2. Restaurant New Owner Application (Transitional Permit Application)
4. NOTICE: Once issued by the Health Department, a Transitional Permit is valid for 180 days from the date of issuance. All non-compliant items listed on this temporary permit must be brought into compliance with the NC Food Code within 180 days or the permit will be revoked.
6. Current Name of the Establishment:*
8. Address of Establishment:*
10. City:*
11. State:*
12. Zip Code:*
16. New Establishment Name:*
18. Name of New Owner:*

    (Person, Corporation, or Partnership)

20. Mailing Address:*
22. City:*
23. State:*
24. Zip Code:*
26. Phone Number:*
27. Email Address:*
29. Number of Seats Proposed:*

    (Type N/A if no seating provided for customers)

31. Projected Date of Purchase:*
    Projected Date of Purchase:
35. Please list any changes that you are considering for this facility:*

    Type "N/A" if no changes are going to be made to the facility.

37. **If layout or equipment changes are planned, please provide a floor plan drawn to scale (1/4" = 1 foot) showing the placement of each piece of food service equipment, all sinks, storage areas, and trash can wash facilities. **
39. **Provide specification sheets for each piece of new or replacement equipment. ALl new equipment must be identified on a separate list. All equipment must be NSF listed, UL classified for sanitation or be constructed to meet NSF/ANSI standards.**
41. Floor plan upload
42. Spec Sheets
43. Proposed Menu*
44. Additional Documents
48. Proposed Hours of Operation:
50. Monday:*
    Monday: Start Time

    —

    Monday: End Time
51. Tuesday:*
    Tuesday: Start Time

    —

    Tuesday: End Time
52. Wednesday:*
    Wednesday: Start Time

    —

    Wednesday: End Time
53. Thursday:*
    Thursday: Start Time

    —

    Thursday: End Time
55. Friday:*
    Friday: Start Time

    —

    Friday: End Time
56. Saturday*
    Saturday Start Time

    —

    Saturday End Time
57. Sunday:*
    Sunday: Start Time

    —

    Sunday: End Time
59. Type of Food Service (check all that apply)*

    1. Restaurant
    2. Food Stand (no seats provided)
    3. Drink Stand
    4. Commisary for a Mobile Food Unit or Push Cart
    5. Meat Market

    1. Sit down meals
    2. Take-out
    3. Catering
    4. Lodging Food Service
    5. Other
61. If other, Please Specify
63. Single Service Items (Disposable)*

    Check all that apply.

    1. Plates
    2. Cups
    3. Flatware (forks, spoons, butter knives)
    4. No Single Service Items used
64. Multi-use Items (reusable)*

    Check all that apply.

    1. Plates
    2. Glassware
    3. Flatware
    4. No Multi-use Items used.
68. Projected number of Meals to be served Daily:

    Ex: Breakfast=10, Lunch=10, Dinner= 20. Total meals served is 40 (10+10+20=40).

70. Total Number of Seats inside Restaurant*

    Type N/A if this does not apply to you.

71. Total number of seats outside of Restaurant:*

    Type N/A if this does not apply to you.

73. Total Square Feet of Dining Area:*

    Type N/A if this does not apply to you.

77. Specialized Processes

    Specialized processes require an applicaiton to the State for an approved variance.

79. Indicate any specialized processes that will take place:*

    Check all that apply.

    1. No special processes used.
    2. Curing
    3. Smoking
    4. Fermentation
    5. Acidification (sushi, etc.)
    6. Reduced Oxygen Packaging (vacuum sealing)
    7. Sprouting Beans
    8. Other
80. If any are selected, explain the processes being used below:
82. If other type of special process is selected, explain below:
86. Water Supply - Sewage Disposal - Equipment Specification
88. Water Supply:*
    -- Select One --CityWell
89. Sewer:*
    -- Select One --CityOnsite Septic System
91. Water Heater Specifications:

    Manufacturer information sheet or plate on tank.

92. Water Heater Specifications:*
    -- Select One --GasElectricInstantaneous
93. Manufacturer Name and Model Number:
95. Tank Size (Gallons)

    If applicable

96. Recovery at 100°F Rise:

    (gallons per hour)

97. Power Rating: Gas

    (BTU'S)

98. Power Rating: Electric

    (kW)

102. Dish Machine
104. Do you have a dish machine?*
     -- Select One --YesNo
106. Manufacturer Name:
107. Model Number:
108. Gallons Per Hour:
110. Booster Heater?
     -- Select One --YesNo
111. Chemical Sanitizer?
     -- Select One --YesNo
112. Leased Machine?
     -- Select One --YesNo
116. Three Compartment Pot Wash Sink
118. Sink Size: Length (in inches)

     (Front to back)

119. Sink Size: Width (inches)
120. Sink Size: Depth (inches)
122. Drainboard: Width

     (inches)

123. Drainboard: Length

     (inches)

124. Will you be using any indirect drainboards?
     -- Select One --YesNo
128. Can Wash/Mop Sink & Solid Waste Disposal
130. Location of Can wash/Mop sink

     The Can wash/Mop Sink has to be at least 36" x 36".

131. Choose the following solid waste storage that will be used:
     -- Select One --DumpsterRoll out Cart
135. Complete the following sections only if changes to the menu and food preparation is planned.
137. Thawing

     Check the appropriate box(s) to indicate how food will be thawed.

139. Refrigerator:

     1. Meat
     2. Seafood
     3. Poultry
     4. Vegetables
     5. Other
140. Under Running Water:

     1. Meat
     2. Seafood
     3. Poultry
     4. Vegetables
     5. Other
141. Cooked Without Thawing:

     1. Meat
     2. Seafood
     3. Poultry
     4. Vegetables
     5. Other
142. Thawing in Microwave as Part of Cooking Process:

     1. Meat
     2. Seafood
     3. Poultry
     4. Vegetables
     5. Other
144. If Other was selected for any of the above Thawing methods, please specify what "other" items will be thawed with which method:
148. Cooling

     Check the appropriate box(s) to indicate how food will be cooled rapidly from 135°F to 41°F after being cooked.

150. In the refrigerator in shallow pans:

     1. Meats
     2. Seafood
     3. Poultry
     4. Vegetables
     5. Soups
     6. Sauce
151. In an Ice Bath:

     1. Meats
     2. Seafood
     3. Poutlry
     4. Vegetables
     5. Soup
     6. Sauce
152. Using a Blast Chiller:

     1. Meats
     2. Seafood
     3. Poultry
     4. Vegetables
     5. Soup
     6. Sauce
156. Preparation Procedures
158. Will PRODUCE be purchased fully prepared and pre-rinsed?
     -- Select One --YesNo
159. If No, where will produce be prepared and/or rinsed?
161. Will SEAFOOD be purchased fully prepared and pre-rinsed?
     -- Select One --YesNo
162. If No, where will seafood be prepared and/or rinsed?
164. Will POULTRY be purchased fully prepared and pre-rinsed?
     -- Select One --YesNo
165. If No, where will poutlry be prepared and/or rinsed?
167. Will pork and/or red meat be purchased fully prepared and pre-rinsed?
     -- Select One --YesNo
168. If No, where will pork or red meat be prepared and/or rinsed?
172. Additional Supporting Documents If needed

     Example: equipment spec sheets, variance, HACCP plan

174. Additional Documents
175. Additional Documents
176. Additional Documents
177. Additional Documents
179. Additional Documents
180. Additional Documents
181. Additional Documents
182. Additional Documents
Leave This Blank:


184. 1. Receive an email copy of this form.
185. Email address

     This field is not part of the form submission.

186. Submit

* indicates a required field