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RETAIL/FOOD SERVICE ESTABLISHMENT
PLAN REVIEW APPLICATION FOR LOGAN COUNTY
ٱ New ٱ Remodel ٱ Conversion
Name of Establishment________________________________________________________
Business Address ___________________________________________________________
Mailing Address _____________________________________________________________
Phone # ___________________________________________________________________
Name of Owner ______________________________________________________________
Phone # ___________________________________________________________________
(daytime) (evenings)
Previous Name of Establishment (if applicable) ______________________________________
Name of Individual Submitting Plans ______________________________________________
(owner, manager, architect, etc...)
Phone _____________________________________________________________________
Name of licensed plumber ______________________________________________________
Plumber=s State of Illinois license # _______________________________________________
I have submitted plans/applications to the following:
(Please note date of submittal on application line)
City of Lincoln Code Enforcement ______________________________
(If in the city limits)
Fire Department ____________________________________________
Other ____________________________________________________
Projected Date for Start of Construction: ___________________________________________
Projected Date for Completion of Project: __________________________________________
Hours of Operation: Monday _______________ Friday _______________
Tuesday _______________ Saturday _____________
Wednesday _____________ Sunday ______________
Thursday _______________
Meals to be Served: ٱ Breakfast ٱ Lunch ٱ Dinner
Type of Service ٱ Sit Down Meals ٱ Take Out
(Check all that apply)
ٱ
Caterer ٱ OtherAmount of Seating ______________________________________
Please enclose the following documents:
ٱ Proposed Menu
ٱ Drawings or Blue Prints
ٱ Location and Type of Equipment Noted on Plans
ٱ Equipment New? ٱ NSF Approved?
Used Equipment? ____________________________________________________________
(used equipment shall be approved by the health department prior to installation)
All equipment if not sealed to the floor shall be easily moveable, have quick disconnects and be a minimum of 6" off the floor.
Plan Review/Equipment Check List
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EQUIPMENT |
YES |
NO |
N/A |
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Hand Lavatory in food preparation area |
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3-Compartment Sink (drain boards) |
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Utility Sink |
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Produce Sink |
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Automatic Dish Machine (type, booster, etc.) |
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Exhaust Hoods |
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Protective Light Shields (food preparation storage, walk-in, etc.) |
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Sneeze Shields for salad bars, buffets, etc. |
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INDIRECT CONNECTIONS |
YES |
NO |
N/A |
COMMENTS |
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Dishwasher |
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3-Compartment Sinks |
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Steam Tables |
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Dipper Well |
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Refrigerator Drains |
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Ice Machines |
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Drink Dispensers |
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AUTOMATIC DISHWASHING |
YES |
NO |
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Sanitize by heat (1800 F final rinse) |
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Chemical Sanitizer (50 ppm chlorine final rinse) |
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VECTOR AND RODENT CONTROL |
YES |
NO |
COMMENTS |
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Screens on all outer openings |
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Self-closing outer doors |
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Building rodent proof |
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Pest control provided |
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Cleaning Schedule |
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SOLID WASTE |
YES |
NO |
COMMENTS |
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Concrete or asphalt base for dumpster |
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Covers for waste receptacle |
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Plug for dumpsters |
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Covers for grease barrels |
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Note: Locate dumpster and grease receptacles as far from door as possible.
SEWAGE DISPOSAL
Public Sewer System ٱ Yes ٱ No Private Disposal System ٱ Yes ٱ No
If yes, date installed ________________ Installation Contractor:________________________
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TOILET ROOM FACILITIES |
YES |
NO |
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Ventilation |
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Self-closing doors |
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Hand drying facilities |
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Hot and Cold water |
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Anti-siphon ballcocks |
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Covered waste receptacles |
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Hand soap |
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WATER SUPPLY
Public water supply ______________________Private water supply _____________________
If a private water supply, has it been tested? ٱ Yes ٱ No
If yes, date tested ________________ Results:__________________________
TYPE OF FLOOR, WALL AND CEILING MATERIALS TO BE USED
(smooth, easily cleanable, and non-absorbent)
Food preparation area ________________________________________________________
Storage areas _______________________________________________________________
Toilet rooms ________________________________________________________________
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MISCELLANEOUS |
YES |
NO |
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Metal stem thermometers ( 00 - 2200 F) |
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Sanitizer |
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Test strips for sanitizer |
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Thermometers for all cooling units |
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IDPH Food handlers certificate |
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Certified Handlers Name ________________________________Expiration Date __________
NOTE: ALL SINKS SHALL BE PLUMBED WITH HOT AND COLD POTABLE WATER. IN ADDITION, ALL PLUMBING SHALL BE INSTALLED BY A STATE OF ILLINOIS LICENSED PLUMBER.
NOTE: PLEASE CONTACT THE DEPARTMENT OF JUSTICE FOR THE AMERICAN WITH DISABILITIES ACT (ADA) REQUIREMENTS (800) 514-0301.
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