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HomeMy WebLinkAbout765 SULLIVAN AVE n10"'" S`�< `� TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT J 1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address .n 1530 Sullivan Ave., South Windsor, CT 06074—Office Address Phone Number: (860) 337-6173, Fax Number: (860) 644-1930 1��tiUR•l ` APPLICATION FOR ITINERANT FOOD SERVICE LICENSE Owner Name: r L Mailing ["DS 1r-/ Address: yl Moo roe S�f�'c i Telephone#: ( 8(c)L) 5315 Fax#: Cell Phone#: ( 3 6 0 ) c- -0 I Email Address: C U►' Operator Name: Mailing Address: Telephone#: ( ) Fax#: ( ) Cell Phone#: Email Address: (11tv,S c 104) corL1 Qualified Food Operator Required: YES a NO ❑ Certificate#: f �(p Name: L rr)e-s j Date: 7 /5 1 to Please submit latest copy of the Food Operator certificate to the office. Name of Business/Unit: w-�95 , Jc- L�L-T`S Water Supply: Public Private Well El License Plate# U(o'� 3 Wastewater Disposal: Public❑ . On-Site ❑ _ Site Location: -r J r C'T Electricity Available: YES LK NO ❑ If Other,Please Explain: Propane Use: YES NO ❑ *Please contact Fire Marshal 860-282-0669* Menu: (Note"Please list Items in as much detail as possible,or a copy of a menu attached is applicable) 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: L ' Date: / Office Use Only Inspector Name (Print): Inspector Signature: Date: Food Class: 1 ❑ 2 ❑ 3 ❑ 4 ❑ FEE: $100 Application 0 OFO Cert ❑ Base of Ops ❑ Zoning ❑ Fire ❑ Expiration Date: W pKe TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT 1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address �► q afi 1530 Sullivan Ave., South Windsor, CT 06074—Office Address Phone Number: (860) 337-6173, Fax Number: (860) 6"-1930 z ITINERANT VENDOR QUESTIONNAIRE Name of Establishment: C a r b S',je- CA-lef'_s 1. What foods will be prepared on and served out of the unit? I p d (� L U«� d ct t C U y�1 fY1L L cc` t Gl- n l� cz•��S o n � !G-rA�111 d) 2. What is the source of the food to be dispensed? Provide the name and address of the food distribution facility. 7 CA a US ev .-vd a 1 0 b-(a6 3. How will foods be kept hot or cold on the unit? What type of thermometer will be used? How will they be sanitizggd? e TQ.r f e �-ur, e can d oven , Lje-- Use. Ct -} k � n cd Ch u k W grin ,�d i I r. 4. How and where will utensils, pans, etc. be cleaned at the end of the day? Be specific. L Cu mmu o G.1 14 V(-�-ten - "rug cl') o cl IA'sj- ��r d_ 5. Describe the method of handwashing used at the unit. 6. Describe how food will be protected. (Note: in large units where food is prepared inside, screening is required to prevent the entrance of insects). r �' �S s Ir Fria rc� s free Z��s G,-►o) 5+0f-a*She Ives 7. How are water taQks filled? Where is wastewater disposed? �� Narti d� czar+-Po-r d - 8. Where will excess food and paper products be stored? AC9-n cin acA�[X 6 -�Xc err. �Jrl►� ©� �U cK 9. How will garbage be disposed on the unit and at the Base of Operations? We. have- � g r ber m(,.J I. III► r'C'CC fi Ics. n ltl chapoe— at Ha", (xn d 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. QUALIFIED FOOD OPERATOR DEMONSTRAED KNOWLEDGE STATEMENT Pursuant to Public Health Code (PHC) Section: 19-13-842(s)(6), 19-13-848(j)(5), 19- 13-1349(t)(5), in the absence of documentation that the Qualified Food Operator has passed a test administered by a testing organization approved by the department, a signed statement must be provided by the owner/operator of the food service, itinerant food vending or catering food service establishment (as applicable), attesting that the qualified food operator has demonstrated knowledge of food safety as specified below: (A) ELEMENTS OF KNOWLEDGE (i) IDENTIFY FOODBORNE ILLNESS- DEFINE TERMS ASSOCIATED WITH FOODBORNE ILLNESS; RECOGNIZE THE MAJOR MICROORGANISMS AND TOXINS THAT CAN CONTAMINATE FOOD AND THE PROBLEMS THAT CAN BE ASSOCIATED WITH THE CONTAMINATION; DEFINE AND RECOGNIZE POTENTIALLY HAZARDOUS FOODS; DEFINE AND RECOGNIZE ILLNESS THAT CAN BE ASSOCIATED WITH CHEMICAL AND PHYSICAL CONTAMINATION; DEFINE AND RECOGNIZE THE MAJOR CONTRIBUTING FACTORS FOR FOODBORNE ILLNESS; RECOGNIZE HOW MICROORGANISMS CAUSE FOODBORNE DISEASE. (ii) IDENTIFY TIME/TEMPERATURE RELATIONSHIP WITH FOODBORNE ILLNESS-RECOGNIZE THE RELATIONSHIP PRODUCTIEEN ON); DESCRIBE ERATURE ANDTHE USE OF THECRMOMETERS IN GROWTH, MON TORING FOOD AND TOXIN TEMPERATURES. (iii) DESCRIBE THE RELATIONSHIP BETWEEN PERSONAL HYGIENE AND FOOD SAFTEY-RECOGNIZE THE ASSOCIATION BETWEEN HAND CONTACT AND FOODBORNE ILLNESS; RECOGNIZE THE ASSOCIATION BETWEEN PERSONAL HABITS AND BEHAVIORS AND FOODBORNE ILLNESS; RECOGNIZE THE ASSOCIATION BETWEEN HEALTH OF A FOOD HANDLER AND FOODBORNE ILLNESS; RECOGNIZE HOW POLICIES, PROCEDURES AND MANAGEMENT CONTRIBUTE TO IMPROVED FOOD HYGIENE PRACTICES. (iv) DESCRIBE METHODS FOR PREVENTING FOOD CONTAMINATION FROM PURCHASING TO SERVING-DEFINE TERMS ASSOCIATED WITH CONTAMINATION; IDENTIFY POTENTIAL HAZARDS PRIOR TO DELIVERY AND DURING DELIVERY; IDENTIFY POTENTIAL HAZARDS AND METHODS TO MINIMIZE OR ELIMINATE HAZARDS AFTER DELIVERY. (v) IDENTIFY AND APPLY CORRECT PROCEDURES FOR CLEANING AND SANITIZING EQUIPMENT AND UTENSILS-DEFINE TERMS ASSOCIATED WITH CLEANING AND SANITIZING; APPLY PRINCIPLEESS CLEANINGA EHZ SANITIZING;EQUIPMENT, DETERGENT, APPLY APPROPRIATE METHODS OF CLEANING AND DENTIFY FREQUENCY OF CLEANING AND SANITIZING. (vi) RECOGNIZE PROBLEMS AND POTENTIAL SOLUTIONS ASSOCIATED WITH FACILITY, EQUIPMENT AND LAYOUT ENTSENTIFY DENTIFACILITY, DESIGN, AND FY EQUIPMENT AND UTENOSILTRUCTION DESIGN AND OABLE CATIONR FOOD SERVICE ESTABLISHMENTS; (vii) RECOGNIZE PROBLEMS AND POTENTIAL SOLUTIONS ASSOCIATED WITH,TEMPERATURE CONTROL, PREVENTING CROSS CONTAMINATION, HOUSEKEEPING AND MAINTENANCE- IMPLEMENT SELF INSPECTION PROGRAM; IMPLEMENT PEST CONTROL PROGRAM; IMPLEMENT CLEANING SCHEDULES AND PROCEDURES; IMPLEMENT EQUIPMENT AND FACILITY MAINTENANCE PROGRAM. (B) DEMONSTRABLE ELEMENTS OF COMPETENCY (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. 0900*0.•.•.•..•..•.•.0*000*•.•........•.•...•...•0•••••••.•••••.•••••0*0000••••.•••••• QUALIFIED FOOD OPERATOR DEMONSTRATED KNOWLEDGE STATEMENT I attest that t r fl e S+ OSAT-el (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. Sig nature nature and Title 1 0 Date (Signed by Owner/Operator of the Establishment) � 7 Signature and Title - Date I 1 (Sigried by Qualified Food Operator) Name of Establishment (-- b 5;de- C ) _s Address of Establishment 101 i'Ylun roe S�''- + cj_ (yoI I L ** Please attach corresponding certificate of completion for approved training course." ALTERNATE PERSON IN CHARGE DEMONSTRATED KNOWLEDGE STATEMENT Pursuant to Public Health Code (PHC) Section: 19-13-842(s)(8)(13) and 19-13- I349(t)(7)(13),the owner or manager of the food service/catering food service establishment shall designate an alternate person who has demonstrated the elements of knowledge and competency listed below, as per PHC Section 19-13-1342(s)(6), 19- 13-1349(t)(5), to be in charge at all times when the qualified food operator cannot be present. The alternate person in charge shall be responsible for ensuring that all employees comply with the regulations and that foods are safely prepared; handling emergencies; admitting the inspector; and receiving and signing the inspection report. A signed statement must be provided by the owner/operator of the food service or catering food service establishment(as applicable), attesting that the alternate person in charge has demonstrated knowledge of food safety as specified below: A. Elements of Knowledge (i) Identify foodborne illness—define terms associated with foodborne illness; recognize the major microorganisms and toxins that can contaminate food and the problems that can be associated with the contamination; define and recognize potentially hazardous foods; define and recognize illness that can be associated with chemical and physical contamination; define and recognize the major contributing factors for foodborne illness; recognize how microorganisms cause foodborne disease. (ii) Identify time/temperature relationship with foodborne illness— recognize the relationship between time/temperature and microorganisms (survival, growth and toxin production); describe the use of thermometers in monitoring food temperatures. (iii) Describe the relationship between personal hygiene and food safety— recognize the association hand contact and foodborne illness; recognize the association between personal habits and behaviors and foodborne illness; recognize the association between health of a food handler and foodborne illness; recognize how policies, procedures and management contribute to improved food hygiene practices. (iv) Describe methods for preventing food contamination from purchasing to serving— define terms associated with contamination; identify potential hazards prior to delivery and during delivery; identify potential hazards and methods to minimize or eliminate hazards after delivery. (v) Identify and apply correct procedures for cleaning and sanitizing equipment and utensils —define terms associated with cleaning and sanitizing; apply principles of cleaning and sanitizing; identify materials, equipment, detergent, sanitizer; apply appropriate methods of cleaning and sanitizing; identify frequency of cleaning and sanitizing. (vi) Recognize problems and potential solutions associated with facility, equipment, and layout— identify facility, design and construction suitable for food service establishments; identify equipment and utensil design and location. (vii) Recognize problems and potential solutions associated with, temperature control, preventing cross contamination, housekeeping and maintenance— implement self inspection program; implement pest control program; implement cleaning schedules and procedures; implement equipment and facility maintenance program. (viii) Identify and recognize the foods most commonly associated with food allergies. B. Demonstrable elements of competency (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. ................................................................................. I rVies J�- attest that 1���(rCS�AJ (Print Name of Owner or Operator) (Print Name of Alternate Person in Charge) is employed as the alternate person in charge and has demonstrated to me the elements of knowledge and demonstrable elements of competency as described in A and B, as listed above. Signature and Title: —��1 Date: i 1 It (Sig ri, wner/Operator of the Establishment)Signature and Title: Sa44 Date: _l �l�2 A (Sign TP b ernate Person in Charge) Name of Establishment: C'Urbs� Je. Lh(4-s - Address of Establishment: 1 '4 � Mce)fbe, S�-- �.rk �(D 0�,10011 "+� TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT .4 rs 1540 Sullivan Ave., South Windsor, CT 06074 — Mailing Address 1530 Sullivan Ave., South Windsor, Cl 06074—Office Address F; Phone Number: (860) 337-6173, Fax Number: (860) 644-1930 DECLA_RATION OF BASE OF OPERATION This form must be submitted with your application For permit. Mobile Vendor Business Name: CUrbs� de �25 -- Mobile Vendor Owner/Operator Name: Business Name of Base Of Op.: & w - -- Address of Base Of Op.: 55 �rk-f mp,w He.. 'Aar4x A CT 0(,,!� Owner of Business for Base Of Op.: Is k Telephone Number of Base Of Op.: Coo--7 0!0- THE FOLLOWI-G PORTION TO BE FILLED OUT BY THE OW' `ER OF THE FOOD ESTABLISHMENT USED AS THE BASE OF OPERATION. A 54 L. Jattest that my licensed food establishment Owner of Food Establishment used as base known as L!" c ( ti /A• r/{ t,� / is available as the Name of Food Establishment base of operations for C' vtrb5je. D-A owned by Name of Mobile Vendor Business FDSW Owner of Mobile Vendor Business Signature of owner of Food Establishment **Please include a copy of the Base of Operation food permit issued by the local health department.** Recipe Name: Fried Macaroni&Cheese Type: Side Source Chef: Ernest Foster Yield: Ingredients Amount Extension Pasta shell 2 Boxes Cheddar Cheese 4 Cups Eggs 4 Milk 2 Cups Cream Cheese 1 Package Garlic Powder 2 Tablespoons Paprika 2 Tablespoons Salt& Pepper 2 Tablespoons Method of Preparation 1. Cook pasta at Prep Kitchen(Commissary)the night before 2. Mix all ingredients with cooked pasta 3. Cook at 375 degrees for 45 minutes 4. Place in freezer after cooled. 5. Place in truck freezer for day of service 6. Upon order move from freezer to flour based batter 7. After flour coating move to fryer and served Recipe Name: Hamburger Type: Meal Source Chef: Ernest Foster Yield: Ingredient Amount Extension Beef(80/20) .25 Pound(1/4 lb scoop) Salt Pinch Pepper Pinch Cheese(American,Cheddar) 1 Slice Rolls 1 Optional Toppings Bacon 1 Slice Ketchup Customer discretion Mustard Customer discretion Mayonnaise Customer discretion Method of Preparation 1. Raw beef will be seasoned,scooped and then shaped into patties, placed onto wax paper and refrigerated 2. Raw beef patties will go from refrigerator to grill by cook 3. All patties will be served well done 4. If ordered cheese and bacon will be added after hamburger is cooked and still at the grill 5. Cooked hamburger moved from grill to prep area where bun and toppings will be added Recipe Name: Hot Dog Type: Meal Source Chef: Ernest Foster Yield:24 per package ingredient Amount Extension All Beef One unit Pre-packaged Rolls 1 Optional Toppings Bacon 1 Slice Chili 2 Tablespoons Ketchup Customer discretion Mustard Customer discretion Mayonnaise Customer discretion Method of Preparation 1. From Refrigerator to grill as ordered 2. From grill to prep station 3. Packaged and sold with toppings upon request Recipe Name:Cr Cheese Steak Grinder Type: Meal Source Chef: Ernest Foster Yield Ingredient Amount Extension Shaved Steak .25 Pound Salt Pinch Pepper Pinch Onion Upon request Peppers Upon request Mushrooms Upon request Cheese(American,Cheddar) 1 Slice Rolls 1 Method of Preparation 1. Upon order steak will be moved from refrigerator to grill 2. Seasoned with salt&pepper and onions, peppers and mushrooms provided upon request 3. Cheese added on top 4. Served on toasted grinder roll Recipe Name:Cr Chicken Cheese Steak Grinder Type: Meal Source Chef: Ernest Foster Yield Ingredient Amount Extension Shaved Chicken .25 Pound Salt Pinch Pepper Pinch Onion Upon request Peppers Upon request Mushrooms Upon request Cheese (American,Cheddar) 1 Slice Rolls 1 Method of Preparation 1. Upon order chicken will be moved from refrigerator to grill 2. Seasoned with salt&pepper and onions, peppers and mushrooms provided upon request 3. Cheese added on top 4. Served on toasted grinder roll