage & Refuse Storage Mop Service Sink Ware washing Area Walk-in Refrigerators & Freezers Other 6 PLEASE ENCLOSE THE FOLLOWING DOCUMENTS ☐ Completed Food Establishment Plan Review Application Form All Applicable Fees. Cash is not accepted. Please make checks / money orders made payable to the All ☐ “City of Newton”. Fees are non-refundable. ☐ A copy of the Written Employee Health Policy (if new establishment and / or new owner) Proposed Menu or complete list of food and beverages to be offered (Including seasonal, off site and banquet / catering ☐ menus) Plan(s) or Sketch of Food Establishment drawn to scale showing location of equipment, plumbing, electrical and ☐ mechanical services ☐ Equipment schedule including location, plumbing, drain and electrical connections ☐ Manufacturer Equipment Specification Sheets for each piece of equipment to be used in the Food Establishment Previously “used” or refurbished equipment must be evaluated by a Certified Refrigeration Company / HVAC (Heating ☐ Ventilation and Air Conditioning) / Professional. This evaluation must be submitted Site plan showing location of food establishment location of building on site including alleys, streets and location