"Food Service Inspection Inquiry Form" - Georgia (United States)

Food Service Inspection Inquiry Form is a legal document that was released by the Georgia Department of Early Care and Learning - a government authority operating within Georgia (United States).

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BRIGHT FROM THE START
Georgia Department of Early Care and Learning: Nutrition Services
2 Martin Luther King Jr. Drive, SE, Suite 754, East Tower, Atlanta, Georgia 30334
(404) 656-5957
Food Service Permit Inquiry Form
Child and Adult Care Food Program (CACFP) and Summer Food Service Program (SFSP)
The purpose of this form is to assist CACFP institutions and SFSP sponsors with determining food service permit
requirements for non-licensed Program facilities based upon the type of meal service operation. Please be sure to complete
all sections below and return to DECAL via facsimile to: 404-651-7430 Attn: Nutrition Services Application Specialist.
When requesting an evaluation to determine whether a food service permit is required from your local health authority,
CACFP institutions and SFSP sponsors must:
1.
Provide a copy of this form to the authority for review along with:
 a copy of a sample menu for each meal type being served during Program operations; and
 a copy a receipt/invoice of vended meals purchased (for institutions or sponsors purchasing meals from a food service
management company or food distributor).
Ensure the form has been authorized (signed and dated) by both the delegated principal and local health department prior
2.
to submission to DECAL.
Program(s):
SFSP - Agreement Number _____________________
(SFSP Program Operation Begin Date:__________ Program Operation End Date: __________)
CACFP - Agreement Number _____________________
CACFP – At-Risk Afterschool - Agreement Number _____________________
Organization Name: _____________________________________________________________________________
Address: ______________________________________________________________________________________
City: ____________________ State: ______________ County:________________ Zip:____________________
Name of Program Contact/Delegated Principal: ____________________________________________________
Contact Number: ______________________________ Fax Number: ______________________________________
Email Address: ______________________________________________________
Institutions/sponsors completing this form must fall under one or more of the following categories. School food authorities,
government agencies, National Youth Sports Program (NYSP), residential camps, and Upward Bound programs are exempt
from this process. Please select all that applies:
Institution/Sponsor Type:
Private Non-Profit Organization
Church/Church Affiliates
At-risk Afterschool Program
Program/Meal Service
Vended (meals preparation is outsourced)
Description:
Self-Prep (meals prepared in central kitchen by Program staff)
Vended and Self-prep
BRIGHT FROM THE START
Georgia Department of Early Care and Learning: Nutrition Services
2 Martin Luther King Jr. Drive, SE, Suite 754, East Tower, Atlanta, Georgia 30334
(404) 656-5957
Food Service Permit Inquiry Form
Child and Adult Care Food Program (CACFP) and Summer Food Service Program (SFSP)
The purpose of this form is to assist CACFP institutions and SFSP sponsors with determining food service permit
requirements for non-licensed Program facilities based upon the type of meal service operation. Please be sure to complete
all sections below and return to DECAL via facsimile to: 404-651-7430 Attn: Nutrition Services Application Specialist.
When requesting an evaluation to determine whether a food service permit is required from your local health authority,
CACFP institutions and SFSP sponsors must:
1.
Provide a copy of this form to the authority for review along with:
 a copy of a sample menu for each meal type being served during Program operations; and
 a copy a receipt/invoice of vended meals purchased (for institutions or sponsors purchasing meals from a food service
management company or food distributor).
Ensure the form has been authorized (signed and dated) by both the delegated principal and local health department prior
2.
to submission to DECAL.
Program(s):
SFSP - Agreement Number _____________________
(SFSP Program Operation Begin Date:__________ Program Operation End Date: __________)
CACFP - Agreement Number _____________________
CACFP – At-Risk Afterschool - Agreement Number _____________________
Organization Name: _____________________________________________________________________________
Address: ______________________________________________________________________________________
City: ____________________ State: ______________ County:________________ Zip:____________________
Name of Program Contact/Delegated Principal: ____________________________________________________
Contact Number: ______________________________ Fax Number: ______________________________________
Email Address: ______________________________________________________
Institutions/sponsors completing this form must fall under one or more of the following categories. School food authorities,
government agencies, National Youth Sports Program (NYSP), residential camps, and Upward Bound programs are exempt
from this process. Please select all that applies:
Institution/Sponsor Type:
Private Non-Profit Organization
Church/Church Affiliates
At-risk Afterschool Program
Program/Meal Service
Vended (meals preparation is outsourced)
Description:
Self-Prep (meals prepared in central kitchen by Program staff)
Vended and Self-prep
BRIGHT FROM THE START
Georgia Department of Early Care and Learning: Nutrition Services
2 Martin Luther King Jr. Drive, SE, Suite 754, East Tower, Atlanta, Georgia 30334
(404) 656-5957
Food Service Permit Inquiry Form
Child and Adult Care Food Program (CACFP) and Summer Food Service Program (SFSP)
Inspection Inquiry Form (Page 2 of 4)
Please select the item(s) that best describes your meal service:
Item #
Description
1.
Fully cooked, complete unitized meals or snacks are catered (prepared) by a third party and are picked-up or
delivered to each CACFP facility or SFSP site ready to consume. [Copy of food service permit from catering
company is required.]
2.
Pre-packaged/self-contained food items/components are purchased in bulk from a food service management
company or food distributor (vendor or supplier), delivered to a location (central kitchen, CACFP facility or SFSP
meal site) to be combined, cooked and prepared to create a unitized meal or snack. [Requires a Food Service
Permit/Food Service Inspection]
3.
Individual food items/components purchased from multiple locations (super market/wholesale market, vendor or
supplier), and cooked/prepared at a kitchen facility (owned or rented). Cooked items are later combined to make a
unitized meal and served for consumption. [Requires a Food Service Permit/Food Service Inspection]
4.
Individual food items/components purchased from multiple locations (super market/wholesale market, vendor or
supplier), and cooked/prepared at a certified shared kitchen, kitchen incubator or rented/leased kitchen facility.
Cooked items are later combined to make a unitized meal and served for consumption at a CACFP facility or SFSP
meal site. [If using an incubator/shared kitchen type of operation, the permit holder must have an approved variance
from the Georgia Department of Public Health (DPH) and it would require the operator to enter into a contractual
agreement with the permit holder to agree that the permit holder will oversee the preparation of the food and maintain
active managerial control over the food items from preparation to delivery to service. A copy of the food service
permit from the certified shared kitchen, kitchen incubator or rented/leased kitchen space is required.]
Meal components are received from a third party caterer which are delivered to the Sponsor’s location; meals are
5.
assembled by SFSP/CACFP meal service operators/kitchen staff for buffet style serving, or meal service operators
plate meals for consumption. If staff from the permitted catering establishment remains on site to further assemble or
plate the food, the only required form of documentation would be the food service permit from the catering
establishment. [Requires a copy of food service permit from the catering company.] **However, if the CACFP/SFSP
staff further manipulates the food, a food service permit is required for that feeding location. [See Item #7].
6.
Meals are received/served pre-packaged and ready-to-consume to SFSP/CACFP participants (e.g., hot/cold pre-
packaged components, unitized meals where the participant receives a complete meal as a single packaged unit, ready
to eat fruits/vegetables (e.g., apples, oranges, bananas for snack meals). Pre-packaged meals go directly to the
SFSP/CACFP participants for opening and consumption. Pre-packaged meals are not opened or manipulated in any
way by the food service operators/kitchen staff before the participant receives the meals for consumption. [A food
service permit/food service inspection is not required.]
7.
Pre-packaged meals are assembled and served to SFSP/CACFP participants (e.g., hot/cold pre-packaged
components); involves CACFP/SFSP food service operators/kitchen staff: (a) combining non-unitized meals, (b)
separating items from packages and (c) plating and serving meals for consumption (e.g., cold cut sandwiches, etc.).
[Requires a food service permit/food service inspection at the location where the food is being combined,
manipulated, handled, which would receive regular routine inspections. A copy of a permit from where the pre-
packaged meals were originally prepared would also be required (e.g., food service management companies).]
8.
Prepared/cooked hot/cold meals are served to participants; involves purchasing, ordering cooked or uncooked food
items, separating items from their original packaging, preparing the food items (e.g., cleaning, dicing, seasoning,
cooking, heating), plating and serving the food items for SFSP/CACFP participant consumption. [Requires a food
service permit/food service inspection at the location where the food is being manipulated, packaged, diced, cooked,
etc., which would receive regular routine inspections.]
None of the above
Other (Please explain) _____________________________________________________________________________
___________________________________________________________________________________________________
BRIGHT FROM THE START
Georgia Department of Early Care and Learning: Nutrition Services
2 Martin Luther King Jr. Drive, SE, Suite 754, East Tower, Atlanta, Georgia 30334
(404) 656-5957
Food Service Permit Inquiry Form
Child and Adult Care Food Program (CACFP) and Summer Food Service Program (SFSP)
Inspection Inquiry Form (Page 3 of 4)
Certification Statement:
I certify that the information contained in this document is true and correct and that listing false or incorrect information and
failure to notify DECAL when the information contained in this document changes may result in the denial of reimbursement,
termination and disqualification of the organization, its responsible principals and/or individuals from participation the SFSP
or any other Child Nutrition Programs.
___________________________________________
______________________________
Signature of Delegated Principal
Date of Submission
List of Affiliated Kitchen/Feeding Locations
Please list below each feeding site/facility serving SFSP or CACFP meals. Please include the physical address of the central
location from which food is prepared and the address of the feeding site/facility where meals are delivered and then consumed if
different from the central kitchen. To add additional sites, please add separate sheet to the back of this form.
Site/Facility Name
Approximate
Central Kitchen Address
Feeding site/facility
Central Kitchen
(if meals are delivered
Number of
Contact
from the kitchen
Meals Served
Name/Number
address to a separate
Daily (all meals
location)
combined)
For Local Health Department Use Only:
Food Service Permit is:  Required  Not Required
Item Number(s) ____________ have been selected and are applicable to this CACFP Institution and/or SFSP Sponsor.
Name of Health Department Official ________________________________ Department/Office __________________
Health Official Signature_______________________________________________________ Date _______________
BRIGHT FROM THE START
Georgia Department of Early Care and Learning: Nutrition Services
2 Martin Luther King Jr. Drive, SE, Suite 754, East Tower, Atlanta, Georgia 30334
(404) 656-5957
Food Service Permit Inquiry Form
Child and Adult Care Food Program (CACFP) and Summer Food Service Program (SFSP)
Inspection Inquiry Form (Page 4 of 4)
List of Affiliated Kitchen/Feeding Locations (Cont.)
Site/Facility Name
Approximate
Central Kitchen Address
Feeding site/facility
Central Kitchen
(if meals are delivered
Number of
Contact
from the kitchen
Meals Served
Name/Number
address to a separate
Daily (all meals
location)
combined)
Page of 4