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HomeMy WebLinkAboutTemp Food Inspection 150 Never Road 1540 Sullivan Avenue South Windsor,CT 06074 Ph: 860-644-2511 ext.248 SoUth Windsor Fax: 860-644-7280 Health Department Fax To: Paul Petrillo,S.W.Jaycees From: Sherry McGann Fax: 860-644-7280 Pages: 4(including cover) Pie: 860-573-6780 Date: 5/2/2012 Paws in the Park Re: Temporary Food Event CC: ❑Urgent 0 For Review ❑Please Comment ❑Please Reply ❑Please Recycle •Comments: Good morning, I am faxing the permits for the 'Paws In the Park" event to be held on May 5, 2012. An on-site inspection will not be required based upon a review of the the information provided by the applicants. Permits are to be posted in an area visible to the public. Please call me if you have any questions. ZL if X SOUTH WINDSOlt HEALTH DEPARTMEN 'r TEMPORARY FOOD PERMIT EVENT : PAWS IN THE PARK LOCATION : NEVERS PARK APPLICANT : YUKON KETTLE CORN VALID : MAY 59 2012 (RAINDATE MAY 6TH) THE RECIPIENT OF THIS PERMIT SHALL OPERATE IN ACCORDANCE WITH THE REGULATIONS OF THE SOUTH WINDSOR HEALTH DEPARTMENT AND THE CONNECTICUT PUBLIC HEALTH CODE. 00(IL o4 ol m 14 SHERRY MCG ENVIRONMENTAL HEALTH OFFICER DATE SIGNED: THIS PERMIT MUST BE DISPLAYED IN AN AREA VISIBLE TO EVENT PATRONS AND IS NON TRANSFERABLE PERMIT ONLY VALID IF SIGNED BY HEALTH OFFICIAL mY- RL SOUTH WINDSOR HEALTH DEPARTMEN TEMPORARY FOOD PERMIT EVENT : PAWS IN THE PARK LOCATION : NEVERS PARK APPLICANT : RITA' S ITALIAN ICE VALID : MAY 59 2012 (RAIND ATE MAY 6TH) THE RECIPIENT OF THIS PERMIT SHALL OPERATE IN ACCORDANCE WITH THE REGULATIONS OF THE SOUTH WINDSOR HEALTH DEPARTMENT AND THE CONNECTICUT PUBLIC HEALTH CODE. SHERRY MCG ENVIRONMENTAL HEALTH OFFICER DATE SIGNED: THIS PERMIT MUST BE DISPLAYED IN AN AREA VISIBLE TO EVENT PATRONS AND IS NON-TRANSFERABLE PERMIT ONLY VALID IF SIGNED BY HEALTH OFFICIAL ,, Sir Mm " 31MI K SOUTH WINDSOft HEALTH DEPAftTMEN � TEMPORARY FOOD PERMIT EVENT : PAWS IN THE PARK LOCATION : NEVERS PARK APPLICANT : CAMPION ' S PIZZA VALID : MAY 59 2012 (RAIND ATE MAY 6TH) THE RECIPIENT OF THIS PERMIT SHALL OPERATE IN ACCORDANCE WITH THE REGULATIONS OF THE SOUTH WINDSOR HEALTH DEPARTMENT AND THE CONNECTICUT PUBLIC HEALTH CODE. SHERRY MC N, ENVIRONMENTAL HEALTH OFFICER DATE SIGNE THIS PERMIT MUST BE DISPLAYED IN AN AREA VISIBLE TO EVENT PATRONS AND IS NON TRANSFERABLE ' PERMIT ONLY VALID IF SIGNED BY HEALTH OFFICIAL ...M APR-24-2012 09:40 FROM-ABBOTT BALL 860 233 1069 T-247 P.001 F-823 FAX MESSAGE To: Sherry McGann From: Paul Petrillo SW Health Department Date: 4/24/11 No. Pages (including this page).- 10 Fax#: 860-644-7280 If there are any problems with this transmission, please call me at 860-23$-5901 X 242 Sherry Here are the Campion's and Rita's forms Please let me know if you have any questions Sincerely, Paul Petrillo South Windsor Jaycees APR-24-2012 09:40 FROM-ABBOTT BALL 860 233 1069 T-247 P.002 F-023 TEMPORARY FOOD SERVICE EVENT COORDINATOR' S APPLICATION This form must be filed 14 days prior to opening event.Application musr be submitted to the Town of South Windsor Health Department at 1540 Sullivan Avenue,South Windsor,Connecticut 06074 Phone 860-644 2511 Extension 248 Fax 860-644-7280 This form is not a license. Temporary food events will not exceed of 1 to 5 days Name of Event Paws in the Park Date(s) of.Event May 5t4 (rain date May 6�') Hours of Event 10-3 Number of Food Vendors 3 Name of Event Coordinator South Windsor Jaycees—Paul Petrillo Address of Event Coordinator I'O Box 486 _South Windsor, CT Cell Phone#860-573-6780 Home Phone# 860-632-1544 Work Phone# E-Mail_pawsintheparksW aol.com Name of On—Site Coordinator T Paul Petrillo QFO (please check if On site coordinator is QFO and provide a copy of QFO certificate) List of Vendors attending event _Campions's Pizza _Rita's Italian Ice Yukon Fettle Corn Each vendor must complete the Temporary Food Service Event Vendor Application.Application not received fourteen days prior to the event will not be accepted and the vendors will not be allowed to open for business. The Event coordinator must make,arrangements 5 days in advance with the Town of South Windsor Health Department to determine the time of pre-will comply with the Connecticut Public Health Code and the Tov4i of South Windsor Code of Ordinances. Signature of Event Coordinator Date April 22,2012 C\Paul's MeslSoudi Windsorlaycces\Puws in die Park\Tcmpontry_FooCCoordinaTor Application 201 Ldoc APR-24-2012 09:40 FROM-ABBOTT BALL 880 233 1069 T-247 P.0031010 F-823 VENDOR APPLICATION FOR TEMPORARV FOOD EVENT The VENDOR of each temporary food eve application and must be filed 14 days prior to the opening event. This application must be submitted to the Town of South Windsor Health Deparcmcm, 1540 Sullivan Avenue, South Windsor, CT 05074, This application is not a license. Temporary food events will not exceed a period of I to 5 days. Today°s Date Name of Event i a L A S 4N& Q ,. Date of Event Time of Event Location of Event NPc"crs-, r- Event Coordinator Event Coordinator Address W-6 Event Coordinator Phone it RX ��1 6 29;E:) Event Coordinator E-Mail Address Event Coordinator Phone#(cell, work&home) Name of Applicant "D iuti. G 1'Ln 1)e Name of Applicants Business (please indicate if mobile vendor) Cain^ i orS �i Z Z cL Applicants Address I _W� a.011-Ckcjl CT 060� r 1 Applicants E-Mail Address IL_v. �cj)tjC t_go a�q� Applicants Phone#(cell, work&home) yG��^6`l u 0'6� Set up time � ft� APR-24-2012 09:40 FROM-ABBOTT BALL 860 233 1069 T-247 P.004/010 F-823 Please provide the following; (If any of the following does not apply to you put N/A) 1. List 11 food and beverage items to be prepared and served(menu).Attach a separate sheet if NOTE;Any changes to the menu must be submitted to the Health Department 10 days prior to the event. H o1- &5 s �-`6'M h f"r 9 cVs 2. Describe specifically how frozen, cold,and hot foods will be transpoiled to the event. 3. List all places (name&address) where a meats, poultry, seafood, shellfish, and ice will be purchased. sa-m S CA V� 4. List names,phone numbers, addresses, and shifts to be worked of all employees. See attachment#1. 5. Use Attachment# in this packet to sketch a drawing showing the event area and where your operation will be. APR-24-2012 09:40 FROM-ABBOTT BALL 860 233 1069 T-247 P.005/010 F-823 6. e cn e the number, Iocation and set up of handwashing facilities to be used by employees. ©L-{- alrtacpe' o+L- [wcq�'�-V iVV ctl, a,�,�-t1cr q4- broth kS,,- 5 C��,�-;ru�`o.�5 �kN�v►tiJ �u,� r S C' atir� q�bac�er;Q I so�c,p 7. Describe how and where utensil/equipment washing will take place. If no facilities are available, describe how alternate steps will be taken. INA- r�i tics oA- Si d b r►vS+ W; II 6P ('lacIeJ iti 1 ral�� b1 N 0.i/Gt b/',Jr,5t,i- b tc k -o CkMpian.,S I�(� tZZ 4L �0 bf 8.Describe how wastewater will be collected,stored and disposed. �C CtileC+�c.Qiti sg�.(t�v b;tc4ei ' Rum bc.►.j ut q LA, �(`�t�r✓ Doti h. o4l S i k i 9. Describe the number and location of garbage containers. P(0" d ed bt c� -Ce e S 10.Describe what heat source will be used to keep hot foods hot(140 degrees and above). Ga s , �11 wi ( he �.s td Coo e� �-t�i-�Pr, s f-Iq�.►�w izzAS la, 1 l 4 6,00�� �-1- C� �,��,s� .L L � f s r�,Q, '"V f�Ztcz I��Cy .�Cf✓'1 j a. �'�{f'^1.9� (Jk�S !� e d e"4r 11, Describe``how cold foods will be kept cold (45 degrees and below). R efiidg?rA:�r^ 12.Describe how food temperatures are monitored, cleaned and sanitized. er•�.o ti4�-tr mp 13.Will foods be prepared on site? Tf no, where will foods be purchased? (enclose copy of food license) (V (� 1,t Ccv rX 0&/ S he ddye APR-24-2012 09:40 FROM-ABBOTT BALL 860 233 1069 T-247 P.006/010 F-823 ATTACHMENT #1_ NAME OF EMPLOYEE PHONE# ADDRESS SHIFT 1. CaMp Pe,v 6,7?,me L(6T9-,c�Awj,u op I-,,—C(�r� 2. ,�t,���r•t �c.,C U''�,�,t, �W y.�`�[�2� `'� �t vav aa ! 3� 3. M IG s Am �Gb' 6` ,5-472 f ��Cc.v� �l` v� G ti — � � I'Ga.t �1��,- � p t C 1.ps e 4. 5. 6. 7. 8. 9. 10, APR-24-2012 09:40 FROM-ABBOTT BALL 860 233 1069 T-247 P.007/010 F-823 Y ATTACHMENT, #2 NDOR OPERATORS Metal probe thermometer(0—220 degrees F range) -- Thermometers for all refrigerators � _Coolers and ice packs(if ice is to be used for cooling of foods, where is water to be drained) Plastic wrap/Alurninum foil Extra utensils: tongs, spatulas,spoons, and knives Water source �. _Buckets/tubs for washing, rinsing, sanitizing food equipment ,Bleach for sanitizing, test strips for checking Waste water disposal container Containers)for grease collection Clean wiping cloths and a container to store them in Garbage eonrainers and plastic bags Hats/hair restraints Crates, shelves to store food off of the ground _Gloves for food handling Nand washing station lU)k ' C\eon 1 � c ti` APR-24-2012 � 09:40 FROM-ABBOTT BALL BBO 233 1089 T-247 P.008/010 F-823 VENDOR APPLIcAnom FOR T,EMPOiRART MOD EVENT The VENDOR of each ternI*IUU food prior Lo the opening event.'!'his application must be submitted to the'rawn of South Windsor FIealth Department, 1540 Sullivan Avenue, South Windsor,CT 06074. This anp►lication is not a license,Temporary food events will not exceed a period of 1 to 5 days- Today's Date 31& h Z Name of Event i r, �c� Piar Date of Event -.�-r.Ycy Time of Event- qo t Location of Evenc.. 4 c-r �eti �+:. „'—L` 'S 10or^K Event Coordinator P«•-�-1 Event Coordinator Address Event Coordinator Phone# Event Coordinator E-Mail Address Event Coordinator Phone-#(cell,work&home) Name of Applicants c.j: L rn Namo of Applicants Business (please indicate if mobile vendor)^ ', 's 1-4r,I,.=r. --Ve Applicants Address 1935 Zl 1,n , .�r� 5 c..�'�G G�sc - i 1^Applicants E-Mail Address ._ -� 4 r+"r,c C C- GLe. Applicants Phone#(cell, work&home) ` ►�a " :7 oa 0 A APR-24-2012 ,09:40 FROM-ABBOTT BALL 860 233 1069 T-247 P.009/01O F-823 picase provide the following:(If any of the following does not apply to you put NIA) 1. List all food And beverage item to be prepared and served(menu).Attach a separate sheet if 7�,occbsary. NOTE:Any changes to the menu must be submitted to the Health Department 10 days prior to the event. 41 1 a ►rV t�V1 y 2.Describe speciBcally how frozen.cold,and hot foods will be transported to the event c ems' v � c 3.list all places(name&address)where meats,poultry,seafood,shellfish,and ice will be purchased. l 1 Ql fir,a r 4.List names,phone numbers,addresses,and shifts eo be worked of all employees. See attachment#2. S.Use Attachment#K2 in this packet to sketch a drawing showing the event area and where your operation will be. APR-24-2012 09:40 FROM-ABBOTT BALL 860 233 1089 T-247 P-010/010 F-823 6.Describe the number,]ocauon and Set up of�hjandwashing facilities to be used by employees. 1�t�'� ��(� j')q/•� �Y�.� malt�'1"1 Z•z;r-- .....�C� 7, Describe how and where utensil/equipment washing will take place, if no facilities are available, describe how alternate steps will be taken. 8.Describe how wastewater will be collected,stored and disposed. 9.Describe the number and.location of garbage containers. 10.Describe what heat source will be used to keep hot foods her(140 degrees and above). Pql 11.Describe how cold foals will be kept cold(45 degrees and below). 12.Describe bow food temperatures are monitored,cleaned and sanitized. 13.Will foods be prepared on site?1_'f no,w bere will foods be purchased'?(enclose copy of food license) VENDOR APPLICATION AND GUIDELINES FOR TEMPORARY FOOD SERVICE EVENTS C:\DOCUME—I\ADMINI—I\LOCALS—I\Temp\Temporary Food Vendor Application 201 Ldoc VENDOR APPLICATION FOR TEMPORARY FOOD EVENT The VENDOR of each temporary food event must complete this application and must be filed 14 days prior to the opening event. This application must be submitted to the Town of South Windsor Health Department, 1540 Sullivan Avenue, South Windsor, CT 06074 This application is not a license. Temporary food permits will.not exceed a period of 1 to 5 days. Today's Date 1 Z Name of Event Paws in the Park Date of Event _May 5,2012 Time of Event 10 a.m.-3 p.m. Location of Event Nevers Park, South Windsor Event Coordinator_South Windsor Jaycees/Paul Petrillo Event Coordinator Address PO Box 486, South Windsor, CT 06074 Event Coordinator Phone#_860-573-6780 Event Coordinator E-Mail Address PawsintheParkSW@aol.com Event Coordinator Phone#(cell,work&home)_860-573-6780 Name of Applicant o(�,EGA Al l 'l e►n Name of Applicants Business(please indicate if mobile vendor) "l y lko,ii Le we G-�-n Applicants Address 506 P Ve ne l I e pok. Applicants E-Mail Address r� o.L L e n '/S (a? Y�,, Applicants Phone#(cell, work&home) 31 S Set up time `,OCR o• w. Please provide the following: (If any of the following does not apply to you put N/A) 1.List all food and beverage items to be prepared and served(menu). Attach a separate sheet if necessary. NOTE: Any changes to the menu must be submitted to the Health Department 10 days prior to the event. 2 2. escn a specifically how frozen, cold,and hot foods will be transported to the event. 3. List all places (name&address)where meats,poultry, seafood, shellfish,and ice will be purchased. 4. List names,phone numbers, addresses,and shifts to be worked of all employees. See attachment#1. 5. Use attachment#2 in this packet to sketch a drawing showing the event area and where your operation will be. A+ } S -} m e i' n o-l- � w 1 l 1 �'tee- uu � ©u� /a'x Jo,, �oca�1-h {�e . 6. Describe the number, location and set up of handwashing facilities to be used by employees. �1av�1 w�Sh q <S �-4-t o✓t o n a� -�,b I Q i✓i fhe boc�.7-, W Q �Q✓e_ a IAJ Joy�-C�- �o,� it E P w v``�'in � �o{-� hc�ad� So C 1 7. Describe how and where utensil/equipment washing will take place. If no facilities are available, describe how+alternate steps will be taken. u+e'A S113, T only e CZn01 Scoop —�-p 0-peke . 2 8. Describe how wastewater will be collected, stored and disposed. In o�' Jouck ..t- (tor "Loash;r-C�) P os-e d-f- I - +k-4�7_ �-y'g✓�-�- i �ate;b l� o-i' a-- o,^^-e 9. Describe the number and location of garbage containers. I �o r�9e Ca-n Loco--+eJ' J u5+ Garbage cans will be located throughout the grounds 10. Describe what heat source will be used to keep hot foods hot(140 degrees and above). NIA 11. Describe how colds foods will be kept cold(45 degrees and below). N A 12. Describe how food temperatures are monitored. P1A 13. Will foods be prepared on site? If no, where will foods be purchased? (enclose a copy of food license) 3 NAME OF EMPLOYEE PHONE# ADDRESS SHIFT 1. Mlke Allen -o,-aer (;-� P-CLveneI laa_in -3aM N � �-�sv�hor�t.a,le CST 2. oG ZSS 3. 4. 5. 6. 7. 8. 9. 10. 4 R.� r C a ' a AM }L,Lw �� E q �i - Azal. Is.,is to... cert ' .� a,.'V�. _�. 'h�.°"ftu�i6 j•�.�s. FR1- �5.� !,e •.,'.�+A 4 � P met Irletc,*wcesivary re d, 0.1 quirements and Aft Food .. � C . -9 � � qzp R.�;'f, � Vication. g , •�. y:. 1! Exam Date, 4/ul 6 4" Expe ivor Assessments0m, LLC , i � Q 080- . 4 i Establishment: Sr Inspection Date: Time: ; Roins RE[nsp ddress/City: Healt De t: _LA ilk i. Class: 1 2 O4 Based on an inspection this day,fhe items marked DNC identify the violations in operation or facilities which must be corrected by the date specified on page 2. RISK FACTOR ITEMS:Listing comp ies not observed not applicable]1 NIA[ Pp 1 �Tg7177 3 1 DNC[does not comply] 0[other] RTE[ready-to-eat] d2° ;i s°' raeI�uirith fet o�'restricted 6t Desigt�tetlAlternate x° 2 C N/A 4' 62 Written documentation of training ro•ram A Food workers have no exposed infected lesions/burns 2 B Personnel with infection restricted 1 Apprroved source,wholesome,ntsnadttlterated C /A 4' A Approved shellfish,finflsh,meat&poultry USDA approved C Communicable disease of worker reported to local health director 't3 ;Handwashirt B Food cans in good condition(not dented,rusty,bloated,leaking) ti facilities provided,ha�wasltletl,clean C 0 NA 4 C Wholesome/nonadulterated foods/Safe A Handwash facilities in all food prep/dispensing&warewash areas D Commercial products(no home grown/canned food) B Handwash facilities in or immediately adjacent to toilet rooms C Handwash facilities accessible/convenient to use E Potentially hazardous foods received at proper temperature 0 D Personnel hands washed,clean/Proper handwaslT procedure 3 Rotelfs[ hzargus RfeBS teleratir at appropriate times Handwashing duetrr6 s�age,per;par don,des sy!sprir7t � at� t} } 1 S Ihrji ntc cacti es " C N/0: WA 2 A Hot holding greater than or equal to 140°F. (whole beef/pork roasts 1300 F.) 77 ❑ No eating ❑ No smoking while working B Cold holding less than or equal to 45°F. B Wounds covered adequately C Proper cooling C Proper sink used for handwashing D Proper re-heating 0 E Proper internal cooking/consumer advisory posted 0 A Approved sanitizeravailable/adequate concentration ofsanitizer 4 kdtatie°faoflr€s to mai $aitil o B Food-contact surfaces and utensils used for potentially te�pe re,thermcirineters r[d , 4v hazardous food sanitized at least every 4 hours A Food thermometer available and accurate C Adequate ❑dishwashersanitizer ❑final rinse temp B Proper food thermometer for product _L Proper sanitizin rocedure C Thermometers appropriately placed in cooler units E Sanitizing between raw animal origin&ready-to-eat food 0 0 t PI, display,service and transportation A Cloths and/or sponges in good repair and clean A Produce washed B Wiping cloths kept in sanitizer between uses B Raw meats not stored/prepared near ready-to-eat foods V, O C Food covered properly0,11 A Food equipment clean,utensils clean,equipment interiors clean D Adequate splash guards/sneeze guard V V IB Single use gloves changed when soiled E No unauthorized personnel F No pooling of eggs not cooked immediately C Food--contact surfaces clean Vf 0 8 Food containers stored off the floor t g 9 Handling of'fooel minimized' 9; A No unnecessary handling RTE and/or cooked foods with bare hands A Soap/paper towels I drying device available B Dispenser(s)working: ❑Soap ❑Paper towel - B Minimize food handling,other than ready-to-eat,with bare hands C Adequate utensil(s)for dispensing food/ice C Handwash sink(s)clean/waste receptacle at handwash sink 0 0 •DESCRIBE DEFICIENCIES ON CONTINUATION SHEETS The following information is not debitable and does not affect your score. KEY: QFO[qualified food operator],DA[designated alternate],PHF[potentially hazardous food],FB[foodborne] PHFs are hot held at: OF. PHFs are cold held at: °F. Describe illness conditions when you would exclude a food worker from working: Are internal cooking temperatures taken? Y N *To what temperature do k-y Poultry Ground Beef otl What diseases related to FB illness are you required to report to th department? Roasts Other Describe re-heating procedures: Is there a written illness policy that require od worker to report specific illness conditions Are temperatures recorded/logged for olding foods/equipment? Y N and diseases to the QFO? Y *Do you have a paid sick leave policy? Y N Are foods cooked in adv and cooled? Y N *Are leftovers saved? Y N Is there a I arrier between inspector&QFO? Y N indicate language spoken List products cool by O/DA: *Can the QFO/DA read the inspection report? Y N Descr' cooling methods: Indicate who answered the above questions: Name(print):i Is coaling monitored for time&temp? Y N Is the monitoring of cooling recorded? Y N Indicate the title of above person(circle all that apply):QF DA Mgr Cook Owner FW •Obtain signature of the person who rec we the QFO response ilities information at the time of the Is there a produce washing policy? N *Describe what is washed and inspection: —)I giiiii where: Note: This report is a two page form(total of 62 debitable items) Page 1 of 2 � ��tn Establishment: ti ,` Date of inspection- J<I ddress: m Owner or Operator: ADDITIONAL FOUR POINT ITEMS KEY: DNC [DOES NOT COMPLY] 6 Foods not re-served. -Unwrapped foods not re served 4 31 Sewage disposal approved. -Potentially hazardous foods not re-served -Operating as required 11 Toxic chemicals. 34 No cross connections,back siphonage,backflow -Stored properly,labeled properly,used properly groper type/installation/backflow prevention device/air gap for: -Sanitizer concentration not to exceed maximum permitted -Food equipment -Hose connections -Dish machines -No unnecessary toxics on the premises -Soda system carbonator -Beverage dispensers -Toilet tanks -Pesticides/rodenticides properly dispensed -Chemical dispensers -Ice machines Proper drain for: 29 Water source adequate,safe. -Food equipment -Dish machines -Ice machines -Well/well head protected from contamination 35 Toilet facilities. Adequate,convenient,accessible, -Water quality in compliance -Monitoring in compliance designed,properly installed OTHER ITEMS KEY: DNC [DOES NOT COMPLY] Sources of food:Original container,properly labeled 40 Garbage/rubbish storage area/rooms,enclosures-properly constructed,dean 5 Potentially hazardous food properly thawed 41 Garbage/rubbish disposed of in an approved manner,at approved frequency 10 Food dispensing utensils properly stored 42 Vermin Control: No insects/rodents present 14 Food worker:Clean outer clothes,effective hair restraints 43 Outeropenings protected against entrance of insects/rodents Floors: Floor covering installed,constructed as required,good repair,clean 16 Food-contact surfaces designed,constructed, maintained,installed, 5 Floors graded,drained as required located 6 17 Nonfood-contact surfaces designed,constructed,maintained, Floor,wall juncture covered installed,located 7 Mats removable,good repair,clean 18 Single service articles,storage,dispensing 8 Exterior walking,driving surfaces,good repair,clean 19 No reuse of single service article 49 Walls,ceilings attached,equipment properly constructed,good 20 Dishwashing facilities approved design,adequately constructed, repair,clean.Wall&ceiling surfaces as required maintained installed located 50 Dustless cleaning methods used,cleaning equipment properly stored Equipment&Utensils: I anlin s 51 Adequate lighting provided as required 21 Preflushed,scraped,soaked and racked 52 Room free of steam,smoke odors 22 Wash water clean,proper temperature 53 Rooms&equipment hoods,ducts,vented as required 23 Accurate thermometers provided,dish basket,if used 54 Rooms adequate,clean,adequate lockers provided,facilities clean 27 Nonfood-contact surfaces of utensils&equipment clean 55 Establishment and premises flee of litter,no insect/rodent harborage, 28 Equipment/utensils,storage,handling no unnecessary articles 32 Proper disposal of waste water 56 Complete separation from living/sleeping quarters and laundry 33 Plumbing location,installation,maintenance 57 Clean/soiled linens stored properly 36 Toilet rooms enclosed with self-closing door 58 No live birds,turtles,or other animals(except guide dogs) 37 Proper toilet fixtures provided,good repair,clean 59 Seats 75 or more:Nonsmoking area provided,sign(s)posted at entrance(s),smoking area indicated by sign(s) 39 I Approved garbage/rubbish containers,adequate number,covered, rodent proof,clean outine Inspection ❑Reinspection ❑ Preoperational Inspection INSPECTOR: PERSON IN CHARGE: Other Inspection: Demerit core: *Include demerits from page 1 4 3 2 1 Total I Rating signature signature�,y� prin name prin�ame r � r Zo Zu �� Z phone number � a�¢ title DATE CORRECTIONS DUE:tM n � v Page 2 of 2 plus continuation pages V Focused Inspection 112002 Page of FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH CONTINUATION SHEET NAME OF ESTABLISHMENT TOWN DATE OF INSPECTION INSPECTION FORM# REMARKS I o S� 3S* • s 0 INITIAL(INSPECTOR) Svv INITIAL(PERSON IN CHARGE) ' Distribution: 1st-White-Health Department 2nd-Yellow-Owner/Manager i stablishment: Inspection Date: Time: :oc)qu1 Ro[n REinsp ddress/City: ,r,y Health ept: S class; 1 2 3)4 Based on an inspection this day,the items marked MC identify the violations in operation or facilities which must be corrected by the date specified on page 2. RISK FACTOR ITEMS:Listing is not inclusive of all possible debitabl it DNC does not comply] 0 other no applicable] [ 00 3 [ P Yl [ 1 [ready-to-eat] 2 A Food workers have no exposed infected lesions/burns . s 2 B Personnel with infection restricted 'f C Communicable disease of worker reported to local health director A Approve shellfish,finfish,meat& oult USDA approved B Food cans in good condition(not dented,rusty,bloated,leaking) C Wholesome/nonadulterated foods/safe V A Handwash facilities in all food prep/dispensing&warewash areas B Handwash facilities in or immediately adjacent to toilet rooms D Commercial products(no home grown/canned food) C Handwash facilities accessible/convenient to use E Potentially hazardous foods received at proper temperature 0 D Personnel hands washed,clean/Proper handwash procedure E Handwashing at appropriate times 0 x W tl A Hot holding greater than or equal to 1400 F. (whole beeflpork roasts 7300 F) A ❑ No eating ❑ No smoking while working B Cold holding less than or equal to 45°F. B Wounds covered adequately C Proper Cooling C Proper sink used for handwashing D Proper re-heating 0 E Proper internal cooking/consumer advisory posted 0 A Approved sanitizeravailable/adequ ate concentration ofsanitizer B Food-contact surfaces and utensils used for potentially hazardous food sanitized at least every 4 hours A Food thermometer available and accurate C Adequate ❑dishwashersanitizer ❑final rinse temp B Proper food thermometer for product L Proper sanitizin rocedure C Thermometers appropriately placed in cooler units E Sanitizing between raw animal origin&ready-to-eat food 7H 0 0 1 1 =Cloths sponges in good repair and clean A Produce washed kept in sanitizer between uses B Raw meats not stored/prepared near ready-to-eat foods C Food covered properly VA Food equipment clean,utensils clean,equipment interiors clean D Adequate splash guards/sneeze guard g Single use gloves changed when soiled E No unauthorized personnel C Footl—contact surfaces clean F No pooling of eggs not cooked immediately 0 8 Food containers stored off the floor 0 A No unnecessary handling RTEand/or cooked foods with bare hands A Soap/paper towels/ drying device available B Dispenser(s)working: ❑Soap El Paper towel B Minimize food handling,other than ready-to-eat,with bare hands C Handwash sink(s)clean/waste receptacle at handwash sink C Adequate utensil(s)for dispensing food/ice 0 O •DESCRIBE DEFICIENCIES ON CONTINUATION SHEETS The following information is not debitable and does not affect your score. JiEY-: QFO[qualified food operator],DA[designated alternate],PHF[potentially hazardous food],FB[foodbome] PHFs are hot held at: IF. PHFs are cold held at: OF. Describe illness conditions when you would exclude a food worker from working: Are internal cooking temperatures taken? Y N *To what temperature do you cook: Poultry Ground Beef Pork What diseases related to FB illness ire to report to the local health department? Roasts Other Describe re-heating procedures: Is there a written illalsis policy that requires the food worker to report specific illness conditions Are temperatures recorded/logged for cold holding fo quipment? Y N and diseases to the CFO? Y N *Do you have a paid sick leave policy? Y N Are foods cooked in advance and cooled N *Are leftovers saved? Y N Is there a language barrier between inspector&QFO? Y N lames indicate language spoken List products cooled: by QFO/DA: +Can the QFO/DA read the inspection report? Y N Describe cooling methods: Indicate who answered the above questions: Name(print): p Is cooling monitored for time&temp? Y N Is the monitoring of cooling recorded? Y N Indicate the title of above person(circle all that apply):QFO DA gr Cook Owner FW •Obtain signature o the person wh eceived the 0,FO responsibilities information at the time of the Is there a produce washing policy? Y N *Describe what is washed and inspection: where: Note: This report is a o page form(total of 62 debitable items) Page f of 2 Establishment: Date of Inspection! ddress: bib Ytrwt Owner or Operator: ADDITIONAL FOUR POINT ITEMS KEY: DNC [DOES NOT COMPLY] 6 Foods not re-served. -Unwrapped foods not re-served 4 31 Sewage disposal approved. -Potentially hazardous foods not re-served -Operating as required 11 Toxic chemicals. 34 No cross connections,back siphonage,backflow -Stored properly,labeled properly,used properly Proper type/installation/backflow prevention device/air gap for: -Sanitizerconcentration not to exceed maximum permitted -Food equipment -Hose connections -Dish machines -No unnecessary toxics on the premises -Soda system carbonator -Beverage dispensers -Toilet tanks -Pesticides/rodenticides properly dispensed -Chemical dispensers -Ice machines Proper drain for: 29 Water source adequate,safe. -Food equipment -Dish machines -Ice machines -Well/well head protected from contamination 35 Toilet facilities. Adequate,convenient,accessible, -Water quality in compliance -Monitoring in compliance designed,properly installed OTHER ITEMS KEY: DIC [DOES NOT COMPLY] Sources of food: Original container,properly labeled 0 Garbage/rubbish storage area/rooms,enclosures-properly constructed,clean 5 Potentially hazardous food properly thawed 41 Garbage/rubbish disposed of in an approved manner,at approved frequency 10 Food dispensing utensils properly stored 42 Vermin Control: No insects/rodents present 14 Food worker:Clean outer clothes,effective hair restraints 43 Outeropenings protected against entrance of insects/rodents 4 Floors: Floor covering installed,constructed as required,good repair,clean 1 Food-contact surfaces designed,constructed,maintained,installed, 45 Floors graded,drained as required located 17 Nonfood-contact surfaces designed,constructed,maintained, 6 Floor,wall juncture covered installed,located 7 Mats removable,good repair,clean 18 Single service articles,storage,dispensing 8 Exterior walking,driving surfaces,good repair,clean 19 No reuse of single service article 49 Walls,ceilings attached,equipment properly constructed,good 20 Dishwashing facilities approved design,adequately constructed, repair,clean.Wall&ceiling surfaces as required maintained installed located 50 Dustless cleaning methods used,cleaning equipment properly stored Equipment&Utensils: Cleanlines 51 Adequate lighting provided as required 21 Preflushed,scraped,soaked and racked 52 Room free of steam,smoke odors 22 Wash water clean,proper temperature 53 Rooms&equipment hoods,ducts,vented as required 23 Accurate thermometers provided,dish basket,if used 541 Rooms adequate,clean,adequate lockers provided,facilities clean 27 Nonfood-contact surfaces of utensils&equipment clean 55 Establishment and premises free of litter,no insect/rodent harborage, 28 Equipment/utensils,storoge,handling no unnecessary articles 32 Proper disposal of wastewater 56 Complete separation from living/sleeping quarters and laundry 33 Plumbing location,installation,maintenance 57 Clean/soiled linens stored properly 36 Toilet rooms enclosed with self-closing door 58 No live birds,turtles,or other animals(except guide dogs) 37 Proper toilet fixtures provided,good repair,clean 59 Seats 75 or more:Nonsmoking area provided,sign(s)posted at entrance(s),smoking area indicated by sign(s) 39 Approved garbage/rubbish containers,adequate number,covered, rodent proof,clean 99outine Inspection ❑Reinspection ❑ Preoperational Inspection INSPECTOR: PERSON IN CHARGE: Other Inspection: Demerit Score: *Include demerits from page 1 4 3 2 1 Total Rating signatu a tsignatureprint name e b Z phone number a title DATE CORRECTIONS DUE: Page 2 of 2 plus continuation pages Focused Inspectlon 1/2002 Page_ of FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH CONTINUATION SHEET NAME OF ESTABLISHMENT TOWN DATE OF INSPECTION S . W I r_�Ir- � z. INSPECTION FORM# REMARKS h- 3 'Zarb n, UU ro c a, T i b yv, vv co 3e r�M6 A- C.00\cr — Z=:a 0 (-\0c4"k -�o VL4 b-� L Coo INITIAL(INSPECTOR) �� INITIAL(PERSON IN CHARGE) Distribution: Ist-White-Health Department 2nd-Yellow-Owner/Manager i Establishment: S Inspection Date: L Time R0]nsp REinsp Address/City: Health Mot: c }p2, class: 2 Based on an inspection this day,the items marked DNC identify the violations in operation or facilities which must be corrected by the date specified on page 2. FACTOR ITEMS:Listing 8 flat inelusive of all Y2 KEY C[complies] NIO[not observed] NIA[not applicable] possible dubitable 3 DNC[does not comply] 0[other] RTE[ready-to-eat] jj7 t fgna ` 1a6' v 2 1 � ,.vv€tEie {ti'r esr i ed' C N1:. , tit Written documentation of training program A Food workers have no exposed infected lesions I burns 2 B Personnel with infection restricted 11 f Appreved source,wholesome,nonadulterated C X/A C Communicable disease of worker reported to local health director A Approved shellfish,finfish,meat&poultry USDA approved 13 1#and-n►us#rth tTsvld B Food cans in good condition(not dented,rusty,bloated,leaking) g P, $ C AtJ 4" C Wholesome/nonadulterated foods/safe A Handwash facilities in all food prep/dispensing&warewash areas B Handwash facilities in or immediately adjacent to toilet rooms 40 D Commercial products(no home grown/canned food) C Handwash facilities accessible/convenient to use E Potentially hazardous foods received at proper temperature 0 Lloo D Personnel hands washed,clean/Proper handwash procedure , E Handwashing at appropriate times Ptiat fiat fgod trlep ' idutg&ahaue,prener�tion,d)af I , �° � � 0 37 5 #� �1 tC'.prac#tces C N10 4A 2 A Hot holding greater than or equal to 140°F. (whole beef/porkroasts 130°F.) A El No eating ❑ No smoking while working B Cold holding less than or equal to 45°F B Wounds covered adequately C Proper Cooling C Proper sink used for handwashing D Proper re-heating p E Proper internal cooking/consumer advisory posted A Approved sanitizes availableladeq � uate concentration of sanitizer `f feces to rn pni� � B Food-contact surfaces and utensils used for potentially Adequatilletemperature,thermometers; hazardous food sanitized at least every 4 hours A Food thermometer available and accurate C Adequate Aishwashersanitizer Ofinal rinse temp B Proper food thermometer for product D Pro ersanitizin rocedure C Thermometers appropriately placed in cooler units Sanitizing between raw animal origin&ready-to eat food 0 0 7 �mei••ilti ` N/Q! N/ i` display,sery a tra sport oo A Cloths and/or sponges in good repair and cleanAe ' A Produce washed B Wiping cloths kept in sanitizer between uses B Raw meats not stored/prepared near ready-to-eat foods C Food covered properly A Food equipment clean,utensils clean,equipment interiors clean D Adequate splash guards/sneeze guard g Single use gloves changed when soiled E No unauthorized personnel F No pooling of eggs not cooked immediately C Food contact surfaces clean 8 Food containers stored off the floor WW­ tin' of o' trtnimrii,d"° ufitrt dsprooldrd, A No unnecessary handling RTE and/or cooked foods with bare hands A Soap/paper towels/drying device available ILI B Minimize food handling,other than ready-to-eat,with bare hands B Dispenser(s)working: ❑Soap ❑Paper towel C Adequate utensil(s)for dispensing food/ice Handwash sink(s)clean/waste receptacle at handwash sink 0 0 •DESCRIBE DEFICIENCIES ON CONTINUATION SHEETS The following information is not debitable and does not affect your score. KEY: QFO[qualified food operator],DA[designated altemate],PHF[potentially hazardous food],FB[foodborne] PHFs are hot held at: IF. PHFs are cold held at: OF. Describe illness conditions when you would exclude a food worker from working: Are internal cooking temperatures taken? Y N *To what temperature do you cook: Poultry Ground Beef Pork What diseases related to FB illness are you required to report to the local health department? Roasts Other Describe heating procedures: Is there a written illness policy that requires the food worker to report sped ii s conditions Are temperatures recorded/logged for cold holding foods/equipment? Y N and diseases to the QFO? Y N *Do you have a paid ' e policy? Y N Are foods cooked in advance and cooled? Y N *Are leftovers sav N Is there a language barrier between inspector Y N If yQs indicate language spoken List products cooled: by QFO/DA: an the QFO/DA read the inspection report? Y N Describe cooling methods: Indicate who an�theperson ve questions: Name(print): Is cooling monitored for time&temp? Y N e monitoring of cooling recorded? Y N Indicate the title (circle all that apply):QFO pA Mgr Cook Owner FW Obtain sign rwho received the QFO responsibilities information at the time of the Is there a produce washing policy? Y N *Describe what is washed and inspection: where: Note: This report is a two page form(total of 62 debitable items) Page 1 of 2 LJOCA ,A f aDR1S Establishment: t f Date of Inspection: 'L ddress: Owner or Operator: ADDITIONAL FOUR POINT ITEMS " c: KEY: DNC [DOES NOT COMPLY] 6 Foods not re-served. -Unwrapped foods not re-served 4° 31 Sewage disposal approved. -Potentially hazardous foods not re-served I-Operating as required 11 Toxic chemicals. 34 No cross connections,back siphonage,backflow -Stored properly,labeled properly,used properly Propertype/installation/backflow prevention device/air gap for: -Sanitizer concentration not to exceed maximum permitted -Food equipment -Hose connections -Dish machines -No unnecessary toxics on the premises -Soda system carbonator -Beverage dispensers -Toilet tanks -Pesticides/rodenticides properly dispensed -Chemical dispensers -Ice machinesProper drain for: 29 Water source adequate,safe. -Food equipment -Dish machines -Ice machines -Well/well head protected from contamination 35 Toilet facilities. Adequate,convenient,accessible, -Monitoring in compliance -Water quality in compliance ��, � designed,properly installed OTHER ITEMS KEY- DNC [DOES NOT COMPLY] Sources of Original container,properly labeled 2 d 0 Garbage/rubbish storage area/moms,enclosures-properly constructed,clean 5 Potentially hazardous food properly thawed 41 Garbage/rubbish disposed of in an approved manner,at approved frequency 0 ood dispensing utensils properly stored 2 ermin Control: No insects/rodents present. 14 Food worker:Clean outer clothes,effective hair restraints 43 Outer openings protected against entrance of insects/rodents 4 loors: Floor covering installed,constructed as required,good repair,clean 16 Food-contact surfaces designed,constructed,maintained,installed, located 5 Floors graded,drained as required = 6 Floor,wall juncture covered 17 Nonfood-contact surfaces designed,constructed, maintained, 7 Mats removable,good repair,clean installed,located 18 Single service articles,storage,dispensing 8 Exterior walking,driving surfaces,good repair,clean �� ails,ceilings attached,equipment ro 19 No reuse of single service article 9 properly constructed,good 20 Dishwashing facilities approved design,adequately constructed, epair,clean.Wall&ceiling surfaces as required maintained installed located 50 Dustless cleaning methods used,cleaning equipment properly stored Equipment&Utensils: Cleanliness 51 Adequate lighting provided as required 21 Preflushed,scraped,soaked and racked 52 Room free of steam,smoke odors 22 Wash water clean,proper temperature 53 Rooms&equipment hoods,ducts,vented as required 23 Accurate thermometers p rovided,dish basket,if used 54 Rooms adequate,clean,adequate lockers provided,facilities clean 7 Nonfood-contact surfaces of utensils&equipment clean 55 Establishment and premises free of litter,noinsect/rodentharborage, quipment/utensils,storage,handling no unnecessary articles 32 roper disposal of waste water 56 Complete separation from living/sleeping quarters and laundry 33 Plumbing location,installation,maintenance 57 Clean/soiled linens stored properly 36 Toilet rooms enclosed with self-closing door 58 No live birds,turtles,or other animals(except guide dogs) 59 Seats 75 or more:Nonsmoking area provided,sign(s)posted at 37 Propertoiletfixturesprovlded,good repair,clean entrance(s),smoking area indicated by sign(s) 39 Approved garbage/rubbish containers,adequate number,covered, rodent proof,clean outine Inspection ❑Reinspection ❑ Preoperational Inspection Other Inspection: IN PETD PERSON IN CHARGE:qh De 6 A-9-- merit Score: *Include demerits from page 1 4 3 2 1 0 l Rating si nature signature t CU A ,�ui2/rJez D z�/e CII g" print name print name 9 -et _ phone number title DATE CORRECTIONS DUE: Page 2 of 2 plus 'L/ continuation g Focused Inspection 1/2002 CIO re 0 v Page 3 of INSPECTION REPORT STATE OF CONNECTICUT FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH CONTINUATION SHEET NAME OF ESTABLISHMENT TOWN DATE OF INSPECTION PZ,/2,/ INSPECTION FORM# REMARKS A- co J,_vfm p �/o (0 C9 ?J2:�si)-i J-5 �_4 (7 u, 4 A-Ck t ok�j �S � (P 10 ),-.,ex L40 �j 4�(Lt.- I _1V�Psfl s J/_U z® W -- Lu c� 2— _ ,,,,� c2 4-(�A,5 i -)v T 627 j r RZL<-Q— A S aA 0 ` 2f ® 6ua ca5c&tQ10 Lf �- � LAO,,, r c ci ,�. jp INITIAL(INSPECTOR) llktO INITIAL(PERSON IN CHARGE) , Distribution: 1st-White-Health Department 2nd-Yellow-Owner/Manager :_ Page 7 of Y INSPECTION REPORT STATE OF CONNECTICUT FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH CONTINUATION SHEET NAME OE EST(ABL�ISH TOWN ^ f j Av 4Z,t_ DATE OF INSPE TIO INSPECTION FORM# REMARKS �jk J ^c 43� is(A M(t d6^0--> Af LIJ crto Uvl u c e vt L L CfA t" �a-f� C�� C�l✓1 � � �4✓�A✓(L�� Gc.� t wt R s- �5� INITIAL(INSPECTOR) J' INITIAL(PERSON IN CHARGE) `® Distribution: 1st-White-Health Department 2nd-Yellow-Owner/Manager _ __