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Introduction & Checklist

The intent of this application is to provide information in addition to the plans regarding the operational procedures of the facility.
The Governing the Sanitation of Food Service Establishments (15A NCAC 18A .2600) require that plans be submitted for approval prior to construction. Plans must be submitted with the necessary paperwork (see following checklist) to the Richmond County Health Department.
Submittal Checklist for Mobile Units
The following items must be submitted with this application:
1. Completed Commissary Form (Completed by both applicant and restaurant permittee/owner)
2. Food Equipment Layout drawn to scale showing the placement each piece of food service equipment
3. Plumbing Schematic showing hot and cold water lines, potable and sewer tanks
4. Manufacturer specification sheets for Food Service Equipment List
Submittal Checklist for Pushcarts
1. Completed Commissary Form (Completed by both applicant and restaurant permittee/owner)
2. Pushcart Specification Sheet (cooking equipment, bun storage, cooler, sink(s), water pump, potable and wastewater tanks, etc.)
Establishment Plans
Upload Establishment Plans, Commissary Form, and Menu
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Unit Information & Contacts

Mobile Food Units & Pushcarts Menu Page

This page must be completed. A separate menu may also be submitted.
All produce must either be washed at the Commissary or be purchased prewashed. Be sure to specify where (at Commissary or on unit) that the food will be thawed, cut/wash, assembled, cooked, cold/hot held, and reheated. Please use one group of fields for each food item, and include all beverages.
Menu items are subject to approval and may be restricted.
Food
Food Supplier or Source
Thaw
Cut / Wash / Assemble
Cook
Cold/Hot Holding
Cooling
Reheating
Food
Food Supplier or Source
Thaw
Cut / Wash / Assemble
Cook
Cold/Hot Holding
Cooling
Reheating
Food
Food Supplier or Source
Thaw
Cut / Wash / Assemble
Cook
Cold/Hot Holding
Cooling
Reheating
Food
Food Supplier or Source
Thaw
Cut / Wash / Assemble
Cook
Cold/Hot Holding
Cooling
Reheating
Food
Food Supplier or Source
Thaw
Cut / Wash / Assemble
Cook
Cold/Hot Holding
Cooling
Reheating
Food
Food Supplier or Source
Thaw
Cut / Wash / Assemble
Cook
Cold/Hot Holding
Cooling
Reheating
Food
Food Supplier or Source
Thaw
Cut / Wash / Assemble
Cook
Cold/Hot Holding
Cooling
Reheating
Food
Food Supplier or Source
Thaw
Cut / Wash / Assemble
Cook
Cold/Hot Holding
Cooling
Reheating
Food
Food Supplier or Source
Thaw
Cut / Wash / Assemble
Cook
Cold/Hot Holding
Cooling
Reheating
Food
Food Supplier or Source
Thaw
Cut / Wash / Assemble
Cook
Cold/Hot Holding
Cooling
Reheating
Food
Food Supplier or Source
Thaw
Cut / Wash / Assemble
Cook
Cold/Hot Holding
Cooling
Reheating
Food
Food Supplier or Source
Thaw
Cut / Wash / Assemble
Cook
Cold/Hot Holding
Cooling
Reheating
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Food Service Equipment

All equipment with the exception of microwaves, mixers, toasters, hot water heaters, and hoods must be NSF/ANSI approved. Equipment must also be used for its intended purpose. Please list the equipment.
Equipment Number 1
Equipment Type
Brand
Model Number
Equipment Number 2
Equipment Type
Brand
Model Number
Equipment Number 3
Equipment Type
Brand
Model Number
Equipment Number 4
Equipment Type
Brand
Model Number
Equipment Number 5
Equipment Type
Brand
Model Number
Equipment Number 6
Equipment Type
Brand
Model Number
Equipment Number 7
Equipment Type
Brand
Model Number
Equipment Number 8
Equipment Type
Brand
Model Number
Equipment Number 9
Equipment Type
Brand
Model Number
Equipment Number 10
Equipment Type
Brand
Model Number
Equipment Number 11
Equipment Type
Brand
Model Number
Equipment Number 12
Equipment Type
Brand
Model Number
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Acknowledgement & Signature

Acknowledgement of Compliance*
Completion of this application indicates that the applicant understands and intends to comply with the provisions of all related sanitation laws, rules, and regulations pursuant to 15A NCAC 18A .2600 of the Rules Governing the Sanitation of Food Protection of Food Establishments and the NC Food Code Manual. Construction shall not begin until plans have been approved. It is understood that:
1. Any permit issued may be suspended by the Health Department for failure to comply with the requirements of the regulations. Permit and then grade card will remain posted on unit visible to public.
2. The operator will notify the Richmond County Health Department of any new locations where the unit will be operating.
3. The operator will also notify the applicable Health Departments in other counties where the unit will be operating. The operator will notify the Health Department of any change in menu or equipment.
4. The Mobile Food Unit/Pushcart will report to the Commissary on a daily basis during days of operation for food preparation, utensil washing, supplies, cleaning, and servicing.
Acknowledgement of Accuracy*
I hereby certify that the information in this application is correct, and I understand that any deviation without prior approval from this Health Regulatory Office may nullify plan approval.
1. I understand.
Electronic Signature Agreement*
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature*
Date*
Date
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Mobile Food Unit / Pushcart Plan Review Application

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Food Service Equipment

Acknowledgement & Signature

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