PLANS AND SPECIFICATIONS MUST BE APPROVED BEFORE CONSTRUCTION AND RENOVATION
BEGINS.
Louisiana Administrative Code Title 51, Part XXIII, Chapter 3, §307.A.
Retail Food Plan Review Questionnaire
Name of establishment:
Phone #: ( )
1.
2.
Physical address of establishment:
3.
Mailing address if different from physical address:
4.
Owner of business:
5.
Name of corporation, partnership, LLC, or LLP (if applicable):
6.
If a partnership, list partner name(s):
7.
Business owner contact information: Home #: ( ) Cell phone #: ( )
Email address:
*Used for inspection reporting, recall information, boil water advisories, and other pertinent information.
Owner of the real property (land and building):
Phone #: ( ) Cell phone #: ( )
8.
9.
Has the facility for which this application is hereby made been previously permitted by the Department
of Health for the purposes of operating a Retail Food Establishment?
yes
no
10.
If you answered yes to the previous question, what was the name of the previous business?
11.
Will the occupancy classification (i.e. bar, restaurant, grocery) of the business for which you are
applying remain exactly the same as the previous business?
yes
no
12.
Name of responsible agent if different from business owner:
Phone #: (
) Email address:
Mailing Address:
13.
Type of business: Enter letter for type of business from choices:
I.
seafood market
J.
meat market
K.
bakery
L.
hospital/clinic cafeteria
M.
day care/with food prep
A.
B.
C.
D.
E.
F.
G.
H.
restaurant
restaurant/bar
bar
grocery- Packaged only (chips and candy)
grocery – deli (kitchen)
nursing home cafeteria
group home – number of residents
other–be specific
*Please complete a Mobile Unit Plan Review Questionnaire if you will be operating a mobile unit.
RFPRQ Rev. 9/2021
PLANS AND SPECIFICATIONS MUST BE APPROVED BEFORE CONSTRUCTION AND RENOVATION BEGINS.
Louisiana Administrative Code Title 51, Part XXIII, Chapter 3, §307.A.
15.
Type of submission: Enter letter from choices below:
change of existing business ownership only
conversion of non-food establishment to food establishment
new construction of retail food establishment
renovation/remodel of existing retail food business
reopening of previously closed food establishment. How long was it closed?
A.
B.
C.
D.
E.
F.
change of existing retail food business and real property ownership
G.
other – be specific
16.
If increasing the square footage of the business or the usable area, indicate the
following:
Existing footage:
+
=
Proposed square footage change:
Total:
17.
Total square footage of the business:
Usable square footage of the business:
18.
Plumbing:
Ladies
# toilets *
(*For information purposes only)
Restrooms
UNISEX
# toilets *
# hand wash sinks
Men
# toilets * #urinals *
# hand wash sinks *
# hand wash sinks
Self-closing doors (when applicable):
yes
no
yes
no
Self-closing, self-metered faucets (when applicable):
no
Mechanically vented to outside atmosphere:
yes
Public access:
yes
no
Toilets are in separate compartments/stalls:
yes
no
Privacy partition provided for urinals:
yes
no
Floor drains:
yes
no
not applicable (reason) _
Other plumbing
*Water fountains: number provided
not applicable (state reason)
Indirect drain connections provided at food preparation sinks (including three compartment sink):
yes
no
not applicable (state reason) _ _ _
19.
Does this establishment now hold or will apply for an alcohol license?
yes
no
20.
Does this establishment now or in the future plan to wholesale food products?
If yes, you must contact the Food and Drug Office at (225) 342-7533.
If wholesale product is seafood contact the Seafood Office at (225) 342-7653.
yes
no
Retail Food Plan Review Questionnaire
Page 2 of 6
☐
☐
☐
☐
PLANS AND SPECIFICATIONS MUST BE APPROVED BEFORE CONSTRUCTION AND RENOVATION BEGINS.
Louisiana Administrative Code Title 51, Part XXIII, Chapter 3, §307.A.
21.
Is this establishment connected to a public water system?
yes Name of System:
no (must submit water well plans)
Is this establishment connected to a public sewer system?
yes Name of System:
no (must submit sewage system plans)
Grease trap provided or proposed for facility
22.
23.
24.
What is the method of garbage/waste disposal?
25.
If a dumpster pad is required, will hot and cold water be available to the site for cleaning and will a drain
to the approved sewage system be available directly in the dumpster area?
Yes
No
26.
Will you serve raw oysters?
Yes
No
Note: You must indicate on the menu, on placards, at any point of sale,
clearly visible messages to the consumer either of the following advisories regarding the consumption of
raw oysters and other protein products. LAC Title 51. Part XXIII. §1109. A.
"1."THERE MAY BE A RISK ASSOCIATED WITH CONSUMING RAW SHELLFISH AS IS THE CASE WITH OTHER RAW
PROTEIN PRODUCTS. IF YOU SUFFER FROM CHRONIC ILLNESS OF THE LIVER, STOMACH OR BLOOD OR HAVE OTHER
IMMUNE DISORDERS, YOU SHOULD EAT THESE PRODUCTS FULLY COOKED"; or
2."CONSUMING RAW OR UNDERCOOKED MEATS, POULTRY, SEAFOOD, SHELLFISH OR EGGS MAY INCREASE YOUR
RISK OF FOODBORNE ILLNESS, ESPECIALLY IF YOU HAVE CERTAIN MEDICAL CONDITIONS."
27. Will you serve crawfish or shrimp that originated in a country other than the United States?
Yes
No
Note: If you use menus and serve crawfish or shrimp that originates in a foreign country, you must indicate on
the menu its country of origin or use the term "imported" immediately adjacent to the menu listing of the
seafood item being sold, in the same font, size and shade as the menu item. Alternately, if menus are not used, a
sign must be posted at the main entrance to the establishment that states"Certain crawfish and shrimp originate
from a foreign country". The sign must be 18 inches tall and 18 inches wide, written in English letters at least 1
inch in size and posted in a conspicuous location not less than thirty-six inches from the floor.
Retail Food Plan Review Questionnaire
Page 3 of 6
Permits are not transferable. After permitting, any change in operation requires notification be made to the
Louisiana Department of Health Environmental Office and may require submission of a modified plans review
packet. Substantial renovation is defined in the definitions section of the Sanitary Code Retail Food Part XXIII.
PLANS AND SPECIFICATIONS MUST BE APPROVED BEFORE CONSTRUCTION AND RENOVATION BEGINS.
Louisiana Administrative Code Title 51, Part XX III, Chapter 3, §307.A.
A MENU MUST BE SUBMITTED WITH THIS APPLICATION. Please complete MENU
ATTACHMENT A.
Days and Hours of Operation:
FLOOR PLAN IS REQUIRED (HAND-DRAWN OR PROFESSIONALLY-DRAFTED ) Please attach the
finish schedule for walls, ceilings and floors.
Louisiana law requires a Louisiana Department of Health Food Safety Manager Certificate verifying an owner
or employee has been certified as a Food Safety Manager for facilities preparing food. See requirements and
exemptions link below. Do you employ a Food Safety Manager with a current LDH Food Safety Certificate?
28.
29.
30.
☐ Yes ☐ No
Certificate #
Expiration Date
Name of the Certificate Holder
I have received a copy of Act 66. ☐ Yes
☐
31.
No
Signature Required
PLANS AND SPECIFICATIONS MUST BE APPROVED BEFORE CONSTRUCTION AND
RENOVATION
BEGINS. Louisiana Administrative Code Title 51, Part XXIII, Chapter 3, §307.A.
Signature of person preparing this form
Date of signature
Printed Name and Title of person preparing and signing this form
Permits are not transferable. After permitting, any change in operation requires notification be
made to the Louisiana Department of Health Environmental Office and may require submission
of a modified plans review packet. Substantial renovation is defined in the definitions section of
the Sanitary Code Retail Food Part XXIII.
Contacts and important information:
State Sanitarian located in the Parish you wish to operate: http://ldh.la.gov/index.cfm/page/394
It is recommended that you obtain a copy of Title 51 (Public Health - Sanitary Code) Part XXIII
Retail Food Operations:
http://www.doa.la.gov/Pages/osr/lac/books.aspx
Food Safety Manager Certification Provider List and Application: http://new.dhh.louisiana.gov/index.cfm/
page/632/n/228
Page 4 of 6
Retail Food Plan Review Questionnaire
PLANS AND SPECIFICATIONS MUST BE APPROVED BEFORE CONSTRUCTION AND RENOVATION
BEGINS.
Louisiana Administrative Code Title 51, Part XXIII, Chapter 3, §307.A.
List each food item and its preparation procedures.
Retail Food Plan Review Questionnaire
Page 5 of 6
COMMERCIAL
PRE-
PACKAGED
ITEM
Menu Attachment A
Process Review Form is not Fillable
HOT
HOLDING
How?
Where?
REHEATING
How? Where?
COOLING
How?
Where?
COOK
How?
Where?
COLD
HOLDING
How?
Where?
CUT/WASH/
ASSEMBLE
How? Where?
THAW
How?
Where?
FOOD
PLANS AND SPECIFICATIONS MUST BE APPROVED BEFORE CONSTRUCTION AND RENOVATION BEGINS.
Louisiana Administrative Code Title 51, Part XXIII, Chapter 3, §307.A.
ACT 66 NOTICE
A new Louisiana law, Act 66, authorizes the Louisiana Department of Health to charge a fee of $150 to
any permitted food establishment that fails to correct the necessary sanitary code violations to be in
compliance following its 1st re-inspection.
The implementation date is September 1, 2017.
This new law is intended to help prompt facilities to make the necessary corrections and come into
compliance as soon as possible to protect public health.
Re-inspections are required when there are five or more uncorrected non-critical violations and/or one or
more uncorrected critical violations remaining at the conclusion of an inspection.
The fee is only charged if the necessary violations are not corrected following the 1st re-inspection,
resulting in a 2nd re-inspection and possibly other subsequent re-inspections.
Establishments can avoid this fee if the violations noted on the routine inspection report are corrected
by, or during, the 1
st
re-inspection.
The $150 fee is payable within 30 days’ notice, and failure to pay shall result in revocation of the permit.
Page 6 of 6
Retail Food Plan Review Questionnaire
