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Some items may not be required for limited food service establishments or beverage bars. Please consult our office for more information or consult the WA State Retail Food Code

WA State Retail Food Code--click below:

WA State Retail Food Code

Are you using a commissary kitchen?*

If yes, list name and location:

Commissary Letter

Upload valid commissary letter

In order to use your own potable well, you must have the water system approved as a public water system from Jefferson County Environmental Public Health or the Washington State Department of Health. Please contact our office to determine the approval requirements. Your water system must be approved prior to operating the food service establishment.

Connecting to a well:*

Yes
No
N/A

Connected to public sewer:*

Yes
No
N/A

If yes, name:

Connecting to an on-site sewage system:*

Yes
No
N/A

Note:

If your establishment is connecting to an on-site sewage system, a review of our records will be accomplished to ensure it was permitted and approved. Food Establishment sewage systems are required to be checked on an annual basis. The owner is required to supply the Jefferson County Environmental Public Health Department with a record of any maintenance or checks performed annually. A list of septic system pumpers is available at our office.

Grease trap installed and accessible for easy cleaning:*

Yes
No
N/A

Three-compartment sink installed for washing, rinsing and sanitizing equipment and utensils that is large enough for complete immersion of equipment and utensils, except fixed and excessively large equipment:*

Yes
No
N/A

Commercial food service dishwasher installed with indicating thermometers on machine. Ware washing dishwasher must have a backflow assembly installed on the plumbing between dishwasher and sewer line:*

Yes
No
N/A

Hot and cold running water provided to all required plumbing fixtures: *

Yes
No
N/A

Drain boards at dishwashing equipment drain by gravityinstalled for both clean and soiled tableware and equipment:*

Yes
No
N/A

One or two-compartment sink installed for food preparation:*

Yes
No
N/A

Separate hand washing sink installed in food preparation area:*

Yes
No
N/A

Single-use hand towel dispenser or heated air hand dryers and liquid soap, provided at kitchen hand washing sink: (The use of hand sanitizer or a bleach bucket is not a substitute for hand washing):*

Yes
No
N/A

Mop sink installed outside food preparation area:*

Yes
No
N/A

Fountain syrup dispenser system isolated from water supply with a vented dual check valve or other approved backflow prevention device (Fountain soda dispenser):*

Yes
No
N/A

Appropriate indicating thermometers provided for all hot and cold food service equipment, food storage and food transport units:*

Yes
No
N/A

Equipment and utensils for food service are with the current standards and listingof the National Sanitation Foundation (NSF):*

Yes
No
N/A

If equipment and utensils are not NSF approved, please explain:*

Yes
No
N/A

Buffet and/or salad bar commercial quality construction, equipped with sneeze guards and capable of maintaining potentially hazardous foods at 135oF or above, or 41oF or below during service:*

Yes
No
N/A

Adequate commercial refrigeration for cooling foods,cold holding, and storage of raw and ready to eat potentially hazardous foods:*

Yes
No
N/A

Salad bar indirectly drained:*

Yes
No
N/A

*Indirect drain is a drain that has an air gap between piping segments or between the outflow pipe and floor drain to prevent backflow from occurring. WAC 246-215 states that the air gap between the water supply inlet and flood level rim must be at least twice the diameter of the water supply inlet and not less than 1 inch.

Food preparation sinks indirectly drained:*

Yes
No
N/A

Two foot backsplashes provided behind all sinks, food preparations surfaces:*

Yes
No
N/A

Installation of utility service lines does not obstruct floor,wall, ceiling and equipment cleaning:*

Yes
No
N/A

Storage

Permeable food storage containers are kept 6” off the floor andprotected from contamination:*

Yes
No
N/A

Exposed or unprotected sewer lines or other utility lines constructed in a manner that does not subject foods and containers of foods to contamination:*

Yes
No
N/A

Separate area provided for cleaning equipmentsuch as mops, brooms, chemicals etc.:*

Yes
No
N/A

Location of these items:

Designated location for employee storage of personal belongings:*

Yes
No
N/A

Location:

Adequate lighting provided throughout establishment:*

Yes
No
N/A

Lights shielded from breakage in the food preparation, service, storage and display areas and where utensils and equipment are cleaned and stored:*

Yes
No
N/A

Ventilation and fire suppression equipment installed for facility, toilet rooms, and cooking equipment as required:*

Yes
No
N/A

Filters or other grease-extracting equipment used in ventilation devices readily removable for cleaning and replacement,or designed to be cleaned in place:*

Yes
No
N/A

Health Department regulations require public restrooms when customer seating is provided:*

Yes
No
N/A

Restrooms: Employees

Hand washing sink with liquid soap and hand towel(s) or heated air hand drying devices and toilet tissuedispenser provided in toilet room(s):*

Yes
No
N/A

Hot (minimum temperature of 100 ̊F) and cold running water provided through a mixing faucet:*

Yes
No
N/A

Will a dumpster be used on-site:*

Yes
No
N/A

If yes, name of disposal company and pick-up frequency:

Additional Requirement for Mobile Units

Letter/lease giving permission for mobile operators to useRestrooms (within 200 feet), parking site, and approved commercial kitchen: *

Grey water tank is 15% larger than potable water tank and has a capacity of minimum 5 gallons fresh water storage:*

Food grade hose for filling potable water tank:*

All mobile food units must contact The Washington State Department of Labor and Industries (L&I at 1-800-547-9411) for an electrical inspection. No permit can be issued until your mobile food unit has passed the L&I inspection. Be ready to show copy of approved inspection.*

Search Forms:

2022 Full Packet Food Establishment Permit Application -- Jefferson County Public Health

Steps

Step One

FOOD SERVICE ESTABLISHMENT APPLICATION GUIDELINES

FOOD SERVICE ESTABLISHMENT PLAN REVIEW APPLICATION

New or Remodeled Food Service Establishment Requirements

Step Five