RETAIL FOOD PLAN REVIEW SUBMISSION FORMS

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ARKANSAS DEPARTMENT OF HEALTH

GENERAL ESTABLISHMENT INFORMATION

Construction Type (please check one):

____ NEW ____ REMODEL ____ COMMERCIAL/INCUBATOR/CONTRACT OPERATOR KITCHEN

____ NEW OWNER EXISTING ESTABLISHMENT _____MOBILE /PUSHCART _____ CONVERSION

____PARTIAL REMODEL (FIRE/FLOOD) ____ RESUBMIT (Previous Submission Date) __________

Projected Start Date: _______________ Projected Date for Completion: ___________________

Name of Establishment / Project: __________________________________________________

Physical Address: ____________________ City: _______________ State: ________Zip: _______

County: _______________________ Phone Number: __________________________________

OWNER INFORMATION

Name of Owner: ________________________________________________________________

Owner’s Mailing / Billing Address: ______________________________ City: _______________

State: ________ Zip: _________ Contact Phone Number: _______________________________

Owner’s Email Address: _______________________ Gov. ID #: __________________ State: ___

TYPE OF ESTABLISHMENT (Please Check Only One Category)

____ Restaurant _____ Food Store _____ Kiosk ____Private School ____ Public / Charter School

_____ Private Food Service Contractor for Public Schools _____ Daycare / Childcare

_____ Food Mobile/Truck ______ Hotdog Cart / Pushcart ______ Food Salvage

_____ Summer Feeding/Afterschool _____ Food Pantry / Food Storage

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RETAIL PLAN REVIEW SUBMISSION DOCUMENTATION:

The items below have been included with the plans being submitted at this time. It is understood that

omission of any requested information will result in a delay in the plan approval. Once all required items

are received and any required fee paid, the plans will be reviewed within the time allotted by the

Arkansas Department of Health.

YES

REQUIRED SUBMITTED INFORMATION

Proposed Menu

Completed set of plans drawn to scale or with drawing legend

List or Set of Manufacturer equipment specifications or list of equipment

Standard Operating Procedures

Plumbing plans showing hot and cold-water supply, sink locations, floor drains,

waste lines from fixtures, water heaters

Warewashing facilities and food prep sinks

Hand sinks and toilet facilities with soap and towel provisions

Restrooms / toilet facilities

Storage rooms / area for food storage

Service sink / cleaning facilities area

Chemical storage area

Employee storage area / changing room

*HACCP Plan and supporting documentation (if required for specialized process)

*Variance Request Form and Documentation (if required for specialized process)

Equipment plan and schedule showing location of equipment

SOURCE OF WATER: _____ Municipal ______ Well ______ Other: ________

SOURCE OF WASTEWATER: ______ Municipal Sewage _____ Septic System

ADDITIONAL REQUIREMENTS FOR FOOD TRUCKS – PUSH CARTS:

Size and location of Fresh Water Tank and material to construct

Size and location of Gray Water Tank and material to construct

Service Area Agreement and Commissary Prep location

*SPECIALIZED PROCESS: Check All That Applies

_____ Curing ____ Acidification (sushi, etc.) ____ Smoking _____ Live Molluscan Shellfish

____Reduced Oxygen Packaging ROP (eg: Vacuum packaging, sous vide, cook-chill etc.)

____ Custom Processing ____ Sprouting ____ Other, please describe and explain:

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OPERATION INFORMATION

HIGHLY SUSCEPTIBLE POPULATION: Will this facility cater to or serve any of the following:

(Check all that applies)

____ Assisted Living ____ Childcare ____ Health Care /Immunocompromised

______ Nursing Home _____ School with pre-school aged children

HOURS OF OPERATION

_____ This is a Mobile Unit/Food Truck, and my hours vary.

Day Of Week

Open Time

Closed Time

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Estimated Meals (provide number)

Buffet Service

Breakfast

Lunch

Dinner

Other

(snacks meals)

Total

anticipated daily

TYPE OF SERVICE (CHECK ALL THAT APPLY):

____ Sit Down Meals ____ Take Out/Delivery ____ Catering ____ Buffet/Self-Service

____ Outdoor Service Area ____ Full-Service Bar ____ Other

 Number of Indoor Dining Seats: _____________

 Number of Outdoor Dining Seats: ____________

 Number of Staff (Maximum per shift): ____________

 Total Square Footage of Facility: ____________

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STORAGE FOR OPERATION

COLD STORAGE

Anticipated frequency of frozen food delivery: ___________________ (example every Thursday)

Anticipated frequency of refrigerated food delivery: ________________

Provide information on the amount of space allocated:

 Refrigerated Storage:

 Frozen Storage:

DRY STORAGE

Anticipated frequency of dry storage and paper goods: ____________________

Identify the location and containers that will be used to store bulk food products like rice, flour,

sugar, etc.

Provide Information on the amount of space allocated for Dry Storage…

HOT AND COLD HOLDING

HOT HOLDING: List all foods that will be hot held prior to service:

COLD HOLDING: List all foods that will be held cold prior to service:

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Appe�zers

Desserts

Soup & Salads

Main / Meats

Sides

Drinks

Please include menu items being served. While a copy of your actual menu is preferred the following is a

template to assist you in this process if you do not have an official menu. Include additional pages if necessary.

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Standard Operating Procedures for Food Service Establishments

Who must have standard operating procedures?

• All new food establishments, including but not limited to Mobile/Pushcarts, Feeding Programs,

Cooking or Prep Kitchens, Concession Stands, Temporary Establishments and Food Trucks.

• Remodeled food establishments that change menu or operation must update and resubmit.

• Establishments using a HACCP Plan or Variance.

What are standard operating procedures?

• Procedures specific to your operation describing the activities necessary to complete

tasks in accordance with the food code and Arkansas food law. The procedures are

used to train the staff members responsible for the tasks.

• Three purposes for establishing SOPs for your operation are: (1) to protect your products

from contamination from microbial, chemical, and physical hazards; (2) to control microbial

growth that can result from temperature abuse or poor personal hygiene; and (3) to ensure

procedures are in place for maintaining equipment and assisting with Active Managerial

Controls within the food establishment.

Why must procedures be submitted?

• Arkansas Food Regulations requires standard operating procedures to be established prior to

opening or reopening. These procedures must be maintained in the facility and accessible to

the staff and regulatory authorities upon request.

How must procedures be developed?

• Procedures are mostly for use by managers and staff. Develop procedures in the

language, style, and format best for the establishment. An English copy of the procedures

is needed for the plan reviewer.

What procedures must all establishments submit?

• Handwashing.

• Personal hygiene, including cuts and sores.

• Preventing bare hand contact with ready-to-eat food (gloves, utensils, etc.).

• Employee/Staff illness.

• Purchasing food from approved sources.

• Cleaning and sanitizing food contact surfaces.

• Norovirus Cleanup (See Regulatory Authority for assistance with approved procedure)

What procedures must all establishments develop when applicable to their operation?

• Cross-contamination prevention within the establishment

• Warewashing manual dishwashing

• Date-marking ready-to-eat, and TCS (time/temperature control for safety food).

• Using time only (not time and temperature) as a method to control bacterial growth.

• Thawing TCS foods (time temperature control for safety food).

• Cooking TCS foods (time temperature control for safety food).

• Cooling TCS foods (time temperature control for safety food).

• Reheating foods.

• Hot holding foods.

• Cold holding foods.

Procedures can be sent with the plans at time of initial review and maintained on-site and used by the

person in charge and staff. Technically correct procedures must be in place by the pre-opening

inspection.

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KITCHEN FLOOR PLAN

Please include the type of materials used for floors,

walls, and ceilings. Acceptable finishes would

include sealed concrete or tile for flooring; quarry

tile, fiberglass reinforced plastic (FRP) or stainless

steel for wall areas and coated tiled or other

smooth ceiling materials.

Photographs of the Facility/Mobile Units are encouraged.

Detailed images of the inside and outside of the food service

facility or mobile unit will be helpful and speed up the overall

review process for those already constructed facilities.

Example of Images to Take

• Kitchen layout, Equipment, Vent-hood, lighting

• Sinks, three-compartment, handwashing, mop sinks

• Buffet line, Dry Storage Unit, Hot Holding cabinets,

• Floors, Walls, Ceiling

• Walk-Ins, Freezers, Coolers

Plans should be remitted to:

Environmental Health Protection

Plan Review

Arkansas Department of Health

4815 W Markham St, Slot 46

ttle Rock, AR 72205

EHP-PR1(4/24)

FOR AGENCY USE ONLY

FOR ESTABLISHMENTS NOT NEEDING RETAIL PLAN REVIEW

I have reviewed the paperwork submitted, have had conversations with the prospective new

operator related to their intended food preparation practices and menu, and/or have current

working knowledge of the condition of this facility. It is my recommendation that this facility

does not need to go through a Retail Plan Review.

EHS: ____________________________________ Signature: __________________________

DATE: ______________________________

RETAIL PLAN REVIEW COMMENT SECTION

Date Received Plans: ____________________ Date Completed: ________________

Final Approval Status: ________________ (Approval / Provisional Approval / Disapproval)

ACTION

DATE OF ACTION

BY WHOM

COMMENTS

Scanned PR Documents

Sent PR Letter

Put Plans On Hold

Plans Returned

Additional Documents

Rec’d

Payment Received

PLANS ON HOLD FOR THE FOLLOWING REASONS:

Reasons Plans Returned:

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Page 1 of 2

Arkansas Department of Health

Project Cost Estimate Worksheet

As required by A.C.A. § 20-7-123, this worksheet must be completed and submitted with appropriate fee(s)

PROJECT NAME

COUNTY

PROJECT LO

CATION (911 if available)

CITY, STATE, ZIP

OWNER/SUBMITTER NAME PHONE

MAILING ADDRESS

CITY, STATE, ZIP CODE

EMAIL (if available)

COST ESTIMATE: ESTIMATED COST SHALL BE BASED ONLY ON THOSE IMPROVEMENTS THAT REQUIRE

A DEPARTMENT OF HEALTH REVIEW

1. WATER SYSTEM IMPROVEMENTS (non-plumbing)................................ $

For questions regarding water system improvements ENGINEERING (501) 661-2623

2. SEWER SYSTEM IMPROVEMENTS (non-plumbing) ................................ $

For questions regarding sewer system improvements ENGINEERING (501) 661-2623

3. PLUMBING…………………………………….……………….................. $

For questions regarding plumbing plans

(501) 661-2650

4. SWIMMING POOL (public)….………………............................................. $

For questions regarding swimming pool plans

(501) 661-2171

FOOD SERVICE- Retail or Wholesale/Manufacturing (new/reno) .………......... $

For questions regarding food establishment plans

(501) 661-2171

TOTAL ESTIMATED COST ................................................................. $

A. PLAN REVIEW FEE .................................................................................. $

1% of total est. cost, not less than $50.00 and not to exceed $500.00 (See #1 on page 2)

TOTAL FEES SUBMITTED ................................................................... $

(Checks or money orders made payable to ADH)

PREPARED BY: DATE

PRINT NAME: __________________________________________________________

*For Individual Onsite Wastewater System permits and Subdivision, RV Parks, Mobile Home parks utilizing individual disposal systems

please continue to page 2 or contact Engineering (501) 661-2623.

PROJECT ID# (ADH Use Only)

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EXPLANATION OF PLAN REVIEW FEES

#1) A.C.A. § 20-7-123 establishing a fee for the review of plans and specifications which are

required by law or regulation to be reviewed by the Department (Line items #

1,2,3,4,5 on page 1). The fee is 1% of the estimated cost of improvements, with a minimum fee

of $50.00 and a maximum fee of $500.00. An Engineering estimate must accompany the plans

unless the maximum fee of $500.00 is paid.

IF TOTAL ESTIMATED COST IS $5,000.00 OR LESS, REVIEW FEE IS $50.00.

IF TOTAL ESTIMATED COST IS $50,000.00 OR MORE, REVIEW FEE IS $500.00.

IF TOTAL ESTIMATED COST IS BETW EEN $5,000.00 AND $50,000.00, CALCULATE AS FOLLOWS:

PLAN REVIEW FEE = (0.01) x (TOTAL ESTIMATED COST) = $

Complete Below Only for plans utilizing onsite wastewater systems including subdivisions

containing lots < 3 acres, mobile home and RV parks.

#2) A.C.A. § 14-236-116 establishing a fee for the review of plans for subdivisions containing lots

<3 acres utilizing individual onsite wastewater systems.

Subdivisions on Individual Onsite Wastewater :

FIRST LOT @ $100.00 $ 100___

ADDITIONAL LOTS @ $25.00/each .......................... $

TOTAL ........................................... $

(Maximum Fee = $1500.00)

#3) A

.C.A. § 20-27-1201 established a review fee for Mobile Home Parks and Recreational Vehicle

Parks utilizing onsite wastewater systems and is based on the number of spaces.

Mobile Home & RV Parks utilizing Onsite Wastewater Systems:

2-25 SPACES………………….

$25.00

26-50 SPACES………………..

$50.00

51-75 SPACES………………..

$75.00

76 OR MORE…..……………. $100.00

PLAN REVIEW FEE:

Total Submitted (#2 + #3) ___________________________________

(Checks or money orders payable to ADH)

For more information regarding Sections #2 and #3, please contact ADH Engineering 501-661-2623.

4815 W. Markham St., Slot 46

Little Rock, AR 72205

Yes No

4-24

owner(s) or responsible representative(s)

Date

-4/24)