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Home My WebLink AboutApplication 770 Sullivan Avenue 4 O0re� TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT ^ 1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address Io' 1530 Sullivan Ave., South Windsor, CT 06074—Office Address Phone Number: (860) 337-6173, Fax Number: (860) 644-1930 �tGs"R'` APPLICATION FOR ITINERANT FOOD SERVICE LICENSE Owner Name: ��L l j�j'y( C�(�(?j Mailing L _ Address: Tc!cphanct: - (kc�iU ) Fax#: ( ) Cell Phone#: Email Address: x: Operator Name: / �'` Mailing C (1- C� Address: Y" ►""�� Telephone#: rl0 Fax#: ( ) Cell Phone#: ( ) Email Address: Qualified Food Operator Required: YES❑ NO Certificate#: Name: Date: Please submit latest copy of the Food Operator certificate to the office. Name of ' Business/Unit: S Water Supply: Public❑ Private Well ❑ License Plate# RR 0ACC 7o Wastewater Disposal: Pub' On-Site El Site Location: La Electricity Available: YES NO ❑ If Other,Please Explain: Propane Use: YES NO LA Please contact Fire Marshal 860-282-0669* Menu: (Note"Please list Item n as much#etail as opsible or a copy of a menu attached is applicable) cbuo k�efVIV1 y�(i.Sto C4 t� So CCa d'iztc re 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§ervice kcense will be issued after the Food Inspector has completed his/her inspection. Applicant Name (Print): Applicant Signature: Date:J Office Use Only Inspector Name (Print): Inspector Signature: Date: Food Class: 1 ❑ 2 ❑, 3 4 ❑ Application 0'CIFO Cert ❑.-Base of Ops Zoning❑ Fire ❑ Expiratlo JUN 00 2011 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, CT 06074— Office Address 'O Phone Number: (860) 337-6173, Fax Number: (860) 644-1930 A. `4� ITINERANT VENDOR QUESTIONNAIRE Name of Establishment: k � ,- � ` Ca V I vu ��S-SCIPS L O NN]Mt foods ill e,prep a an ser ed out o 'the unit? {{�� ll ES 2. What is the source of the food to be dispensed? Provide the na and address�of the food d' trib{�tio ail S 01 -7 J G Cro6o `� 3. How foods be kept hot or cold on the unit? What type of thermometer will be used? How will they be sanitized?� I i,tl� I I,,,, qA _�u14 0 et tk �L � V" f V' u JV I)lI I 4. How an w erq will utensils, pans, eQ bcleaned t the end of�the day?, Be sp ciflc (.v1,4,jn wkj,�'-� Ct' C,o c o� D scribe them h =ofha" wash' Q used at t(e unit.L_3 " i- 6. Describe how food will be protected. (Note: in large units where food is prepared inside, sgreening is required to prevent the entrance f insects). 7. How ar water tanks filled? Where is wastewater d' posed? YY x_kAs �Q 8. Where will excess food and paper products be stored? Q� 3 1v1,vLL CGI� 1'1/l.A.y►-e.e.49�� w•- _ C,��v�S �N�'l�.e.e-�Sdn 9. How will 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. TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT y 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address 1530 Sullivan Ave., South Windsor, CT 06074—Office Address h Phone Number: (860) 337-6173, Fax Number: (860) 644-1930 'tUSAR•CtY�. DECLARATION OF BASE OF OPERATION This form must be submitted with your application for permit. Mobile Vendor Business Name: I Y Mobile Vendor Owner/Operator Name: G� l Business Name of Base Of Op.: 1 Address of Base Of Op.: /(,5 Owner of Business for Base Of Op.: � Telephone Number of Base Of Op.: U�� .:)6710 THE FOLLOWING PORTION TO BE FILLED OUT BY THE OWNER OF THE FOOD ESTABLISHMENT USED AS THE BASE OF OPERATION. I, Manedl P.` attest that my licensed food establishment Owner of Food stablis ment used Tay known as a is available as the Name of Food Esta hment base of operations for Otto, lrya' owned by Name of Mobile Vendor Business Owner of M ile Vendor Business Signatur caner of�FoodE ishment "Please include a copy of the Base of Operation food permit issued by the local health department." RECEIVED RECEIVED JUN tl JUN 0 5 2017 SOUTH WINDSOR SOUTH WINDSOR W-ALTH DGPT .. DEPT. I