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Home My WebLink AboutMisc Letters e[ � " Description of a Mobile Food Dispensing Unit Any food service establishment that is self propelled or otherwise moveable from place to place,that is self contained and does not use electrical or other utility connections of any kind,in which food is prepared and/or dispensed,and that complies with all applicable requirements set forth by the Florida Department of Business Regulations,division of Hotels and Restaurants,or its successor agency, including but not limited to those regulations set forth in Rule 7G1.03,Florida Administrative Code. Property Owner Information: Name: �E1-46 t f 4 (--A�2AR U LLKT Phone No: .-1"22.- --fin ZG -- 1 -7 L+ Address: City: State: FL Zip Code: 5 L+Iqq-7 Date: I, ABS(.._L,,(- ,owner of the following described property,authorize ( C K-i S i C L C-C- to place a mobile food/produce unit on my property. Property Tax Identification#: - "T 0 ,'k 0 0 0 Legal Description: �i r2AC:C 1-5 i .I?,C C',C L/- L4 c -.-Fi G, —1b (-x-)j,j St}f 1&7 S 0 v7 H PAS-Zcr-_ f < .? �c C c G-f ""� L.i_�C.{`7 r-C_J Li�..i C`7` �.- t_f{bl...s L.. cf•��j•—(' C:: t.%� 1 z Gy L i!�� /tk3 L�<✓L h I Property Owner's Name(Please Print) r Prope ' Owner's Signature State of Florida,County of ('f`Y� Q "e The foregoing instrument was acknowledged before me-this (e, day of�20_D who is personally known to me or who has produced (_ f as identification. C- L�ji�-s"P 1i (Seal) Signature o�otary Type or print Name of Notary ' Title: Notary Public Commission Number: SLCPDS Revised 07/21/2014 uuu '''�TflICIA C L'ISSETT I.lotary Public-state of Florida 1 _ Gommisslon FF 213092 6+ J 4' Nom' o; iN Comm.Expires fear 24,2019 ':;eoFF�o�: y Assn. " c; ,,,,,,,,,. 0ondad through National Notary Florida Department of Agriculture and Consumer Services Division of Food Safety IM��U�� IIS r Visit#.2538-0006-81 FOOD SAFETY INSPECTION REPORT Bureau of Food Inspection ^- Attention:Records Section ADAM H.PUTNAM Chapter 600,Florida Statutes 3125 Conner Boulevard,C-26 COMMISSIONER (850)245-5520 Tallahassee,FL 32399-1650 Print Date:October 17,2017 Food Entity Number. Food Entity Name: WICKIES ICE Date of Visit October 17,2017 Food Entity Address: 3695 NW ADRIATIC LN JENSEN BEACH, FL34957 Food Entity Mailing Address: 3695 NW ADRIATIC LN JENSEN BEACH, FL 34957-3112 Food Entity Type/Description: 164/Mobile Vendor Food Entity Owner: WICKIES ICE LLC Owner Code: INSPECTION SUMMARY-Met Inspection Requirements On October 17,2017,WICKIES ICE was inspected by MARK RYAN,a representative of the Florida Department of Agriculture and Consumer Services.Any violations observed during this inspection must be corrected to be in compliance with Chapter 500, Florida Statutes,and Rule 5K-4,Florida Administrative Code. PERMIT APPLICATION INFORMATION The permit application information was verified with management or a qualified representative. COMPLIANCE KEY IN=In Compliance OUT=Not In Compliance N/O=Not Observed WA=Not Applicable FOODBORNE ILLNESS RISK FACTORS AND PUBLIC HEALTH INTERVENTIONS Violation Compliance Number Status Violation Description 1 IN Supervision:Person in Charge present,demonstrates knowledge,and performs duties 2 OUT Employee Health:Management,food employee and conditional employee; knowledge, responsibilities and reporting 3 IN Employee Health:Proper use of restriction and exclusion 4 IN Good Hygienic Practices:Proper eating,tasting,drinking,or tobacco use 5 IN Good Hygienic Practices:No discharge from eyes,nose,and mouth 6 IN Preventing Contamination by Hands:Hands clean and properly washed 7 IN Preventing Contamination by Hands:No bare hand contact with ready-to-eat foods or approved alternate method properly followed 8 IN Preventing Contamination by Hands:Adequate handwashing sinks,properly supplied and accessible 9 IN Approved Source:Food obtained from approved source 10 N/A Approved Source: Food received at proper temperature 11 IN Approved Source: Food in good condition,safe and unadulterated 12 N/A Approved Source: Required records available:shellstocktags,parasite destruction 13 N/A Protection from Contamination:Food separated and protected 14 IN Protection from Contamination: Food-contact surfaces:cleaned and sanitized FDACS 14205 Rev.07113 Page 1 of 3 -. '. Florida Department of Agriculture and Consumer Services Division of Food Safety . MEMBER FOOD SAFETY INSPECTION REPORT Visit2538-00 Bureau Inspection of Food nspection —_ Attention:Records Section ARAM H.rPUTNAM Chapter 600,Florida 6tatutea 3125 Conner Boulevard,C-26 COMMISSIONER (850)245-5520 Tallahassee,FL 32399-1650 Print Date:October 17,2017 Food Entity Number: Food Entity Name: WICKIES ICE Date of Visit: October 17,2017 Food Entity Address: 3695 NW ADRIATIC LN JENSEN BEACH, FL34957 Food Entity Mailing Address: 3695 NW ADRIATIC LN JENSEN BEACH, FL 34957-3112 Food Entity Type/Description: 164/Mobile Vendor Food Entity Owner: WICKIES ICE LLC Owner Code: FOODBORNE ILLNESS RISK FACTORS AND PUBLIC HEALTH INTERVENTIONS Violation Compliance Number Status Violation Description 15 IN Protection from Contamination: Proper disposition of retumed, previously served,reconditioned,and unsafe food 16 N/A Potentially Hazardous Food Time/Temperature:Proper cooldng time and temperature 17 N/A Potentially Hazardous Food Time/Temperature:Proper reheating procedures for hot holding 18 N/A Potentially Hazardous Food Time/Temperature:Proper cooling time and temperatures 19 NIA Potentially Hazardous Food Time/Temperature:Proper hot holding temperatures 20 N/O Potentially Hazardous Food Time/Temperature:Proper cold holding temperatures 21 N/A Potentially Hazardous Food Time/Temperature:Proper date marldng and disposition 22 NIA Potentially Hazardous Food.Time/Temperature:Time as a public health control:procedures and records 23 N/A Consumer Advisory:Consumer advisory provided for raw or undercooked foods 24 N/A Highly Susceptible Populations:Pasteurized Foods, Prohibited Re-service,and Prohibited Foods* 25 IN Chemical: Food additives:approved and properly used 26 IN Chemical:Toxic substances properly identified,stored,and used 27 N/A Conformance with Approved Procedures OBSERVATIONS AND CORRECTIVE ACTIONS COS=Corrected on Site P=Priority Citation Pf=Priority Foundation Citation (Directly Associated with Foodbome Illnesses) (Supports or Leads to a Priority Citation) INSPECTION:RISK BASED Violation Number Citation Description COS Observation 2. Person in charge does not correctly respond to ❑ DID NOT RESPONDED Pf questions that relate to foodbome disease by a food CORRECTLY-GAVE GUIDELINES employee who has a disease,medical condition or AND REVIEWED symptom that may cause foodbome disease or does not comply with reporting responsibilities and exclusion or restriction of food employees. 2-102.11(C)(2)-(3)&(17)Pf ---------------------------------------------------------------------------------------------------------------------------------------------- �'t?QSf1i Florida Department of Agriculture and Consumer Services `r Division of Food Safety lul 6-81 FOOD SAFETY INSPECTION REPORT Visit a 2f Food Inspection Bureau of Food Inspection Attention:Records Section ADAM H.PUTNAM Chapter 500,Florida Statutes 3125 Conner Boulevard,C-26 COMMISSIONER (850)245-5520 Tallahassee,FL 32399-1650 Print Date:October 17,2017 Food Entity Number. Food Entity Name: WICKIES ICE Date of Visit October 17,2017 Food Entity Address: 3695 NWADRIATIC LN JENSEN BEACH, FL34957 Food Entity Mailing Address: 3695 NW ADRIATIC LN JENSEN BEACH, FL 34957-3112 Food Entity Type/Description: 164/Mobile Vendor Food Entity Owner: WICKIES ICE LLC Owner Code: COMMENTS I ACKNOWLEDGMENT I acknowledge receipt of a copy of this document,and I further acknowledge that I have vlocation and mailing ddresses on the first ge of this document are correct,or I have written the correct information q the first p e of this documeny i (Signature of FD CS Representative) (Sign ure of Repr enta ve) I MARK RYAN,SANIT ION AND SAFETY SPECIALIST 2DAL, Print Name and Title FDACS 14205 Rev.07/13 Page 3 of 3 Florida Department of Agriculture and Consumer Services Division of Food Safety Bureau of Food and Meat Inspection 3125 Conner Boulevard.C-26.... . ... COMMISSARY LETTER OF AGREEMENT Tallahassee,FL 32395-1620 (854)245-5520 ADAM H.PUTNAM COMMISSIONER This form is to be filled out and given to the FDACS inspector in the field and submitted as part of a mobile food establishment permit application or with a package ice plant self-vending permit application that requires a commissary. .SECTION a4'�IC�B LL(r' 000 ES L1sHN1ENT(SAFE SOI�u��6�C�Ibtt�{� , . ,.. ... � . .�... l` Owner Name Phone Number(include area code) i Owner Mailing Address Permit umber I City Zip Code(+4 optional) County 3 tr\ Co i hereby certify the provided Intomoation Is correct and understand permit approval is on verification of an app rov d commissary. Print Name(owner of MFE or SVIU) Signature(owner of or S Date Wit 3� Apr^� � x �� '� w w » '. Et37llaN M1 _ f±Ci1�It6AISSARY il11EORIV) `rtON" xz a r e t z `.e..__�.... Primary Commis F Na e i tG�o1J� � g �S�e►�� Commissary Address �.. Zip Cod 40 onai) County XV Primary Phone Number(include area cod ) JC Commissa ;o, ec J4i Primary E-Mail d ♦ i NK- i"i��+t(/lt7►N,mSd JrEIQS. C C Licensed Sy J,� /Boo � pDepartment of Agriculture&Consumer E3Depaftmentoff ��0� Business and y apartment of Health ❑None (check one) Services Professional Regulation {"- Water Supply of Primary 0 MunicipaWblity Ci Supplier Name Commissary E3 On-site Well ❑Permit Number i4mumcipallUtirity El Supplier Name Wastewater Disposal of ❑Septic Tank System �E]P--Wit Number Primary Commissary ❑Package Plant I intend to provide the following activities at this commissary. Dish or equipment washing I$Yes ONo Storing of food and dry goods(room temperature) ❑Yes ONO Dumping wastewater JbYes rjNo Cold Storage of food(including Ice and drinks) Oyes ONo Receiving potable water loYes ❑No Cooking and/or reheating food Eyes 1l0 Washing the outside of the vehicle ❑Yes ffINO Three compartment sink 1'1(es ❑No Restroom facilities Yes ❑No Otter(Describe below) [Yes ❑No Describe other activities here: Signing this document will allow FDACS Food Inspectors entry to my business during normal hou eration for evaluation of facilities. Print Nam (pf Person in Charge of Co missary) Signature(of Person in e f Cls scary) Date �sNp,J iJ� JA /7l Are additional commissaries used? L]Yes UNo If yes use as many pages as needed. FDACS-14223 Rev.10/15 Page i of 1 Florida Department of Agriculture and Consumer Services �I I�@q�',pII AAn�I {'p��'�'�I pnn��IIm', IMIIIIINIOIIEINMIIIIII 111 - Division of Food Safety ANNUAL FOOD PERMIT APPLICATION Visit 2538000681 Chapter 500,Florida Statutes Bureau of Food Inspection ADAM H.PUTNAM (850)2455520 Attention:Records Section 3125 Conner Boulevard,C-26 COMMISSIONER Tallahassee,FL 32399-1650 Print Date: October 17,2017 Note:Inspection by the Department is required prior to submission of this application The Florida Department of Agriculture and Consumer Services is the exclusive regulatory and permitting authority for any person, business or corporation engaged in manufacturing, processing, packing, holding or preparing food or selling food at wholesale or retail. For purposes of this application, food is considered to include, but is not limited to, all prepackaged grocery items, prepared foods, packaged ice, bottled or vended wafter, candy and other snack foods, soda, infant formula, vitamin and mineral dietary supplements. INFORMATION ABOUT THE LOCATION TO BE PERMITTED Food Entity Number: Food Entity Type:164 Territory:904 Established Date: 10/17/2017 Sells directly to consumer ()Sells to other businesses ()Both ()Water treatment: (X)Waste disposal type:Municipal Water source:Municipal 'V.New Business ()Corrected Information ()Other: Food Entity Name: WICKIES ICE Type Description: Mobile Vendor Location Address: 3695 NW ADRIATIC LN County.Martin City/State/Zip: JENSEN BEACH, FL34957 Phone Number: (941)374-7786 Directions: INSIDE PORTOFINO COMPLEX OFF US 1 AND GOLDENROD INFORMATION ABOUT THE OWNER Name of the owner. WICKIES ICE LLC Business Type: CORPORATION Phone Number. (941)374-7786 Mailing Address: 3695 NW ADRIATIC LN City/State/Zip: JENSEN BEACH, FL 34957-3112 E-mail: BRADVICKERS7@GMAIL.COM Federal Employers ID#(FEIN): 821863844 Sales Tax#: This application must be signed by the applicant,owner or chief executive of the applicant,without the need for witness. If a corporation is in the hands of a receiver or trustee,this application shall be executed on behalf of the corporation by the receiver or trustee.I certify that I am empowered to execute this application as required by Chapter 500,Florida Statutes. Print Name of Applicant: C 1<00 Title Signature of Applicant Z4Date tl FDACS 14205 Rev.07/13 Page 1 of 1 FORM Conditional Employee or Food Employee Reporting Agreement 1-B Preventing Transmission of Diseases through Food by Infected Conditional Employees or Food Employees with Emphasis on Illness due to Norovirus,Salmonella Typhi,Shigella spp., Enterohemorrhagic(EHEC)or Shiga toxin-producing Escherichia coli (STECI or Hepatitis A Virus The purpose of this agreement is to inform conditional employees or food employees of their responsibility to notify the person in charge when they experience any of the conditions listed so that the person in charge can take appropriate steps to preclude the transmission of foodborne illness. I AGREE TO REPORT TO THE PERSON IN CHARGE: Any Onset of the Fo&Wn—a Symptoms,Either While at Work or Outside of Work,Including-the Date of Onset. 1.Diarrhea 2.Vomiting 3.Jaundice 4.Sore throat with fever 5.Infected cuts or wounds,or lesions containing pus on the hand,wrist,an exposed body part,or other body part and the cuts,wounds,or lesions are not properly covered(such as boils and infected wounds, (however small) Future Medical Diagnosis: Whenever diagnosed as being ill with Norovirus,typhoid fever(Sahnonella Typhi),shigellosis(Shigella spp.infection),Escherichia coli 0157:H7 or other EHEC/STEC infection,or hepatitis A(hepatitis A virus infection) Future Exposure to Foodborne Pathogens: 1.Exposure to or suspicion of causing any confirmed disease outbreak of Norovirus,typhoid fever, shigellosis,E.coli 0157:H7 or other EHEC/STEC infection,or hepatitis A. 2.A household member diagnosed with Norovirus,typhoid fever,shigellosis,illness due to EHEC/STEC,or hepatitis A. 3.A household member attending or working in a setting experiencing a confirmed disease outbreak of Norovirus,typhoid fever,shigellosis,E.coli 0157:H7 or other EHEC/STEC infection,or hepatitis A. I have read(or had explained to me)and understand the requirements concerning my responsibilities under the Food Code and this agreement to comply with: 1. Reporting requirements specified above involving symptoms,diagnoses,and exposure specified; 2. Work restrictions or exclusions that are imposed upon me;and 3. Good hygienic practices. I understand that failure to comply with the terms of this agreement could lead to action by the food establishment or the food regulatory authority that may jeopardize my employment and may involve legal action against me. Applicant or Food Employee Name(please print) .Signature of Applicant or Food Employee Date Signature of Permit Holder's Representative Date