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GERALD M. THORNTON Freeholder KEVIN L. THOMAS, M.A. Health Officer Public Health Coordinator JOSEPH R.TORDELLA, D.O. Medical Director CAPE MAY COUNTY DEPARTMENT of HEALTH 4 Moore Road Cape May Court House, N.J. 08210-1601 (609)465-1209 after hours (609) 465-1190 Fax: (609) 465-6564 Hazard Analysis Critical Control Point (HACCP) Plan Review Application Establishment Name: Site Address: Telephone Owner/Person-in-Charge: HACCP Plan Contact: Telephone Email: Please review/use this checklist to verify that you have included the following in your plan: Purpose of Submission (i.e. Variance or Code Requirement) Name of food product and process for which the plan is being submitted. Include formulation of ingredients Include facility layout Include copy of labeling A flow chart, showing how the product flows through the establishment, including an accurate description of how the food is prepared, held, served, transported, etc. Identification of each Critical Control Point (CCP) in the process. For Each CCP…… A description of the hazard(s) A description of monitoring procedure(s) and a sample of form(s) that will be used to document the monitoring activities A description of corrective action(s) and sample of form(s) that will be used to document the corrective action(s). A description of verification procedure(s) and sample of form(s) that will be used to document verification activities by PIC. ---PAGE BREAK--- Page 2 A description of plan verification and validation procedures (ex. Annual review, scientific data, modifications to plan.) Please include: A statement that an updated, signed copy of the plan will be maintained on the premises for review by the regulatory authority. Name of person responsible for administering and updating plan A statement that the regulatory authority will be informed of any significant changes in the process that may affect the accuracy or effectiveness of the plan prior to implementation, and A statement that updated plans will be submitted to the regulatory authority, upon request. Laboratory data, if required. Employee training plan and sample form(s) that will be used to document employee training. All of the information submitted is accurate to the best of my knowledge. All violations noted during previous food safety inspections have been corrected and the operation is in compliance with Chapter 24 “Sanitation in Retail Food Establishments and Food and Beverage Vending Machines”. I understand that failure to comply with this plan and/or falsification of monitoring, corrective action, or verification records may result in a suspension of operations in accordance with Chapter 24. Permit Holder or Person-in-Charge Signature/Title/Date For Board of Health Use: Date Reviewer Comments Accepted Rejected Implementation Date: