HomeMy WebLinkAboutCLE201600272 Application 2016-12-12Application for Zoning Clearance
CLE # A0/66,t�L, ? -)_
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PLEASE REVIEW ALL 3 SHEETS
OFFICE U E ONLY
Check # IV&'61- Date: u,z
Receipt # 10 3 Staff: 2 4/
PARCEL INFORMATION //1
Tax Map and Parcel: r' "f, /Iz ' G��"lG� ^ /��0 b
Existing Zoning �yt��Jp��/
L �J
Parcel Owner:
Parcel Address: L8 tkr,, City L.r�L�f— State L,-f
Zip ZZc1
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? ?—crp hc�e. +y—or^( k j
Address: SC> 6 City 4-Jej—il II Mate
Zip
'
Office Phone: (_) Cell # `'i3 �(—S z_- S, fa3x # E-mail
�p C ��� ' 1 ,
L a tr
AYYLIUAIN 1 IIN YO RNIA'110N
Check any that apply: ange of ownership Change of use Change of name New business
Business Name/Type: G r Z -e— t-
Previous Business on this site (� q 4-----
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
vehicles, and any additional information that you can provide: _ I c> e_ri.pIe__ 7 ` S n c', !f)
*This Clearance will only be valid on the parcel for which it is approved. If you change, intensify or move the use to a new location, a new Zoning
Clearance will be required.
I hereby certify that I own or have the owner's pennission to use the space indicated on this application. I also certify that the information provided
is true and accurate to the best my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed4
(APPROVAL INFORMATION
�j Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, x117,
[ ] No physical site inspection has been done for this clearance. Therefore, it is not a determination of compliance with the existing
site plan.
[ ] This site complies with the site plan as of this date.
Notes:
Building Official - Date
Zoning Official Date , z 6�
Other Officialy�`� U Date z12
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
C_
Revised 11/l/2015 Page 2 of
Intake to complete the following:
Y /-N)
Is use in LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
D N
Will there be food preparation?
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health
Dept, FAX DATE
Circle the one that applies
Is parcel on private well qq public water?
If private well, provide Heh �t nt form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that appJ"�
Is parcel on septic i public sewer?
Y/O
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y /
Will re be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use:,c,
/ N p
Permitted as:
Under Section: ZD .�
Supplementary regulations section:
Parking formula: i1
Required spaces:
Y /
Items to be verified in the field:
Inspector : Date:
Notes:
Vio ons:
Y /
If so, List:
Proffe :
Y /
If so, List:
Varia ce:
Y /
If so, List:
SP's:
4) / N
If so, List:
Clearances:
SDP's
J C�
i
Revised 11/1/2015 Page 3 of 3
12/7/2016
Print Inspection Report for New Violation Codes
Commonwealth Of Virginia — Department Of Agriculture & Consumer Services
Food Safety Program
PO Box 1163 — Richmond, VA 23218 — 804-786-3520
Retail Inspection Report
Firm Name: Crozet Great Valu #5030
Firm No: 2234301
Address: 5728 Three Notch'd RD Crozet, VA 22932
Phone No: (434) 882-5585
Extent: Full Inspection
Purpose(s): Routine
Attention: Raphael Strumlauf,Owner/Manager
Inspection ID: 2429301 Start: 11/17/2016 End: 11/17/2016
No of Risk Factor/Intervention violations : 0 No of repeat Risk Factor/Intervention on Violations: 0
IN=in compliance OUT=not in compliance NA=not applicable NO=not observed COS=corrected on -site during inspection R=re eat violation
Compliance Status ICOSI R
Compliance Status JCOSJ R
Supervision
ATpproved Source
1
IN
Person in charge present, demonstrates knowledge, and
performs duties
14 NA
Required records available: shellstock tags, parasite
destruction
2
1 NA
ICertified Food Protection Manager
Protection from Contamination
Employee Health
15
IN
Food separated and protected
3
IN
Management, food employee and conditional employee;
knowledge, res onsibilities, and reporting
16
IN
Food -contact surfaces: cleaned and sanitized
17
IN
Proper disposition of returned, previously served,
reconditioned, and unsafe food
4
IN
Proper use of restriction and exclusion
5
IN
Procedures for responding to vomiting and diarrheal events
Time/Temperature Control for Safety Food
Good Hygienic Practices
18
IN
Proper co king time and temperatures
6
1 IN jProper eating, tasting, drinking, or tobacco use
19
NO
Proper reheating procedures for hot holding
7
1 IN INo discharge from eyes, nose, and mouth
20
NO
Proper cooling time and temperatures
Preventing Contamination by Hands
21
IN
Proper hot holding temperatures
8
IN
Hands clean and properly washed
22
IN
Proper cold holding temperatures
9
IN
No bare hand contact with ready -to -eat food or a pre -approved
alternative procedure properly followed
23
IN
Proper date marking and disposition
24
NA
Time as a Public Health Control: procedures and records
10
IN
Adequate handwashing sinks properly supplied and accessible
Consumer Advisory
Approved
Source
251 NA lConsumer advisory provided for raw/undercooked foods
11
IN
Food obtained from approved source
Food/Color Additives and Toxic Substances
121
NO
IFood received at proper temperature
261
NA
IFood additives: approved and properly used
131
IN
IFood in good condition, safe, and unadulterated
271
IN
IToxic substances properly identified, stored, and used
;t
Conformance with Approved Procedures
28 NA Com liance with variance/specialized rocess/HACCP
Compliance Status JCOSJ R
at the
Compliance Status ICOSI R
Safe Food and Water
Proper Use of Utensils
29
IN
Pasteurized eggs used where required
43
IN
Utensils, equipment and linens:propedy stored, dried, and
handled
30
IN
Water and ice from approved source
311
NA lVariance
obtained forspecialized processing methods
44
IN
Sin le-use/sin le -service articles: properly stored and used
Food Temperature Control
45
IN
Gloves used properly
32
IN
Proper cooling methods used; adequate equipment for
tern erature control
Utensils, Equipment, and Vending
46
OUT
Food and nonfood -contact surfaces cleanable, properly
constructed, and used
33
IN IPlant
food properly cooked for hot holding
34
NO JApproved
thawing methods used
--designed,
47
IN
Warewashing facilities: installed, maintained, and used; test
strips
35
IN IThermometers
provided and accurate
Food Identification
48
OUT
Nonfood contact surfaces clean
361 IN IFood properly labeled; original container
Physical
Facilities
Prevention of Food Contamination
49
IN
Hot and cold water available; adequate pressure
37
IN
Insects, rodents, and animals not present
50
IN
Plumbing installed; proper backflow devices
38
IN
Contamination prevented during food preparation, storage and
display
51
IN
Sewage and waste water properly disposed
52
IN
Toilet facilities: properly constructed, supplied, and cleaned
39
IN
Personal cleanliness
53
IN
Garbage and refuse properly disposed; facilities maintained
40
OUT
Wiping cloths: properly used and stored
54
IN
Physical facilities installed, maintained, and clean
41
IN
Washing fruits and vegetables
55
IN
Adequate ventilation and lighting; designated areas used
Proper Use of Utensils
Preoperational Inspections
421 IN In -use utensils: ro erI stored
56 IN Preo erational inspection conducted
oday's findings were discussed with the most responsible person at the firm
respond.
Imminent Health Hazards
571 NA ICease operations during certain circumstances
time of the inspection and this person was given the opportunity to
A complete copy of the Retail Food Establishment Regulations for Enforcement of the Virginia Food Laws is available at
http://Iaw.l is.vi rgi nia.gov/adm i ncodeexpand/title2/agency5/chapter585/
Establishment (Signature) _- Received By Title
Raphael Strumlauf Owner/Manager
Inspector (Signature)
Olinger, Allyn
https://I ap01152. cov.vi rgi ni a.gov:8890/pl s/vdacs/apex/f?p=123:3433:10391515656211:::: P3433_SYS I N SPN O:2429301 1 /2
12/7/2016
Print Inspection Report for New Violation Codes
Firm Name: Crozet Great Valu #5030
Firm No: 2234301
Address: 5728 Three Notch'd RD Crozet, VA 22932
Phone No: (434) 882-5585
Extent: Full Inspection
Purpose(s): Routine
Attention: Raphael Strumlauf,Owner/Manager
Inspection ID: 2429301 Start: 11/17/2016 End: 11/17/2016
No of Risk Factor/Intervention violations : 0 No of repeat Risk Factor/Intervention on Violations: 0
�7
Prevention of Food Contamination; #40: 2VAC5-585-570 — Wiping cloths, use limitation.
1. One used wiping cloth was observed on the prep counter in the produce department.
2. Three used wiping cloths were observed on the prep tables in the meat cutting room of the meat department.
Utensils, Equipment, and Vending; #46: 2VAC5-585-1100 — Food -contact surfaces; cleanability. A badly scared prep board was observed being used in the produce
department.
Utensils, Equipment, and Vending; #48: 2VAC5-585-1800 — Nonfood -contact surfaces. A build-up of mold residue was observed on the wall adjacent to the equipment
sink in the meat department.
oday's findings were discussed with the most responsible person at the firm at the time of the inspection and this person was given the opportunity to
respond.
A complete copy of the Retail Food Establishment Regulations for Enforcement of the Virginia Food Laws is available at
http://law.l is.vi rgi ni a.gov/adm i ncodeexpand/title2/agency5/chapter585/
Establishment (Signature) Received By Title
Raphael Strumlauf Owner/Manager
Inspector (Signature)
Olinger, Allyn (i(,�'•t��►'�
https://I apOl l 52. cov.vi rgi ni a. gov:8890/pl s/vdacs/apex/f?p=123:3433:10391515656211:::: P3433_SYS I N SPN 0:2429301 2/2