Pages *-** ask structural and equipment questions that the operator may wish to have the contractor or architect assist in completing.

Refer to the Fixed Food Establishment Plan Review Manual for technical assistance in completing this worksheet. This manual is available from your reviewing agency or by visiting; http://www.michigan.gov/mdard/0,4610,7-125-50772_50775_51203 00.html

It is important to complete this document in its entirety. Sections that are left blank may cause delays in the plan review of your food establishment. If a section is not pertinent to your operations, writing in NA for not applicable in that section would suffice.

Food Manager Knowledge

Under the Food Law of 2000, as amended, food establishments are REQUIRED to have a

person in charge (PIC) during all hours of operation and at least one active managerial employee that has completed and obtained a Certified Food Manager (CFM) certificate under a program accredited by American National Standards Institute (ANSI). A list of ANSI accredited programs can be found at: https://www.ansi.org/Accreditation/credentialing/personnel-certification/food-protection-manager/ALLdirectoryListing?menuID=8&prgID=8&statusID=4

A designated person in charge shall demonstrate knowledge of foodborne disease prevention, application of food safety, (HACCP) principles, and the requirements of the Food Code.

Please check all that apply:

Certified Food Manager's (CFM) Certificate submitted: YES NO

Employee currently in or signed up for CFM class: YES NO

If yes, submit invoice for class.

Menu

It is REQUIRED to provide a full menu including all beverages or minimally a list of foods offered. The menu does not have to be the final print version; this will be requested later. It is suggested that a “proof” copy of the menu be submitted for approval prior to final printing. Additionally, it should be noted if the establishment will host guest chefs or “popup” restaurants that may serve food items not listed on the menu.

The customer must be informed by means of a consumer advisory that a menu item contains raw or undercooked foods of animal origin. A guidance document on providing a consumer advisory can be found at: http://www.michigan.gov/documents/mda/MDA_FCConsAdvisMay08_245934_7.pdf

Menu submitted: YES NO

Will establishment host guest chefs or “popup” restaurants: YES NO

Menu items contain raw or undercooked animal-based foods: YES NO

If YES, the menu contains a consumer advisory: YES NO

SOP’s and HACCP

It is REQUIRED to provide a full set of Standard Operating Procedures (SOP’s). A SOP manual can be accessed at: http://www.michigan.gov/mdard/0,4610,7-125-50772_50775_51203 00.html . SOPs should be specific to your menu, food processes, and equipment.

Standard Operating Procedures (SOP’s) submitted: YES NO

Hazard Analysis and Critical Control Points (HACCP) plan is a written document that outlines the formal procedure for specialized food processes such as smoking food for preservation, curing, reduced oxygen packaging, fermentation, and/or packaging raw unpasteurized juice (FDA Food Code 3-404.11, 3-502.11, 3-502.12, 3-801.11). Products produced for wholesale under the Code of Federal Regulations, may also require specific HACCP plans under these regulations. Please consult your regulatory agency if you plan to wholesale products (i.e. sell to another retail or food service operation).

Facility performing a specialized food process: YES NO

If YES, HACCP plan submitted: YES NO

Facility making products to wholesale: YES NO

**Submission of a HACCP plan, during the plan review process, does not mean the submitted HACCP plan is automatically approved. Further review of your submitted HACCP plan by the regulatory authority will be conducted and communicated with you.

Food Preparation Review

(See Fixed Food Establishment Plan Review Manual Parts 1 and 3)

1.How will time/temperature control for safety (TCS) food be thawed? List food items that apply.

Thawing Method

Food less than 1” thick

Food more than 1” thick

Refrigeration

Running water (less than 70ºF)

Microwave as part of cooking process

Cook from frozen

Other (please describe):

2.Cooking and reheating TCS foods: List all cooking or reheating equipment and mark all applicable boxes for the listed equipment.

Equipment Name

Cooking

Reheating

New

Used

NSF Certified or Equivalent

3.Hot and cold holding of TCS food: List all hot or cold holding equipment and mark all applicable boxes for listed equipment.

Equipment Name

Hot Hold

Cold Hold

New

Used

NSF Certified or Equivalent

4.Will ice be used as a refrigerant for TCS food? YES NO

If YES, list the types of foods involved. Ensure this process is described within your standard operating procedures.

5.Will time as a public health control be used instead of hot or cold holding? YES NO

If YES, list the types of foods involved. As a reminder, a standard operating procedure must be submitted for this process.

6.Cooling TCS food: List foods that will be cooled using each of the following methods. Hot TCS foods must be cooled from 135ºF to 70ºF in 2 hours or less and within a total of 6 hours from 135ºF to 41ºF or less. If prepared from room temperature or pre-chilled ingredients (i.e. tuna salad) then the foods must be cooled from 70ºF to 41ºF within 4 hours.

Cooling Method

Food Items

Shallow pans

under refrigeration

Ice bath

Volume Reduction

(e.g. quartering a large roast)

Rapid chill equipment

(e.g., blast chillers)

Ice paddles

Other (describe method as well as listing foods)

7.Bare hand contact: How will employees avoid bare hand contact with ready-to-eat foods? Check all that apply.

Disposable Gloves Deli Tissue

Suitable Utensils Other: Describe:

8.Will produce be cleaned on-site? YES NO

If YES, describe which sink(s) will be used for food preparation:

9.Date marking: When TCS food is ready-to-eat and will be kept under refrigeration for more than 24 hours after preparation/opening, a date marking system must be utilized. Note: The day of preparation counts as Day 1.

Will the establishment have food items that must be date marked? YES NO

If YES, list the foods or types of foods involved. Ensure a standard operating procedure is submitted for this process.

10.Catering/off-Site/satellite: This section is intended for food that will be served by establishment employees off-site from the planned establishment. This section does not pertain to the delivery of pre-ordered food to a customer (e.g. delivering a pizza).

Complete section A through F, if establishment employees will be serving food off-site at other locations.

A.List of menu items to be served off-site:

B.Maximum number of meals per day taken to or prepared at off-site location:

C.How will hot food be held at proper temperature during transportation and at the off-site location?

D.How will cold food be held at proper temperature during transportation and at the off-site location?

E.What type of vehicle(s) will be used to transport food?

F.What types of food shields or food protection devices will be used at the off-site location? (See plan review manual Part 4)

***Food that is prepared off-site from the planned establishment, would not be covered under the planned establishment’s food license and additional food licensure may be needed for this off-site food preparation. Consult with your regulatory agency regarding possible additional food licensing.

Sinks & Warewashing Facilities

(See Fixed Food Establishment Plan Review Manual Part 8)

11.Dishwashing methods, mark all that apply. Dishmachine 3-Compartment Sink(s)

Dishwashing Sinks

Length (inches)

Width (inches)

Depth (inches)

1st 3-compartment sink, size of compartments (basins)

2nd 3-compartment sink, size of compartments (basins)

3rd 3-compartment sink, size of compartments (basins)

A.The 3-compartment sink must accommodate immersion of the largest item needing cleaning. What is the largest item that will have to be washed in a sink and its size? Please list all dimensions (length, width, and depth or height and diameter for a round item).

B.List the location of all garbage disposals (Disposals cannot be in a food preparation sink or the basin of a warewashing sink.)

C.If a dishmachine/glasswasher will be utilized, list the make and model number of unit and how the unit will sanitize (e.g. chemical or high temperature).

Dishmachine/Glasswasher

Make

Model #

Sanitizing Method

1st Unit

2nd Unit

3rd Unit

12.What type of mop (service) sink will be provided (e.g. curbed floor drain, mop sink on legs, etc.)? Ensure location of this sink is indicated on the equipment plan.

General

(See Fixed Food Establishment Plan Review Manual Part 16)

13.Will employee dressing rooms be provided? YES NO

If NO, describe how and where personal belonging will be stored.

14.Will laundry be done on-site? YES NO

If YES, mark which of the following will be used on-site. Washer Dryer

Describe what will be laundered on-site.

Room Finish Schedule

(See Fixed Food Establishment Plan Review Manual Part 10)

Describe the floor, coving, wall, and ceiling materials that will be used in each of the listed areas. See plan review manual Part 10 for a list of possible materials.

Area

Floor

Coving*

Wall

Ceiling

15.Preparation

16.Cooking

17.Dishwashing

18.Dry Storage

19.Bar

20.Dining

21.Public and/or Employee Restrooms

22.Dressing Room

23.Walk-in Cooler

24.Walk-in Freezer

25.Garbage Room

26.Janitor

Closet/Mop Sink Room

27.

28.

*List the material that will be used to provide a smooth, rounded and cleanable surface where the floor and wall joins. Note: Please explain abbreviations.

Water Supply

(See Fixed Food Establishment Plan Review Manual Part 5)

29.Mark the water supply type: Municipal Existing Well New Well

30.If using a well, is the local health department in the process of approving? YES NO*

Sewage Disposal

(See Fixed Food Establishment Plan Review Manual Part 5)

31.Mark the sewage disposal type: Municipal Existing Septic New Septic

Field Field

32.If using an on-site septic system, is the local health department or Michigan

Department of Environmental Quality in the process of approving? YES NO*

*It is required that you contact your local health department to begin the approval process.

Insect and Rodent Control

(See Fixed Food Establishment Plan Review Manual Part 13)

33.Will outside doors be self-closing? YES NO

34.Will the facility have a drive-thru or walk-up window? YES NO

If YES, describe the method of pest entrance prevention (e.g. self-closing unit, air curtains,

other effective means, etc.)

35.Will openings around pipes, electrical conduits,

chases, and other wall perforations be sealed? YES NO

Solid Waste/Refuse Storage

(See Fixed Food Establishment Plan Review Manual Part 17)

36.Outside Solid Waste/Refuse Storage

A.What type of storage will be used? Compactor* Dumpster* Cans

B.Describe the type of surface that will be under the container.

C.What is the anticipated minimum pick-up frequency?

D.Describe how solid waste/refuse will be transported from the interior of the establishment to the outside waste/refuse storage area.

*Remember to show details on site plan, including unit location and slope of surface under the unit.

37.Inside Storage

A.Describe any inside solid waste storage (garbage, boxes, etc.) or solid waste container cleaning area (e.g. garbage can cleaning area).

B.Will any compactors, garbage rooms, garbage

transport carts, or dumpsters be located inside? YES NO

If YES, make sure to show location on site plan

C.Describe the location where damaged merchandise or unacceptable products to be returned will be stored.

D.Describe how and where waste grease from equipment such as fryers will be handled and stored.

E.Describe how and where redeemables/returnables/recyclables will be stored.

F.Mark the types of materials that will be recycled.

Glass Metal Paper Cardboard Plastic

Plumbing Cross-Connections

(See Fixed Food Establishment Plan Review Manual Part 12)

The following technical information is needed on the proposed plumbing. This section is best completed by a qualified plumber, architect or engineer. Be sure to include all devices, equipment and fixtures that have cross-connection protection. Remember to complete both the water supply and sewage disposal sections (e.g., a dishwasher may have an AVB on the water supply and an air-gapped drain). Mark appropriate boxes.

Backflow Prevention Device Abbreviations

AVB=atmospheric vacuum breaker PVB=pressure vacuum breaker

RPZ=reduced pressure principle backflow preventer DC w/AV= Double check valve with an atmospheric vent

Fixture

Sewage Disposal

Water Supply

Air Gap

Air Break

Direct

Connect

AVB

PVB

RPZ

Hose Bibb

DC w/AV

Air Gap

38. Dishwasher

39. Glasswasher

40. Garbage grinder

41. Ice machine

42. Ice storage bin

43. Mop sink

44. 3-compartment sink

45. Culinary (food preparation)

Sink

46. Other sinks, except

handsinks, (1 or 2

compartments)

47. Steam tables/Bain-marie

48. Dipper wells

49. Hose connections

50. Refrigeration condensate

drain lines

51. Beverage dispenser with

carbonator

52. Water softener drain

53. Walk-in floor drain

54. Wok range

55. Chemical dispenser

56. Outside sprinkler or

irrigation system

57. Power washer

58. Retractable hose reel

59. Toilet

60. Urinal

61. Boiler

62. Espresso machine

63. Combi-style oven

64. Kettle

65. Rethermalizer

66. Steamer

67. Overhead spray rinse

68. Hot water dispenser

69. Coffee machines, juice

dispensers or other non-

carbonated beverage

dispensers

70. Other (describe):

Formula Information

Several calculations are utilized to determine if there will be adequate hot water, dry storage space and refrigerated storage space. This information requested on the following two pages provides the necessary data for performing calculations. See the plan review manual for formulas and directions. While the following information will be used to provide a good calculated baseline of how much hot water, refrigerated storage, and dry storage space may be needed, your regulatory agency does have the authority to adjust these calculated amounts based upon the specific operations of your facility.

71.Hot Water

(See Fixed Food Establishment Plan Review Manual Part 12)

List each plumbing fixture that has a hot water supply line. Each fixture should only be listed once.

Fixture Count

Handsinks (not including restroom sinks)

Restroom Sinks

Single Compartment Sink

Double Compartment Sink

Triple (three) Compartment Sink

Food Preparation Sink

Overhead Spray Rinse

Bar Sink-three compartment

Bar Sink-four compartment

Cook Sink

Hot Water Filling Faucet

Steam Table/Bain-Marie

Coffee Urn

Kettle Stand

Garbage Can Washer

9 & 12 lb. Clothes Washer

16 lb. Clothes Washer

Shower Heads

Mop Sink

Dump Sink

Dishmachine/Glasswasher

Other (describe):

Other (describe):

72.Water Heater

Manufacturer: Model #:

A.Water heater proposed size:

KW: Or BTUs:

B.Water heater storage capacity in gallons:

C.Water heater recovery rate @100ºF:

D. Tankless units:

Gallons per minute @ 70 F rise:

and

Gallons per minute @ 100 F rise:

Attach information for any additional water heaters. Specify what area each water heater services and whether units will be installed in series or parallel.

73.Dishmachine Booster Heater:

Manufacturer: Model #:

Booster heater proposed size:

KW: Or BTUs:

Refrigerated and Dry Food Storage

(See Fixed Food Establishment Plan Review Manual Parts 3 & 7)

It is essential that a reliable estimate be made of the number of meals/customers that are served between deliveries to calculate dry and refrigerated storage capacities.

A.# meal/customers estimated to be served per day:

B.# days between deliveries: Dry food Refrigerated food

C.# meals/customers between

deliveries (A x B =): Dry Food Refrigerated food

Please describe any assumption made in determining the meal quantity estimate.

74.Refrigerated/Freezer Storage

(See Fixed Food Establishment Plan Review Manual Part 3)

Working, preparation or line refrigerators/freezers should not be included in this section. While these

types of units may be needed in the operation of your facility, these are not intended for long term

cold storage.

Walk-in Item #

**Interior Usable Height (ft)

Interior Length (ft)

Interior Width (ft)

**The usable height within a walk-in is the space available for storage. Food is to be stored

6” from the floor and generally 12” to 18” from the ceiling of the unit.

Reach in Item #

Interior Depth (in)

Interior Width (in)

Interior Height (in)

Will the reported cold storage space be utilized for storage of bulky food items (e.g. boxes of whole produce, kegs, large meat boxes, bottled beverage), storage of any non-food items or for any food preparation processes (e.g. cutting of meat, drying/aging/fermentation of food)? YES NO

If YES, what units, or what percentage of the reported cold storage space, will be used for these purposes?

75.Dry Storage

(See Fixed Food Establishment Plan Review Manual Part 7)

*Storage Rooms

**Usable room height (ft)

Interior Length (ft)

Interior Width (ft)

Usable Floor Space

*Please note the location of any auxiliary storage (e.g. outside storage) on site plans.

**To determine usable height, determine height from floor to ceiling, then subtract height of food off

floor (usually 6”) and height of food from ceiling (usually 12-18”). Average usable height is 4 to 7 feet.

Usable Floor Space is the actual percentage of floor space available for storage, this is typically

0.3 to 0.8 (30% to 80%).

Or, if there is no dry storage room proposed, report all dry storage shelf dimensions:

Storage Shelving

Length of Shelf (ft)

Depth of Shelf (ft)

Clearance/Height between Shelves (ft)

# of Shelves per Unit

# of Units Proposed

Will the reported dry storage space be utilized for storage of non-food items such as equipment/utensils, cleaning supplies, maintenance supplies, empty bottles/cans, linens, promotional items, etc.? YES NO

If YES, what shelving units, or what percentage of the reported dry storage space, will be used for this purpose?

Ventilation

(See Fixed Food Establishment Plan Review Manual Part 15)

Sufficient ventilation is needed to keep rooms free of excessive heat, steam, condensation, vapors, obnoxious odors, smoke and fumes.

76.List the equipment that will be underneath a ventilation hood or will utilize a ventless system and mark the type of ventilation proposed for that equipment.

Equipment

Type I Hood

Type II Hood

Ventless

Open Dining, Exposed Food Preparation Areas & Outdoor Cooking Operations

(See Fixed Food Establishment Plan Review Manual Part 18)

77.Will your facility have a dining area that will be exposed to the outdoors by being located directly outdoors OR by having walls, windows, or doors that can be opened, exposing the dining area to the outdoor environment? YES NO

If YES, explain how you intend to protect your kitchen and any food, utensils, and food equipment located in the dining area from outdoor contamination and pest entry (e.g. using air curtains, screens, tight fitting doors, etc.).

78.Will there be an outdoor food preparation or cooking area at the facility? YES NO

If YES, answer the following questions:

A.What food items are you intending to prepare/cook outdoors?

B.What food equipment will be used for outdoor preparation/cooking and will this equipment be portable or permanently fixed outdoors? Complete following chart and mark appropriate boxes.

Outdoor Equipment

Portable

Permanent

C.How do you intend to transport food between the outdoor preparation/cooking area and the interior of the kitchen?

D.How will handwashing be addressed at the outdoor preparation/cooking area?

E.Where will the outdoor preparation/cooking area be located on the premises? Ensure this is indicated on your site plan.

F.How will the outdoor preparation/cooking area be protected from unauthorized access?

G.What overhead protection will be provided? What materials will be used?

H.Will walls be provided? If so, what materials will be used and what coving material will be provided?

I.What type of floor/ground will be present in the outdoor preparation/cooking area?

J.What type of cooking fuel will be used and how will refuse and waste ash be collected in the outdoor preparation/cooking area?

K.What lighting will be provided in the outdoor preparation/cooking area and how will it be shielded?

Suggestion Sheet

Food Establishment Plan Review Worksheet

Suggestions for changes to this plan review worksheet are welcomed from all users (e.g., food service operators, architects, engineers and regulators, etc.). Revisions to documents are made periodically as needed. Thank you for taking the time to submit your ideas.

Name: Phone: Fax:

Address:

City, State, Zip:

E-mail:

Submit to:

Plan Review Specialist

Food Service Sanitation Section

Food & Dairy Division

Michigan Department of Agriculture

PO Box 30017

Lansing, MI. 48909

E-mail: adxm69@r.postjobfree.com mailto:adxm69@r.postjobfree.com

For suggested changes, please indicate the specific location(s) in document. You may list your suggestions below or attach separate sheets. Please be specific and clear.

Michigan Department of Agriculture and Rural Development

Food & Dairy Division

Michigan Department of Agriculture

and Rural Development

P.O. Box 30017

Lansing, MI 48909

800-***-****

To be completed by the operator and submitted to the local health department

or the Michigan Department of Agriculture and Rural Development,

(whichever will be conducting the plan review).

Establishment Name:

Address:

City, State, Zip:

Fixed Food Establishment

Plan Review Worksheet

Food & Dairy Division

Michigan Department of Agriculture

and Rural Development

PO Box 30017

Lansing, MI 48909

800-***-****

www.michigan.gov/mdard

Contact this candidate