PERMIT APPLICATION FOR
FOOD SERVICE ESTABLISHMENTS,
EXTENDED FOOD SERVICE OPERATIONS,
AND MOBILE FOOD SERVICE BASE OF OPERATIONS
PERMIT APPLICATION FOOD SERVICE ESTABLISHMENTS
AND MOBILE FOOD SERVICE BASE OF OPERATIONS
NOTICE
THIS PERMIT APPLICATION PACKET IS COMPOSED OF THREE PARTS: ADMINISTRATIVE
INFORMATION; OPERATIONAL INFORMATION; AND PLAN REVIEW INFORMATION.
ADMINISTRATIVE INFORMATION: THIS INFORMATION WILL BE USED TO ESTABLISH
COMMUNICATION BETWEEN THE LOCAL HEALTH AUTHORITY AND THE PERMIT APPLICANT/PERMIT
HOLDER. IT WILL ALSO BE USED TO ADMINISTER THE PERMITTING AND ESTABLISHMENT
INSPECTION PROCESSES.
OPERATIONAL INFORMATION: THIS INFORMATION WILL BE USED TO ENABLE THE LOCAL HEALTH
AUTHORITY TO BECOME FAMILIAR WITH THE QUESTIONS OF WHAT TYPES, WHEN, HOW MUCH,
AND WHERE FOOD WILL BE PREPARED AND SERVED BY THE PROPOSED FOOD SERVICE
ESTABLISHMENT.
PLAN REVIEW INFORMATION: IN ACCORDANCE WITH DPH RULE 511-6-1-.02(4)(A), THIS
INFORMATION WILL BE UTILIZED BY THE LOCAL HEALTH AUTHORITY IN ITS REVIEW AND
APPROVAL PROCESS OF SUBMITTED PLANS AND SPECIFICATIONS FOR PROPOSED NEW
CONSTRUCTION, OR REMODELING AND CONVERSION OF EXISTING BUILDINGS FOR PROPOSED
FOOD SERVICE ESTABLISHMENTS. ADDITIONALLY, THIS INFORMATION WILL BE UTILIZED BY THE
LOCAL HEALTH AUTHORITY TO ACCESS THE LEVEL OF COMPLIANCE STATUS OF EXISTING FOOD
SERVICE ESTABLISHMENTS DURING THE OCCURRENCE OF A CHANGE IN PERMIT HOLDER.
AS PER DPH CHAPTER 511-5-14-.02(1)(C), IN ORDER TO QUALIFY FOR A PERMIT TO OPERATE A
FOOD SERVICE ESTABLISHMENT, THE PERMIT APPLICANT MUST DEMONSTRATE SATISFACTORY
COMPLIANCE WITH DPH CHAPTER 511-5-14. TO RECEIVE A PERMIT FROM THE HEALTH AUTHORITY,
THE APPLICANT MUST BE AN OWNER OF THE PROPOSED FOOD SERVICE ESTABLISHMENT OR AN
OFFICER OF THE LEGAL OWNERSHIP, AGREE TO ALLOW THE HEALTH AUTHORITY ACCESS TO THE
FOOD SERVICE ESTABLISHMENT, PROVIDE ALL REQUIRED INFORMATION REQUESTED BY THE
HEALTH AUTHORITY, AND PAY ALL APPLICABLE FEES;
AT THE HEALTH AUTHORITY’S INITIAL INSPECTION OF THE COMPLETED FOOD SERVICE
ESTABLISHMENT AND PRIOR TO THE ISSUANCE OF A PERMIT BY DEMONSTRATING
SATISFACTORILY COMPLIANCE WITH THE PROVISION OF DPH CHAPTER 511-6-1; AND PROVIDING
WRITTEN DOCUMENTATION INDICATING SATISFACTORY COMPLIANCE WITH ALL OTHER
PROVISIONS OF LAWS THAT APPLY TO THE FOOD ESTABLISHMENT’S LOCATION, CONSTRUCTION
AND MAINTENANCE, AND THE SAFETY OF PERSONS THEREIN. APPROVAL OF ALL OTHER
AGENCIES.
INSTRUCTIONS: COMPLETE THE FOLLOWING APPLICATION DOCUMENT IN DUPLICATE AND
FORWARD THE ORIGINAL COMPLETED DOCUMENT TO ENVIRONMENTAL HEALTH, IN WHICH THE
FOOD SERVICE ESTABLISHMENT IS TO BE LOCATED AND OPERATED. KEEP A COPY OF ALL
APPLICATION DOCUMENTS FOR YOUR RECORDS.
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PERMIT APPLICATION FOOD SERVICE ESTABLISHMENTS
AND MOBILE FOOD SERVICE BASE OF OPERATIONS
GLYNN COUNTY FOOD SERVICE PERMIT APPLICATION
Step 1 Beginning the Process
Pick up an Environmental Health application and design a plan for your food facility by following the “ Plan
Review/Construction Guide”. Online construction guide at
http://health.state.ga.us/programs/envservices/FSPlanReviewManual.asp
Contact other agencies including your local Building inspection, Joint Water and Sewer, and the Fire
Inspector for information concerning their requirements.
Step 2 Submittal of Application, Plan and Fees
Turn in your completed application, and a copy of your plan and a full menu/consumer advisory and plan review
fee to the Environmental Health for review.
Allow 10 days for Environmental Health to review all applications and plans.
Step 3 Plan Review Process
Your Plan will be reviewed by the EHS. The proposed facility plan is checked according to the requirements of
the” Georgia Foodservice Rules and Regulations 511-6-1.
New businesses and change of ownership on all facilities will be required to meet the current laws. Inadequate
plans may result in a delay of approval. In this case, a letter may be mailed to you outlining the deficiencies and/or
requesting additional information. If any changes on the plans are desired by the facility, revised plans must be
submitted to Environmental Health for review and approval before construction begins.
Step 4 Construction and Pre-opening Inspections
Two or more inspections may be necessary.
One construction inspection to ensure that installation is completed to specifications.
Second inspection after construction and before opening for business, is required.
The Permit Application fee is due at the time of your final inspection before we issue your Foodservice Permit. All
construction should be finished, all other agencies should have given approval, all equipment should be installed
and functional and your pre opening checklist should be complete,.
Step 5 Routine Facility Inspections
After you are open for business, your EHS will be making periodic unannounced inspections of your facility. An
operating food service facility is required to maintain a clean organized environment in good repair. Employees
are required to practice safe and sanitary methods of handling food at all times. As a “Food Service Operator” you
are required to know the “Georgia Foodservice Rules and Regulations”.
Glynn County Environmental Health. 1725 Reynolds Street #105. Brunswick, GA 31520
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PERMIT APPLICATION FOOD SERVICE ESTABLISHMENTS
AND MOBILE FOOD SERVICE BASE OF OPERATIONS
Phone: 912.279.2940 Fax: 912.267.4879
ADMINISTRATIVE INFORMATION
FOR HEATLH AUTHORITY USE ONLY:
Amt. Date
Due Paid
Date
Approved
Comments
Plan Review Fee
Yearly Inspection Fee
Business Plan
Completed Application
Menu
Floor Plan
Equipment List
Site Plan
Residency Form
Sign Off Sheet
Vomitus/Diarrheal Cleanup
Plan
Employee Health Policy
Variance/HACCP
Plan/Procedures
Food Service Risk
Categorization
Risk Type I
Risk Type II
Risk Type III
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Do not cook any food may reheat commercially precooked ingredients
Cook and/or hold and reheat foods that are prepared on site
Requires a HACCP Plan
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PERMIT APPLICATION FOOD SERVICE ESTABLISHMENTS
AND MOBILE FOOD SERVICE BASE OF OPERATIONS
Name of Establishment: (Legal business name to appear on permit)
Street Address:
City:
State:
Phone:
Email Address:
Date of Project Begining
New Restaurant
New Mobile Unit
New Mobile Base
New Catering Operation
Change of Ownership
ZIP:
Date of Project Completion
New Extended Food Service
Institution (school, hospital, nursing home etc…)
Incubator B (Cubicle/build out units)
Wholesaler
Renovation of Existing Establishment
Name of Business Owner: (the business owner’s name or corporation name as it appears on the business license)
Street Address:
City:
State:
Phone:
Email Address:
ZIP:
Billing Address:
City:
□ Individual
State:
□ Corporation
□ Partnership
Zip:
□ LLC
□ Association
If Corporation, Partnership, LLC, Association, or Other Legal Entity, please provide a listing of all persons comprising the legal
ownership to include the name(s), title(s), address and phone numbers, including owners and officers. Please attach additional
page, if necessary.
Name of regional/district manager:(Person who functions as the immediate supervisor of the food service managers
Street Address:
City:
State:
Phone:
Email Address:
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PERMIT APPLICATION FOOD SERVICE ESTABLISHMENTS
AND MOBILE FOOD SERVICE BASE OF OPERATIONS
OPERATIONAL INFORMAITON
Hours of Operation
Sunday
Thursday
Monday
Friday
Tuesday
Saturday
Wednesday
Total square feet of facility
Number of kitchens
Number of Bars
Total number of seats
Seats outside
Seats Inside
Number of meals per day
Number of Staff (max per shift)
Type of service (check all that apply)
Sit Down Meals
Mobile Unit
Pets in outside dining area
Breakfast
Drive thru
Delivery
Lunch
Take out
Catering
Dinner
Online
Other
CATEGORY (Answer the following based on your operation) (check all that apply):
Thin meats, poultry, fish, eggs (hamburger, sliced meats, fillets)
Seafood and shellfish
Thick meats, whole poultry (roast beef, whole turkey, chickens, hams)
Cold processed foods (salads, sandwiches, vegetables)
Hot processes foods (soups, stews, rice/noodles, gravy, chowders, casseroles)
Bakery goods (pies, custards, cream fillings and toppings)
Fresh Fruit/Produce
Specialty foods (i.e. acidification, curing, drying, reduced oxygen packaging etc…
Establishment does not cook any raw animal foods; only reheats commercially precooked
ingredients
Establishment cooks raw animal foods and reheats cooked foods that are prepared onsite
Establishment serves raw or undercooked animal foods in a ready to eat form (i.e. rare
steaks/burgers, sashimi, raw oysters etc)
Other
YES
NO
If Applicable, identify all counties and/or locations in Glynn County in which Mobile Unit(s) will
operate:
________________________________________________________________________________
________________________________________________________________________________
Imminent Health Hazard
If an imminent Health Hazard exists because of an emergency such as fire, flood, interruption of
electrical or water service for two (2) or more hours, sewage malfunction, misuse of poisonous or
toxic materials, onset of an apparent foodborne illness outbreak, gross unsanitary occurrence or
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PERMIT APPLICATION FOOD SERVICE ESTABLISHMENTS
AND MOBILE FOOD SERVICE BASE OF OPERATIONS
condition or other circumstances that may endanger public health, then operations shall be
immediately discontinued and the Health Authority notified.
___________________________________________
Signature of Authorized Agent
Date
Submit a detailed description of your business plan (which includes a business and concept
description, operations plan, identify your market/consumers and services provided, etc.
You may obtain a copy of the Rules and Regulations for Food Service by visiting our website at
http://dph.georgia.gov/food-rules-and-regulations
FOOD PREPARATION REVIEW
SUPERVISION
CFSM:
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PERMIT APPLICATION FOOD SERVICE ESTABLISHMENTS
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1. Total Number Managers (have supervisory/management responsibility) which are certified in Food Safety?
_________________
2. Name of CFSM _________________________________________________
3. Indicate how and when employees will be trained on employee health policy, food safety, and allergens? Method of
training and tracking training?
_______________________________________________________________________________________________
GOOD HYGIENIC PRACTICES, PREVENTING CONTAMINATION BY HANDS
EMPLOYEE HEALTH:
4.
Is there a written policy to exclude or restrict employees who are ill or have open lesions or cuts? YES  NO 
Attach written policy ( must include reportable illnesses and symptoms for exclusion/restriction ):
5.
Is there a written response procedure for cleaning vomiting or diarrheal events? YES  NO 
Attach written policy:
HANDWASHING:
6. Is there a hand washing sink in each food preparation and ware washing area? YES  NO 
7. Are there reminder signs at each hand sink explaining the hand wash process? YES  NO 
8. List all 5 hand washing steps:
1.
2.
3.
4.
5.
9. Do all hand washing sinks, including those in the restrooms, have a mixing valve or combination faucet?
YES  NO 
10. Do self-closing metering faucets provide a flow of water for at least 15 seconds without the need to reactivate the
11.
12.
13.
14.
faucet? YES  NO  NA□
Is hand soap available at all hand washing sinks? YES  NO 
Are hand drying facilities (paper towels, blowers) available at all hand wash sinks? YES  NO 
Are waste receptacles available at each hand sink and covered waste receptacles available in each restroom?
YES  NO 
Is hot and cold running water under pressure available at each hand sink? YES  NO 
NO BARE HAND CONTACT:
15. Which barrier(s) (such as disposable, single use gloves, utensils, food grade paper etc.) do you plan to utilize to
prevent handling of ready to eat foods with bare hands?
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_______________________________________________________________________________________________
_____________________________________________________________
APPROVED SOURCES
16. Are all food supplies from inspected, permitted approved facilities? YES  NO 
17. List suppliers: ______________________________________________________________________________
18. What are the projected frequencies of deliveries for:
Type of Food
Day of the Week
AM / PM
Frozen Food
Refrigerated Food
Dry Goods
19. Provide information on the amount of space ( cubic feet ) allocated for
Frozen Storage
Cubic Feet
Refrigerated Storage
Cubic Feet
Dry Storage
Cubic Feet
REQUIRED RECORDS, SHELLSTOCK TAGS, PARASITE DESTRUCTION: (Answer Not Applicable if
there is no shellstock or raw fish served in this facility)
20. What is the record keeping procedure for maintaining shellstock tags?
_______________________________________________________________________________________________
_____________________________________________________________________________________________
21. If serving raw fish (sushi, lox, cerviche), will parasite destruction be done on-site or by supplier?
A.
On-site: Provide your procedure on parasite destruction
B.
Supplier: Provide the name of your supplier and documentation to show parasite destruction. (Each invoice
received from the supplier shall state the specific fish by species that have been frozen to meet parasite
destruction requirements)
PROTECTION FROM CONTAMINATION
FOOD SEPARATED AND PROTECTED:
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22. Will raw meats, poultry and seafood be stored in the same refrigerators and freezers with cooked and ready to
eat foods? YES  NO 
If yes, how will cross-contamination be prevented? (How is food stored from top
to bottom in refrigeration units?)
PROPER DISPOSITION OF RETURNED, PREVIOUSLY SERVED FOOD:
23. What is the procedure for food that has been returned, previously served? (ie is it discarded, reserved etc…)
SELF SERVICE AREA(S):
24.
25.
26.
27.
Will you provide self service food to your customers?
Will you have a buffet or salad bar?
Is it mechanically refrigerated/ or heated?
If no, how is temperature of TCS food maintained?
YES  NO 
YES  NO 
YES  NO 
28. How is food in self serve area protected (sneeze guard etc….)?
N/A 
29. What will happen to any food leftover from buffet (will it be cooled and reused)?
N/A 
FOOD CONTACT SURFACES CLEANED AND SANITIZED:
DISHWASHING FACILITIES:
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30. Will sinks or a dishwasher be used for warewashing? Check all that apply.
3 Compartment sink □
Chemical Type: Quat, Chlorine, Iodine
Concentration: _____________ Test kit YES  NO 
Dish Machine
□
Dishwasher type of sanitizer used:
High Temp:________ Booster Heater _______ Chemical Type: Quat, Chlorine, Iodine Test kit YES  NO 
31. Is ventilation provided for dish machine as required?
YES  NO 
32. Do all dish machines have templates with operating instructions?
YES  NO 
33. Do all dish machines have temperature/pressure gauges as required that are accurately working?
YES  NO 
34. Does the largest pot and pan fit into each compartment of the pot sink? YES  NO 
35. Are there drain boards on both ends of the pot sink? YES  NO 
36. How will large equipment, such as cutting boards, countertops, that CANNOT be submerged in sinks or put through
a dishwater be sanitized?
Chemical Type: Quat, Chlorine, Iodine
Concentration: _________________ Test kit YES  NO 
PROPER COOKING TIME AND TEMPERATURE:
37. Will food product thermometers be used to measure final cooking/reheating temperatures of TCS* foods?
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Yes
□
No□
38. What type of temperature measuring device will be used? ________________________________
39. List types of cooking equipment _____________________________________________________
Minimum cooking time and temperatures
Beef roasts (using convection and conduction heating equipment)
130 F (121 minutes)
Seafood
145 F (15 Seconds)
Eggs for immediate service
145 F (15 Seconds)
Eggs for hot holding or pooled eggs
155 F (15 Seconds)
Pork
145 F (15 Seconds)
Comminuted/Ground Meats/Fish
155 F (15 Seconds)
Poultry (chicken/Turkey)
165 F (15 Seconds)
Reheated for hot holding of cooked and cooled TCS foods
165 F (15 Seconds)
Reheated commercially precooked TCS foods
135 F (15 Seconds)
*TCS – Temperature controlled for safety
REHEATING:
40. How will 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 F for 15 seconds? Indicate the type and number of units for reheating foods.
_______________________________________________________________________________
_______________________________________________________________________________
CONSUMER ADVISORY:
41. Will meat, poultry, eggs, or fish be offered raw or undercooked on the menu?
Yes □ No□
42. If yes, do you have a consumer advisory and asterisks on each of the items offered undercooked or raw?
YES  NO 
(Choose A or B advisory)
A. Consuming raw or undercooked meats, poultry, seafood, shellfish, or eggs may increase your risk of foodborne
illness.
OR
B. Consuming raw or undercooked meats, poultry, seafood, shellfish, or eggs may increase your risk of foodborne
illness, especially if you have certain medical conditions.
HOLDING OF TCS FOODS:
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43. Are there any other locations besides the main kitchen area in which food is planned to be held (cold or hot) or dry
stored prior to being prepared and/ or served?
YES  NO 
44. If yes, list other locations where food is stored:
45. Will food be transported after preparation (delivery or catering)? YES  NO 
46. Describe equipment used to maintain temperature during transport:
47. What is the food delivery radius (in time/distance traveled)?
COLD HOLDING:
48. How will cold TCS food be maintained at 41 F or below during holding for service?
49. Indicate type and number of cold holding units:
Number of refrigeration units: _________ Number of freezer units: ___________
50. Type of refrigeration units: (ie prep top cooler 15 cubic feet, walk in cooler 134 cubic feet etc…) use extra sheet of
paper if needed
Description of refrigeration unit
Size of unit (cubic feet)
COLD HOLDING:
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51. Type of freezer units: (ie reach in freezer single door, walk in freezer 134 cubic feet, chest freezer 5.1 cubic feet
etc…)
Description of freezer unit
Size of unit (cubic feet)
52. Does each refrigerator have a thermometer in the warmest part of the unit? ( a thermometer that is not part of the
unit itself) YES  NO 
53. Do you have temperature logs for each cold holding/hot holding unit? YES  NO 
HOT HOLDING:
54. How will hot TCS food be maintained at 135 F or above during holding for service?
55. Indicated type and number of hot holding units :
COOLING:
56. Please indicate by checking the appropriate boxes for how TCS food that will be cooled to 41 F within 6 hours ( 135 F
to 41 F in 6 hrs; provided the food reaches from 135 F to 70 F in 2 hrs)
COOLING
THICK MEATS
THIN MEATS
THIN
THICK SOUPS
RICE/NOODLES
METHOD
SOUPS/GRAVY /GRAVY
Shallow Pans
Ice Baths
Reduce
Volume or size
Rapid Chill
Unit
Other
(describe)
COOLING:
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57. Describe how the cooling process for TCS food from 135 F – 70 F within 2 hours and 135 F to 41 F within 6 hours will
be monitored to ensure cooling parameters are met. Indicate cooling strategy, monitoring procedures, type of
measuring equipment used :
58. Will ingredients for cold ready-to-eat foods such as tuna, mayonnaise and eggs for salads and sandwiches be prechilled before being mixed and/or assembled? YES  NO  If not, how will ready-to-eat foods be cooled to 41ºF?
TIME AS A PUBLIC HEATLH CONTROL:
59. Will you use time as a public health control for any foods?
60. If yes, describe how TPHC will be used :
YES  NO 
DATE MARKING:
61. Describe the procedure for date marking of ready-to-eat TCS food items. Include TCS food prepared in house, and
TCS food removed from original packaging: (Maximum hold time is 7 days)
HIGHLY SUSCEPTIBLE POPULATIONS:
62. Will the facility be serving food to a highly susceptible population? YES  NO 
63. If yes how will the temperature of the food be maintained while being transferred between the kitchen and the
service area(s)?
64. Are pasteurized eggs used where required?
YES  NO 
FOOD ADDITIVES:
65. Do you use any additives in foods (ie nitrates, nitrites, sulfates)? YES  NO 
CHEMICALS:
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66. Are chemicals/cleaning products/sanitizers stored separately from food and clean equipment? YES  NO 
67. Are all toxics for use on the premise (this includes personal medications), stored away from food preparation and
storage areas?
YES  NO 
68. Is this area located on the floor plan?
YES  NO 
69. Are all containers of toxics including sanitizing spray bottles clearly labeled?
YES  NO 
COMPLIANCE WITH APPROVED PROCEDURES:
70. Will you conduct food processing within your facility? (canning, bottling, sous vide, smoking meats for preservation)
YES  NO 
71. Will you be smoking meat at a method of cooking?
72. Is the smoker located on the floor plan?
YES  NO 
YES  NO 
Check Appropriate Block(s) for any proposed specialized processes for your establishment.
□ Smoking for preservation*
□ Sprouting seeds or beans* □ Reduced Oxygen Packaging+
□ Operating a molluscan shellfish life-support system*
□ Curing*
□ Canning/bottling
□ Using food additives or adding components to render food non-TCS or for preservation*
□ Other *+
____________________________________________________________________________
* Requires a variance, HACCP plan, and written procedures
+ May require a variance and HACCP plan depending on the procedures
Give a description of the specialized process you will be doing:
Provide the written HACCP plan if it has been completed
SAFE FOOD AND WATER, FOOD IDENTIFICATION:
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WATER SUPPLY:
73. Is water supply:
Public  or Private 
74. If private, has source been approved? YES 
NO  PENDING  Please attach a copy of written approval.
ICE MACHINE:
75. Is ice made on premises 
or purchased commercially? 
76. If ice is not made on premises, how will you provide ice needed for processes (such as cooling) in this facility?
77. If ice is purchased, who is the supplier?
78. Is the ice machine provided indirectly drained?
YES  NO 
79. Describe location and method for ice scoop storage:____________________________________________________
80. Describe the cleaning schedule for the bulk ice machine _________________________________________________
_______________________________________________________________________________________________
FOOD IDENTIFICATION:
81. Are food storage containers properly labeled?
YES  NO 
FOOD TEMPERATURE CONTROL:
THAWING FROZEN POTENTIALLY HAZARDOUS FOOD:
Please indicate by LISTING FOODS TO BE THAWED in the appropriate boxes how frozen TCS
food will be thawed. More than one method may apply.
Thawing Method
*THICK FROZEN FOODS
*THIN FROZEN FOODS
Refrigeration
Running Water Less than 70ºF
Microwave (as part of cooking process)
Cooked from Frozen state
Other (describe)
* Frozen foods: approximately one inch or less = thin, and more than an inch = thick.
82. If thawing under running water in what sink raw meats will be thawed? ______________________________
THERMOMETERS:
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83. List steps in calibrating a food thermometer using the ice point method:
1.
2.
3.
4.
84. Do you have the appropriate thermometers for checking internal temperatures of food? Ie thin meat themometers
for items such as burgers, chicken breasts, fish etc…
YES  NO 
85. Are accurate thermometers placed in the warmest part of each cooler?
YES  NO 
PREVENTION OF FOOD CONTAMINATION
DRY STORAGE:
86. Are bulk food containers constructed of safe food grade material? (this would include containers for sugar, flour,
spices etc…)
YES  NO 
87. Do containers have tight fitting lids? YES  NO 
88. Are they labeled? YES  NO 
89. Are they equipped with a scoop that has a handle?
YES  NO 
90. Are all storage units at least 6” above the floor so that a mop and broom may fit easily underneath for cleaning?
YES  NO 
91. Are storage shelves made of smooth, cleanable, non-absorbent material?
YES  NO 
92. Are dry goods stored anywhere other than the main kitchen area?
YES  NO 
If yes, indicate all areas where dry goods may be stored:
93. Is there an area to store returnable damaged goods?
YES  NO 
PERSONAL CLEANLINESS:
94. Are hair restraints provided for every employee working with food?
YES  NO 
95. Is the area for personal belongings storage ( ie purse, coats, backpacks, umbrellas)
located away from food, clean utensils, and clean equipment (is it shown on the floor plan) ? YES  NO 
WIPING CLOTHS:
96. Will cleaning cloths and any other linens be laundered on site?
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97. If no, how will cloths used from cleaning be laundered?
98. What is the location of clean cloths?
99. What is the location of dirty cloths?
WASHING FRUITS AND VEGETABLES:
100.
101.
102.
Are fruits and vegetables served on the menu or ingredients in dishes? YES  NO 
If yes, is a dedicated sink provided for washing raw fruits and vegetables prior to their preparation?
YES  NO 
Does the produce sink have an indirect drain? YES  NO 
UTENSIL/EQUIPMENT STORAGE:
103. Are all utensils and single service items and pieces of equipment stored at least 6” off the floor with food contact
surfaces protected from contamination?
YES  NO 
HOT AND COLD WATER AVAILABLE:
104. Is there hot and cold water available at all sinks or equipment where required? YES  NO 
105. What is the capacity of the hot water generator?_______________________________________
106. Is the hot water generator sufficient for the needs of the establishment? YES  NO 
107. Please provide the Water Heater: Make _____________ Model ________________ Storage Capacity ______
BTU or KW ________
BACKFLOW DEVICES:
108.
Is there a water treatment device? YES  NO 
109. If yes, how will the device be inspected & serviced?
______________________________________________________________________________________________
110. How are backflow prevention devices inspected & serviced?
______________________________________________________________________________________________
SEWAGE DISPOSAL:
111.
112.
Is the building connected to municipal sewer?
If no, is the private disposal system approved?
YES  NO 
YES  NO  If yes, provide copy of the approval.
GREASE TRAP:
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113. Is a grease trap provided? YES  NO 
114. Do you have written approval from the governing agency for the grease trap? YES  NO  Provide a copy of
the approval or a statement from the agency that a grease trap is not required.
RESTROOMS: (check with the fire department about handicap accessability)
115.
116.
117.
118.
Is there a restroom available to the public? YES  NO 
Is there access to this restroom without going through the kitchen? YES  NO 
Is there a covered trash can in each rest room?
YES  NO 
Are restroom doors equipped with self- closing doors?
YES  NO 
GARBAGE AND REFUSE:
Inside:
119.
120.
121.
122.
123.
Do all containers have lids? YES  NO 
Will refuse be stored inside? YES  NO 
If so, where? ____________________________________
What is the schedule for trash pickup? 1x per week 
2x per week 
3 x per week 
Trash pickup service? ______________________________________________________________________
Is there an area designated for garbage can and floor mat cleaning? YES  NO 
If so, where? ______________________________________________________________________________
Outside:
124. Will a dumpster be used? YES  NO 
125. Will a compactor be used? YES  NO 
126. Describe the surface and location where dumpster/compactor/garbage cans are to be stored:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
(surface should be hard, cleanable, non-absorbent – not grass, dirty or rock)
Grease Receptacle:
127. Will a receptacle be used for storing used grease from fryers etc…? YES  NO 
128. Name of the grease receptacle provider, and frequency of pickup ______________________________________
129.
Describe the surface and location where grease receptacle is to be stored:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
(surface should be hard, cleanable, non-absorbent – not grass, dirty or rock)
Recycled Materials:
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130. Will materials be recycled?
GLASS
METAL
CARDBOARD
YES  NO 
PLASTIC
Check all that may apply
PAPER
OTHER__________________________________
131. Describe the surface and location where recycled items are to be stored:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
(surface should be hard, cleanable, non-absorbent – not grass, dirty or rock)
MOP SINK / JANITORIAL SINK:
132.
133.
What type of mop sink is installed?  Prefabricated floor basin  Laundry tub  Wall mounted sink
Is there a heavy duty mop rack capable of holding wet mops above the mop basin? YES  NO 
LIGHTING:
134. Are all light fixtures over food preparation, display, service, storage, and utensil washing areas shielded or
shatter resistant? YES  NO 
135. Do lighted areas meet the light intensity requirements? YES  NO 
Lighting requirements:
1. At least 10 foot candles in walk in refrigeration units, and dry storage areas.
2. At least 20 foot candles at the surface where food is provided for consumer self service such as buffets and salad
bars or where fresh produce or packaged foods are sold or offered for consumption.
3. At least 20 foot candles inside equipment such as reach in coolers, and under counter refrigerators.
4. At least 20 foot candles above the floor in areas used for hand washing, warewashing, and equipment and
utensil storage, and in toilet rooms.
5. At least 50 food candles at a surface where a food service employee is working with food or working with
utensils or equipment such as knives, slicers, grinders, or saws where employee safety is a factor.
VENTILATION:
136. Is there adequate ventilation to keep rooms free of excessive heat, steam, condensation, vapors, obnoxious
odors, smoke, and fumes? YES  NO 
137. Has the hood system been approved by the governing agency? YES  NO 
Provide a copy of the approval from the fire department or governing agency.
INSECT AND RODENT CONTROL:
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138.
139.
140.
141.
142.
143.
144.
Will all outside doors be self closing and rodent proof? YES  NO NA 
Are screens provided on all entrances left open to the outside? YES  NO NA 
Are #16 screens provided on all windows opening to the outside? YES  NO NA 
Is the placement of pest electrocution devices identified on the floor plan? YES  NO NA 
Are all pipes, electrical conduit chases, ventilation systems, exhaust and intake systems protected? YES  NO 
Is the area around the building clear of unnecessary brush, litter, boxes and other harborage for pests?
YES  NO 
Will air curtains be used? YES  NO 
If yes, where _______________________________________
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FINISH SCHEDULE
Applicant must indicate which materials (quarry tile, stainless steel, 4" plastic coved molding, etc.) will be used in
the following areas.
FLOOR
COVING
WALLS
CEILING
Kitchen
Bar
Food Storage
Other Storage
Toilet Rooms
Dressing
Rooms
Garbage &
Refuse Storage
Mop Service
Basin Area
Warewashing
Area
Walk-in
Refrigerators
and Freezers
PLUMBING CONNECTIONS (Write NA if not applicable)
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OPERATIONAL INFORMATION
AIR GAP
AIR
BREAK
*INTEGRAL
TRAP
*P
TRAP
VACUUM
BREAKER
CONDENSATE
PUMP
Toilet
Urinals
Dishwasher
Garbage Grinder
Ice machines
Ice storage bin
Mop sink
Handwash sink
3 Compartment sink
2 Compartment sink
1 Compartment sink
Water Station
Steam tables
Dipper wells
Refrigeration condensate/drain lines
Hose connection
Potato peeler
Beverage Dispenser w/carbonator
* TRAP: A fitting or device which provides a liquid seal to prevent the emission of sewer gases without materially affecting the flow of sewage or waste
water through it. An integral trap is one that is built directly into the fixture, e.g., a toilet fixture. A “P” trap is a fixture trap that provides a liquid seal in the
shape of the letter “P”. Full “S” traps are prohibited.
32. Are floor drains provided & easily cleanable, if so, indicate location: _______________________
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OPERATIONAL INFORMATION
________________________________________________________________________________
The undersigned hereby applies for a permit to operate a Food Service Establishment pursuant to
O.C.G.A. 26-2-371-373 and hereby certifies that he has received a copy of the Rules and
Regulations for Food Service, Chapter 511-6-1, Georgia Department of Public Health. Further and if
granted a permit by the Health Authority to operate a food service establishment, the undersigned
agrees to comply with all provisions contained with the Rules and Regulations of Chapter 511-6-1.
Signed: ______________________________
Print Name: ___________________________
Date: ________________________________
Title:_________________________________
(State Whether Business Owner or Authorized Agent)
NOTE: ANY CHANGES IN THE EXISTING FOOD SERVICE ESTABLISHMENT FACILITY WILL
REQUIRE THE OWNER OR AGENT TO CONTACT THE LOCAL HEALTH AUTHORITY. IT IS
ILLEGAL FOR FOOD SERVICE ESTABLISHMENTS TO BEGIN OPERATION TO SERVE FOOD
TO THE PUBLIC WITHOUT FIRST OBTAINING A VALID FOOD SERVICE PERMIT FROM THE
LOCAL HEALTH AUTHORITY
STATEMENT: I hereby certify that the above information is correct, and I fully understand that any deviation
from the above information and approved food service plans and specifications without prior permission from
the local health authority may nullify this approval. Approval of these plans and specifications by the local health
authority DOES NOT indicate compliance with any other code, law or regulation that may be required – federal,
state, or local. It DOES NOT constitute endorsement or acceptance of the completed establishment (structure
or equipment). A final inspection of each completed establishment with the necessary equipment will be
necessary to determine if it complies with the Georgia Rules and Regulations Governing Food Service
Establishments. A food Service permit from the local health authority must be secured before this establishment
can operate as a food service establishment.
Signed: _______________________________________
Print Name: ___________________________________
Date ______________________________
Title: __________________________________
(State Whether Business Owner or Authorized Agent)
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