APPLICATION FOR A PERMIT TO OPERATE A

FOOD SERVICE ESTABLISHMENT

***Zoning approval is required prior to submitting this application.

Plan Review requires $250 for new construction, remodeling or additions of existing establishment ONLY

No Charge for the actual permit to operate.

*This application must be completed in its entirety with supporting documents attached, or review will be significantly delayed.*
Zoning Approval	Site and Building Plans Drawn to Scale
Proposed Menu	Specification Sheets for All Equipment
Type of Construction:	New	Remodel/Addition(s)
Name of Establishment:
Establishment Address:
City:	State:	NC	Zip:
Telephone Number:	Email:
Owner/Corporate Name:
Manager/Person-in-Charge:
Mailing Address:
City:	State:	Zip:
Telephone Number:	Email:
Owner of Building:
Mailing Address:
City:	State:	Zip:
Telephone Number:	Email:
Type of food service establishment: (check/complete all that apply)
Restaurant with seating: Number of seats:	Square footage:
Food Stand: Square footage:	(No more than 8 seats, Ref. Session Law 2015-104)
Commissary	Sit-down Meals
Meat Market	Take-out Meals
Education Food Service	Catering/ Delivery
School Lunchroom	Customer Self-Service Buffet/Bar
Elderly Nutrition Site, Prepared On-site
Other: (ex: hot bar, sushi bar, salad bar)
Daily Hours of Operation:
Sun	Mon	Tue	Wed
Thu	Fri	Sat
Meals Prepared: (check all that apply)
Breakfast Lunch Dinner
Water Supply and Sewage:
Water supply:	Public/Municipal	Private Water Supply
Sewer:	Public/Municipal	On-site Wastewater System
Will a grease trap/interceptor be provided?	Yes No
Will ice be:	Made on premises	Purchased
Water heater(s):
Tank type:
a. Manufacturer and model:
b. Storage capacity:
Electric water heater:	kilowatts (kW) Gas water heater:	BTU’s
Tankless:
a. Manufacturer and model:
b. Quantity of tankless water heaters:
Hot water heaters will need to be sized based on the fixtures in the facility, the capacity will be determined using the sizing calculator provided by the NCDHHS Plan Review unit. https://ehs.dph.ncdhhs.gov/faf/food/planreview/app.htm

Check the appropriate box indicating equipment drains:
Indirect Waste	Direct Waste
Plumbing Fixtures	Floor Sink	Hub Drain	Floor Drain
Warewashing Sink
Prep Sinks
Handwashing Sinks
Warewashing Machine
Garbage Disposal
Dipper Well
Refrigeration
Steam Table
Other:
Other:

Refuse and Recyclables:
Will refuse be stored inside?	Yes	No
If yes, where:
Provision for refuse disposal:	Dumpster	Compactor
Will a contract for off-site cleaning of the dumpster/compactor be obtained?	Yes No
If yes, indicate the name of the cleaning contractor:
Will the dumpster/compactor be cleaned at the establishment?	Yes No
Describe location for storage of recyclables: (cooking grease, cardboard, glass, etc)

Warewashing Equipment:
Manual Warewashing:
Size of each compartment (inches)	Length	Width	Depth:
*A 3-compartment utensil sink is required.
What type of sanitizer will be used?
Chlorine Quaternary Ammonium Hot Water Iodine Other (specify)
Mechanical Warewashing:
Will a warewashing machine be used? Yes No
Warewashing machine manufacturer and model:
Type of sanitization:	Hot water (180F) Chemical
Type of Utensils used:
Single-service (disposable):	Multi-use (reusable):
Plates Glassware Silverware	Plates Glassware Silverware
General:
Describe how cooking equipment, cutting boards, slicers, counter tops, other food contact surfaces and clean in place equipment that cannot be submerged in sinks of put through a dishwasher will be cleaned and sanitized:
Describe location and type: (drainboards, wall-mounted or overhead shelves, stationary or portable racks) of air drying space:
Specialized Processes:
Will specialized processes be used as specified in Section 3-502.11 of the North Carolina Food Code?
Yes No
If YES, indicate which processes will be used:
Curing	Acidification	Reduced Oxygen Packaging (e.g. Vacuum)
Smoking	Sprouting Beans	Other
Explain checked processes:
Cold Storage Equipment:
The volume of cold storage must be adequate to maintain cold holding, the cooling and thawing of foods.
List what equipment will be provided for cold holding, cooling and thawing of foods:
Cold Holding:
List foods items that will be held cold:
Hot Holding Equipment:
List what equipment will be provided for hot holding foods:
Hot Holding:
List food items that will be held hot:
Cooling:
Indicate by checking the appropriate boxes how cooked food will be cooled to 41F within 6 hours.
If “Other is checked indicate the type of food:
Cooling Process	Meat	Seafood	Poultry	Other
Shallow Pans
Ice Baths
Rapid Chill**
(**Check only if rapid chill equipment such as blast chillers are provided.)
Thawing:
Indicate by checking the appropriate boxes how food in each category will be thawed.
If “Other is checked indicate the type of food:
Thawing Process	Meat	Seafood	Poultry	Other
Refrigeration
Running Water less than 70F
Cooked Frozen
Microwave
Food Handling Procedures:
Explain the following with as much detail as possible. Provide descriptions of the specific area of the kitchen and corresponding items on the plan where food will be handled.
Explain the handling procedures for the following categories of food. Describe the process from receiving to service including:
How the food will be arrive? (frozen, fresh, packaged, etc.)
Where the food will be stored?
Where (specific pieces of equipment with their corresponding equipment schedule numbers) and how the food will be handled? (washed, cut, marinated, breaded, cooked, hot held, etc.)
When (time of day and frequency/day) food will be handled?
1. Ready-to-eat-foods: Edible without additional preparation necessary. e.g., salads, cold sandwiches, raw molluscan shellfish
2. Produce, grains and pasta: e.g., beans, rice, macaroni
3. Poultry:
4. Meat:
5. Seafood:
Consumer Advisory:
Will raw animal foods be offered raw or undercooked? Yes No
If so, how are you going to advise the consumer of such hazards? (menu, table top tent, placard on wall)
Time as a Public Health Control (TPHC):
Will TPHC be used for Time/Temperature Control for Safety (TCS) foods? Yes No
If so, please submit a copy of the written procedures for review.
Dry Storage:
Dry storage space must be adequate for the storage of all dry goods (e.g. canned & bottled goods, single service items)
Where will dry goods be stored?
Finish Schedule:
Indicate floor, wall, ceiling, baseboard finishes (e.g., quarry tile, stainless steel, vinyl coated acoustic tile)
Area	Floor	Base Coving	Walls	Ceilings
Kitchen
Bar
Food Storage
Dry Storage
Toilet Rooms
Dressing Rooms
Garbage & Refuse Storage
Service Sink
Other:
Other:
Handwashing:
Indicate number and location of handwashing sinks:
Employee Accommodations:
Indicate location for storing employees’ personal items (ex. coats, purses, medication, etc.)
Service Sink:
Location and size of service (mop) sink/can wash:
Describe location for storage of cleaning implements (e.g. mops, brooms, hoses, etc.)
Insect and Rodent Control:
How is protection provided on all outside doors?
Self-closing door Fly Fan Screen Door
How is protection provided on windows (including drive-thru windows) or other openings to the outer air?
Self-closing door Fly Fan Screening N/A
Linen:
Indicate location of clean and dirty linen storage: N/A (no linen storage on-site)
Poisonous and Toxic Material:
Indicate location of poisonous and/or toxic materials (chemicals, sanitizers, etc.) storage:
Person-in-Charge (PIC):
Is the future PIC(s) a certified food protection manager from an accredited program? Yes No
If YES, please list name(s):
Employee Health Policy:
An Employee Health Policy or method of requiring employees to report symptoms and certain illnesses as described in 2-201.11 thru 2.201.13 of the North Carolina Food Code will be required. Please refer to Annex 2.2 in the following link: http://ehs.ncpublichealth.com/faf/food/foodcodeannex.htm
Vomit & Diarrhea Clean-Up Plan:
A Vomit & Diarrhea Clean-Up Plan as described in 2-501.11 of the North Carolina Food Code will be required.

To assure that your application is processed in a timely manner, you must submit a completed application, which includes the following:

Zoning Permit

Proposed menu

Seating capacity

Site Plan showing the following: all structures, property lines, wells, septic systems, and dumpster/ recycling bins.

Building floor plan drawn to scale showing the location of the following: All sinks (dishsink, hand sink, food prep sink(s), mop sinks, etc.) refrigeration, prep tables, bathrooms, dining room, dry storage, chemical storage, and other equipment (e.g., deep fryer, slicer, ovens, hoods, etc).

Important basic design information:

All equipment shall be ANSI approved for commercial use or meet parts 4-1 & 4-2 of the NC Food Code. Exception: residential toasters, mixers, microwave ovens, and hot water heaters may be used.

Manufacturer’s specification sheets for each piece of equipment should be included.

At least one (1) hand wash sink shall be located in the food preparation area.

Plans shall be approved by the Cleveland County Environmental Health prior to initiating construction. Construction shall comply with approved plans. Any and all revisions made to plans after initial approval must be re-submitted.

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Review and approval of these plans and specifications by the Cleveland County Environmental Health does not indicate compliance with any other federal, state, or local code, law or regulation. A pre-opening inspection of the establishment with equipment will be necessary to determine compliance with the local and state laws governing food service establishments. You will be responsible for obtaining approval from appropriate zoning and building inspection departments. Their numbers are included below to assist you.

ZONING / BUILDING INSPECTION	FIRE MARSHALLS

Shelby 704-484-6805	704-484-6816

Kings Mountain 704-734-4599	704-734-0555

Cleveland County 980-484-4975/4997	980-481-4841

If your business will be located in any jurisdiction other than those listed above, please check with your city manager and/or town hall for permitting assistance.

If the 250.00 plan review fee is required with this application then a completed application with payment should be submitted to the Cleveland County Permits office located at 1333 Fallston Road, Shelby, NC 28150.

Proposed opening date:
Date Application Submitted:
Applicant’s Signature:

APPLICATIONS CAN BE SUBMITTED IN PERSON OR BY MAIL TO:

Cleveland County Permits Office

1333 Fallston Road

Shelby, NC 28150

***Please call 980-484-4779 to arrange for submission and payment of fees***

Rev. 12/23