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Home My WebLink AboutApplication (2) 14 TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT 1540 Sullivan Ave.,South Windsor, CT 06074-Mailing Address 1530 Sullivan Ave., South Windsor, Cr 06074-Office Address Phone Number: (860)337-6173, Fax Number: (860)644-1930 "INO° APPLICATION FOR ITINERANT FOOD SERVICE LICENSE Owner Name: n2Zq, Vlt Mailing Address: jct W6- f'l l� ed Telephone*: ( ) xj G1�, l DCU-14 Fax*: Cell Phone*: Email Address: 5 YI?ApI22(,& yW NCO M Operator Name: Paul M 4Z2Qrf ilk Aaailing ALAAt Telephone*: ( _) Fax*: ( ) Cell Phone*: Email Address: Qualified(Food Operator Required: I YES 91 NO ❑ certificafie#: a I 5Y p Name: IVUWM Date: Please submit latest copy of the Food Operator certlHcaW to the office. Name of Business/Unit: W )(�j EjY ule LLC_ water supply: Public[' Private Well ❑ License Plate* -NA 1,51c,14 Wastewater Disposal: Public On-Site ❑ Sete Location: Electricity Available: YES Ll NO If Other,Please Explain: 6�neazZS Propane Use: YES NO *Please contact Fire Marshal 860-282-0669* Menu: (Note"Please list items in as much detail as possible,ore copy of a menu attached is applicable) Logy ) , p12ZAS I ozza s Ic6 , BO+W DnMKS Agreement and Signature By submitting this application,I affirm that the facts set forth in it are true and complete.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 the Town of South Windsor. Food Service License will be Issued after the Food Inspector has completed his/her inspection. Applicant Name(Print): Applicant Signature: Date: .S.Ze i Office Use Only Inspector Name(Print): "-P1A u,6' 4- Inspector Signature: f,4�- Date: l 13 Food Class: 1 ❑ 2 3 D--4 ❑ / Application ❑ OFO Cert❑ Base of Ops g Zon ❑ Fire❑ Expiration Date: 3 RECEIVED JUN 0 2 2017 SOUTH WINDSOR HEALTH DEPT, p TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address A 1530 Sullivan Ave., South Windsor, Cr 06074—Office Address Phone Number: (860) 337-6173, Fax Number: (860) 644-1930 ITINERANT VENDOR QUESTIONNAIRE Name of Establishment: -SW A LjLuk Fun Z 26 1. What foods will be prepared on and served out of the unit? 2. What is the source of the food to be dispensed? Provide the name and address of the food distribution facility. t irru It j�eTirt �lc� � Y�ILI yV li )j flAthA, c i 3. How will foods be kept hot or cold on the unit? What type of thermometer will be used? How will hey be it. ed? 4. How and where will utensils, pans, etc. be cleaned at the end of the day? Be specific. 5. D vibe the method of handwashing used at the unit. i`ana tskl 64.) -fina.te 6. Describe how food will be protected. (Note: in large units where food is prepared inside, screening is�r wired Zre,ve,nt the entrance of insects). 7. How are water tanks filled? Where is wastewater disposed? 8. Where wiY1 excess food and paper products be stored? D Li Sli,�-W (a , 9. How wi I garbage be disposed on the unit and at the Base of Operations? PLEASE CONTACT THE TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT AT LEAST 48 HOURS IN ADVANCE TO HAVE THE MOBILE VENDING UNIT INSPECTED PRIOR TO LICENSING OR RE-LICENSING. (i) ASSESS THE POTENTIAL FOR FOODBORNE ILLNESS IN A FOOD SERVICE ESTABLISHMENT- PERFORM OPERATIONAL FOOD SAFETY ASSESSMENT; RECOGNIZE AND DEVELOP STANDARDS, POLICIES AND PROCEDURES, SELECT AND TRAIN EMPLOYEES; IMPLEMENT SELF AUDIT/ INSPECTION PROGRAM; REVISE POLICY AND PROCEDURE(FEEDBACK LOOP); IMPLEMENT CRISIS MANAGEMENT PROGRAM. (ii) ASSESS AND MANAGE THE PROCESS FLOW-IDENTIFY APPROVED SOURCE; IMPLEMENT AND MAINTAIN A RECEIVING PROGRAM; IMPLEMENT AND MAINTAIN STORAGE PROCEDURES; IMPLEMENT AND MAINTAIN PREPARATION PROCEDURES; IMPLEMENT AND MAINTAIN HOLDING/SERVICE/DISPLAY PROCEDURES; IMPLEMENT AND MAINTAIN COOLING AND POST PREPARATION STORAGE PROCEDURES; IMPLEMENT AND MAINTAIN RE-SERVICE PROCEDURES; IMPLEMENT AND MAINTAIN TRANSPORTATION PROCEDURES. ...................................................................................... QUALIFIED FOOD OPERATOR DEMONSTRATED KNOWLEDGE STATEMENT I _ PAU l I 1 A-1XI"116 attest that hu 'l m i2 M(M11 A_ (Print name of Owner or Operator) (Print name of Qualified Food Operator) is employed in a full-time supervisory position and has demonstrated to me the elements of knowledge and demonstrable elements of competency as described in A and B, as listed above. i Signature and Titl " Date / 4;1. by Owner/Operator of the Establishment) /f, ,�,, .�►r Signature and Tide / Date (Signed by Qualified Food Operator) ' Name of Establishment 3U6 144A EYZA Address of Establishment lti ** Please attach corresponding certificate of completion for approved training course.** � 4""0 TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT 1540 Sullivan Ave., South Windsor,Cr 06074—Mailing Address 1530 Sullivan Ave.,South Windsor,Cr 06074—Office Address Phone Number: (860)337-6173, Fax Number: (860)644-1930 DECLARATION OF BASE OF OPERATION This form most be submitted with your application for permit. Mobile Vendor Business Name: AUJ I kV nnpd r zZ� , Lf Mobile Vendor Owner/Operator Name: PAW I 1 QZ Z-aff 1 I A Business Name of Base Of Op.: _10 _P�t4- Address of Base Of Op.: M 3TA-% J?y!- PW 5&4144 C! Owner of Business for Base Of Op.: Te iek z 44vkA Telephone Number of Base Of Op.: a�3 . �� /�Z03 - THE FOLLOWING PORTION TO BE FILLED OUT BY THE OWNER OF THE FOOD ESTABLISHMENT USED AS THE BASE OF OPERATION. I, 7it--A /' u��ll� attest that my licensed food establishment Owner of Food Establishment used as base �� known as /Vo4 _�t z,-, is available as the Name of Food Establishment base of operations for -54ake'0( Iflze . owned by Name of Mobile Vendor Business P-o%)r AAZzoswre,11m,- Owner of Mobile Vendor Business Signature of Owner of Food s6blishrnett **Please include a copy of the Base of Operation food permit issued by the local health department.**