ENGINEERING SERVICES SECTION
Instructions for Neighborhood Kitchen(s)
Waiver
RANGE HOOD WITH EXTINGUISHING SYSTEM
General Waiver Information
This is the standard waiver form for a licensed nursing home using a Range Hood with
Extinguishing System in neighborhood kitchens. This waiver permits the use of residential type
food service equipment in a neighborhood kitchen with certain limitations and conditions. This
waiver does not include an under-counter dishwasher.
Please read the waiver form carefully. If the conditions and limitations are acceptable as
detailed in the waiver form, complete the form, sign it and return it to the address that appears
at the end of this document. Please include with your completed signed waiver form a floor
plan (paper size not to exceed 11x17) clearly identifying the locations of the kitchen(s) that you
have indicated on the waiver form table.
Any changes to this standard waiver will be denied. If you desire any changes in the conditions
and/or limitations, please advise the Engineering Services Section in a separate letter.
Waivers are not effective until approved by Engineering Services at MDH. Your completed
waiver will be evaluated and either approved, approved with conditions or denied, and
returned to you in a timely manner.
If you have any questions concerning the waiver or these instructions, email
[email protected] or call 651-201-4229.
Filling Out the Waiver Form
There are five areas on the Neighborhood Kitchen(s) Waiver for Range Hood with Extinguishing
System form that must be completed:
•
Date
•
Facility administrator name, facility name and address
•
Facility HFID number
•
A table containing the kitchen location(s) and number of residents served at that
location
NEIGHBORHOOD KITCHEN(S) WAIVER – LIMITED FOOD PREPRATION/COOKING
•
Signature of the facility administrator, accompanied by the “typed” administrator name
and the facility name
Four of these areas are in red text and the table on page two is in regular (black) text. The
remaining portions of this form cannot be modified.
To enter information into these areas, navigate the white arrow pointer or the “I” bar over the
red text on the form. The field will turn gray indicating you can begin entering text. Click your
mouse to type inside the gray field.
Examples of Entering Information Over Red Text
Moving the “I” bar over the red text will turn the field gray.
While the “I” bar is over the gray field click on the mouse to expose the field to enter text into.
Begin typing and text will appear in the field.
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Revised 2-1-2016
NEIGHBORHOOD KITCHEN(S) WAIVER – LIMITED FOOD PREPRATION/COOKING
Follow this procedure until you have populated all the areas that contain red text on both the
first and second page of the waiver form.
Note: HFID is an acronym for Health Facility Identification. If you do not know your facility’s
HFID number visit the link below. Follow the steps on this link to display information about your
facility from the Provider Directory. Your HFID number will be included under the column
labeled “ID.”
http://www.health.state.mn.us/divs/fpc/directory/providerselect.cfm
On the second page of the waiver form you will find a table. Click inside the first column labeled
Kitchen Location and type in the location of each neighborhood kitchen (i.e. floor, wing, unit,
etc.). In the second column provide the number of residents served at that location. Refer to
the example below.
In addition to the completed waiver form also submit a floor plan (paper size not to exceed
11x17) clearly identifying the locations indicated on the table above.
Print and sign the waiver form. Mail or hand deliver your completed form to:
MAIL COMPLETED FORM TO:
COURIER/STREET ADDRESS:
MDH – Health Regulation Division
Engineering Services Section
P.O. Box 64900
St. Paul, MN 55164-0900
MDH – Health Regulation Division
Engineering Services Section
85 7th Place East, Suite 220
St. Paul, MN 55101
Or attach your completed waiver form and floor plan and email them to:
[email protected].
Waivers are not effective until approved by Engineering Services at MDH. Your completed
waiver will be evaluated and either approved, approved with conditions, or denied, and
returned to you in a timely manner.
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Revised 2-1-2016