New Establishment Change of Owner Change of Name

Su M Tu W Th F Sa

H H : M M AM PM H H : M M AM PM

Months of Operation: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Owner Address

Additional Contact Name:

Additional Contact Full Address:

ESTABLISHMENT OPERATIONS

FOOD ESTABLISHMENT INFORMATION

OWNER INFORMATION

Legal Owner Type: Corporation Individual Partnership Other:

FOOD ESTABLISHMENT CONTACT

Direct all correspondence to: Establishment Address

Additional Contact Email:

to

Additional contact

Days of Operation:

Hours of Operation:

Zip Code:

Establishment Fax Number:

Owner City:

Owner Name:

Owner Address:

PART A: FACILITY REVIEW AND PERMIT APPLICATION

This part of the application package must be completed in order to initiate the process to obtain the Permit to

Operate a Food Establishment. Please complete all sections and sign the certification statement.

Remodel

Zip Code:Establishment City:

Establishment Address:

Establishment Name:

Establishment Phone Number:

This application is for (check one ):

Owner Phone Number:

Owner Email:

EHF68A 8-2016 Application Pg 1

Type of Food Establishment (check one) :

Adult Care Home Caterer Fast Food Restaurant Nursing Home Seasonal Full Service

Adult Day Care Childcare Full Service Restaurant Private School

Brewery Commissary Hospital Public School Winery/Wine Tasting

Carry-out Continental Breakfast Jail Food Service Seasonal Fast Food Other:

Y N 1.

Y N 2.

Y N 3.

Y N 4.

Y N 5.

Y N 6.

Y N 7.

8.

Y N No smoking allowed

Y N Designated smoking area

Y N Outdoor smoking area

Y N

What is the average number of meals or patrons served each day (check one )?

Change of Equipment

Change in Layout

Note: The Health Department will require a

HACCP Plan for specialized food processes.

Please fill out this questionnaire about your food handling procedures. Answers to these questions will

determine the Health Department's risk categorization and inspection frequency for your food establishment.

Time/Temperature control for safety food (TCS food). TCS foods are those foods which will support the rapid growth of foodborne

illness-causing bacteria. In general, these foods have a high moisture and protein content and low acidity. TCS foods include meats, poultry,

cooked vegetables, cooked grains, eggs, fish, dairy products, gravies, casseroles, combination salads, cut melons and sprouts. TCS food does

not include commercial hard cheeses, commercially prepared mayonnaise or salad dressings, raw and uncut vegetables or fruits.

Do the following food handling procedures apply to your food establishment operation?

FOOD HANDLING PROCEDURES

Smoking designation?

1 Year or More

If you are applying for a change of owner, please answer the following questions:

Change to Menu

Change in Seating

Do you prepare, offer for sale, or serve TCS foods? (See above for the definition of TCS food )

Do you cook TCS foods from raw animal products (beef, eggs, fish, lamb, pork, poultry, and/or shellfish)?

Have the following occurred? When was the previous business closed?

Less than 90 Days

ATTENTION NEW OWNERS: If there are no changes in menu, seating, equipment, layout, or smoking designation AND

ownership was assumed within the last 90 days, the new owner may begin operation of the food establishment when payment

of the facility review and permit application fees has been made. If there are any of these changes OR the previous

business has been closed for more than 90 days, please also complete Parts B of this application package.

Not Applicable or Unknown

90 Days to 1 Year

Do you prepare TCS foods in advance and hold (cold or hot) before service?

Do you prepare ready-to-eat TCS foods and hold/refrigerate for more than 24 hours before sale or service?

Do you cool any cooked or reheated TCS foods for later use?

Are you conducting one or more of the following specialized food processes (check all that apply )?

Smoking / Curing

Reduced Oxygen Packaging (ROP)

Ice Cream Shop/Parlor

<100 101 to 400 > 400

Will the food establishment serve a highly susceptible population (i.e., persons who are immunocompromised,

preschool age children, or older adults)?

Cook-Chill ROP

Sous Vide ROP

Using food additives or ingredients, such as vinegar, as a method to preserve food or render the food a non-TCS food (i.e.,

sushi rice and making yogurt)

Operating a molluscan shellfish tank to store and display shellfish that are offered for consumption?

Sprouting seeds or beans

Custom processing animals that are for personal use as food but not offered for sale or service in the food establishment

EHF68A 8-2016 Application Pg 2

M M D D Y Y

$

EHS Area: Y N

Y N If yes, permit is not approved at this time

If no, permit was provided in person

Permit was mailed

OFFICE USE ONLY

AP Number: License Number: Transaction Number:

Entered by: Date:Permit Application Fee:

Date

SignedTitle of Authorized Individual

Print Name of Authorized Individual

CERTIFICATION STATEMENT: I attest to the accuracy of the information provided in this application. I affirm that I will

comply with the Fairfax County Food and Food Handling Code and will allow the Health Department access to the food

establishment during any reasonable time to inspect, conduct tests or collect samples.

Signature of Authorized Individual

Reviewed By: Part A Approval Date:

EHS Notified:

Approval for Health Department permit is granted. This facility review and permit application shall serve

as your permit until your regular permit is delivered to you. No equipment replacement, addition, or

changes are allowed without approval by the Health Department.

Part B Required:

EHF68A 8-2016 Application Pg 3

Completed building permit application

FOOD ESTABLISHMENT PERMIT REQUIREMENTS

In order to obtain the Fairfax County Permit to Operate a Food Establishment, an application package shall be submitted to

the Fairfax County Health Department for review and approval (Fairfax County Ord. §43.1-5-1). A permit application is

required for:

Facility review is the process to obtain a Fairfax County Permit to Operate a Food Establishment. The applicant shall

submit a permit application package at least 30 calendar days before the date planned for opening. To ensure a timely review of

a permit application package, please submit all required paperwork as soon as possible. The following is a checklist of the

paperwork that is required in order to obtain a permit:

The Fairfax County Permit to Operate a Food Establishment is not transferable from one owner to another. If a new permit is

not issued, the new owner will be operating a food establishment without a valid permit. All new owners of existing food

facilities shall submit a permit application package at least 30 days prior to assuming ownership of the food establishment.

• An existing food establishment with remodeling/addition.

Certified Food Manager (CFM) documentation

A complete permit application package to include:

Three (3) copies of architectural plans / five (5) copies of architectural plans for City of Fairfax

Copy of proposed menu

• A new food establishment (where no current permit exists).

Fairfax, VA 22030

703-246-2201

Please return all permit application packages to:

Please call the number listed below if you have questions. Notify the office at least five (5) business days before

planned opening to schedule a pre-opening inspection.

Fairfax County Health Department

Division of Environmental Health

FINISH REQUIREMENTS

ARCHITECTURAL PLAN

FOOD ESTABLISHMENT REQUIREMENTS CHECKLIST

• A food establishment that is permitted but has had a change in owner.

Specification sheets for all equipment

10777 Main Street, Suite 102

Payment of all permit and facility review fees

PART B: FACILITY PERMIT REVIEW

PART A: FACILITY REVIEW AND PERMIT APPLICATION (copy of menu and BPOL)

Fairfax County Business, Professional and Occupational License (BPOL)

EHF68A 8-2016 Application Requirements