DHEC Form 1769 "Retail Food Establishment Application & Permit Document" - South Carolina

What Is DHEC Form 1769?

This is a legal form that was released by the South Carolina Department of Health and Environmental Control - a government authority operating within South Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2020;
  • The latest edition provided by the South Carolina Department of Health and Environmental Control;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DHEC Form 1769 by clicking the link below or browse more documents and templates provided by the South Carolina Department of Health and Environmental Control.

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Download DHEC Form 1769 "Retail Food Establishment Application & Permit Document" - South Carolina

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RETAIL FOOD ESTABLISHMENT
APPLICATION & PERMIT DOCUMENT
Bureau of Environmental Health Services
Division of Food and Lead Risk Assessment
F
O
U
O
Fees Received (8-302.13(D), 8-304.11(A)(3)) Date
OR
FFICE
SE
NLY
Application reviewed
Date
Reviewer
Permit issued
Date
Reviewer
Process/Risk Category
1
2
3
4
Permit #
This document is intended for new and change of ownership Retail Food Establishments only. Application must be complete and legible. Any
missing information will result in delays in processing this application. Any section that requires additional space or documentation shall be
included as an attachment in the 8.5” X 11” format and labeled to identify the appropriate section (8-302.14(A)(1)). If making changes in an
existing permitted Retail Food Establishment, please complete Change to Existing Retail Food Establishment Permit (D-1716) instead of this
form. Please complete the Application for Event Authorization (D-1717) form for: Temporary Food Establishments (9-8), Community Festivals
(9-9), RFE- South Carolina Farmers Markets, and Seasonal Series and Remote Service (9-11). Throughout this document, applicable sections
from
Regulation 61-25 – Retail Food Establishments
are referenced in parenthesis. Regulation 61-25, fact sheets, and other useful documents
are available by searching
scdhec.gov
for
“Food
Safety-Education.”
Establishment Name
Establishment Address
City
Zip
Phone
E-mail
County
List Hours of Operation: Su _________ M __________ Tu __________ W __________ Th __________ F _________ Sa _________
24-hour Emergency Contact(s) (name, phone, and e-mail)
_________________________________________________________________________________________________________
Permit Holder(s)/ Owner(s)
Billing Address
City
State
Zip
Phone
____ Mobile
E-mail
1. Facility Type
(8-302.14, 8-303)
New/Converted/Remodeled
Change of Ownership
Operation Type
Continual
Seasonal
Start Month/Date
End Month/Date
2. Type of Retail Food Establishment
(Check all that apply. Additional operations must meet all criteria that apply.)
(1-201.10
(106))
Restaurant
Convenience Store
Institution (Schools, Jails, etc.)
Sushi^
Grocery Store (check only those areas to be covered by this permit)
Meat Market
Seafood Market
Deli
Bakery
Produce
Sushi^
Other
Mobile Food (9-1)
Document(s) Attached
Shared Use Operations/Commissary (9-5)
Document(s) Attached
Immediate Outdoor Cooking (9-6)
Document(s) Attached
Barbecue Pit/Pit-Cooking Room Construction (9-7)
Document(s) Attached
^ Preparation onsite
3. Certified Food Protection Manager(s) (CFPM)
A minimum of one (1) person in charge with food safety/training responsibilities.
2-102.12(A),
2-102.20
Copies Attached
Variance request required
Certain types of food operations may be exempt from CFPM. (2-102.12(C))
Copies Attached
Food Handlers Certificate
At all times during operation, the person in charge with food safety/training responsibilities.
2-102.12(B)
Copies Attached
DHEC 1769 5/20
DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
Page 1 of 4
Information collected on this form is subject to public scrutiny or release and the Freedom of Information Act
RETAIL FOOD ESTABLISHMENT
APPLICATION & PERMIT DOCUMENT
Bureau of Environmental Health Services
Division of Food and Lead Risk Assessment
F
O
U
O
Fees Received (8-302.13(D), 8-304.11(A)(3)) Date
OR
FFICE
SE
NLY
Application reviewed
Date
Reviewer
Permit issued
Date
Reviewer
Process/Risk Category
1
2
3
4
Permit #
This document is intended for new and change of ownership Retail Food Establishments only. Application must be complete and legible. Any
missing information will result in delays in processing this application. Any section that requires additional space or documentation shall be
included as an attachment in the 8.5” X 11” format and labeled to identify the appropriate section (8-302.14(A)(1)). If making changes in an
existing permitted Retail Food Establishment, please complete Change to Existing Retail Food Establishment Permit (D-1716) instead of this
form. Please complete the Application for Event Authorization (D-1717) form for: Temporary Food Establishments (9-8), Community Festivals
(9-9), RFE- South Carolina Farmers Markets, and Seasonal Series and Remote Service (9-11). Throughout this document, applicable sections
from
Regulation 61-25 – Retail Food Establishments
are referenced in parenthesis. Regulation 61-25, fact sheets, and other useful documents
are available by searching
scdhec.gov
for
“Food
Safety-Education.”
Establishment Name
Establishment Address
City
Zip
Phone
E-mail
County
List Hours of Operation: Su _________ M __________ Tu __________ W __________ Th __________ F _________ Sa _________
24-hour Emergency Contact(s) (name, phone, and e-mail)
_________________________________________________________________________________________________________
Permit Holder(s)/ Owner(s)
Billing Address
City
State
Zip
Phone
____ Mobile
E-mail
1. Facility Type
(8-302.14, 8-303)
New/Converted/Remodeled
Change of Ownership
Operation Type
Continual
Seasonal
Start Month/Date
End Month/Date
2. Type of Retail Food Establishment
(Check all that apply. Additional operations must meet all criteria that apply.)
(1-201.10
(106))
Restaurant
Convenience Store
Institution (Schools, Jails, etc.)
Sushi^
Grocery Store (check only those areas to be covered by this permit)
Meat Market
Seafood Market
Deli
Bakery
Produce
Sushi^
Other
Mobile Food (9-1)
Document(s) Attached
Shared Use Operations/Commissary (9-5)
Document(s) Attached
Immediate Outdoor Cooking (9-6)
Document(s) Attached
Barbecue Pit/Pit-Cooking Room Construction (9-7)
Document(s) Attached
^ Preparation onsite
3. Certified Food Protection Manager(s) (CFPM)
A minimum of one (1) person in charge with food safety/training responsibilities.
2-102.12(A),
2-102.20
Copies Attached
Variance request required
Certain types of food operations may be exempt from CFPM. (2-102.12(C))
Copies Attached
Food Handlers Certificate
At all times during operation, the person in charge with food safety/training responsibilities.
2-102.12(B)
Copies Attached
DHEC 1769 5/20
DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
Page 1 of 4
Information collected on this form is subject to public scrutiny or release and the Freedom of Information Act
4. Written Employee Health Policy
(2-201.11, 2-201.12)
Document(s) Attached
Written Vomit & Fecal Event Clean-up Policy
(2-501.11)
Document(s) Attached
5. Variance(s) Requested
(3-401.11(D)(4), 3-404.11, 3-502.11, 3-502.12, 8-103.10(A,B,C), 8-103.11, 8-201, 8-302.14(A)(4))
Not Applicable
Special Process
Construction/Equipment
Other
Document(s) Attached
6. Menu or List of Foods to be Served
(8-302.14(A)(2))
Document(s) Attached
7. Consumer Advisory
(3-603)
Not Applicable
Advisory
Location
8. Cooking Processes
No cooking step (deli meats, ice cream, etc.)
Cook and serve
Cook, Cool, and Reheat (food will be cooked, cooled, and reheated for later service)
9. Water Supply
(5-101.11, 8-302.14(A)(5))
Public
Provider
Well
Permit Number
Sewage Disposal
(5-403.11, 8-302.14(A)(6))
Public
Provider
Septic (or similar onsite system)
Number of Seats (per OSWW)
10. Refuse Contractor(s)
(5-501, 5-502)
Refuse (Trash)
Contractor
Grease Disposal
Contractor
11. Grease Trap(s) or Grease Interceptor(s)
(5-402.12)
Not Required
Installed Location
Size
12. Equipment, Mechanical Warewashing, Manual Warewashing
(4-101, 4-202, 4-204.113, 4-204.117, 4-204.119, 4-205, 4-301.11,
4-301.12, 4-301.13, 4-302.13,
4-501,
4-603.12, 4-603.15, 4-603.16, 8-302.14(A)(9))
Equipment, including refrigeration, must meet ANSI/NSF, BISSC (or other accredited ANSI commercial food equipment certification).
NSF/ANSI Certified
If the list of cooking, heating, preparation, refrigeration, and cooling equipment exceeds the provided space, please provide a complete
list instead as an attachment and check the “Document(s) Attached” box.
Document(s) Attached
Type
Manufacturer
Model Number
Location
DHEC 1769 5/20
DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
Page 2 of 4
Information collected on this form is subject to public scrutiny or release and the Freedom of Information Act
13. Backflow Prevention Devices
To protect the drinking water supply from contamination by questionable water, chemicals, or pollution,
(
backflow prevention must be provided at each point of use.
5-202.13, 5-202.14, 5-203.14, 5-203.15, 5-204.12)
Not Applicable
ASSE Certified
Warewasher
Hose Reel
Disposal
Steam Table
Scrapping Trough
Dipper Well
Waste Pulper
Steamer
Pasta Cooker
Combi-therm Oven
Wok Stove
Rotisserie Oven
Water Chiller
Proofer
Rack Oven
Beverage Dispensers
Coffee/Tea
Other
14. Notes
1. Applicant shall be the owner of the proposed Retail Food Establishment or the presiding officer of the legal entity owning the proposed
Retail Food Establishment. (8-302.13(A))
2. To submit an application, request a preoperational inspection, or to obtain additional information, contact your local DHEC office by visiting
https://www.scdhec.gov/ea-regional-offices.
3. Applicant shall submit a completed application for permit at least thirty (30) calendar days before the
date planned for opening of the new facility (8-302.11). Within fifteen (15) calendar days of a change
of ownership (8-303.20(A)(1)(a)), the applicant shall submit a completed application for permit.
4. Applicant must pay the application fee of one-hundred dollars ($100) plus the applicable annual
inspection fee for the anticipated annual gross sales of food and food products at the time the
completed application has been submitted.
(8-302.13(D),
8-304.11(A)(3))
5. Applicant must request the preoperational inspection fourteen (14) days prior to an inspection to
issue a permit. (8-203.10)
6. Applicant must operate as a retail food establishment (serve or sell food) for no less than fifteen (15) consecutive days annually or be in
operation for at least one (1) day a week for no less than fifteen (15) weeks annually. (8-304.11(A)(5))
I, the undersigned, attest to the accuracy of the information provided in this application, and I affirm that the retail food establishment
will comply with SC DHEC Regulation 61-25. I understand that changes in food preparation types, additions of equipment, and/or structural
changes must be approved by the Department prior to implementation and may require that I submit a new application.
It is unlawful for a person to willfully give false, misleading, or incomplete information on a document, record, report, or form required by the
laws of this State.
Should the facility fail to adhere to the requirements of Regulation 61-25, the permit to operate may be subject to enforcement action, which
may include civil penalties pursuant to Section 44-1-150(B) of the South Carolina Code of Laws and/or permit suspension/revocation pursuant
to Regulation 61-25, Retail Food Establishments.
Owner/Presiding Officer Signature (8-302.13(A))
Print Name
Submittal Date
DHEC 1769 5/20
DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
Page 3 of 4
Information collected on this form is subject to public scrutiny or release and the Freedom of Information Act
SOUTH CAROLINA DEPARTMENT OF
HEALTH AND ENVIRONMENTAL CONTROL
DHEC FORM 1769
Instructions for Completing
1. Provide the establishment name.
2. Provide the establishment’s physical address to include the city and zip code.
3. Provide the establishment’s phone number including the area code.
4. Provide the email address to be used by the retail food establishment.
5. List the seven-day hours of operation. If there are days when the facility is not in operation, please print
“Closed” for the day. If the facility never closes, print “24 hours” beside each day.
6. Provide 24-hour emergency contact information – including name, email address, and phone number
(including area code).
7. Provide the permit holder(s)/owner(s) name.
8. Provide the billing address if different from the above physical address to include city, state, and zip code.
9. Provide an alternate contact number for the permit holder(s)/owner(s) – land line or mobile to include
area code.
10. Provide the permit holder(s)/owner(s) email address.
11. Identify whether the facility is new, converted, remodeled, or a change of ownership by checking one of the
boxes. If the facility is seasonal, provide the start and end date of operation.
12. Identify the type of retail establishment by checking all boxes that apply. If needed, attach additional
document(s).
13. Attach a copy(ies) of the Certified Food Protection Manager (CFPM) certificate that includes the date,
expiration date, course taken, and institution. The CFPM is not required for mobile food pushcarts.
14. Attach a copy(ies) of the Food Handlers Certificate for the person(s) in charge.
15. Attach a copy of the retail food establishment’s employee health policy.
16. Attach a copy of the retail food establishment’s vomit and fecal event cleanup policy.
17. If it applies, attach variance documentation and check the box(es) for the type of variance.
18. Attach a menu or list of foods to be served.
19. If it applies, attach a copy of the consumer advisory.
20. Check the box for the cooking processes used in the retail food establishment.
21. Provide information on the water supply and sewage disposal systems.
22. Provide refuse contractor information for trash pickup and if it applies, for grease disposal.
23. Provide grease trap or grease interceptor information, if installed.
24. Provide the type, manufacturer, model number, and location of food equipment for cooking, heating,
preparation, refrigeration, and cooling. If list of equipment is more than will fit in the space provided, check
the documents attached box and provide a complete list of equipment as an attachment.
25. Identify equipment in the retail food establishment where backflow prevention devices are installed by
checking each box that applies.
26. Application must be signed by the owner/presiding officer. Include the printed name of the owner/presiding
officer and the date of submittal provided.
Retention schedule for this form is: 11701- Retail Food Establishments.
DHEC 1769 5/20
DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
Page 4 of 4
Information collected on this form is subject to public scrutiny or release and the Freedom of Information Act
Page of 4