Operating a retail food establishment in South Carolina requires close attention to various regulations to ensure public health and safety, a process prominently involving the DHEC1769 form. This comprehensive application form is a critical first step for anyone looking to open a new establishment or manage an existing one within the state's jurisdiction. It encompasses essential information such as the establishment's name, address, contact details, and the type of ownership, ranging from individual to non-profit organization, each potentially impacting the required documentation and fee structure. Additionally, the form carefully outlines requirements for emergency contact information, a move underscoring the seriousness with which emergency preparedness is treated. Detailed sections request information on the source of water supply, sewage disposal, waste disposal methods, operational days and hours, and the specific nature of the food establishment - whether it serves as a restaurant, grocery store, convenience store, or engages in catering, among others. It also delves into specifics regarding the types of food preparation involved and whether any special processes that may require additional oversight, such as Hazard Analysis Critical Control Point (HACCP) plans, are utilized. The necessity of a permit attests to the commitment of the South Carolina Department of Health and Environmental Control (DHEC) to uphold high standards of food safety, ensuring that establishments are well-equipped and knowledgeable about maintaining health codes to protect the public.
| Question | Answer |
|---|---|
| Form Name | Form Dhec1769 |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | dhec d 1769, sc dhec form 1769, filling out dhec 1769, DHEC1769 |
APPLICATION FOR RETAIL FOOD ESTABLISHMENT PERMIT
Establishment name:
Establishment address:
County:
Establishment phone number:
Establishment fax number:
Permit holder/owner(s):
Permit holder phone number for 24 hour emergency contact:
(Emergencies constitute, but not limited to, imminent health hazards, boil water notiications, appointments)
Business phone number if different from above:
Permit holder business fax number if different from above:
Billing address if different from above:
Would you like to receive your inspections
Type of ownership (check one): o Individual |
o Partnership o Limited Liability Company (LLC) |
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o Corporation |
o |
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Manager(s) or Person(s) directly responsible for Daily Operations:
Give title, name, address and 24 hour emergency contact number if different from owner
Has the person named above taken a food safety course? If so provide the following information. Course taken:
Date of certiication:
Institution:
Number and capacity of refrigeration units (cubic feet if known):
Source of Water Supply: o Municipal (city) water |
Provider name: _____________________________________ |
oWell (approved by
Facility total square feet:Number of seats:
Sewage Disposal: o Municipal (city) sewer *Grease traps must be installed approved, and maintained as per the provider. ________Initial here that you have consulted with the sewer authority on your grease trap.
Provider name: ______________________________________________
o Septic Tank system with grease trap (approved by DHEC) provide copy of approval
Waste Disposal (check all that apply): o Public dumpster o Private dumpster o Grease container
oOther (describe): ______________________________________________________________________________
List days and hours of operation:
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OPERATIONS INFORMATION
Type of Retail Food Establishment (check all that apply): |
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Restaurant: o |
o |
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Institution: o School |
o Jail Cafeteria (check one) |
o State operated |
o Private contractor |
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Grocery Store (only check those preparation areas to be covered by this permit): |
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o Meat Market |
o Seafood Market |
o Bakery |
o Deli |
o Produce |
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Convenience Store or other facility that engages in Limited food preparation: check applicable menu items:
oOffers menu of fully cooked items with little preparation. i.e. - Hotdogs (describe):
oOffers foods that do not require cooking with little preparation i.e. - ice cream (describe):
oCatering - Supplemental Catering Application must be completed
oBase station/ Commissary for Mobile Unit - Supplemental Mobile Unit Application must be completed
oIndoor Bar o Outdoor bar o Modiied Bar (open air)
Food Preparation
oPotentially hazardous foods are cooked, cooled and reheated
oPotentially hazardous foods are cooked and served immediately
oPotentially hazardous fully cooked foods are prepared and served (hot or cold)
o
Special Processes
The following types of food preparation may require Hazard Analysis Critical Control Point (HACCP) plan(s), Standard Operating Procedure(s) (SOP) or Consumer Advisories.
o Offers raw or undercooked food (describe) ____________________________________________________
(I.e., Shell ish, in ish, poultry, pork, beef, bison, ratites)
o Reduced Oxygen Packaging o Sous Vide o Cook/Chill |
o Churrascaria Style |
Outdoor Cooking Section
Continue this section if engaging in outdoor cooking.
I understand that any outdoor cooking activity must comply with all the provisions of Regulation
OWNER/MANAGER Initial here_______________
Type of Indoor Cooking Equipment: o Stove(s) ____# o Smoker(s) ____# o Fryer(s) ____#
oOther: (describe)________________________________________________________________
Type of Outdoor Cooking Unit: o Covered Grill o Smoker o Other:(describe) ___________________________
Frequency of Outdoor Cooking: o *Daily o *Weekly o *Monthly o Annual o *Outdoor handsink installed
List all foods cooked outside:
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Barbeque Pit Room Cooking Section
Continue this section if you have a Barbeque Pit Room
I understand that any Barbeque Pit Room cooking activity must comply with all the provisions of Regulation
OWNER/MANAGER Initial here______________________
Pit room location:
oSeparate attached/detached structure
oInside restaurant facility
Attach a menu of all meals served, or if menu varies, a sample of a typical menu
I, the undersigned, attest to the accuracy of the information provided in this application and I afirm that the retail food establishment will comply with S.C. DHEC Regulation
Furthermore, should the facility fail to adhere to the requirements of Regulation
Signature of Applicant ____________________________________________________
Signature of Individual or Corporate Name ____________________________________
Date _______________________________
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