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HomeMy WebLinkAboutTUP2023-382009/15/16 Tarrant County Public Health Department Environmental Health Promotion 1101 S. Main Street, Room 2300 Fort Worth, Texas 76104 Phone: (817) 321-4960 Fax: (817) 321-4961 Temporary Food Establishment Permit Application PLEASE COMPLETE & RETURN THIS FORM WITH FEE FOR EACH STAND AT LEAST 10 DAYS BEFORE THE START OF THE EVENT. Fee Information: (submit one of the following) 1) $35.00 for each stand or unit. We are unable to accept credit/debit cards by phone or online. 2) IRS 501 (c) (3) official recognition documentation for tax exempt charitable organizations. General Event Information: 3) Name of Event: ___________________________________________________________ 4) Date(s) of Event: __________________________________________________________ 5) Hours of Operation: ________________________________________________________ 6) Location of Event: _________________________________________________________ 7) Event Coordinator: Name: ___________________________________________ Phone: ________________ Address: ________________________________________________________________ Applicant Information: 8) Your Organization/Business Name: ___________________________________________ 9) Applicant’s Name: _________________________________________________________ Address: ________________________________________________________________ City: ____________________________ State: _________________ Zip: ____________ Business Phone: _______________________ Home Phone: _______________________ Mobile Phone: _________________________ Fax: ______________________________ Email: __________________________________________________________________ 10) Does this business have a current mobile food unit or pushcart permit from the Tarrant County Health Department? [ ] Yes [ ] No If yes, what is the permit type and site number? __________________________________ Note: Vendors with these types of health permits are not required to pay the permit fee for a temporary food service establishment. 11) List full menu to be served at the event: ________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 09/15/16 Temporary Food Establishment Permit Application Page 2 Tarrant County Public Health Department 12) Where will the food be purchased/obtained from: ________________________________ _______________________________________________________________________ 13) Will any foods be prepared prior to the start of the event? [ ] Yes [ ] No If yes, where will the food be prepared? _______________________________________ _______________________________________________________________________ If answering yes to question 11, all foods prepared prior to the event are required to be made in an approved and permitted facility. A copy of the Food Establishment Permit and signed Commissary Agreement (attached) are required for approval of this application. Applications submitted without this information will be returned. Has a copy of the Food Establishment Permit and signed Commissary Agreement been included with this application? [ ] Yes [ ] No [ ] N/A 14) Will frozen foods be thawed at the event? [ ] Yes [ ] No If yes, describe process/method to be used: ____________________________________ 15) How will any leftovers of cooked food be handled at the end of the day? _______________________________________________________________________ 16) How will food temperatures be checked during the event? __________________________ 17) Describe equipment used at the event for: a) Cold holding: _________________________________________________________ b) Hot holding: _________________________________________________________ c) Cooking/Reheating: ___________________________________________________ 18) Describe hand washing facilities inside your temporary food establishment: [ ] Plumbed Sink [ ] Gravity Flow Set-up 19) Describe utensil washing facilities inside your temporary food establishment: [ ] 3 Compartment Sink [ ] 3 Basin Set-up 20) How will hot water be made available for the hand wash and utensil washing stations? _______________________________________________________________________ 21) What type of sanitizer will be used at the event? _________________________________ 22) How will potable water be obtained during the event? _____________________________ 23) How will waste water from hand & utensil washing be disposed? ____________________ _______________________________________________________________________ Form completed by: ___________________________________________________________ Name/Title Date FO O D H A N D L E R S : Av o i d f o o d h a n d l i n g w h e n y o u h a v e t h e f o l l o w i n g sy m p t o m s .  Di a r r h e a .  Vo m i t i n g .  So r e t h r o a t w i t h f e v e r .  Pe r s i s t e n t c o u g h i n g , s n e e z i n g o r n a s a l d i s c h a r g e .  Wo u n d c o n t a i n i n g p u s u p o n y o u r f i n g e r s , h a n d s , wr i s t s .  Ye l l o w i s h e y e s o r s k i n w i t h d a r k c o l o r e d u r i n e . Re p o r t a n y o f t h e s e s y m p t o m s t o y o u r m a n a g e r i m m e - di a t e l y . Pe r s o n n e l t h a t h a n d l e f o o d m u s t w a s h t h e i r ha n d s a s f r e q u e n t l y a s n e c e s s a r y . D i s p o s a - bl e g l o v e s m a y b e u s e d b u t t h e i r u s e d o e s no t s u b s t i t u t e f o r h a n d w a s h i n g . Th e u s e o f t o b a c c o i n a l l f o r m s i s p r o h i b i t e d i n t h e f o o d pr e p a r a t i o n o r s e r v i c e a r e a s . Pe r s o n n e l s h a l l n o t e a t o r d r i n k i n t h e f o o d p r e p a r a t i o n or s e r v i c e a r e a s . Ha i r r e s t r a i n t s a n d c l e a n c l o t h i n g a r e r e q u i r e d o f p e r - so n n e l d o i n g f o o d p r e p a r a t i o n . F o o d h a n d l e r s a r e n o t pe r m i t t e d t o w e a r o r n a t e h a n d j e w e l r y . Un a u t h o r i z e d p e r s o n n e l s u c h a s s m a l l c h i l d r e n a r e n o t pe r m i t t e d i n b o o t h s . BA R E H A N D C O N T A C T : Ba r e h a n d c o n t a c t o f r e a d y t o e a t f o o d b y w o r k e r s i s no t a l l o w e d . Re a d y -to -ea t f o o d i n c l u d e s a n y f o o d , f r u i t o r v e g e t a b l e pr o d u c t t h a t i s e d i b l e w i t h o u t w a s h i n g , c o o k i n g , o r a d - di t i o n a l p r e p a r a t i o n b y w o r k e r s , a n d i s r e a s o n a b l y e x - pe c t e d t o b e c o n s u m e d i n t h a t f o r m . Av o i d t o u c h i n g f o o d w i t h b a r e h a n d s b y u s i n g u t e n s i l s , di s p o s a b l e g l o v e s , d e l i t i s s u e o r o t h e r s u i t a b l e m e t h o d s . Te m p o r a r y F o o d Es t a b l i s h m e n t Re q u i r e m e n t s Ta r r a n t C o u n t y P u b l i c H e a l t h D e p a r t m e n t 11 0 1 S . M a i n S t . , R o o m 2 3 0 0 Fo r t W o r t h , T e x a s 7 6 1 0 4 81 7 -32 1 -49 6 0 CH E C K L I S T :  Va l i d t e m p o r a r y o r m o b i l e f o o d u n i t p e r m i t i s s u e d by T a r r a n t C o u n t y P u b l i c H e a l t h D e p a r t m e n t .  Fo o d f r o m a n a p p r o v e d s o u r c e . N o f o o d p r e p a r e d in a p r i v a t e h o m e . Fo o d i n v o i c e s / r e c e i p t s m u s t b e av a i l a b l e a t b o o t h f o r i n s p e c t o r ’ s a u d i t .  Ad e q u a t e s u p p l y o f p o t a b l e w a t e r a t b o o t h .  Wa s t e w a t e r c o n t a i n e r s a n d p r o p e r d i s p o s a l s i t e .  Bo o t h s w i t h c l e a n a b l e f l o o r (g r a s s a n d d i r t c o v e r e d wi t h a p p r o v e d m a t e r i a l ) a n d o v e r h e a d p r o t e c t i o n .  BB Q a n d d e e p -fr y i n g c o o k i n g a r e a s f e n c e d o f f fr o m p u b l i c a c c e s s .  Ad e q u a t e c o n t a i n e r s , c o v e r s , w r a p p i n g s o r o t h e r me a n s t o e f f e c t i v e l y p r o t e c t f o o d f r o m i n s e c t s a n d ot h e r e n v i r o n m e n t a l c o n t a m i n a t i o n .  Ha n d w a s h s t a t i o n s e t u p a n d r e a d y f o r u s e .  5 g a l . c o n t a i n e r w i t h n o n -se l f -cl o s i n g s p i g o t .  Li q u i d s o a p i n p u m p d i s p e n s e r .  Pa p e r t o w e l s .  Wa s t e w a t e r c a t c h b u c k e t .  Ut e n s i l c l e a n i n g s t a t i o n s e t u p a n d r e a d y f o r u s e .  3 c o n t a i n e r s (s i z e d t o i m m e r s e a l l i t e m s )  So a p y w a t e r i n 1 st co n t a i n e r .  Cl e a n r i n s e w a t e r i n 2 nd co n t a i n e r .  Sa n i t i z i n g s o l u t i o n i n 3 rd co n t a i n e r .  Sa n i t i z e r c o n c e n t r a t e (b l e a c h ) an d t e s t s t r i p s .  En o u g h e q u i p m e n t p r o v i d e d t o h o l d A L L :  Co l d f o o d s a t 4 1 ° F o r b e l o w .  Ho t f o o d s a t 1 3 5 ° F o r a b o v e .  Pr o b e -ty p e , m e t a l s t e m f o o d t h e r m o m e t e r w i t h pr o p e r r a n g e (0 ° F t o 2 2 0 ° F ) .  Ut e n s i l s a n d d i s p o s a b l e g l o v e s p r o v i d e d t o m i n i - mi z e h a n d c o n t a c t w i t h f o o d .  Wo r k e r s a r e w e a r i n g c l e a n c l o t h i n g a n d h a i r i s ef f e c t i v e l y r e s t r a i n e d .  Wo r k e r s h a v e n o o p e n s o r e s a n d a r e f r e e o f i l l n e s s sy m p t o m s l i s t e d i n b r o c h u r e .  Wo r k e r s k e e p h a n d s c l e a n a n d w a s h h a n d s f r e - qu e n t l y .  No b a r e h a n d c o n t a c t w i t h r e a d y t o e a t f o o d .  Co n d i m e n t s p r o v i d e d i n s i n g l e -se r v i c e , p u m p -ty p e or s q u e e z e c o n t a i n e r s .  Sn e e z e g u a r d s a n d b a r r i e r s t o p r o t e c t e x p o s e d f o o d an d f o o d w o r k s u r f a c e s f r o m c u s t o m e r s . TE M P O R A R Y F O O D E S T A B L I S H M E N T : Th e t e r m t e m p o r a r y f o o d e s t a b l i s h m e n t a p p l i e s t o a n es t a b l i s h m e n t t h a t o p e r a t e s a t a f i x e d l o c a t i o n f o r a p e r i - od o f t i m e o f n o t m o r e t h a n 1 4 c o n s e c u t i v e d a y s i n c o n - ju n c t i o n w i t h a s i n g l e e v e n t o r c e l e b r a t i o n . PE R M I T R E Q U I R E D : Pe r s o n s v e n d i n g o r o f f e r i n g s a m p l e s o f f o o d o r b e v e r a g e pr o d u c t s m u s t s e c u r e a v a l i d T a r r a n t C o u n t y H e a l t h D e - pa r t m e n t p e r m i t p r i o r t o o p e r a t i o n . P e r m i t s i s s u e d b y ot h e r h e a l t h a u t h o r i t i e s a r e n o t a c c e p t a b l e . Ve n d o r s h a n d l i n g o n l y c o m m e r c i a l p r e - p a c k a g e d , s h e l f - st a b l e , n o n -po t e n t i a l l y h a z a r d o u s f o o d s d o n o t n e e d a pe r m i t . CO N S T R U C T I O N O F S T A N D : Al l s t a n d s m u s t h a v e a s u i t a b l e t i g h t - fi t t i n g , w a t e r r e p e l l e n t r o o f o r c e i l i n g t o p r o v i d e f o r o v e r - he a d p r o t e c t i o n o f f o o d p r e p a r a t i o n , c o o k i n g a n d s e r v i n g ar e a s . Al l s t a n d s m u s t h a v e a p p r o v e d f l o o r i n g , w h i c h i n c l u d e s co n c r e t e , a s p h a l t o r t i g h t -fi t t i n g p l y w o o d o r o t h e r s i m i l a r ap p r o v e d m a t e r i a l . If f u l l w a l l s a n d s c r e e n i n g a r e p r o v i d e d , o t h e r s u i t a b l e me t h o d s o f p r o t e c t i n g f o o d f r o m c o n t a m i n a t i o n , s u c h a s co n t a i n e r s , c o v e r s o r w r a p p i n g s m u s t b e u s e d . Ad e q u a t e c o v e r e d r e c e p t a c l e s f o r d i s p o s a l o f s o l i d w a s t e mu s t b e p r o v i d e d . Ad e q u a t e t o i l e t f a c i l i t i e s m u s t b e a c c e s s i b l e f o r w o r k e r s . WA T E R S U P P L Y & W A S T E W A T E R D I S P O S A L : Po t a b l e w a t e r m u s t b e f r o m a n a p p r o v e d s o u r c e a n d k e p t on -si t e i n s u f f i c i e n t q u a n t i t i e s f o r e a c h d a y ’ s u s e . Al l w a s t e w a t e r g e n e r a t e d f r o m t h e t e m p o r a r y f o o d e s - ta b l i s h m e n t ( f r o m b e v e r a g e d i s p e n s e r s , s i n k s , s t e a m t a - bl e s , i c e m e l t , e t c . ) m u s t b e d i s p o s e d o f i n t o t h e s a n i t a r y se w e r s y s t e m o r a p p r o v e d s e p t i c s y s t e m . UT E N S I L W A S H I N G : Th o s e s t a n d s t h a t d o n o t h a v e 3 -co m p a r t m e n t s i n k s w i t h ho t a n d c o l d r u n n i n g w a t e r m u s t p r o v i d e t h e f o l l o w i n g : Th r e e ( 3 ) s t u r d y p l a s t i c o r s t a i n l e s s s t e e l b u c k e t s o r tu b s o f a d e q u a t e s i z e t o b e u s e d f o r u t e n s i l c l e a n i n g an d s a n i t i z i n g . On e b u c k e t o r t u b s h a l l b e u s e d t o w a s h ( s o a p y w a - te r ) ; On e b u c k e t o r t u b s h a l l b e u s e d t o r i n s e ( c l e a n , c l e a r wa t e r ) ; On e b u c k e t o r t u b s h a l l b e u s e d t o s a n i t i z e ( l i q u i d ch l o r i n e b l e a c h / w a t e r s o l u t i o n w i t h 2 t e a s p o o n s o f bl e a c h p e r g a l l o n w a t e r ) . U s e c h l o r i n e t e s t s t r i p t o ve r i f y p r o p e r s t r e n g t h o f 5 0 t o 1 0 0 p p m . HA N D W A S H I N G : So a p , p a p e r t o w e l s a n d a c o n t a i n e r ( 5 g a l l o n m i n i m u m ) wi t h a s p i g o t t h a t r e m a i n s o p e n t o w a s h b o t h h a n d s s h a l l be p r o v i d e d f o r h a n d w a s h i n g . Co n t a i n e r s w i t h s e l f -cl o s i n g s p o u t s a r e n o t a c c e p t a b l e . In a d d i t i o n , a b u c k e t t o c a t c h w a s t e w a t e r s h a l l b e p r o - vi d e d . FO O D P R E P A R A T I O N : Al l f o o d s m u s t b e f r o m a n a p p r o v e d s o u r c e a n d / o r l i - ce n s e d f a c i l i t y o r p r e p a r e d i n t h e t e m p o r a r y b o o t h . An a p p r o v e d s o u r c e i s a n e s t a b l i s h m e n t th a t i s u n d e r i n s p e c t i o n a n d / o r l i c e n s e d b y a h e a l t h a u t h o r i t y . NO fo o d s p r e p a r e d i n a p r i v a t e h o m e m a y be s o l d o r s e r v e d t o t h e p u b l i c . On l y s i n g l e -se r v i c e , d i s p o s a b l e i t e m s a r e t o b e p r o v i d e d fo r c u s t o m e r u s e . Al l f o o d s , f o o d c o n t a i n e r s , u t e n s i l s , n a p k i n s , b e v e r a g e cu p s , s t r a w s a n d o t h e r s i n g l e s e r v i c e i t e m s m u s t b e s t o r e d at l e a s t s i x i n c h e s a b o v e t h e f l o o r a n d p r o t e c t e d f r o m sp l a s h , d u s t , i n s e c t s , w e a t h e r o r o t h e r c o n t a m i n a t i o n . Al l p o t e n t i a l l y h a z a r d o u s f o o d p r o d u c t s m u s t b e st o r e d a t 4 1 ° F o r l o w e r o r a t 1 3 5 ° F o r a b o v e . A me t a l s t e m p r o d u c t t h e r m o m e t e r ( 0 ° F t o 2 2 0 ° F ) mu s t b e a v a i l a b l e a t t h e s t a n d s t h a t s e l l p o t e n t i a l l y ha z a r d o u s f o o d s . Se l f -se r v i c e o f i c e b y p a t r o n s i s n o t p e r m i t t e d . I c e s c o o p s mu s t b e u s e d b y w o r k e r s t o d i s p e n s e i c e . I c e f o r h u m a n co n s u m p t i o n m u s t b e s t o r e d s e p a r a t e l y f r o m i c e u s e d t o ch i l l o t h e r f o o d s o r b e v e r a g e s . Fo o d s a n d b e v e r a g e s c h i l l e d i n i c e m u s t n o t b e s u b - me r g e d i n w a t e r . T h e i c e s t o r a g e u n i t m u s t h a v e o p e n dr a i n s a n d c o v e r s . S t y r o f o a m i c e c h e s t s a r e n o t a c c e p t a - bl e f o r t h e s t o r a g e o f i c e o r o t h e r f o o d s p r o d u c t s . Al l c o n d i m e n t s , i n c l u d i n g o n i o n s , r e l i s h , c a t s u p , m u s t a r d , ma y o n n a i s e , e t c . , a v a i l a b l e f o r c u s t o m e r s e l f -se r v i c e m u s t be a v a i l a b l e i n s i n g l e s e l f -se r v i c e p a c k e t s o r p r o p e r l y di s p e n s e d f r o m s a n i t a r y d i s p e n s e r s . Cu s t o m e r s e l f -se r v i c e o f o p e n c o n d i m e n t s f r o m c o n t a i n - er s , e v e n i f p r o v i d e d w i t h l i d s , i s n o t a l l o w e d . So a p SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 9/19/2023 Marsh &McLennan Agency LLC 8144 Walnut Hill Lane,16th Floor Dallas TX 75231 Marisa Medina 214-686-3838 marisa.medina@marshmma.com National Fire Insurance Co of Hartford 20478 ULTIMTEALL Continental Casualty Company 20443UltimateTea,LLC 1685 Carlyle Ct Roanoke TX 76262 Certain Underwriters at Lloyd's 55555 The Continental Insurance Company 35289 10546124 A X 1,000,000 X 1,000,000 10,000 1,000,000 2,000,000 X B7012948631 9/20/2023 9/20/2024 2,000,000 A $1,000,000 X X B7012948631 9/20/2023 9/20/2024 B X X 1,000,000B70129487269/20/2023 9/20/2024 1,000,000 X 10,000 D XWC7129487099/20/2023 9/20/2024 1,000,000 1,000,000 1,000,000 C Food Borne Illness WPV Ded.$5K TNR229983 9/25/2023 9/20/2024 Resturant/Suppl Evts Ded Workplace Violence $500,000 $2,500 $150,000 Insurer:U.S.Specialty Insurance Company Policy #U722-917932 Policy Eff Dates:09/20/2023 -09/20/2024 Limit of Liability: Insuring Agreement A:$1,000,000 Each Claim and $1,000,000 Aggregate Insuring Agreement B:$1,000,000 Each Claim and $1,000,000 Aggregate Total Policy Aggregate Limit:$1,000,000 Deductibles: See Attached... City of Grapevine P.O.Box 95104 Grapevine TX 76051 ACORD 101 (2008/01) The ACORD name and logo are registered marks of ACORD © 2008 ACORD CORPORATION. All rights reserved. THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER:FORM TITLE: ADDITIONAL REMARKS ADDITIONAL REMARKS SCHEDULE Page of AGENCY CUSTOMER ID: LOC #: AGENCY CARRIER NAIC CODE POLICY NUMBER NAMED INSURED EFFECTIVE DATE: ULTIMTEALL 1 1 Marsh &McLennan Agency LLC Ultimate Tea,LLC 1685 Carlyle Ct Roanoke TX 76262 25 CERTIFICATE OF LIABILITY INSURANCE Insuring Agreement A:$5,000 Each Claim Insuring Agreement B:$5,000 Each Claim Retroactive Date:09/20/2021 Third Party Coverage Form #EPL 3000 (4.2017) Blanket Additional Insured form #SB146932G edition 10/2019 applies to the General Liability. Blanket Waiver of subrogation form #SB146932G edition 10/2019 applies to the General Liability. Blanket Primary &Non-Contributory General Liability form #SB146932G edition 10/2019 . Notice of Cancellation form #CNA68021XX edition 02/2013 applies to the Umbrella policy The General Liability policy includes a blanket additional insured endorsement to the certificate holder only when there is a written contract between the named insured and the certificate holder that requires such status. The General Liability policy contains an endorsement with “Primary and Non-Contributory”wording that may apply only when there is a written contract between the named insured and the certificate holder that requires such wording. The General Liability policy contains a blanket waiver of subrogation endorsement that may apply only when there is a written contract between the named insured and the certificate holder that requires such wording. The Umbrella policy includes a blanket notice of cancellation to the certificate holder endorsement,providing for (30)days’advance written notice if the policy is canceled by the company,or 10 days’written notice before the policy is canceled for nonpayment of premium.Notice is sent to certificate holders with mailing addresses on file with the agent or the company.The endorsement does not provide for notice of cancellation to the certificate holder if the named insured requests cancellation. GM GM N89°27'41"E 117.50' S 0 4 ° 3 7 ' 1 4 " E 2 6 8 . 0 6 ' S89°45'41"W 97.26'N79°38'31"W 20.37' N 0 4 ° 4 4 ' 1 9 " W 2 6 3 . 7 3 ' W. NORTHWEST HIGHWAY STATE HWY 114 & 121; LOOP 382 100' PUBLIC ROW WEST WALL STREET VARIABLE WIDTH PUBLIC ROW H T E A O F F E : 6 2 5 . 4 5 ' 2 , 3 5 0 S F O U T D O O R P A T I O RE F . A - 2 . 0 / A - 2 . 1 H T E A O F F E : 6 2 5 . 4 5 ' 2 , 3 5 0 S F O U T D O O R P A T I O RE F . A - 2 . 0 / A - 2 . 1 GM GM N89°27'41"E 117.50' S 0 4 ° 3 7 ' 1 4 " E 2 6 8 . 0 6 ' S89°45'41"W 97.26'N79°38'31"W 20.37' N 0 4 ° 4 4 ' 1 9 " W 2 6 3 . 7 3 ' W. NORTHWEST HIGHWAY STATE HWY 114 & 121; LOOP 382 100' PUBLIC ROW WEST WALL STREET VARIABLE WIDTH PUBLIC ROW H T E A O F F E : 6 2 5 . 4 5 ' 2 , 3 5 0 S F O U T D O O R P A T I O RE F . A - 2 . 0 / A - 2 . 1 H T E A O F F E : 6 2 5 . 4 5 ' 2 , 3 5 0 S F O U T D O O R P A T I O RE F . A - 2 . 0 / A - 2 . 1 19 10 4 25' FRONT BUILDING SETBACK R5' R30' LANDSCAPE ISLAND ADA PARKING RESTRIPE EXISTING ADA PARKING ADA SIGN ADA SIGN EXISTING WODDEN TRASH ENCLOSURE EXISTING TRANSFORMER LANDSCAPE AREA 6" PARKING STRIPING 18.0' 10.0' 11.3' 1 2 . 9 ' 23.2' 44.0' 15.2'31.3' MENU BOARD R40' 24.0' 6 5 . 0 ' CONCRETE CURB STOP 10' SIGN SETBACK PROPOSED POLE SIGN 2 18.0' 15.7' 2 4 . 0 ' PAVEMENT DIRECTIONAL MARKING 2 4 . 0 ' 9.7' 21.0' 25.1' PROPOSED ENTRANCE SIGN PROPOSED EXIT SIGN 18.0' 9 . 0 ' T Y P . 9 . 0 ' T Y P . PROPOSED LIGHT POLE PROPOSED LIGHT POLE PROPOSED LIGHT POLE PROPOSED LIGHT POLE PROPOSED LIGHT POLE 29 . 0 ' 14.0' R 5 . 0 ' R5.0' 9 . 0 ' T Y P . 9 . 0 ' T Y P . 24.0' 24' COMMON ACCESS EASEMENT 24' COMMON ACCESS EASEMENT REPAIR 24,045 SF OF EXISTING PAVEMENT 12.0'12.0' 24' FIRE LANE 6" PARKING STRIPING R5 . 0 ' V: \ 0 7 0 3 9 1 - H t e a O D r i v e - T h r o u g h G r a p e v i n e T x \ 0 7 0 3 9 1 - 0 1 - 0 0 1 ( E N G ) - P h o t o m e t r i c P l a n \ E n g i n e e r i n g - C i v i l \ E n g i n e e r i n g P l a n s \ C o n s t r u c t i o n P l a n s \ C 3 . 0 - S I T E P L A N . d w g , S I T E P L A N , A p r i l 2 0 , 2 0 2 1 , 1 2 : 4 8 P M , b b o r o RE V I S I O N S 04 / 1 9 / 2 0 2 1 PA R K I N G S P A C E R E L O C A T I O N 1 HT e a O 11 1 3 W . N O R T H W E S T H I G H W A Y GR A P E V I N E , T X 7 6 0 5 1 © B o w m a n C o n s u l t i n g G r o u p , L t d . TB P E F i r m R e g i s t r a t i o n N o . F - 1 4 3 0 9 P R E L I M I N A R Y N O T F O R C O N S T R U C T I O N Know what's below. before you dig.Call R BB PK KA 070391-01-001 Ph o n e : ( 9 7 2 ) 4 9 7 - 2 9 9 0 Fa x : ( 5 1 2 ) 3 2 7 - 4 0 6 2 ww w . b o w m a n c o n s u l t i n g . c o m 82 0 1 P r e s t o n R d . , Su i t e 7 0 0 B Da l l a s , T e x a s 7 5 2 2 5 SITE DATA & AREA CALCULATIONS CURRENT LAND USE CLASSIFICATION: COMMERCIAL FUTURE LAND USE CLASSIFICATION: COMMERCIAL CURRENT ZONING CLASSIFICATION: HC- HIGHWAY COMMERCIAL CURRENT LOCAL JURISDICTION: CITY OF GRAPEVINE MAX. ALLOWED BUILDING HEIGHT: 2 STORIES OR 35' MAX PROPOSED BUILDING HEIGHT: 1 STORY OR 19' EXISTING BUILDING SIZE: 2,455 SF PROPOSED BUILDING SIZE: 2,350 SF SITE AREA TOTAL: 31,270 SF (0.717 AC) EXISTING IMPERVIOUS AREA: 27,980 SF (0.642 AC) IMPERVIOUS AREA %: 89.48% PERVIOUS AREA OPEN SPACE: 3,290 SF (0.075 AC) PERVIOUS AREA %: 10.52% FLOOR AREA RATIO: 7.85% PROPOSED BUILDING AREA: 2,350 SF (0.054 AC) BUILDING AREA %: 7.52% GROSS PARKING IMPERVIOUS AREA: 24,045 SF (0.552 AC) IMPERVIOUS AREA %:76.89% PERVIOUS AREA OPEN SPACE: 4,875 SF (0.112 AC) PERVIOUS AREA %: 15.59% FLOOR AREA RATIO: 7.51% PARKING DATA REQUIRED SPACES: 12 SPACES + 1 SPACE PER 50 SF FLOOR AREA SERVICE AREA: 914 SF FLOOR AREA = 19 SPACES KITCHEN:1 SPACE PER 3 OCCUPANTS = 2 SPACES OUTDOOR SEATING: 2 SPACES PER 6 OUTDOOR SEATS = 2 SPACES REQUIRED SPACES: 12 + 19 + 2 + 2= 35 SPACES PROVIDED: 33 REGULAR 2 ADA 35 TOTAL TYPICAL DIMENSIONS:9' WIDTH 18' DEPTH PROPOSED LEGEND PROPOSED BUILDING PROPERTY LINE STD. 6" CONCRETE CURB PARKING SPACE COUNT 1 5/8" IRON ROD FOUND 5/8" IRON ROD AND CAP FOUND BOLLARD LAMP/POWER POLE GAS METER GUY ANCHOR IRRIGATION VALVE TELEPHONE PEDESTAL TREE SIGN BOUNDARY LINE ADJOINING PROPERTY LINE EDGE OF PAVEMENT BACK OF CURB FRONT OF CURB EDGE OF CONCRETE EDGE OF BUILDING CONCRETE SIDEWALK MAJOR CONTOUR LINE MINOR CONTOUR LINE PARKING SPACE STRIPE EASEMENT LINE WOOD FENCE FINISHED FLOOR ELEVATION OFFICIAL PUBLIC RECORDS OF TARRANT COUNTY, TEXAS BUILDING IRON FENCE EXISTING LEGEND GM SI T E P L A N 7 GENERAL SITE NOTES 1. ALL DIMENSIONS SHOWN ARE TO THE FACE OF CURB, PROPERTY LINE OR CENTERLINE OF STRIPING UNLESS OTHERWISE NOTED. 2. ALL EXISTING EASEMENTS, RIGHTS-OF-WAY, AND LOT LINES MAY NOT BE SHOWN. REFER TO THE ALTA/NSPS LAND TITLE SURVEY PREPARED BY BOWMAN CONSULTING GROUP, DATED DECEMBER 23, 2020, FOR COMPLETE BOUNDARY INFORMATION AND ASSOCIATED ENCUMBRANCES. 3. A PRE-CONSTRUCTION MEETING WITH CITY ENGINEER SHALL BE HELD PRIOR TO CONSTRUCTION COMMENCEMENT. 4. THE CITY OF GRAPEVINE SHALL BE GIVEN AT LEAST 48 HOURS NOTICE PRIOR TO PERFORMING ANY INSPECTIONS. 5. TRAFFIC CONTROL SHALL BE IN ACCORDANCE WITH THE PROJECT PLANS, THE CURRENT EDITION OF THE ODOT DESIGN STANDARDS AND THE LATEST MANUAL ON UNIFORM TRAFFIC CONTROL DEVICES (MUTCD). 6. ALL MECHANICAL EQUIPMENT TO BE ROOF MOUNTED AND SCREENED FROM HE STREET. 7. CONTRACTOR TO PROVIDE AS-BUILTS OF ALL IMPROVEMENTS TO THE SITE. AS-BUILTS TO INCLUDE HORIZONTAL AND VERTICAL LOCATIONS OF ALL UNDERGROUND UTILITIES INCLUDING, BUT NOT LIMITED TO, PIPES, FITTINGS, STRUCTURES, AND OTHER APPURTENANCES. ELEVATIONS OF PIPES AT CROSSING POINTS MUST BE SUFFICIENT TO IDENTIFY MINIMUM SEPARATION OF UTILITIES. IN ADDITION TO THE AFOREMENTIONED CRITERIA AS-BUILTS MUST MEET ALL LOCAL AND JURISDICTIONAL REQUIREMENTS FOR CERTIFICATION OF CONSTRUCTION. 8. ALL AFFECTED SIDEWALKS, RAMPS AND CROSSWALKS, WILL BE BUILT AND INSPECTED TO MEET CURRENT ADA REQUIREMENTS. 9. BUILDING SETBACK DIMENSIONS MEASURED TO OUTERMOST ARCHITECTURAL FEATURE. CONTRACTOR TO REFER TO ARCHITECTURAL PLANS FOR BUILDING DIMENSIONS. 10. ALL CURB RADII ARE 3' UNLESS SHOWN OTHERWISE. 11. PRIOR TO INSTALLATION, CONTRACTOR MUST VERIFY LOCATIONS OF LIGHT POLES, LANDSCAPING AND UTILITIES. 12. CONTRACTOR TO REFER TO ARCHITECTURAL PLANS FOR BUILDING FOOTPRINT. 13. CONTRACTOR TO REFER TO PHOTOMETRIC PLAN FOR LIGHT POLE DETAILS. CASE NAME: CASE NUMBER: ADDRESS: 1113 WEST NORTHWEST HIGHWAY, GRAPEVINE, TX 76051 SITE PLAN CITY OF GRAPEVINE APPROVED APPROVAL DOES NOT AUTHORIZE ANY WORK IN CONFLICT WITH ANY CODES OR ORDINANCES. _____________________ PLANNER _____________________ DATE SHEET: 7 OF 16 DEPARTMENT OF DEVELOPMENT SERVICES FIRE LANE STRIPING NOTES 1. STRIPING SHALL BE BRIGHT RED IN COLOR. 2. STRIPE WIDTH SHALL BE NO LESS THAN 6 INCHES. 3. WHERE STRIPING IS NEXT TO A CURB, THE CURB SHALL BE PAINTED ALSO. 4. WHERE STRIPING IS NOT POSSIBLE, FIRE LANE SIGNS SHALL BE PROVIDED. 5. THE WORDS "FIRE LANE NO PARKING TOW AWAY ZONE" SHALL BE PAINTED ON THE STRIPE SPACED EVERY 25'. Location of Cpusins trailer Ingree and Egress and fire exit plan remainunaffected from normal operations