CoreOne - LCP

FOOD RETAIL PLAN REVIEW QUESTIONNAIRE FOR NEW BUSINESS-REMODEL-CONVERSION-OWNERSHIP CHANGE

Food Retail Plan Review questionnaire is to be completed by the Owner/Operator. Please refer to the Tennessee Retail Food Store Sanitation Regulations 0080-04-09 for the basic requirements.

* 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)

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

* STORE CONTACT (name, title, phone (if different from above), and email (if different from above))

TYPE OF APPLICATION

* DESCRIBE YOUR BUSINESS (Check all that apply)

* WATER SOURCE (Water source can be answered Not Applicable for Farm Based Meat Businesses)

SUBMIT WATER TEST RESULTS (Required if your business uses Well or Spring water. Upload copy of the water approval from local environmental field office or from the TN Dept of Environment & Conservation.)

* MUNICIPAL SEWAGE SYSTEM OR SEPTIC TANK (Sewage question can be answered Not Applicable for Farm Based Meat Businesses)

SUBMIT SEPTIC APPROVAL LETTER (An Inspection Letter, Certification, or Approval from TDEC for the Septic System is required if your business is on Septic.)

BUILDING SIZE (square feet)

* DOES YOUR BUSINESS HAVE MORE THAN 16 SEATS? (Over 16 seats require 2 restrooms)

HOURS OF OPERATION

* DAYS OF OPERATION

* BUSINESS OPERATIONAL MONTHS

DATE OF OPENING

FACILITY AND EQUIPMENT

HAS THIS THE FACILITY EXHAUST AND PLUMBING BEEN APPROVED BY THE LOCAL CODES DEPARTMENT (IF APPLICABLE)?

EQUIPMENT USED FOR WARE WASHING (check all that apply; leave empty if Not Applicable.)

TYPE OF SANITIZER BEING USED FOR EQUIPMENT AND UTENSIL SANITIZATION (check all that apply; leave empty if Not Applicable.)

ARE TEST PAPERS OR KITS AVAILABLE TO CHECK CLEANING AND SANITIZER CONCENTRATIONS?

REQUIRED FOR ALL RETAIL FACILITIES

* IS A MOP SINK OR CURBED SERVICE SINK AVAILABLE AT THE FACILITY? (A mop sink is required for all retail establishments except Farm Based Meat or Mobile Food Establishments.)

* ARE HANDSINKS CONVENIENTLY LOCATED IN FOOD PREP AREAS, RESTROOMS, AND IN WARE WASHING AREAS? (Only Not Applicable for Farm Based Meat or Mobile Food Establishments. Note the location of all hand sinks, if applicable, on Floor Plans.)

DESCRIBE COMPLETE PROCESS of how and what food products are cooked, prepared, and labeled? List types of food to be sold. Farm Based Meat Applicants: Name the USDA processing facility with establishment number and address; list species of meat. Mobile Units: list vehicle model, year, VIN, color, and license plate.

* SUBMIT PROOF OF REGISTRATION WITH TENNESSEE DEPARTMENT OF REVENUE OR A BUSINESS LICENSE ISSUED BY A LOCAL GOVERNMENTAL AUTHORITY

* SUBMIT PLANS (ELECTRONIC PREFERRED) DRAWN TO SCALE OF THE FOOD RETAIL FACILITY, (HAND DRAWN IS ACCEPTABLE) SHOWING LOCATION OF EQUIPMENT, ALL HANDSINKS, RESTROOMS, WARE WASHING EQUIPMENT AND MOP/SERVICE SINK

SUBMIT ALL LABELS (IF APPLICABLE) FOR PRODUCTS PRODUCED AND/OR PACKAGED IF FOODS ARE BEING PACKAGED FOR RESALE (optional)

FOR FARM BASED MEAT APPLICANTS ONLY (A copy of your final label is required to be submitted before your application can be processed. The State of Tennessee also requires that your farm information (including address) is either on the label from the processor or your own label that you provide.)

Business Website

STATEMENT: 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.

NAME

TITLE

SIGNATURE

DATE

APPROVAL OF THESE PLANS AND SPECIFICATIONS BY THE CONSUMER AND INDUSTRY SERVICES 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 CONSUMER AND INDUSTRY SERVICES 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 REGULATIONS. PERMIT APPROVAL WILL BE CONTINGENT UPON ACTUAL FACILITY INSPECTION.

If you are cooking and serving fresh food, your Mobile Unit is regulated by the local Health Department. Please contact GEH.Health@tn.gov.

Tennessee Department of Agriculture

Consumer and Industry Services

Retail Business Application

FOOD RETAIL PLAN REVIEW QUESTIONNAIRE FOR NEW BUSINESS-REMODEL-CONVERSION-OWNERSHIP CHANGE

Business Information

FACILITY AND EQUIPMENT

REQUIRED FOR ALL RETAIL FACILITIES