HomeMy WebLinkAboutFood Service Establishment Inspection 20 (3) r
Town of South Windsor
1540 Sullivan Avenue South Windsor, CT 06074
860-644-2511 PHONE
960-644-7290 FAX
FOOD ESTABLISHMENT PLAN REVIEW APPLICATION
for Class 1 Food Establishments
SOUTH WINDSOR HEALTH DEPARTMENT
1540 SULLIVAN AVENUE
SOUTH WINDSOR,CT 06074
❑NEW ❑ REMODEL ❑ ALTERATIONCHANGE OF OWNERSHIP
Name of Establishment:
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Establishment's Address:
e
Phone(if available):
Name of Owner or Owner's Representative: Chu
Owners Mailing Address: b
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Tele hone:
Applicant's Name and Relationship to Owner(self,manager,etc.):
Applicants Mailing Address:
y
Applicants Telephone Number: \
Garbage and Refuse
Inside
Will refuse be stored inside?
YES NO
If so,describe where receptacles will be located
Outside
Will the area around premises be maintained clear of
unnecess brush,litter,boxes and other vermin harborage? NO
NO
Will a dumpster be used? Cn
Number Frequency of pickup
Where will the dumpster be located?
Identify the Waste Hauler that will be used '
Will th dumpster be cleaned by an off-site contracted cleaning se ice?
If YES,please provide name and address of the fern contracted for this service.
Will a compactor be used?
Number Size Frequency of pickup
Where will the compactor be located?
Will the compactor be cleaned on site?
If the compactor is cleaned on site,the wastewater from the cleaning operation must
discharge to the sanitary sewers stem.
Will the compactor be cleaned by an off-site contracted cleaning service? I YES NO
If YES,please provide the name and address of the firm contracted for this service.
Describe the surface and location where the dumpster/compactor/barrels will be stored:
YES NO
Will trash barrels be stored outside?
If YES,please describe their locations:
Specif the type and location of cooking grease waste storage receptacles:
Will there be an area
to store recycled containers? YES NO N/A
Describe:
Identi f the location(s)and size(s)oft a grease trap(s):
MOP CLEANING FACILITIES
Will a separate mop basin be provided? YES NO
If YES,please de critLee the acilit for cleaning mops and other maintenance equipment:
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Location of employee toilet. 3
Listing of food and be erages to be sold. (If more space is required attach additional pages)
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Location of all cleaning materials and toxicatems that will be used at the facility.
STATEMENT:I hereby certify that the above information is correct. I fully understand that any deviation from the
above without prior approval from the South Windsor Health Department is prohibited.
Signature(s) 113'a A 4V:5'pL
J Owner(s)or Responsible Representative(s)
Date: 7 /
Approval of these plans and specifications by the South Windsor Health Department does not indicate compliance
with any other code,law or regulation that may be required—federal,state,or local. It further does not constitute
endorsement or acceptance of the completed establishment(structure or equipment). (A pre-opening inspection of
the establishment with equipment in place and operational will be necessary to determine if it complies with
the all laws governing food service establishments).
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Schedule of FumiturA Fixtures, Equipmog
Mlscellaneous and Additional Its= 0
tu
as LE I C'� I DESCRIPTION MAKE / MODEL
FURNITURE cote s w ooR miE sTmmws•«
U07ES I7EM TO BE PURCHASED NOUG 1 COLD STM CI MfRY(X>R M7E STANDARDS PROGRAM.
_.rF1 2 TRASH RECEPTACLE MODEL 415 DT, BLACK 15GAL.
F2 2 FRONT SERVICE COUNTER CUSTOM MILLWORK
F3 1 BACK COUNTER CUSTOM MILLWORK
F4 2 SNEEZE GUARD CUSTOM
F5 0 STAINLESS STEEL TABLE WITH WHEELS TARRISON #WT-3072
F6 1 WIRE RACK 48" LONG x 18" DEEP
F7 2 WIRE-RACK (MOUNTED ABOVE SINK) 8'-0" LONG x 16" DEEP (SPLIT ONE INTO 2 SECTION
TO MOUNT ON EACH SIDE OF FAUCET
F8 1 STAINLESS STEEL TABLE WITH WHEELS- TARRISON #WT-2430
VAULT MASTER - MODEL CSC 2820
F10 0 TABLE BASE AND TOP EMU KISS #955
F11 0 CHAIR EMU COUPOLE #355
F12 4 VINYL COATED SHELVING (MOUNTED AT 7'-6" AFF) CLOSET MAID OR EQUAL, 48" LONG x 16" DEEP
�( F13 2 INDOOR BARSTOOL EMU COUPOLE #380
FUCTEM"
`i X FIAT SB-2424
X2 1 WATER HEATER (MOUNTED ABOVE MOP SINK) RUUD ELDS40 OR EQUAL, SIMULTANEOUS(40 GALLON WACIT
TARRISON #PS3-18LR W/ FISHER.2210-WB PRE-RINS
Now 15" DIPWELL
1 AMERICAN STANDARD LUCERNE
X6 2 BLACK, 5 BLADE CEILING FAN HAMPTON BAY 52" HUNTINGTON III, REMOVE LIGHT K
X7 2 FROST TOP FAUCET FISHER FAUCET 3042
X8 5 12" x 12" FLOOR SINK JOSAM #49020AS-3-45
X9 0 1 COMP. SINK W/ 18" DRAINBOARD UNIVERSAL STAINLESS 1N1618-R-D18
10 0 ELECTRIC HANDICAP DRINKING FOUNTAIN OASIS P8AM BARTER-FREE VERSACOOLER
1 JUST SL-1617-A-GR-ADA
E�KAPMEIVT ---
MASTER BILT, CS-8-121-8
. - W
' d' E3 2 FROST TOP ATLAS WF5
GHEA-12, TO BE ASSEMBLED BY GENERAL CONTRACTOR
MASTER-BILT IHC-48
COLDELITE LB-502
E7 2 CASH REGISTER PANASONIC 5500 POS
REQUIRES PC&DATA CONDITIONED PHONE LINE
GOLD MEDAL MODEL 5020
FSP #82060
E10 1 BLENDER NTA-MIX MODEL 35100 W/1 EXTRA VITA-MIX 15506 CANNISTER
E MASTER-BILT BLG-52HD
E12 I CONVECTION OVEN TURBOFAN E25
SILVER KING SKR-48 DOUBLE DOOR, CASTERS PROVIDED
SILVER KING SKF-27 SINGLE DOOR, CASTERS PROVIDED
E15 1 CREDIT CARD MACHINE
E16 1 490OMM Dl-1 #92000
M1 1 MENU BOARD CUSTOM
M2 1 P.O.P. SIGNAGE CUSTOM
M3 5 STAINLESS STEEL STRAINER BASKET SYSCO
M4 3 LIQUID SOAP DISPENSER SYSCO
4 M5 3 1 PAPER TOWEL DISPENSER SYSCO
M6 1 ORIGINALS BOARD 48" x 48"
M7 3 WALL GRAPHICS 48" x 48"
M8 2 GRANITE STONE- 13 1/2" x 66 1/2" GCO A SIDES OR BOTTOM,
EASED EDE ORIMPALBLAK ABSOLUTE BLACK.
ADMT10ML ITEM
q Al 1 DESK WITH FILE CABINET
lk A2 1 MUZAK SYSTEM
A3 2 PHONE
A4 0 1 MULTIPLE TIER LOCKERS
A5 6 STANCHION POST LAWRENCE METALS- TENSABARRIER
A6 2 ARE EXTINGUISHER 2A:1OBC
1 Ll 9 DOWNLIGHT- LOBBY LSI#26910; SERIES 206V CFL 42W TPL UNIV CLBK DGCF
L2 18 DOWNLIGHT- SERVICE AREA LSI #27282; SERIES 206H CFL 42W TPL UNIV W CL
L3 4 WALL WASH LIGHT- SERVICE AREA LSI 126914; SERIES 206WW CFL 226 QUAD UNIV W LSL
L4 6 2'x 4'TROFFER LIGHT- WORK AREA LSI #26916; SERIES TG 2X4 432W T8 LBA UNIV
L5 1 SURFACE MOUNT LIGHT- RESTROOM LSI #26918; SERIES 78 11-1/2" 4' 232W T8 UNIV
L6 4 EMERGENCY LIGHT LSI #EM-B-120/277, CATALOG#74168
L7 2 EXIT SIGN LSI #EX 2 R B 120/277 EM, CATALOG 174167