CoreOne - LCP

FOOD MANUFACTURER / WAREHOUSE PLAN REVIEW QUESTIONNAIRE

Food Manufacturer plan review questionnaire to be completed by the Owner/Operator and submitted to the Tennessee Department of Agriculture Consumer and Industry Services Division. Please refer to the Tennessee Statutes Title 53. Food, Drug and Cosmetic Act, 21 CFR Part 117 CURRENT GOOD MANUFACTURING PRACTICES, HAZARD ANALYSIS AND RISK-BASED PREVENTIVE CONTROLS FOR HUMAN FOOD for the basic requirements and more information.

* Name (Full Business name including Legal name and "Doing Business As" (DBA))

Name of Business Owner (as it appears on your Business License or Tennessee Department of Revenue letter)

* Physical Address Line 1 (Business Street Address)

Physical Address Line 2 (Suite or unit number)

* Physical City

* Physical State

* Physical Zipcode

Physical County

* Phone #1

Phone #2 (Additional)

* Email (Main email for business)

Additional emails (optional)

Business Mailing Address

* Is the Mailing Address the same as Physical Address? (If "No", please provide the Mailing Address)

Mailing Address Line 1 (Street Address)

Mailing Address Line 2 (Suite or unit number)

Mailing City

Mailing State

Mailing Zipcode

Mailing County (only if in Tennessee)

Business Information

* Business’s Point of Contact (name, title, phone (if different from above), and email (if different from above))

* Application Type

* Business Legal Status

Submit Articles of Organization

Submit Nonprofit 501(c)(3) paperwork (for a Nonprofit business)

* Describe the business (Check all that apply)

Distribution of finished products or ingredients from this facility

Supply of finished products or ingredients to this facility

* Water Source

Upload the most recent well/spring water test results. (Results must be dated within the last 12 months. Results must be negative for coliform and E coli. A negative water sample result must be submitted before the application can be processed.)

* Municipal Sewage System or Septic

Submit Septic Approval Letter (An Inspection Letter, Certification, or Approval from the Tennessee Department of Environment and Conservation for the Septic System is required if your business is on Septic. A septic approval letter must be submitted before the application can be processed.)

* Type(s) of products made or held at the facility (Check all that apply)

* Select the product category(s) below that best describe your product(s): (Check all that apply)

List all food products that will be manufactured, prepared, processed, packaged or held. (You may attach a list below)

* Does any product to be covered under this license contain a vaccine, as defined under T.C.A. § 53-1-102?

Product List

* Building size (Enter the square feet of your building (numbers only))

* Estimate number of employees

* Proposed opening date

* Select the Operational Months of the year for the business

* Describe the business hours

* List the days of the week the business is in operation

Does the business have the following programs, persons, or documents? Answer Yes or No.

RECALL PROGRAM

HAZARD ANALYSIS

PREVENTIVE CONTROL QUALIFIED INDIVIDUAL (PCQI)

TRAINING PROGRAM

SANITATION PROGRAM

DOCUMENTED PROCESSES

List your FDA Registration number (if known)

* Describe the complete process of how products are prepared. List all steps of how it is processed, cooked, packaged, and labeled. Give examples of pH levels, cooking temperatures, and verification that food grade containers and closures will be used.

Attach documents that describe your process. Include flow diagrams.

Submit Floor Plans of the food manufacturing facility. Include the location of all sinks, sanitation areas, major production equipment, doors, and other key facility features. This is not required if operating in a licensed community kitchen. (draw plans to scale)

* Submit all labels for products produced and/or packaged.

* Submit proof of Business Tax Filing Status Certificate or business license issued by a local governmental authority.

Submit a written Sanitation Plan

I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT. I FULLY UNDERSTAND THAT ANY DEVIATION FROM THE ABOVE WITHOUT PRIOR PERMISSION FROM THIS STATE REGULATORY AGENCY MAY NULLIFY FINAL APPROVAL.

* Signature

* Application Date

APPROVAL OF THESE PLANS AND SPECIFICATIONS BY THIS REGULATORY AUTHORITY 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). THE REGULATORY AUTHORITY SHALL CONDUCT ONE OR MORE INSPECTIONS TO VERIFY THAT THE FOOD ESTABLISHMENT IS CONSTRUCTED AND EQUIPPED IN ACCORDANCE WITH THE APPROVED PLANS OR MODIFICATIONS AS REQUIRED OF PLANS AS NECESSARY TO ACHIEVE COMPLIANCE WITH THE APPROPRIATE REGULATION. PERMIT APPROVAL WILL BE CONTINGENT UPON ACTUAL FACILITY INSPECTION.

Licenses/permits issued under the Tennessee Food, Drug and Cosmetic Act extend only to items defined as food under the Act and do not extend to items that contain either substances prohibited by state or federal law for inclusion in food or substances that otherwise categorize the food item as a drug.

Revised 05/22/2025

Tennessee Department of Agriculture

Consumer and Industry Services

Food Manufacturing Business Application

FOOD MANUFACTURER / WAREHOUSE PLAN REVIEW QUESTIONNAIRE