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EXAM FORM NO. 10167
CERTIFICATE NO. 7536779
fe e Certi
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ificat
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for successfully completing the standards set forth for the ServSafe®Food Protection Manager Certification Examination,
which is accredited by the American National Standards Institute(ANSI)-Conference for Food Protection(CFP).
1/20/2011
DATE OF EXAMINATION
i
1'/20/2016
uj DATE OF EXPIRATION
Local laws apply.Check with your local regulatory agency for recertification requirements.
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Town of South Windsor — Health Department y, �7 1
041
v 1540 Sullivan Avenue, South Windsor, CT 06074
Phone: 860-644-2511 ext. 248 Fax: 860-644-7280 'yOFp�R
FOOD ESTABLISHMENT PLAN REVIEW APPLICATION
*for Class 3 or 4 establishments
NEW REMODEL CONVERSION Y—CHANGE OF OWNERSHIP
Name of Establishment:
Category:Restaurant,Institution ,Daycare ,Retail Market , Other
Address: 3a, Wk r A&brz- CT— 03-
Phone(if available): F5o0— 4�2— 9 S�O0
Name of Owner: MSu& � ���S`a►� Ll.
Mailing Address: lcvoo dJ c. \hc.�C o �� r2Zc,4
Telephone: S7^ to'g 9 �o S
Applicant's Name: c—�UCe �t,%A.t v\Sk�/
Title(owner,manager,architect,etc.): VAOwka e I to e Re?' ^e IL
Mailing ae �`'� c�►� ld7(eJ� ?o�, C� �S
Address:
Telephone: S0
Hours of Operation: q
Mon I I Ak*v aen Tues Wed V 1 A-0h— 1 P►A Thu 1 ►fit— 9 PnA
Fri t�PP-- 1 O Pvh Sun I 1 A-M
Number of Seats: 9 () Number of Staff. y (Maximum per shift)
Total Square Feet of Facility: Number of Floors on which operations are conducted
Maximum Meals to be Served:(approx.#) Breakfast Lunch Dinner
Projected Start Date of Project: Projected Completion Date of Project:
Type of Service: Sit Down Meals Take Out Caterer Mobile Vendor Other
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FOOD PREPARATION REVIEW "* '
Check categories of Potentially Hazardous Foods(PHF's)to be handled,prepared and served.
CATEGORY* y S
1. Thin meats,poultry,fish, eggs(hamburger; sliced meats;fillets) ( ) ( )
2. Thick meats, whole poultry(roast beef; whole turkey, chickens,hams) ( ) ( )
3. Cold processed foods (salads, sandwiches,vegetables) ( ) ( )
4. Hot processed foods (soups, stews,rice/noodles, gravy,chowders, casseroles) ( ) ( )
5. Bakery goods (pies, custards, cream fillings &toppings) ( ) ( )
6. Other
*A generic HACCP plan for each category of food may be available from the regulatory
authority for reference.
PLEASE CIRCLEIANSWER THE FOLLOWING QUESTIONS:
FOOD SUPPLIES:
1.Are all food supplies from inspected and approved sources?YES/NO
2.What are the projected frequencies of deliveries for Frozen foods ,
Refrigerated foods ,and Dry goods
3.Provide information on the amount of space(in cubic feet)allocated for:
Dry storage ,Refrigerated Storage ,and
Frozen storage
4.How will dry goods be stored off the floor?
COLD STORAGE:
1. Is adequate and approved freezer and refrigeration available to store frozen foods,and refrigerated foods at
45°F and below?YES/NO
Provide the method used to calculate cold storage requirements.
2. Will raw meats,poultry and seafood be stored in the same refrigerators and freezers with cooked/ready-to-eat
foods?YES/NO
If yes,how will cross-contamination be prevented?
3.Does each refrigerator/freezer have a thermometer?YES/NO
4. #of refrigeration units: #of freezer units: Bulk Ice Machine?YES/NO
-2-
THAWING FROZEN POTENTIALLY HAZARDOUS FOOD:
Please indicate by checking the appropriate boxes how frozen Potentially Hazardous Foods (PHF's)in
each category will be thawed. More than one method may apply. Also,indicate where thawing will
take place.
i Thawing Method *THICK FROZEN FOODS *THIN FROZEN FOODS
Refrigeration
Running Water Less than 70°F
I
Microwave(as part of cooking
process)
Cooked from Frozen state
Other(describe)
*Frozen foods: approximately one inch or less =thin, and more than an inch=thick.
COOKING:
1.Will food thermometers be used to measure final cooking/reheating temperatures of PHF's?YES/NO
What type of temperature measuring device:
2.List types of cooking equipment.
HOT/COLD HOLDING:
1.How will hot PHF's be maintained at 140T or above during holding for service?Indicate type and number of
hot holding units.
2.How will cold PHF's be maintained at 45T or below during holding for service?Indicate type and number of
cold holding units.
-3 -
COOLING:
Please indicate by checking the appropriate boxes how PHF's will be cooled to 45T within 6 hours(140°F to
70°F in 2 hours,and 70°F to 45T in 4 hours).Also,indicate where the cooling will take place.
COOLING THICK THIN THIN THICK RICE/
METHOD MEATS MEATS SOUPS/ SOUPS/ NOODLES
GRAVY GRAVY
Shallow Pans
Ice Baths
Reduce Volume
or Size
i
Rapid Chill
Other(describe)
REHEATING:
1.How will PHF's that are cooked,cooled,and reheated for hot holding be reheated so that all parts of the food
reach a temperature of at least 165T for 15 seconds.Indicate type and number of units used for reheating foods.
2.How will rehearing food to 165°F for hot holding be done rapidly and within 2 hours?
-4-
PREPARATION:
1.Please list categories of foods prepared more than 12 hours in advance of service.
2.Will food employees be trained in good food sanitation practices?YES/NO
Method of training:
Number(s)of employees: Dates of completion:
3.Will disposable gloves and/or utensils and/or food grade paper be used to prevent handling of ready-to-eat
foods?YES/NO
4.Is there a written policy to exclude or restrict food workers who are sick or have infected cuts and lesions?
YES/NO
Please describe briefly:
Will employees have paid sick leave?YES/NO
5. How will cooking equipment,cutting boards,counter tops and other food contact surfaces which cannot be
submerged in sinks or put through a dishwasher be sanitized?
Chemical Type: Concentration: Test Kit:YES/NO
6.Will ingredients for cold ready-to-eat foods such as tuna,mayonnaise and eggs for salads and sandwiches be
pre-chilled before being mixed and/or assembled?YES/NO
If not,how will ready-to-eat foods be cooled to 41°F?
7.Will all produce be washed on-site prior to use?YES/NO
Is there a planned location/designated sink used for washing produce?YES/NO
Describe
-5 -
If not,describe the procedure for cleaning and sanitizing multiple use sinks between uses.
8.Describe the procedure used for minimizing the length of time PHF's will be kept in the temperature danger
zone(45T- 140°F)during preparation.
9.Provide a HACCP plan for specialized processing methods such as vacuum packaged food items prepared on-
site or otherwise required by the regulatory authority.
10.Will the facility be serving food to a highly susceptible population?YES/NO
If yes,how will the temperature of foods be maintained while being transferred between the kitchen and service
area?
A.FINISH SCHEDULE
Applicant must indicate which materials(quarry tile,stainless steel,4"plastic coved molding,etc.)will be used
in the following areas.
-
j FLOOR COVING WALLS CEILING
Kitchen/Bar
Food Storage
Other Storage
a Toilet Rooms
-6-
Dressing Rooms
Garbage&
] Refuse Storage
i
Mop Service
Basin Area
Warewashing
Area
i
Walk-in
Refrigerators
and Freezers
B.INSECT AND RODENT CONTROL (Please check appropriate boxes) YES NO NA
1. Will all outside doors be self-closing and rodent proof? ( ) ( ) ( )
2. Are screen doors provided on all entrances left open to the outside? ( ) ( ) ( )
3. Do all openable windows have a minimum#16 mesh screening? O O ( )
4. Is the placement of electrocution devices identified on the plan? O O ( )
5. Will all pipes &electrical conduit chases be sealed; ventilation systems exhaust and ( ) ( ) ( )
intakes protected?
6.Is area around building clear of unnecessary brush, litter, boxes and other
harborage? O O ( )
7. Will air curtains be used?If yes,where? ( ) ( ) ( )
C.GARBAGE AND REFUSE
Inside
S. Do all containers have lids? ( ) ( ) ( )
9. Will refuse be stored inside? ( ) ( ) ( )
If so,where?
10. Is there an area designated for garbage can or floor mat cleaning? ( ) ( ) ( )
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Outside
11.Will a dumpster be used? YES/NO Number Size
Contractor Frequency of pickup
12.Will a compactor be used? YES/NO Number Size
Frequency of pick up Contractor
13.Will garbage cans be stored outside? YES/NO
14. Describe surface and location where dumpster/compactor/garbage cans are to be stored
15. Describe location of grease storage receptacle
16. Is there an area to store recycled containers? YES/NO (list location)
Indicate what materials are required to be recycled;
( )Glass O Metal O Paper O Cardboard O Plastic
17. Is there any area to store returnable damaged goods? YES/NO
D.PLUMBING CONNECTIONS
AIR AIR *INTEGRAL *"P" VACUUM CONDENSATE
GAP BREAD TRAP TRAP BREAKER PUMP
18.Toilet
a
19.Urinals
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j 20.
i
Dishwasher
i
i
1
21.Garbage
Grinder
22.Ice
machines
23.Ice storage
j bin
24.Sinks
a.Mop
b.Janitor
c.Handwash
d.3Compartment
e.2 Compartment
E 1Compartment
g.Water Station
25.Steam
tables
L
X Dipper
wells
27.
Refrigeration
condensate/
drain lines
28.Hose
connection
29.Potato
peeler
1
-9 -
30.Beverage
Dispenser
w/carbonator
31.Other
32.Are floor drains provided&easily cleanable,if so,indicate location:
E.WATER SUPPLY
33.Is water supply public( )or private( ) ?
34.If private,has source been approved?YES( )NO( )PENDING( )
Please attach copy of written approval and/or permit.
35.Is ice made on premises( )or purchased commercially( ) ?
If made on premise,are specifications for the ice machine provided?YES( )NO{ )
Describe provision for ice scoop storage:
Provide location of ice maker or bagging operation
36.What is the capacity of the hot water generator?
37.Is the hot water generator sufficient for the needs of the establishment?YES O NO( )
38.Is there a water treatment device?YES ( )NO( )
If yes,how will the device be inspected&serviced?
39.How are backflow prevention devices inspected&serviced?
F.SEWAGE DISPOSAL
40.Is building connected to a municipal sewer?YES( }NO( )
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41.If no,is private disposal system approved?YES( )NO( )PENDING( )
*Please attach copy of written approval and/or permit.
42.Are grease traps provided?YES ( )NO( )
If so,where?
Provide schedule for cleaning&maintenance
G.DRESSING ROOMS
43.Are dressing rooms provided?YES( )NO( )
44.Describe storage facilities for employees'personal belongings(i.e.,purse,coats,boots,umbrellas,etc.)
H.GENERAL
45.Are insecticides/rodenticides stored separately from cleaning&sanitizing agents?YES( )NO( )
Indicate location:
46.Are all toxics for use on the premise or for retail sale(this includes personal medications),stored away from
food preparation and storage areas?YES O NO( )
47.Are all containers of toxics including sanitizing spray bottles clearly labeled?YES( )NO( )
48.Will linens be laundered on site?YES ( )NO( )
If yes,what will be laundered and where?
If no,how will linens be cleaned?
49. Is a laundry dryer available?YES O NO( )
50.Location of clean linen storage:
51.Location of dirty linen storage:
52.Are containers constructed of safe materials to store bulk food products?YES( )NO( )
Indicate type:
- 11 -
53.Indicate all areas where exhaust hoods are installed:
LOCATION FILTERS SQUARE FIRE AIR AIR
WOR FEET PROTECTION CAPACITY MAKEUP
EXTRACTION CFM CFM
DEVICES
3
1 .
54. How is each listed ventilation hood system cleaned?
I.SINKS
55.Is a mop sink present?YES ( )NO( )
If no,please describe facility for cleaning of mops and other equipment:
56.If the menu dictates,is a food preparation sink present?YES( )NO( )
J.DISHWASHING FACILITIES
57.Will sinks or a dishwasher be used for warewashing?
Dishwasher( )Two compartment sink( )Three compartment sink( )
58.Dishwasher: Type of sanitization used: Hot water(temp.provided)
Booster heater Chemical type
Is ventilation provided?YES ( )NO( )
- 12-
59.Do all dish machines have templates with operating instructions?YES ( )NO( )
60.Do all dish machines have temperature/pressure gauges as required that are accurately working?YES ( )
NO( )
61.Does the largest pot and pan fit into each compartment of the pot sink?YES O NO( )
If no,what is the procedure for manual cleaning and sanitizing?
62.Are there drain boards on both ends of the pot sink? YES ( )NO( )
63.What type of sanitizer is used?(circle one) Chlorine Quaternary Ammonium Hot Water Iodine
64.Are test papers and/or kits available for checking sanitizer concentration?YES ( )NO( }
K.HANDWASHING/TOILET FACILITIES
65. Is there a handwashing sink in each food preparation and warewashing area?YES ( )NO( )
66.Do all handwashing sinks,including those in the restrooms,have a mixing valve or combination faucet?
YES ( )NO ( )
67.Do self-closing metering faucets provide a flow of water for at least 15 seconds without the need to
reactivate the faucet?YES ( )NO( }
68.Is hand cleanser available at all handwashing sinks?YES ( )NO( )
69.Are hand drying facilities(paper towel dispensers,etc.)available at all handwashing sinks?YES ( )NO ( )
70.Are covered waste receptacles available in each restroom?YES ( )NO( )
71. Is hot and cold running water under pressure available at each handwashing sink?YES ( )NO( )
72.Are all toilet room doors self-closing?YES ( )NO( )
73.Are all toilet rooms equipped with adequate ventilation?YES O NO( )
74.If required,is a handwashing sign posted in each employee restroom?YES ( )NO( )
L.SMALL EQUIPMENT REQUIREMENTS
75.Please specify the number,location,and types of each of the following:
Slicers - Cutting boards
Can openers Mixers
Floor mats Other
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STATEMENT:I hereby certify that the above information is correct,and I fully understand that any
deviation from the above without prior permission from this Health Regulatory Office may nullify final
approval.
Signature:
(Owner or responsible representative)
Print
Name: ��-�
Approval of these plans and specifications by this Regulatory Authority 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
preopening inspection of the establishment with equipment in place&operational will be necessary to
determine if it complies with the local and state laws governing food service establishments.
- 14-