Free REGISTRATION APPLICATION AS A RETAIL FOOD ESTABLISHMENT - Indiana

APPLICATION FOR PLAN REVIEW
State Form 50033 (R2/6-05) Indiana State Department of Health Food Protection Program

Please complete the following, as is applicable to the retail food establishment.
Owner/Corporation Information: Engineer/Architect Information:

Name: Contact Person: Telephone Number: Mailing Address:

Name: Contact Person: Telephone Number: Mailing Address:

Establishment Information:

(Check one) Establishment Name: Contact Person:

New Construction

Existing/Remodel

Project #:

Title: Contact Person Telephone #:

Establishment Telephone #: Establishment Mailing Address: Establishment Street Address: Projected Date for Start of Project: Projected Date for Completion of Project: Hours of Operation:

Days of Operation:

Contents and Specifications for Facility and Operating Plans as required in Section 110 of 410 IAC 7-24:

(Please check items submitted for review) Proposed menu (including seasonal, off-site and banquet menus). Anticipated volume of food to be stored, prepared, and sold or served. Proposed layout, mechanical schematics, construction materials, and finish schedules. Proposed equipment types, manufacturers, model numbers, locations, dimensions, performance capacities, and installation specifications. Evidence that standard procedures that ensure compliance with ISDH Rule 410 IAC 7-24 are developed or are being developed. Plan review questionnaire completed and submitted to the regulatory authority. Note: Other information that may be required by the regulatory authority for the proper review of the proposed construction, conversion or modification, and procedures for operating a retail food establishment.
Additional Information:

Comments:

Signature of Applicant Relationship to Project Date Signed

Note: If all the required information is not submitted to the regulatory authority, it may delay the review process of your plans and possibly delay construction.