Food Service Establishment Permit Application

Jefferson County Public Health Environmental Health Department 615 Sheridan Street Port Townsend, WA 98368 Tel: 360.385.9444 Fax: 360.379.4487 Email: foodsafety@co.jefferson.wa.us Website: www.jeffersoncountypublichealth.org Food Service Establishment Permit Application New Owner/Change of Owner, as well as remodeling New Food Establishments must submit this application and accompanying documents with appropriate fee* to Jefferson County Public Health (JCPH). New and Remodeling Establishments shall also undergo full plan review.** Please allow at least 3 weeks to review all documents prior to opening, remodeling or construction in order to ensure that the needed documents are adequate, and/ or allow for modifications that may be required. Once the Plan Review is complete and the establishment is ready for opening, call the JCPH for a pre-opening inspection at least 1 week in advance. Do not open without JCPH approval. **Plan Review fee (minimum 2 hours, $89.00 per hour = $178.00) (NON-REFUNDABLE). Payment is required upfront. *Additionally, Annual Food Service Permit fees will be determined upon completion of plan review. New Establishment Fee: $178.00 (NON-REFUNDABLE). New Owner/Change of Owner Fee: $112.00 (NON REFUNDABLE). This application is for (Check one): New Business Establishment Remodel New Owner (Certain information may not be needed, please contact us for specific application requirements. Type of Food Service Establishment (Check any category that applies): Restaurant Restaurant/Take-Out Tavern Bakery Bed & Breakfast Caterer FACILITY INFORMATION For Office Use: Commercial Kitchen/Concession Church Espresso Stand Grocery Date Rec d Receipt # Amt : Check # Permit #: Category Comments: Meat/Fish Market Mobile Unit School Cafeteria Name of Establishment Address of Establishment City Zip E-Mail Manager/Operator Establishment Phone ( ) Phone # ( ) Property Tax Parcel # Planned Opening Date Business Owners Legal Name E-Mail Mailing Address City State Zip Bill To (check one) Legal Owner Establishment Location Phone ( ) Days of Operation Hours of Operation # of Seats in Food Establishment # of Staff (Maximum per shift) Meals to be served (check all that apply): Breakfast Lunch Dinner Water Source (Name of Water System and State ID #) Public Sewer Sewage Disposal (check one) On-Site Septic (submit current monitoring inspection report) 1 Rev.01/01/2018_SR

Mobile Food Establishment Information (Only needed if the type of establishment is a mobile unit) Locations where the unit will be set up Hours of operation at each location Address of Commissary Kitchen City Zip L & I # License Plate # Outside Area Location of mobile unit when NOT in use The following documents must be included in order to process your permit application: (For more detailed information on the detail required for each of these items, see the New Food Establishment Guide) Proposed Menu (including seasonal, off-site and banquet menus) Include a consumer advisory for food items that can be ordered raw or undercooked by patrons. Floor Plan drawn to scale of the food establishment showing the locations of all equipment, plumbing, electrical services and mechanical ventilation as well as finished surface materials (See our Food Establishment Guide for more specific information) Plans must be a minimum of 8 ½ x 11 inches in size. Including the layout of the floor plan accurately drawn to scale. Show all rooms or areas that will be used to operate the business (Kitchen, Restrooms, Storage Areas, basements, cellars, dining rooms, bussing area, entrances, exits, loading/unloading areas, dressing rooms, employee items storage area etc.) Show the location of all food equipment. When requested, include elevated drawings of all food equipment. Each piece of equipment must be clearly labeled on the plan with its common name. Submit drawings of self-service hot and cold holding units with sneeze guards. Clearly label and locate separate all sink types (3-Compartment, Food Preparation, Hand wash, Utility, etc.) Equipment schedule that includes the make and model numbers of equipment that is certified or classified for sanitation by an ANSI-accredited (NSF, ETL Sanitation, etc.) certification program (when applicable). Site plan (plot plan) ESTABLISHMENT PLANS AND SUPPORTING DOCUMENTATION Mobile Unit specific documents (Only needed if the type of establishment is a mobile unit): Map of all parking locations and parking times If using someone else s approved kitchen, an agreement or contract from the kitchen owner for use. Restroom agreement letter for all stops of one (1) hour or greater Vending location agreement letter for all vending locations FOOD PREPARATION AND SUPPLIES Food Preparation (Check categories of Potentially Hazardous Foods (PHF's) to be handled, prepared or served): Category Yes / No 1. Thin meats, poultry, fish, eggs (hamburger; sliced meats; fillets) ( ) ( ) 2. Thick meats, whole poultry (roast beef; whole turkey, chickens, hams) ( ) ( ) 3. Cold processed foods (salads, sandwiches, vegetables) ( ) ( ) 4. Hot processed foods (soup, stews, rice/noodles, gravy, chowders) ( ) ( ) 2 Rev.01/01/2018_SR

5. Bakery goods (pies, custards, cream fillings & toppings) ( ) ( ) 6. Other Circle or answer the following questions as they pertain to your food establishment: 1. Please list all food items that are prepared more than 12 hours in advance of service. 2. Will disposable gloves and/or utensils and/or food grade paper be used to prevent handling of ready-to-eat foods? Yes / No 3. Will ingredients for cold ready-to-eat foods such as tuna, mayonnaise and eggs for salads and sandwiches be pre-chilled before being mixed and/or assembled? Yes / No If not, how will these be cooled to 41 F? 4. Will produce be washed on-site? Yes / No Where will produce washing occur and describe the procedure for cleaning and sanitizing the sinks and area between uses? 5. Describe the procedure used for minimizing the length of time PHF's will be kept in the temperature danger zone (41 F - 135 F) during preparation. 6. Will foods be vacuum packaged on-site? Yes / No Food Employees (Circle or answer the following questions as they pertain to your food establishment): 1. Will food employees be allowed to begin work without a valid Washington State Food Workers Card? Yes / No If yes, please describe what type of training the new employees that have not yet obtained a valid Washington State Food Workers Card, will receive? Please explain the training and how records will be kept for the employees who had this training: 2. Will food employees receive additional training in good food sanitation practices, above the required Washington State Food Workers Card? Yes / No If yes, please explain: 3. Is there a policy to exclude or restrict food workers who are sick or have infected cuts and lesions? Yes / No 3 Rev.01/01/2018_SR

Please attach include a copy of the policy or describe briefly: Menu (Circle or answer the following questions as they pertain to your food establishment): 1. Are any food items either cooked to order, served partially cooked or raw? Yes / No If yes, a consumer advisory will be needed at the place of order (menu, table tent, etc.). What will be written and how will it be linked to each food item? Food Supplies (Answer the following questions as they pertain to your food establishment): 1. Where are all food supplies (meats, baked goods, etc.) going to come from? 2. What are the projected frequencies of deliveries for the following foods? Frozen foods Refrigerated foods Dry goods 3. Provide information on the amount of space (in cubic feet) allocated for: Frozen storage Refrigerated storage Dry storage 4. How will dry goods be stored off the floor? Cold Storage (Circle or answer the following questions as they pertain to your food establishment): 1. Will raw meats, poultry and seafood be stored in the same refrigerators and freezers with cooked/ready-to-eat foods? Yes / No If yes, how will cross-contamination be prevented? 2. Does each refrigerator/freezer have a thermometer? Yes / No Number of refrigeration units: Number of freezer units: Hot/Cold Holding (Answer the following questions as they pertain to your food establishment): 1. How will hot PHF's be maintained at 135 F (57 C) or above during holding for service? Indicate type and number of hot holding units. 4 Rev.01/01/2018_SR

2. How will cold PHF's be maintained at 41 F (5 C) or below during holding for service? Indicate type and number of cold holding units and if using ice please elaborate on how ice will be used. Thawing Frozen Potentially Hazardous Food: Please indicate which thawing procedure will be used in order to thaw all frozen potentially hazardous foods (PHF's). More than one method may apply. Also, indicate where thawing will take place and which food items will be thawed. Check Thawing Method Thawing Location Food items to be thawed In the Refrigerator Under Cold Running Water (less than 70 F (21 C)) In the Microwave (As part of the cooking process) Cooked From a Frozen State Other Cooking: Minimum cooking time and temperatures of product utilizing convection and conduction heating equipment: Beef roasts 130 F (121 min) Solid seafood pieces 145 F (15 sec) Other PHF s 145 F (15 sec) Eggs: Immediate service 145 F (15 sec) Pooled* 155 F (15 sec) (*Pasteurized eggs must be served to a highly susceptible population.) Pork 145 F (15 sec) Comminuted meats/fish 155 F (15 sec) Poultry 165 F (15 sec) Reheated PHF s 165 F (15 sec) Circle or answer the following questions as they pertain to your food establishment: 1. Will food product thermometers be used to measure final cooking/reheating temperatures of PHF's? Yes / No 2. What type of thermometers will be used to monitor temperatures (check all that apply): ( ) Metal-Stem Thermometer ( ) Digital Thermometer ( ) Thermocouple 3. List all types of cooking equipment that will be used? 5 Rev.01/01/2018_SR

4. Will there be any overnight cooking or cooking for extended unobservable time periods? Yes / No If yes, please describe how proper temperature monitoring will be done. Cooling (Answer the following questions as they pertain to your food establishment): 1. What PHF s will be cooled in the establishment to serve at another time? If no cooling is to be done in the establishment e.g. all cooked foods will be either served or disposed of, write what will be done below and skip to the next section. 2. Please list what items will be cooled to 41 F (5 C) in Shallow pans of 2 inches or less and where this cooling will take place. Please indicate below how PHF's will be cooled and where the cooling will take place so that 41 F (5 C) will be reached within 6 hours (135 F to 70 F in 2 hours and 70 F to 41 F in 4 hours) by adding your food item and location to each of the cooling method below. List food items in the appropriate category at right Ice Bath Food or Size Reduction Rapid Chill Other Reheating (Answer the following question as it pertains to your food establishment): 1. How will cooked and cooled PHF s be reheated so that all parts of the food reach a temperature of at least 165 F for 15 seconds within 2 hours? Indicate type and number of units used for reheating foods. 6 Rev.01/01/2018_SR

CLEANING AND SANITATION General (Circle or answer the following questions as they pertain to your food establishment): 1. Are all insecticides/rodenticides used approved for food service establishments? Yes / No Indicate chemical storage location: 2. Are all toxics for use on the premise or for retail sale (this includes personal medications), stored away from food preparation and storage areas? Yes / No If yes, please explain: 3. Are all containers of toxics including sanitizing spray bottles clearly labeled? Yes / No 4. What type of sanitizer will be used for food contact surfaces that cannot be submerged in sinks or put through a dishwasher? Chemical Type: Concentration: Test Kit: Yes / No 5. Will linens be laundered on site? Yes / No If yes, what will be laundered and where? If no, how will linens be cleaned? 6. Where will clean linens be stored? 7. Where will dirty linens be stored? 8. Are containers constructed of approved materials (food grade plastics and metals) to store bulk food products? If yes, indicate type: Yes / No / NA 9. Are all light bulbs that are located above food storage or preparation areas properly covered? Yes / No / NA Insect and Rodent Control (Circle or answer the following questions as they pertain to your food establishment): 1. Are outside doors self-closing and/or rodent proof? Yes / No 2. Are screen doors provided on all entrances left open to the outside? Yes / No / NA 3. Do all windows that can open have a minimum #16 mesh screening? Yes / No / NA 4. Will all pipes & electrical conduit cases be sealed; ventilation systems exhaust and intakes protected? Yes / No 5. Is area around building clear of unnecessary brush, litter, boxes and other harborage? Yes / No 7 Rev.01/01/2018_SR

6. Will air curtains be used? Yes / No If yes, where? Handwash and Toilet Facilities (Circle or answer the following questions as they pertain to your food establishment): 1. Is a handwash sink in each food preparation and warewash area? Yes / No 2. Do all handwash sinks, including those in the restrooms, have a mixing valve or combination faucet? Yes / No 3. Do self-closing metering faucets provide a flow of water for at least 15 seconds without the need to reactivate the faucet? Yes / No / NA 4. Is soap available at all handwash sinks? Yes / No 5. Are hand-drying facilities (paper towels, air blowers, etc.) available at all handwash sinks? Yes / No 6. Are waste receptacles available in each restroom? Yes / No 7. Is hot and cold running water under pressure available at each handwash sink? Yes / No 8. Is hot water (100 F min) available at the handwash faucets within 15 seconds? Yes / No 9. Is a handwash sign posted in each employee restroom? Yes / No 10. If catering, is a temporary handwash station available for use when needed? Yes / No Finish Schedule: Indicate which materials (quarry tile, stainless steel, 4" plastic cover molding, etc.) will be used in the following areas: Floor Coving Walls Food Preparation Surfaces Non-food Preparation Surfaces Ceiling Kitchen FACILITY AND EQUIPMENT Bar Food Storage Other Storage Toilet Rooms Garbage & Refuse Storage Mop Service Basin Area Warewashing Area 8 Rev.01/01/2018_SR

Walk-in Refrigerators and Freezers Garbage and Refuse (Circle, check or answer the following questions as they pertain to your food establishment): 1. Will refuse be stored inside, long term? Yes / No If yes, where? 2. What will be used for outside garbage storage? ( ) Dumpster ( ) Garbage Cans Number Size Frequency of pickup Contractor 3. Will a trash compactor be used? Yes / No Number Size Frequency of pickup Contractor 4. Where will the dumpster/compactor/garbage cans be stored? 5. Where will returned or damaged goods be stored? Employee Storage Areas (Answer the following question as it pertains to your food establishment): 1. Where will storage facilities for employees' personal belongings (i.e., purse, coats, boots, umbrellas, etc.) be located? Water Supply (Circle, check or answer the following questions as they pertain to your food establishment): 1. Are floor drains provided & easily cleanable? Make sure they are shown on the floor plans. Yes / No 2. Is the water supply public ( ) or private ( )? 3. If private, has the source been approved? Yes / No / Pending *Please attach copy of written approval and/or permit. 3. Is there a bulk ice machine available? Yes / No If yes, please make sure that it is indirectly drained as indicated in the Plumbing Connections section on next page. 4. Will ice be purchased commercially Yes / No 5. Please describe provision for ice scoop storage: 6. What is the holding capacity and heating capacity of the hot water heater(s)? 7. Is there a water treatment device? Yes / No If yes, how will the device be inspected & serviced? 6. How are the backflow prevention devices inspected & serviced? 9 Rev.01/01/2018_SR

Plumbing Connections: Please check what type of back-flow prevention is plumbed into each of the pieces of equipment listed (For more detailed information, see the New Food Establishment Guide): Dual Check Condensate Air Gap Air Break Valve Pump Dishwasher 3-Compartment Sink Food Preparation Sink Ice machine Ice Storage Bin Dipper Well Beverage Dispenser w/carbonator Walk-in Cooler Refrigeration Condensate/drain lines Other: Sewage Disposal (Circle or answer the following questions as they pertain to your food establishment): 1. Is the building connected to municipal sewer? Yes / No 2. If no, is the private disposal system approved for use? Yes / No / Pending *Please attach copy of written approval and/or permit. 3. Are grease traps provided? Yes / No If yes, have they been approved for use by the building official? Yes / No *Please attach copy of written approval. Where are the grease traps located? 4. Attach or describe the schedule for cleaning and maintenance of grease traps, if present: Dishwashing Facilities (Circle, check or answer the following questions as they pertain to your food establishment): 1. Which of the following will be used for warewashing? ( ) Three-compartment sink ( ) Dishwasher and a Three-compartment sink 2. For the Dishwasher, what type of sanitization will be used? ( ) Hot water (temp. :) ( ) Chemical 3. If chemical, what type of sanitizer will be used? ( ) Chlorine ( ) Quaternary Ammonium ( ) Iodine ( ) Other 4. Do all dish machines have templates with operating instructions? Yes / No 5. Do all dish machines have temperature/pressure gauges as required that are accurately Yes / No working? 6. Does the largest pot and pan fit into each compartment of the pot sink? Yes / No 7. Are there drain boards on both ends of the 3-compartment sink? Yes / No 8. Are test papers and/or kits available for checking sanitizer concentration? Yes / No 10 Rev.01/01/2018_SR

Sinks (Circle or answer the following questions as they pertain to your food establishment): 1. Is a service sink (mop sink) present? Yes / No If no, please describe where and how mops and other equipment (e.g. floor mats, hood filters, etc.) will be cleaned? 3. Is a food preparation sink present? Yes / No If no, please attach or describe all procedures used to properly wash produce, clean seafood, thaw raw meats and seafood and thaw cooked foods? MOBILE FOOD UNITS Complete this section only if submitting application for a mobile food unit: 1. Where will be your food preparation site? Mobile Unit Commissary Other (specify) 2. Is there a commissary licensed by Jefferson County Public Health for the Mobile Food Unit? Yes / No Commissary Name and Address: 3. List Address of all parking locations (if needed, attach a map showing all parking locations, addresses and times): 4. What is the License Plate # for the Mobile Unit? 5. Has Washington State Department of Labor & Industries inspected and approved the unit? Yes / No If yes, what is your vendor #? (This can be found on the L & I sticker) SIGNATURE The undersigned manager or owner does hereby make application to operate a Food Establishment in compliance with the Rules and Regulations of Washington State (WAC 246-215) and the Local Board of Health Ordinance Chapter 8.05 Jefferson County Code. The above information, supplied by me, is true to the best of my knowledge. I UNDERSTAND THAT: 1. Permits are renewable annually and expire January 31 st. Permits shall be renewed before expiration. Delinquent applications and/or permit fees may result in closure. 2. Permits are non-transferable, and are valid only for the current operator and the establishment listed on this application. Changes in the operation or location of the food service establishment require prior approval by the Jefferson County Department of Public Health. Additional requirements, documentation and/or permits may be required. Approval of these plans and specifications by the Jefferson County Department of Public Health 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). 3. No new permit will be issued to persons or businesses that are not in compliance with current the current rules and regulations listed above or that have an outstanding debt owed to the Jefferson County Department of Public Health. Printed Name Signature Date 11 Rev.01/01/2018_SR