Form Dhec1769 – Fill Out and Use This PDF

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:

E-mail address of permit holder:

Would you like to receive your inspections e-mailed in PDF format in addition to a printed copy? o Yes o No

Type of ownership (check one): o Individual		o Partnership     o Limited Liability Company (LLC)
o Corporation	o Non-Proit Organization *documentation may be required for fee exemption

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 DHEC-Environmental Quality Control) provide copy of approval

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:

DHEC1769 (01/2010)

SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL Page 1 of 3

OPERATIONS INFORMATION

Type of Retail Food Establishment (check all that apply):
Restaurant: o Single-service (disposable) dishes and utensils or				o Multi-use (reusable) dishes and utensils
Institution: o School	o Jail Cafeteria (check one)		o State operated		o Private contractor
Grocery Store (only check those preparation areas to be covered by this permit):
o Meat Market	o Seafood Market	o Bakery	o Deli	o Produce

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)

oNon-potentially hazardous food – exceeds minimal preparation

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 61-25 Chapter IX

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:

DHEC1769 (01/2010)

Page 2 of 3

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 61-25 Chapter VIII.

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 61-25. If granted a retail food permit, I understand that changes in food preparation types (Example: going from deli sandwiches to cooking or preparing meals) additions of equipment, and/ or structural changes shall be approved by the Health Department prior to implementation and may require that I submit a new application.

Furthermore, should the facility fail to adhere to the requirements of Regulation 61-25, the permit to operate may be subject to enforcement action, which may include civil penalties pursuant to Section 44-1-150(B) of the South Carolina Code of Laws and/or permit suspension/revocation pursuant to Chapter XIV Regulation 61-25 – Retail Food Establishments.

Signature of Applicant ____________________________________________________

Signature of Individual or Corporate Name ____________________________________

Date _______________________________

DHEC1769 (01//2010)

Page 3 of 3