Title Page

  • Conducted on

  • Applicant Name and Title

  • Location
  • Establishment Name

  • Applicant Name

  • Establishment Mailing Address

  • Establishment Site Address

  • Establishment Number

Checklist

Establish protocols to maintain six feet of physical distance among employees and patrons.

  • Limit occupancy as necessary to maintain six feet physical distancing

  • Space tables appropriately apart to keep patrons six feet apart while seated and moving in and out of chairs

  • Reduce the use of waiting areas and lobbies as feasible

  • Continue to keep playground areas closed

  • Limit employee and patron contact by using a reservation or call ahead model and using contactless payment methods when possible

  • Other measure (specify)

Establish protocols to reduce the risk of sprea of the COVID-19 virus by training employees on cleaning and disinfection procedures, and protective measures.

  • Dedicate certain staff members to disinfection of high contact surfaces throughout the establishment and disinfection of tables between parties

  • Refrain from using pre-set tableware

  • Clean and disinfect coolers, to-go containers, and delivery vehicles often

  • Verify ware-washing machines are operating at the required wash and rinse temperatures and with the appropriate sanitizers each day

  • Require all employees in contact with patrons to wear cloth face coverings and gloves during their shift and change them after touching patron items

  • Recommend all employees in the dish washing room to wear face shields in addition to face coverings and gloves

  • Update employee illness policy and provide COVID-19 staff training.

  • Monitor employee health by screening employees for fever and symptoms before every shift

  • 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

  • Inform staff regarding when they should stay home or when they should leave work due to illness

  • Make sure a procedure is in place for contacting your local public health district if an employee is diagnosed with COVID-19

Identify how close interactions with patrons will be limited.

  • Offer online, digital, or phone-in ordering

  • Offer takeout or delivery service

  • Establish hours of operation for patrons at high-risk of severe disease

  • Limit the number of patrons in the restaurant at one time

  • Direct the flow of traffic in the restaurant to maximize space between people (e.g., lines)

  • Use signage and barrier protection to limit movement and maintain distancing

  • Describe other plans (Consider other strategies such as requiring noncash transactions, using disposable menus or menus that can be disinfected and increasing ventilation throughout the restaurant.)

Sign Off

  • Name and Signature

  • This document is a TEMPLATE EXAMPLE. Please contact your local Public Health District for the preferred form.

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.