DeKalb County, Illinois

 DeKalb County Health Department

Environmental Health

Review Form
Printable Document (.pdf)
Please complete ALL SHEETS of this form and return it to the above address along with a set of facility plans and kitchen equipment layout, with all items clearly identified. Include the required fee.  See "Environmental Health's Home Page" for a list of current fees.    New  $_______   OR    Remodeled  $________

Name of Establishment__________________________________________________________

Location ____________________________________________________________________

Owner’s Name _______________________________________________________________

Address ____________________________________________________________________

Phone _________________________   FAX _______________________________________

Type of food establishment _______________________________________________________

Name of Certified Food Sanitation Manager(s), certificate number(s), and expiration date(s)___________________________________________________________________________

Anticipated Opening Date _______________________________________________________

A copy of the menu or complete list of all foods served must be submitted with the establishment plans.

Fresh produce served?  Yes    No

EQUIPMENT INFORMATION

Number and location of hand washing sinks _______________________________________

Food preparation sink:  Yes  No

Dishwashing facilities:  Mechanical    Manual

Type of sanitizer used:   Chemical _______________________    Heat

Self-service operation:   Yes              No

PLUMBING

Water supply:  Municipal        Private           Non-Community

Sewage disposal:  Municipal   Private 

Water Heater size and type:                                                                                                         

Grease interceptor size and location: _____________________________________________

GARBAGE AND REFUSE DISPOSAL

Number and location of dumpsters _______________________________________________

Dumpster platforms:  Concrete          Asphalt

Name of garbage disposal company: ______________________________________________

Name of grease disposal company: _______________________________________________

Materials recycled: ____________________________________________________________

Recycling hauler: _____________________________________________________________

CONSTRUCTION DETAILS

Wall finishes:   Food prep areas:___________________________________________________

                        Utensil washing areas: _______________________________________________

                        Garbage handling area: ______________________________________________

Ceiling finishes:           Food prep areas: _____________________________________________

                                    Warewashing area: ___________________________________________

Floor finishes: Food preparation areas: ______________________________________________

                        Utensil washing areas: _______________________________________________

                        Restrooms: ________________________________________________________

Self-closing devices:     Restrooms     Outer openings

FOOD SAFETY PROCEDURES

Foods cooked in advance (a day or more before serving):_____________________________________________________________________________

____________________________________________________________________________

_____________________________________________________________________________

Cooling methods: _______________________________________________________________

_____________________________________________________________________________

Reheating methods: ______________________________________________________________

_____________________________________________________________________________

Standard operating procedures are required for these foods and must be made available upon request.

 

Signature of owner: _________________________Date _________________________

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