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Introduction & Checklist

The intent of this application is to provide information in addition to the plans regarding the operational procedures of the food establishment.
North Carolina Food Manual and Rules Governing the Food Protection and Sanitation of Food Establishments (15A NCAC 18A .2600) requires that plans be submitted for approval prior to construction, renovation, modification, change of ownership of such facilities by the local Health Department. Plans must be submitted with the necessary paperwork (see following checklist) to the Richmond County Health Department.
The following items have been included with the plans being submitted at this time. It is understood that omission of any requested information will result in delay in the plan approval. Once all required items are received the plans will be reviewed.
Submittal Checklist
1. Proposed menu
2. HACCP Plan (if required)
3. One set of plans, drawn to scale (recommended one-fourth-inch scale)
4. Standard Operating Procedures (cleaning and sanitizing, training, pest control, operational procedures)
5. Vicinity map and site plan showing location of any outside equipment or storage areas
6. Equipment Plan and schedule showing locations of equipment
7. Plumbing Plan showing hot and cold water, waste lines from fixtures, water heater location, floor drain and sink locations
8. Electric Plan and/or Lighting Plan
9. Interior room finish schedule
10. Kitchen exhaust ventilation plans
11. Hand sink and toilet facilities with soap and towel provisions
12. Warewashing facilities and food preparation sinks
13. Restroom/toilet facilities
14. Storage rooms/areas for food
15. Service sink / cleaning facilities
16. Chemical storage area
17. Employee storage areas
Establishment Plans
Upload Establishment Plans, Menus, Specification Sheets, SOP's, and/or HACCP Plans,
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Project Information & Contacts

Type of Construction
1. New
2. Remodel
Number of Indoor Seats
Number of Outdoor Seats
Facility Total Square Feet
Projected Start Date of Construction
Projected Start Date of Construction
Projected Completion Date
Projected Completion Date
Name of Establishment
Street Address
City
Zip Code
County
Phone Number (If Available)
Fax Number
Owner or Owner's Representative
Street Address
City
State
Zip Code
Phone Number
Fax Number
Email Address
Title
(Owner, Manager, Architect, etc.)
Submitter
Company
Contact Person
Street Address
City
State
Zip Code
Phone Number
Fax Number
Email Address
Title
(Owner, Manager, Architect, etc.)
Acknowledgement*
I certify that the information in this application is correct, and I understand that any deviation without prior approval from this Health Regulatory Office may nullify plan approval.
1. I understand.
Electronic Signature Agreement*
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature*
Date*
Date
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Food Service Details

Food Storage & Handling

Finish Schedule

Indicate floor, wall and ceiling finishes (e.g. quarry tile, epoxy, stainless steel, and vinyl coated acoustic).
Kitchen
Floor
Base
Walls
Ceiling
Bar
Floor
Base
Walls
Ceiling
Food Storage
Floor
Base
Walls
Ceiling
Dry Storage
Floor
Base
Walls
Ceiling
Toilet Rooms
Floor
Base
Walls
Ceiling
Dressing Rooms
Floor
Base
Walls
Ceiling
Garbage & Refuse Storage
Floor
Base
Walls
Ceiling
Service Sink
Floor
Base
Walls
Ceiling
Other 1
Specify Area
Floor
Base
Walls
Ceiling
Other 2
Specify Area
Floor
Base
Walls
Ceiling
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Water & Washing

Refuse & Recyclables

Will refuse be stored inside?
1. Yes
2. No
If yes, where?
Provision for Refuse Disposal
1. Dumpster
2. Compactor
Provision for Cleaning Dumpster/Compactor
1. On-Site
2. Off-Site
If off-site cleaning, provide name of cleaning contractor.
Describe location for storage of recyclables.
(Cooking grease, cardboard, glass, etc.)
Type of Pad Under Dumpster
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Cleaning Facilities

Location & Size of Service (Mop) Sink/Can Wash
Is a separate mop storage area provided?
1. Yes
2. No
If yes, describe type and location.
Location for Mops to Be Hung to Dry
Where will sanitizer spray bottles and/or buckets be located?
Location of Sanitizer Test Kit
Indicate the location of poisonous and/or toxic materials (chemicals, sanitizers, etc.) storage.
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Additional Items

Employee Accommodations
Indicate location for storing employees' personal items.
Indicate location for employee food and drinks.
Insect & Rodent Control
How is protection provided on all outside doors?
1. Self-Closing Door
2. Fly Fan
3. Screen Door
How is protection provided on windows?
1. Self-Closing
2. Fly Fan
3. Screening
Name of Pest Control Company
Linen
Indicate location of clean and dirty linen storage.
How will linens be cleaned?

Leave This Blank:

1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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Restaurant Plan Review Application

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Introduction & Checklist

Project Information & Contacts

Food Service Details

Food Storage & Handling

Finish Schedule

Water & Washing

Refuse & Recyclables

Cleaning Facilities

Additional Items

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