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HomeMy WebLinkAbout465 Buckland Road (12) Town of South Windsor - Health Department o 1540 Sullivan Ave., South Windsor, CT 06074-Mailing Address i 1530 Sullivan Avenue, South Windsor, CT 06074-Office Address Phone Number: (860) 337-6173 Fax: (860) 644-1930 �'NDSUR CnN�`v Establishment Information New Permit® Permit Renewal ❑ Type: Mobile/Itinerant vendor❑ Temporary Event❑ Permanent Food Service Establishment❑ ***(Please Print Clearly)*** CLASS: FEE DUE: Name of Establishment: Name of Person in Charge: Establishment Street Address: City, State, Zip Code: cep, W1.'7CAXe),� Phone#: SM;0 Ye y.S 3 Cell Phone#: i.,y,� Fax#: E-Mail Address: '9u36Ctsv.I/;o/M,i/4 heating Capacity: S'CZ Please submit latest copy of the Certified Food Protection ManagerServSafe certificates to the office. Certified Food Protection Manager YES IT NO ❑ Certificate#: 1 ASS 1 } (CFPM) (Required for ALL Class 2,3&4) f T Name: [iris hlor y6e acv Expiration Date: Testing Organization: �y`rZ �. Phone#: E-Mail Address: C/i/'�S�o.Pci�l�;j�c ernate Phone#: el'/-3 Alternate Person In Charge ko s.141717-9-1; -e/, e^cis Phone#: bU) --S3?—y �30 Restaurant Owner Contact Hi cTnnazuicn, �i:e °,,;,•, I�,,� Please check one of the following for ownership Owner's Name: iC'�A:�gd7�,n�s �y�qSe�os• 8 a ,/� status: Mailing Address: 1� /calc�t�'/'1�// �i�J P Individual❑ Association❑ City, State, Zip Code: 1210r' ti C% U OF c.> Corporation;R Partnership El��yo�/ Other Legal Entity❑ Phone#: Vic', S3cj— Y3.3o Fax #: E-Mail Address: qc,(S 4e fSos �� �y,�. G��-�, Cell Phone#: yeo Renovations J Were there any renovations made last year? YES NO Will there be any renovations? YES❑ NO If Yes, please list all renovations that were done/to be done: �-- Supplemental Questionnaires For Itinerant and Temporary Event applications, please complete the supplemental questionnaire form RECEIVED DEB SOUTH WINDSOR !{ HEALTH DEPARTMENT Restaurant Menu/List of All Items rve {° ' �d Latest Menu Attached? YES,? NO ❑ Please list all menu items in as much detail as NOTE** - --'-- (Must have latest copy on file) Possible or a copy of a menu attached is applicable. Restaurant Food Prep (c ec . t .R ❑Cook to order ONLY ❑Advanced catering for specific quantities Cooking/Cooling/reheating/thawing/freezing/hot or cold holding p ❑Uses Time as a Public Health Control ❑Prepares food for Highly Susceptible Population Prepares food to serve at another site ❑Prepackaged non TCS Food ce P (Preschoolers or the elderly) y ❑Non TCS Food only(food that does not require refrigeration) + dditioija rrito Please check all that apply: State Licenses: 59 Bake r'Y (8 liquor Permit ❑ None Water Supply(check only one): .Z Public ____Private Well Wastewater Disposal (check only one): �—O public ____Septic - ____Other(Please use space below to explain) Agreement and Signature By submitting this application,I affirm that the facts set forth in it are true and complete and that I will comply with the ordinances and regulations of the Town of south Windsor and State of Connecticut. I also affirm to allow the Town of Windsor Health Department access to the establishment as required. I understand that any false statements or other misrepresentations made on this application may result in immediate shutdown or revocation of my Food Service License for Applicant Name (Print): 41, � Applicant Address: .4 eAcs Date of Birth:tl , Applicant Signature: C-`�� Phone#: Date: Office USe Only Inspector Name (Print): Inspector Signature: Date: Food Class: Date Received: ! Expiration Date: Date Approved: ° -� Town of South Windsor — Health Department 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address i s 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address -No$es Phone Number: (860) 337-6173 Fax: (860) 644-1930 FOOD ESTABLISHMENT PLAN REVIEW APPLICATION NEW REMODEL ALTERATION CHANGE OF OWNERSHIP Name of Establishment:_ Establishment's Address: Phone (if available):_ t>L� Name of Owner OR Owner's Representitive: _r ��,7Lj ���,� :Mailing Address: 16) Telephone:_ gd ) ,6_3 7— Applicant's Name and Relationship to Owner(self, manager, architect, etc): 4W� Mailing Address: Telephone: Hours of Operation: Mon //- q Tues //— Wed //— Thurs-// Fri /l-/©Sat Sun /+� _ Number of Seats:_��r__ Number of Staff:_j.!i___ (Maximum per shift) Total Square Feet of Facility: ! ` Q0 Number of Floors on which operations are conducted_ Maximum Meals to be Served:(approx. #) Breakfast _2 06r Lunch Dinner SC.-) OFFICE USE ONLY Inspector Name: (Please Print): Inspector Signature: Date: Food Class: 1 2 3 4 V PLgN REVIEW FEE: $150, Nonprofits exempt Payment:Ork Date Received: Rev.7/16/18 SOUT`,WiNDSOR ,4E' -,Fk DEPARTMENT L COOKING TECHNIQUES (check all that apply): ___ Steamin Broiling_-_- Smoking_ Stewing g— Blanching___-Roasting P Frying _ Dee Fr — Bar-B-Que Grilling Boiling� �Saut6ing Bring _Brazing___ pan Frying ____— Roasting Tyne of Service (check all that apply): Hot Foods Only t0 Hot & Cold Foods Commercially Pre-packaged Foods Cold Foods Only X _Take Out Off-Site Caterin -- _Sit Down Meals g 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= I foot showing location of equipment, plumbing,electrical services and mechanical ventilation and equipment schedule Proposed Menu(including seasonal, off-site and banquet menus) 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 Rev.7/16/18 Other Items Re uired 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 Rev.7/16/1 S Food Preparation Review FOOD SUPPLIES. All Food must be from inspected and approved sources. Identify the food supplier(s)and the frequency of deliveries: yC COLD STORAGE Will raw meats, poultry and seafood be stored in the same refrigerators and freezers with cooked/ready-to-eat foods? Z Yes =No If ves. how will cross-contamination be prevented? W�eachri erator have a thermometerNfrigeration units: YeS ®No Number of freezer units: THAWING Please indicate by checking the appropriate box(es)ho potentially hazardous foods (PHF) in each category will be thawed. More than one method ma , a 1 . Thawing Thick Fish Process Meats Meats Poultry Cold Baked In a Seafood Products Foods Goods refri erator Submerged in Running Water less than 70'F Cooked from a Frozen _ I State Microwave as part of the j cooking rocess I i Rev.7/16/1 S 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. Q, c COOLING Please indicate by checking the appropriate box(es) how PHF will be cooled from 140OF to 70OF in 2 hours and from 70°F to 45°F in an additional 4 hours. Fin Thick Thin Fish Poultry Hot Baked Meats Meats Seafood Products Foods Goff I Refrigerators )G j Ice Baths � X) x Stirring with j Iced Chill Sticks Mechanical i Rapid Chill E ui ment FOOD PREPARATION Please list all food items prepared more than 12 hours in advance of service. cJ .w Rev.7/16/18 How will ingredients for cold ready-to-eat foods such as tuna, mayonnaise and eggs for salads and sandwiches be pre-chilled before mixing and assembly? +'U V. Produce Will roduce be washed or rinsed prior to use? Yes Is there a designated location that will be used No for washin or rinsin produce? Yes No Will this area be used for other operations (i.e. utensil washing?) Yes No_ i Seafood E E�eE hed or rinsed prior to Yes Notion that will be used forin raw seafood? Yes No Will this are be used for other operations (i.e. utensil or produce washing?) Yes No PoultEy r1s:there ill oultr be washed or rinsed prior to use? I Yes No an approved location that will be used washing, rinsin , or thawin oultr ? Yes No ill this area be used for other operations (i.e. produce or utensil washing?) Yes No j DRY GOODS STORAGE/STORAGE OF SINGLE SERVICE ITEMS (PAPER CUPS, PLATES,STRAWS, ETC.) Is appropriate dry good storage space provided for based upon the menu. meals offered, frequency of deliveries, and items being stored? Yes ' No Where will single service items be stored in the service location(s)? t• Rev.7/16/18 Will approved food storage containers be used to store bulk food products? Describe. o At/ t7e.L- Ef t / J PERSONNEL Will disposable gloves and/or utensils and/or food grade paper be used to minimize di of ready-to-eat foods? Yes _ No rect hand contact 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 poli symptoms. cy to restrict food workers with these A.00 ` r �� �-�-� Class III 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 the QFO's: - C/i r,L . _x1e,rC?'6 e AC� + List the names of the Alternate QFO's: Describe the training that the QFO will provide to the food workers and how written records of training will be maintained: Re,.7/16/18 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 (FLOORAVALL WALLS CEILING JUNCTURE) Kitchen/Cooking Area Bar Food Storage Other Storage Toilet Rooms Dressing Rooms Garbage & Refuse Storage Mop Service Area Basement Other Other Other Other Identify the finishes of the counters, cabinets, storage shelves, tables, etc.: Rev.7/16/18 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 j Floor Drain Connection Dishwasher Ice Machine i Ice Storage Bins Food Prep Sinks UtensiUPot wash I Sinks i Steam Tables Dipper Wells Refrigeration CIS Other Other Other Applicants must identify the type of backflow prevention to be used for the water supply to each lumbin 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 Rev.7/I6/I8 DISHWASING FACILITES A three-compartment sink shall be provided and used whenever washing, rinsing, and sanitization of equipment and utensils are conducted. Does the largpet pot, pan, utensil, or container fit into each compartment of the three-compartment sink? Yes No What ty of sanitizer will be used? More than one may apply. Chlorine Quaternary Ammonium Other ------__Iodine Hot Water Chemical Test Kits/Papers available for sanitiz checking er concentrations: Yes ` No Will ventilation be provided over the dishwasher? Yes No All dish machines must have accurate tem erature and ressure au es. Is appropriate air drying space available for the air drying of all washed nsils with the use of drain boards, wall or overhead shelves, stationary or portable racks? Yes No Please describe the type and location of the air-drying space for the cleaned items: WATER SUPPLY Will ice be made on premises or purchased co mercially? Please specify: Describe provision for ice scoop storag S- INSECT AND RODENT CONTROL Please check appropriate boxes. YES NO N/A Will all outside doors be self-closing and have rodent proof flashin /weather stri in ? 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 Re%.7/16/18 GARBAGE AND REFUSE Inside Will all garbage containers have lids" Yes No Will refuse be stored inside? Where'? i<•C� Outside Will the area around mises be maintained clear of unnecessary brush, litter, boxes and other vermin harborage? Yes around Will a dumpster be used? Yes V No Where will the dumpster be located? A, Identify the Waste Hauler to be used: Will a compacter be used? Yes No Where will the compacter be located? Describe the surface and location where the dumpster/compactor/barrels will be stored: Specify the type and location of cooking grease waste storage receptacles: Identify the location�(s)�and size(s) of the grease trap(s): Will there be an area to store recycled containers? Describe. MOP CLEANING FACILITIES Will a separate mop basin be provided: Yes X No If Yes, please describe the facility for cleaning mops and other maintenance equipment: HANDWASHING/TOILET FACILITIES Will there be hand-washing sinks in the food preparation, food dispensing, and ware washing areas? Yes_ No Re%.7/16/18 Will all hand-washing sinks have mixing valves or combination faucets? Yes—ZNo Will self-closing metering faucets provid ow 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 .bb er, 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 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 insecticides/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 stored: Will all containers of toxic/cleaning material, including sanitizing spray bottles, be clearly labeled? Yes_ No- Rec.7/16/18 LINENS Will a laundry washer and dryer be available on the premises? Yes ii0^ If Yes, what items will be laundered? No l� Identify the location of dirty linen storage: r - 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) !7 u 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 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 local and state laws governing food service establishments Rev.7/16/18 S�'Alc Di -\ M� t �Y I � t � J Arta --�----- -�-- --- I L r _ OM _ � i