Title Page
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Conducted on
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Applicant Name and Title
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Location
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Establishment Name
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Applicant Name
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Establishment Mailing Address
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Establishment Site Address
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Establishment Number
Checklist
Establish protocols to maintain six feet of physical distance among employees and patrons.
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Limit occupancy as necessary, to maintain six feet physical distancing
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Consider establishing a maximum number of people per square foot to maintain physical distancing requirements (see example calculator in Resources section)
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Space tables appropriately to keep patrons six feet apart while seated and while moving in and out of chairs
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Eliminate the use of waiting areas and standing areas
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Space seating at counters and bars at least six feet apart between parties while seated
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Prohibit counter and bar ordering and have drinks and food served at tables
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If this the above not feasible, consider appropriate distancing and protective measures for employee safety (e.g. use of sneeze guards, distancing markings on the floor, electronic ordering, etc.)
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Make sure employees and patrons maintain at least a six-foot distance when waiting in line for entrance to the establishment
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For establishments using employees to check identification or collect cover charges, limit employee exposure by requiring face coverings and gloves; ensure patrons standing in line are waiting at least six feet apart
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If live and other entertainment is offered, that may create a congregation of patrons around the entertainment (e.g. dancing or standing front of the stage) consider the provision of a barrier between the patrons and the entertainment to keep at least a six-foot distance
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Other measure (specify)
Establish protocols to reduce the risk of spread of the COVID-19 virus by training employees on cleaning and disinfection procedures, and protective measures.
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Dedicate certain staff members to disinfection of high contact surfaces throughout the establishment and disinfection of tables between parties
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Refrain from using pre-set tableware if food is served
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Refrain from refillable drinks
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Make sure growlers and refillable or reusable containers are cleaned prior to refilling
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Verify ware-washing machines are operating at the required wash and rinse temperatures and with the appropriate sanitizers each day
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Require all employees in contact with patrons to wear cloth face coverings and gloves during their shift and change gloves after touching patron items
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Make sure to disinfect frequently any pool tables, shuffle boards, darts, bag toss and other games being used and if this is not feasible consider eliminating their use
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Update employee illness policy and provide COVID-19 staff training
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Monitor employee health
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Screen employees for fever and symptoms before every shift
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Check temperature with non-contact thermometer; if no fever, which is a temperature greater than 100.4°F, or COVID-19 symptoms are present, require workers to self-monitor and report onset of symptoms during their shift
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Inform staff regarding when they should stay home or when they should leave work due to illness
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Make sure a procedure is in place for contacting your local public health district if an employee is diagnosed with COVID-19
Identify other measures to reduce exposures to COVID-19
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Post signs on the front door or window that states that any customer, who has a fever or other COVID-19 symptoms, must refrain from entering
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Provide signage throughout the establishment reminding patrons to practice physical distancing and proper hand hygiene
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Make hand sanitizer available throughout the establishment
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Limit the number of patrons in the facility at one time
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Direct the flow of traffic in the establishment to maximize space between people (e.g. lines marked on the floor)
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Use signage and barrier protection to limit movement and maintain distancing
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Limit employee and patron contact by using contactless payment methods when possible
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Keep photo booths or other novelty attractions closed (if applicable)
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Use observation personnel to make sure distancing and disinfection procedures are followed
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Dedicate staff to maintain sanitation for high touch surfaces
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Eliminate self-serve snacks and water
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Close drinking fountains
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Create low decibel environments to prevent people from needing to talk loudly, shout or lean close to hear if not providing live or other entertainment
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Improve ventilation, if possible, by opening windows and doors or adjusting the HVAC system
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Describe other plans
Sign Off
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Name and Signature
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This document is a TEMPLATE EXAMPLE. Please contact your local Public Health District for the preferred form.
