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CORTLAND COUNTY HEALTH DEPARTMENT COUNTY OFFICE BUILDING Nicole Anjeski, MS, MPH 60 CENTRAL AVENUE Public Health Director CORTLAND, NEW YORK 13045-2746 Lisa Perfetti BSN, RN (607) 753-5036 Deputy Public Health Director FAX: (607) 753-5209 Ngozi Mezu-Patel, MD http://www.cortland-co.org/432/Health-Department Medical Advisor WORKING TO BUILD A HEALTHY COMMUNITY SINCE 1929 Details of Proposed Food Service Facilities Name of Establishment Establishment Address Owner Info: Name Address Home Phone Cell Phone Email Food Service Details: Existing Food Service Existing Non-food Service New Building Other Proposed opening date Days of operation Hours Type of Establishment: Restaurant Bar Mobile Unit Ice Cream Parlor Concession Push cart Other Size (Square feet): Dining Area Kitchen Bar Other Seating Capacity: Sewage Public Private Water Public Private If private well, what type of disinfection: UV Chlorine N/A OFFICE USE ONLY Pre-operational Review Fee: New $200 Existing $150 Permit Application Worker’s Comp Disability Fee: High $260 Medium$180 Low $150 Catering $100(additional) Waiver/Variance Application: Yes No Application Fee $50 Menu Floor Plan ---PAGE BREAK--- Pre-operational Details Cortland County Health Department Page 2 WORKING TO BUILD A HEALTHY COMMUNITY SINCE 1929 Surface Materials Room Floor Walls Ceiling Type of Lighting and if Shielded Counters Kitchen Serving Area Dining Room Storage Area Restrooms Sinks Yes/No Drain Boards Y/N Location in facility Hand Wash Sink 3-bay wash sink Food prep sink Mop sink Dishwasher Other Indirect drains Y/N Ice machine Refrigeration Prep sink 3-bay sink Dishwasher Steam tables Exhaust/Ventilation Hood Locations Filter used Y/N Hood Area Fire Protection (Ansul) Yes/No Fan air capacity CFM New or Existing Restroom Vents N/A N/A Ventilation Hood Cleaning Company: ---PAGE BREAK--- Pre-operational Details Cortland County Health Department Page 3 WORKING TO BUILD A HEALTHY COMMUNITY SINCE 1929 Equipment List Hot holding, Cold Holding, and Cooking Quantity Unit Name Manufacturer/ Model New/ Used Commercial or Domestic ---PAGE BREAK--- Pre-operational Details Cortland County Health Department Page 4 WORKING TO BUILD A HEALTHY COMMUNITY SINCE 1929 Refuse Storage/Grease Management Cans Quantity: Tight fighting Lids? Yes No Cleanable? Yes No Dumpster Quantity: Tight fighting Lids? Yes No Cleanable? Yes No Company Used for Garbage Removal: Company Used for Grease Removal: Pest Control Type of monitoring: Using Rodenticide/Pesticides: Yes No All gaps/holes/voids sealed: Yes No Company Used for Pest Control: Cleaning Chemicals Type of Ware-washing Disinfection: Hot Water Quaternary Ammonium Chlorine Testing Kit Available? Yes No Type of Sanitizer Chemical for wipe cloth buckets: Quaternary Ammonium Chlorine Other Testing Kit Available? Yes No Company Used for Chemical Program: Food Safety Training Name of Trained Food Worker: Expiration Date: Certifying Agency & Certification Number: MOBILE UNITS ONLY License Plate # Year: Make: Model: Vehicle ID No. Water tank fill process: Waste water tank draining process: (Dishwasher ONLY) Laundry Facilities Linens Handled: Within Facility Outsourced through company Linen/Laundry Handling Process: Company Used: Fresh Water Tank Capacity (Gallons) Waste Water Tank Capacity (Gallons)