Specialized Food Processing Questionnaire printable pdf download

Specialized Food Processing Questionnaire

SAN FRANCISCO DEPARTMENT OF PUBLIC HEALTH

ENVIRONMENTAL HEALTH BRANCH

1390 Market Street, Suite 210, San Francisco, CA 94102

Phone: (415) 252-3800 Fax: (415) 252-3842

Specialized Food Processing Questionnaire

Business Name:

Date:

Business Address:

Owner Name:

(

)

Phone:

E-mail Address:

INDICATE WHICH OF THE FOLLOWING FOOD PROCESSING METHODS ARE USED:

See definitions on Page 3 for additional information

Reduced Oxygen Packaging(ROP)

Canning/bottling (excluding juices)

Modified Atmosphere Packaging (MAP)

Using food additives, such as vinegar, to make the

food non-potentially hazardous

Vacuum packaging

Processing/butchering meats brought in by

Sous vide

customers

Cook-chill

Fermenting foods/ingredients

Smoking

Bottling juices

Curing

Storing live molluscan shellfish in water tanks

Using acidification or reducing water activity to

Other (Example: seed sprouting):

prevent the growth of Clostridium botulinum

NOTE: Equipment used for any of the above processes must meet American National Standards Institute (ANSI) standards

and must be approved by this department prior to installation. (California Retail Food Code Section §114130) See the Plan

Check Guidelines for additional information on equipment.

I certify that this business does not use any method described above at this time and that I will

notify the San Francisco Department of Public Health before beginning any of the above processes in

the future.

I declare under penalty of perjury that to the best of my knowledge and belief, the statements made

herein are correct and true. I hereby consent to all necessary fees and inspections made pursuant to the

operation of this business and for the review of these processes. I also agree to conform to all

conditions, orders, and directions issued pursuant to the California Health and Safety Code, and all

applicable County and City Ordinances.

Owner/Authorized Signature:

Date:

Print Name:

Position/Title:

For Department of Public Health Office Use Only

Reviewed by:______________________________(Print) __________________________________(Sign)

Date:_____________

Location ID:_________________________

Page 1 of 3

Specialized Food Processing Questionnaire

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