HomeMy WebLinkAbout538 Evergreen Way Health Department
Town of South Windsor —
T 1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
1530 Sullivan Avenue, South Windsor, CT 06074—Office Address
Phone Number: (860) 337-6173 Fax: (860) 644-1930
FOOD ESTABLISHMENT PLAN R UI'VIEW APPLICATION
NEW REMODEL ALTERATION CHANGE OF OWNERSHIP
Name of Establishment:
Establishment's Address: (� C-t, / L✓^3�
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Phone(if available):
Name of Owner OR Owner's Representitive: `'� I `� z
Mailing Address: J ��'2� �15 r'\
Telephone: l ;�0 3 -91`A— CDC075 Z
Applicant's Name and Relationship to Owner(self, manager, architect,etc):
CO- Je--, -0-5f- RECEIVED
Mailing Address: 4T t 017
T
Telephone: SADI r1 H nn�ir c ,h
HEALTH DEPT
Hours of Operation:
\Iom 1/-`) Tuesl 16 Wed Thurs / Fri l l Sat Sun /(-D
Number of Seats:
�r—� 0
Number of Staff: £ oZ (Maximum per shift)
Total Square Feet of Facility: 62-a) Number of Floors on which operations are conducted
Maximum Meals to be Served:(approx. #) Breakfast Lunch L(C6 Dinner�
OFFICE USE ONLY
Inspector
(Please Print)
.
Inspector
Signature: Date: 1 1 2,411 Yr
Food class: 1712 ❑ 3 ✓4 ❑ PLAN REVIEW FEE: $150, Nonprofits exempt
Notes: Date Received: 17LI lit
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COOKING TECHNIQUES (check all that apply): _ Steaming— Blanching Roasting
Broiling_Smoking_Stewing_ Bar-B-Que_Grilling Boiling �Sauteing� Baking
Deep Frying_Brazing_ Pan Frying Roasting
Type of Service(check all that apply): Hot Foods Only Cold Foods Only
Hot & Cold Foods Commercially Pre-packaged Foods __) Sit Down Meals
Take Out Off-Site Catering __Mobile Food Unit Push Cart
Customer Self Service Other(Please Describe)
The following documents must be submitted for review:
,' Plan of facility that are a minimum of 11 x 14 inches in size including the layout of the floor plan
accurately drawn to a minimum scale of 1/4 inch= 1 foot showing location of equipment, plumbing, electrical
services and mechanical ventilation and equipment schedule
roposed Menu(including seasonal, off-site and banquet menus) c�
Qualified Food Operator Certificate(s) and Designated Alternate Form(Class 3 and 4)
Manufacturer Specification sheets for each piece of equipment shown on the plan
'� Site plan showing location of business in building; location of building on site including alleys, streets,
driveways, and location of any outside equipment(dumpsters, walk-ins,well, septic system-if applicable)
Payment
Other Items Required for Review and Construction:
_Show the location and when requested, elevated drawings of all food equipment. Each piece of equipment
must be clearly labeled on the plan with its common name. Submit drawings of self-service hot and cold holding
units with sneeze guards.
Designate clearly on the plan equipment for adequate rapid cooling, including ice baths and refrigeration, and
for hot-holding potentially hazardous foods.
Label and locate separate food preparation sinks when the menu dictates to preclude contamination and
cross-contamination of raw and ready-to-eat foods.
Clearly designate adequate handwashing lavatories for each toilet fixture and in the immediate area of food
preparation.
Provide the room size, aisle space, space between and behind equipment and the placement of the equipment
on the floor plan.
On the plan represent auxiliary areas such as storage rooms, garbage rooms, toilets, basements and/or cellars
used for storage or food preparation. Show all features of these rooms as required by this guidance manual.
Include and provide specifications for:
Entrances,exits, loading/unloading areas and docks;
Complete finish schedules for each room including floors, walls,ceilings and coved juncture bases;
Plumbing schedule including location of floor drains,floor sinks, water supply lines, overhead waste-
water lines,hot water generating equipment with capacity and recovery rate,backflow prevention, and
wastewater line connections;
_Lighting schedule with protectors;
_Food Equipment schedule to include make and model numbers and listing of equipment that is certified
or classified for sanitation by an ANSI accredited certification program(when applicable).
Source of water supply and method of sewage disposal. Provide the location of these facilities and
submit evidence that state and local regulations are complied with;
Ventilation schedule for each room;
A mop sink or curbed cleaning facility with facilities for hanging wet mops;
_Garbage can washing area/facility;
Cabinets for storing toxic chemicals;
Dressing rooms, locker areas,employee rest areas, and/or coat rack as required
Food Preparation Review
FOOD SUPPLIES.
All Food must be from inspected and approved sources. Identify the food supplier(s)and the frequency of
delive e
+� CIA
COLD STORAGE
Will raw meats. poultry and seafood be stored in the same refrigerators and freezers with cooked/ready-to-eat
foods? EYes 0 No If yes,how will cross-contamination be prevented?
Will each refrigerator have a thermometer? es 0 No
Number of refrigeration units: Number of freezer units:
THAWING
Please indicate by checking the appropriate box(es) ho potentially hazardous foods (PHF) in each
�. "ory will be thawed. More than one method may appi .
Thawing Thick Thin Fish Poultry Cold Baked
Process Meats Meats Seafood Products Foods Goods
Ina
refrigerator [/
Submerged
in Running
Waterless
than 70'F
Cooked from
a Frozen
State
Microwave
as part of the
cooking
process
Identify which type and how many food product thermometers (0°F-212°F) will be available and be
used to measure final cooking/reheating temperatures of PHF:
Identify how and where will hot PHF be maintained at 140°F or above during holding for service.
Indicate type and number of hot holding units.
COOLING
Please indicate by checking the appropriate box(es) how PHF will be cooled from 140°F to 70°F in 2
hours and from 70°F to 45°F in an additional 4 hours.
Cooling Thick Thin Fish Poultry Hot Baked
Process Meats Meats Seafood Products Foods Goods
Shallow
Pans in
Refrigerators
Ice Baths
Stirring with
Iced Chill
Sticks
Mechanical
Rapid Chill
Equipment
FOOD PREPARATION
Please list all food items prepared more th n 12 hours in adv•nce of service.
How will ingredients for cold ready-to-eat foods such as tuna, mayonnaise and eggs for salads and
"andw is us be pre-chilled before mixing and assembly?
-e
Produce
Will produce be washed or rinsed prior to use? Yes No
Is there a designated location that will be used
for washing or rinsing produce? Yes ► No
Will this area be used for other operations (i.e.
utensil washing?) Yes No
Seafood
Will raw seafood be washed or rinsed prior to Yes No
use?
Is there a designated location that will be used for
washing, rinsing, or thawing raw seafood? Yes No
Will this are be used for other operations (i.e.
utensil or produce washing?) Yes No
Poultry
Will poultry be washed or rinsed prior to use? Yes No
Is there an approved location that will be used
for washing, rinsing, or thawing poultry? Yes No
Will this area be used for other operations (i.e.
produce or utensil washing?) Yes No
DRY GOODS STORAGE/STORAGE OF SINGLE SERVICE ITEMS (PAPER CUPS,
PLATES,STRAWS, ETC.)
Is appropriate dry good storage space 1wovidCLI for based upon the menu, meals offered, frequency of
delkerie,, attd items being ,lured'.' Yes_/L No
Whea} ll single service items be stored in the service location(s)?
Will approved food storage containers be used to store bulk food prod`ucts? Describe.
PERSONNEL
Will disposable gloves and/or utensils and/or food grade paper be used to minimize direct hand contact
of ready-to-eat foods? Yes No
Your food establishment must have a policy to exclude or restrict food workers who are ill with
symptoms compatible with food borne illness (vomiting, diarrhea, nausea, stomach cramps, high fever,
jaundice) or have infected cuts and lesions. Describe your policy to restrict food workers with these
symptoms. ` „ 1� I-- '�)L s
Class IIl and IV food establishments are required to have a Qualified Food Operator employed in a
full-time supervisory position at the establishment. It is recommended that Class I and Class II food
operators consider becoming QFO's as well.
List the names of tthe QFO's:
List the names of the Alternate QFO's:
q.'k 6"-r(if-
Describe the training that the QFO will provide to the food workers and how written records of
training will be inaintain d:
l� ✓'- 1 �-
FINISH SCHEDULE
Applicants must indicate the materials (i.e., quarry tile, stainless steel, 6"plastic cove molding, etc.) to
be used in each area listed below:
BASE
AREA FLOOR (FLOOR/WALL WALLS CEILING
JUNCTURE)
Kitchen/Cooking -�A nl'e�fd�
Area
BarIle
Food Storage
Other Storage
Toilet Rooms
Dressing Rooms
Garbage & Refuse C h /1tr� —
Storage
Mop Service Area
Basement
Other
Other
Other
Other
Identify the finishes of the counters, cabinets, storage shelves, tables, etc.:
PLUMBING
Applicants must identify the type of plumbing connections that will be used on the drains for the
fixtures listed below:
Plumbing Indirect Indirect Other Direct Waste
Fixture Floor Sink Floor Drain Connection
Dishwasher
Ice Machine
Ice Storage Bins
Food Prep Sinks
Utensil/Pot wash
Sinks
Steam Tables
Dipper Wells
Refrigeration
Other
Other
Other
Applicants must identify the type of backflow prevention to be used for the water supply to each
plumbing fixture listed below:
Plumbing Fixture Backflow Prevention Device Air Gap
Hose Connections
Soda Carbonation System
Water Supply for Garbage
Grinders
Water Fill for Soda Guns
Dipper Wells
Other
Other
DISHWASING FACILITES
A three-compartment sink shall be provided and used whenever washing, rinsing, and sanitization of
equipment and utensils are conducted.
Does the largcst pot, pan, utensil, or container fit into each compartment of the three-compartment
sink? Yes _ No
What type of sanitizer will be used? More than one may apply.
Chlorine ^Quaternary Ammonium _Iodine Hot Water
Other
Chemical Test Kits/Papers available for checking sanitizer concentrations: Yeti_ No
Will ventilation be provided over the dishwasher? Yeses No
All dish machines must have accurate temperature and pressure gaugc,�.
Is appropriate air drying space available for the air drying of all washed utensils with the use of drain
boards, wall or overhead shelves, stationary or portable racks? Yes X No
Please describe the type and location of the air-drying space for the cleaned items:
WATER SUPPLY
Will ice h• made on premises or purchased commercially? Please specify:
�4 ye-
Describe provision for ice scoop stor.Wc:
INSECT AND RODENT CONTROL
Please check appropriate boxes.
YES NO N/A
Will all outside doors be self-closing and have rodent proof
flashing/weather stripping?
Screen Doors (minimum#16 Mesh screen)
Air Curtain
Other
Will all pipe penetrations, beverage chases & electrical conduit chases be sealed; ventilation systems,
exhaust and intakes protected? Yes No
GARBAGE AND REFUSE
Inside
Will all garbage containers have lids? Yes No
Will refuse be stored inside,9, Where?
Outside
Will the area around premises be maintained clear of unnecessary brush, litter,boxes and other vermin
harborage' vre Yeti No
Will a dumpster be used? Yes No
Where will the dumpster be located?
Identify the Waste Hauler to be used-
Will a compacter be used? Yes No
Where will the compacter be located? Ca M4A-t- =;r.,r�--\,
Describe the surface and location where the dumpster/compactor/barrels will be stored:
op-L C f C--
Specify the type and location of cooking grease waste storage receptacles:
v/�D q
Identify the location(s) and size(s) of the grease trap(s):
Will there be an area to store recycled containers? Describe.
--1 21 CO/ L.
MOP CLEANING FACILITIES
Will a separate mop basin be provided: Yes No
If Yes, please describe the facility for cleaning mops and other maintenance equipment:
HANDWASHING/TOILET FACILITIES
Will then be hand-washing sinks in the food preparation, food dispensing, and ware washing areas?
Yes No
Will all hand-washing sinks have mixing valves or combination faucets? Yes X No
Will self-closing metering faucets provide a flow of water for at least 15 seconds without the need to
reactivate the faucet? Yes No
Will soap dispensers be available at all hand washing sinks? Yes No
Will hand drying facilities (paper towels, air blower, etc.) and waste receptacles be available at all hand
washing sinks and in each restroom? Yes ,<. No
Will toilet room doors be self-closing? Yes X No
Will unisex and/or women's restrooms have covered receptacles? Yes No
SEWAGE DISPOSAL
Will the building be connected to a municipal sewer? Yes No
DRESSING ROOMS
Will separate dressing rooms be provided? Yes No
Describe the storage facilities for employees' personal belongings (i.e., purses, coats, phones, etc.)
CHEMICAL STORAGE
Will all cleaning materials and toxic items be stored away from food prep and storage areas?
Yes X No
Will inse icides/rodenticides (if used) be stored separately from cleaning and sanitizing agents?
Yes No
Please describe the location of all toxic items storage-including areas in the food prep areas where "in-
use"chemicals Will be st red:
Will all containers of toxic/cleaning material, including sanitizing spray bottles, be clearly labeled?
Yes No
LINENS
Will a laundry washer and dryer be available on the premises? Yes No X
If Yes, what items will be laundered?
Identify the location of dirty linen storage:
STATEMENT: I hereby certify that the above information is correct. I fully understand that any
deviation from the above without prior approval from the Town of South Windsor Health Department
is prohibited.
Signature(s)
Owner(s) or Responsible Representatives
Date: &)!
Approval of these plans and specifications by the Town of South Windsor Health Department does not
indicate compliance with any other code, law, or regulation that may be requiredfederal, state, or
local. It further does not constitute endorsement or acceptance of the completed establishment
(structure or equipment). :k pre-opening inspection of the establishment %s ith equipment in place
and operational will be necessary to determine if it complies with the local and state laws
governing, food service establishment,.
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