"Child and Adult Care Food Program (CACFP) and Summer Food Service Program (Sfsp) Food Service Permit Inquiry Form" - Georgia (United States)

Child and Adult Care Food Program (CACFP) and Summer Food Service Program (Sfsp) Food Service Permit 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 on 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 local Health Authority for review along with:
 a copy of a sample menu for each meal type being served during Program operations; and
 a copy of 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. However, School Food
Authorities (SFAs), governmental agencies, National Youth Sports Program (NYSP), residential camps, and Upward Bound
programs are exempt from this process. Please select all that apply:
Institution/Sponsor Type:
Private Non-Profit Organization
Church/Church Affiliates
At-risk Afterschool Program
Program/Meal Service
Vended (meal preparation is outsourced)
Description:
Self-Prep (meals prepared in central kitchen by Program staff)
Both (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 on 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 local Health Authority for review along with:
 a copy of a sample menu for each meal type being served during Program operations; and
 a copy of 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. However, School Food
Authorities (SFAs), governmental agencies, National Youth Sports Program (NYSP), residential camps, and Upward Bound
programs are exempt from this process. Please select all that apply:
Institution/Sponsor Type:
Private Non-Profit Organization
Church/Church Affiliates
At-risk Afterschool Program
Program/Meal Service
Vended (meal preparation is outsourced)
Description:
Self-Prep (meals prepared in central kitchen by Program staff)
Both (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)
Permit Inquiry Form (Page 2 of 5)
Please select the item(s) that best describe 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]
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]
4.
This section was initially left blank and will be revisited in FY 2020 to capture various other scenarios that are
not depicted within the remaining items listed on this form.
5.
Meal components are received from a third party caterer which are delivered to the Sponsor’s location; meals are
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 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 at the location where the food is being combined, manipulated, handled. 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 at the location where the food is being manipulated, packaged, diced, cooked, etc.]
8(a).
Prepared/cooked hot/cold meals are served to participants from the Sponsor’s central kitchen; 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. If the sponsoring organization is the permit holder, the site supervisors would automatically
be part of the food service establishment since the role of the site supervisor is to oversee the meal service. Whether
the site supervisor was present to see the food being prepared in the central kitchen or not, the site supervisor must
be positioned at the site to receive the meals from the sponsor’s central kitchen and must be present during the entire
meal service [SFSP sponsors hire/assign site supervisors to oversee the meal service for their respective sites and if
the site supervisor remains on site to further assemble or plate the food, the only required form of documentation
would be the food service permit from the Sponsor’s central kitchen.]
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)
None of the above
Other (Please explain) _____________________________________________________________________________
___________________________________________________________________________________________________
Permit Inquiry Form (Page 3 of 5)
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)
Permit Inquiry Form (Page 4 of 5)
Certification Statement:
I certify that the information contained in this document is true and correct to the best of my ability 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 and/or termination and disqualification of the organization, its responsible principals and/or individuals
from participation the CACFP, SFSP, or any other Child Nutrition Program (CNP).
___________________________________________
______________________________
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
Number of
Contact
(if meals are
delivered from the
Meals Served
Name/Number
kitchen address to a
Daily (all meals
separate 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 Department 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)
List of Affiliated Kitchen/Feeding Locations (Cont.)
Site/Facility Name
Approximate
Central Kitchen Address
Feeding site/facility
Central Kitchen
Number of
(if meals are
Contact
Meals Served
delivered from the
Name/Number
kitchen address to a
Daily (all meals
separate location)
combined)
Permit Inquiry Form (Page 5 of 5)