FOOD ESTABLISHMENT PLAN REVIEW APPLICATION NEW REMODEL ALTERATION CHANGE OF OWNERSHIP. Name of Establishment: Establishment s Address:

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1 FOOD ESTABLISHMENT PLAN REVIEW APPLICATION NEW REMODEL ALTERATION CHANGE OF OWNERSHIP Name of Establishment: Establishment s Address: Phone (if available): Name of Owner OR Owner s Representitive: Mailing Address: Telephone: Applicant's Name and Relationship to Owner (self, manager, architect, etc): Mailing Address: Telephone: Hours of Operation: Mon Tues Wed Thurs Fri Sat Sun Number of Seats: Town of South Windsor Health Department 1540 Sullivan Ave., South Windsor, CT Mailing Address 1530 Sullivan Avenue, South Windsor, CT Office Address Phone Number: (860) Fax: (860) Number of Staff: (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 OFFICE USE ONLY Inspector Name: (Please Print): Inspector Signature: Food Class: PLAN REVIEW FEE: $150, Nonprofits exempt Date: Notes: Date Received:

2 COOKING TECHNIQUES (check all that apply): Steaming Blanching Roasting Broiling Smoking Stewing Bar-B-Que Grilling Boiling Sautéing 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 (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 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

3 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 wastewater 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

4 Food Preparation Review FOOD SUPPLIES. All Food must be from inspected and approved sources. Identify the food supplier(s) and the frequency of deliveries: COLD STORAGE 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? Will each refrigerator have a thermometer? Yes 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 category will be thawed. More than one method may apply. Thawing Process In a refrigerator Submerged in Running Water less than 70 F Cooked from a Frozen State Microwave as part of the cooking process Thick Meats Thin Meats Fish Seafood Poultry Products Cold Foods Baked Goods

5 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 Process Shallow Pans in Refrigerators Thick Meats Thin Meats Fish Seafood Poultry Products Hot Foods Baked Goods Ice Baths Stirring with Iced Chill Sticks Mechanical Rapid Chill Equipment FOOD PREPARATION Please list all food items prepared more than 12 hours in advance of service.

6 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? 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 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)?

7 Will approved food storage containers be used to store bulk food products? 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. 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: 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:

8 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 Area Bar Food Storage Storage Toilet Rooms Dressing Rooms Garbage & Refuse Storage Mop Service Area Basement Identify the finishes of the counters, cabinets, storage shelves, tables, etc.:

9 PLUMBING Applicants must identify the type of plumbing connections that will be used on the drains for the fixtures listed below: Plumbing Indirect Indirect Direct Waste Fixture Dishwasher Ice Machine Ice Storage Bins Food Prep Sinks Utensil/Pot wash Sinks Steam Tables Dipper Wells Refrigeration Floor Sink Floor Drain Connection 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

10 DISHWASING FACILITES A three-compartment sink shall be provided and used whenever washing, rinsing, and sanitization of equipment and utensils are conducted. Does the largest 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 Chemical Test Kits/Papers available for checking sanitizer concentrations: Yes No Will ventilation be provided over the dishwasher? Yes No All dish machines must have accurate temperature and pressure gauges. 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 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 commercially? Please specify: Describe provision for ice scoop storage: INSECT AND RODENT CONTROL Please check appropriate boxes. Will all outside doors be self-closing and have rodent proof flashing/weather stripping? Screen Doors (minimum #16 Mesh screen) Air Curtain YES NO N/A Will all pipe penetrations, beverage chases & electrical conduit chases be sealed; ventilation systems, exhaust and intakes protected? Yes No

11 GARBAGE AND REFUSE Inside Will all garbage containers have lids? Yes No Will refuse be stored inside? Where? Outside Will the area around premises be maintained clear of unnecessary brush, litter, boxes and other vermin harborage? Yes 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? 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 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

12 Will all hand-washing sinks have mixing valves or combination faucets? Yes 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 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 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 inuse chemicals will be stored: Will all containers of toxic/cleaning material, including sanitizing spray bottles, be clearly labeled? Yes No

13 LINENS Will a laundry washer and dryer be available on the premises? Yes No 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 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.