HomeMy WebLinkAbout765 SULLIVAN AVE (4) TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
1 L_4U Sullivan Ave., South Windsor, CT 06074 "- ivtailinq Address
l ,30 Su'livan Ave., South Windsor, CT 06-074—Office Adcire-S
Prone Nur ber: (360) 337-6173, Fax Nurrbei: (860) 6441.1g3G
Owner Na Mailing
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ieleph i1�knC; 3,-t
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Business/Uni ��� �.y�a; `� 1G n• Water Supply: Public.( Private `,Neff U
�.; - ?4 LC 1 1 _ _ . ... . Wastewater Disposal: Publi _ On 5:,^ '
License
Plate; f x 6 Electricity Available: YE N
If Other, Please Explain: V< SA_(eAA" E� �^` t L
Propane !�O _ `" �.�
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Menu: i tote—Please items in as much detail as possible, or a copy of a menu aitached is applicable)
Agreement and Sig!; `t tre
h`,'slJbl;lltil!-'CI ftii5 .' I dif'rlll cts ;'_i torUll '-Ii are iru e:'fed caillllloie- I un&{ rsiand that a!lv fal,:e
-. .'t"-C. r71itr.'ClliC_�dK_�. . 'dj_C7: Cil'S applica(kon i?1a'i iC'St;j•. IF—Inhd!�!C shuidovi;t /{)L�.i.f.'i�l ill I1 1'i„cxl Sct'�!c'._ _��cPl. '
fer`tl" nu [ a I !!I { r.•r 5r•. a Fi"" F7 IG .'son
•Li�autl'' ."Ouc SLi"( _tt.:k':�: cV i';�'= l�dl atf__. ill:; Food hi rL•( c as(- 71171utCi;Il!'
Appilcaait Najni�T 'Pt in`) -X f
Applicant Siril.J>-t!re �, i?ar;
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-Office Use Orly
Inspector Name P inC
1nspecol Sig-OaturE: Date
Food Class: 1 "-- '` 3 �— 4
Application 1 ert _.I Base of Ops I Zoning `---I Fire I__! Expiration Dale:
TOWN OF SOUTH WINDSOR HEAL"Hi DEPARTMENT
'--lU sullivall Ave" �OUth \!`hnd' tar, !C Mallii o Andre`-~
J_7i� Sljlrl Jun ,-i'.rF'. South L';/I!:({SOf, +,I 06074 - OM ice ICE_ l�Udress
Phori` (860) 337-(-';173 Fax iVl.l!?!{der: '860) 644-1.930
IT . E ANT VENDOR. QUESTIONNAIRE
rp:\red cJ tnf .ut.� ,'rl ;i. :,i"I II` unit? Ne`er �� - t'�� 1�t4t•�c.�u.>`..r _..
i yl�r,ta, I+ :;o c _l t_f,c I OOP IJ_: _lisp.::l Is�d? C{ cIC{f ;c'SS of the I:lcld
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' :.n d ?V!I1 ut.-nil.$r Puns, CC he C1 `an-ed� at thr. end of the, day? B-e Specific
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5. ._'�SCfihc.- i,, rwetiK'd of { df`ll\1c:S'IIRO Used at l.Cl Uflit
OAc ot"(
W�\Ci3�ht'_ CtE•eT
t'cS 7i'De 'J'.. ill( ? !.'tf!i be nrori_J;'1 (Note: !n large Units v,,heI'_' IMid piop--lit'_!-
SU4'Pillilf� I� r;<'(I i �' ,�,. "il i:,. i�.� 1;1i'•, .I? . ;'. -.
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PLEASE CGS i A� TM- T016N OF SOS.1TH 'VVINDSOR HEALTH DEPARTMENT AT LEAST 48 INGURS
IN, A \r+>:NCE f0 HAVE 7'HE MOBILE VENDING UNIT lNSPEtyTED PRIOR 7 0
LICENSING OP RE-LICENSING.
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R i�{k 07PED.) I,
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Pki'I, 1.i-1 AND
1' ANT.,
lit ij 4F PP I I U'V I I
Ilk �'JIAVA
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Ailf. J-:1
'-ND FIAH 1
QUAL[PIED FOOD OPERAICIR
DEMONSTRATED KNOWWUH)GE STATHAFNT
1 -r 310 c)pt
ALTERNATE PERSON IN CHARGE
DEMONSTRATED KNOWLEDGE STATEMENT
Pursuant to lie. Healuh Carle (PHQ Section. 19-13-1342(s)(8)(B) and 19-1.3-
849(t)(7)(B), e owner or manager of the food service/catering food service
e.sto0shment !1 desig';ate an alternate person who has dernionstrated the elements
of knowledge nd competency listed below, as per PHC Section 19-13-B42(s)(6), 19-
13-B49(11)(5), be ire charge at all times when the qualified food operator r_amnot be
�resiwt�'t:
Tlify cll:1'_lhbte r_','r i I!l fall]'- i lal! be 'r�')QnSICiF for en�un,-m tlldl ,)i) _ llll!'' '?(�S .om l `Ai th the
r'-- J•' �-r r �s- ' �y� i
re;;ula`icns =i!ld 1 t,aods are safely prepared,- handling emerr,:,r:6e5; ad! ,ittitlg th_, inspector, and ref_eivinq
and ci-u{ig tilt, ;rl ep'f)rt
A :_!c _..c , 1T.0 n= must r ! 1 �! the _ N F , _ - !_ov :o !
i) oVCe ":il?�:"�opctatot o, he ood `,ei +icc tli d Irl4 Too set y;C?
leS pkcabl�;i,. atte�ft;- !iqq ' at the. adtemate per :)rl t!i _ large hc�,- a CMG ,.r10','dl cC.0 OF
, Ei;_n-ten of :nov,+;edge
fl-i*fy tood�Otrie IiIrU 55 - define 1Crms associated i':�I,F! foodbom t;lness; roC' erl!Zc
the nia3or miciour(iani".riis and ..oxins that car Tontaminai_-food'! ano Lhe problerns that
Ca:? i,e 3sSOC!l-ted `.^:iti, the co;itan inationl- define and !e- :¢n,Ze pot'.r?mliy haza-HGCu--.
!D'1f) d irlF 3!lCi r:^CGQI ILf_' Ii. = 'hat Carl Y',I, vS ociared ;Jth r'hernwal and ph, :icu!
Carl c:''^I!lr:,tiClr; Cictali' c !l(7 r^CO�n;7� thF i?1 ]GI' C4r'f!!C1LtIt1Cl rlCt.OrS for toodbJlnC !'Ii1Li5;
CigniZ.- iiCiv': niicrooryc?mwic, cause focduoilie GISease
li} oeot!f; t'�',(:l c'1TPeCar..uty r�i3ti�d15! jD t�`Ittl food_�tl r!e illness - ri'COU!117' ihr
!.'ir(Ii1i�`ch`�i uc't"ve'tei! to,ie,t,--mperdtilre am) ioiu-oo,tmil1sms l51.11- iVeI, [irovA!i and loX!n
i'7:Ulr!or,,i' C7c=iLi hr use of thevmc!m etc!S Iil !r')n a!f.' g fooLll tuirlpe12,tli{-S.
D, Ji_il C t_111C rc_idtli_1?Si11r1 !)L'liV(i:n person-j! h?,,gi! iic art! ` ioci Sal(_'I_t/
i iOCl,`L'l,!l lic,liJ Glint lit. 31? !0odbolre eci-lo?, _ !_i!._ &!'ouat!oif i)Ffir,,aCti
orr_>onai habits and" bcha:io1S and 1C,oCiiocime :!In:`S5 i-ccognize th iIsc,'od dorl b tvve.''il
ihriltii of a food Mandl"t and tooCido!lie Iiio SS; rccogrizu 11?-'1 policies, P uc) ,-C!_,rc and
!l dii4igE"-t1Cli`L ConirjbSlt to improved toad, hygievieh
;iv�j ij,,sCrit-'c !"nethods to' re,V ntirlg food cont ail iWa!jon irr,in pLu( acing It) serving
Cir_L!tle te?-I-ns as--oCia'._'(%"Atil Contanivildtion identify potentlai h-)Z3rdt= pl'!C)r Lp
anCilirli G ?i=!IL'C'r f' ICCir1Ci'J potlnntiai f1oZ ! 5 aid r11C;hfiL`: ;Cl !Tii 1ImIZ ' C! eil!i=;rl i'=
ivi-
de.itif}' aiid -:Pp!y coil _CL proceLttui-e s foi Cl`' ming and s`ritonq --ouipm. t a d utc'nsli
- de(ine terms ascuiated W.at) dear,'Jig and sallitizir!q' at)'�Ily pli;n6plem of CI'c'.clilir C) atld
i9n,ItlZit! identify nimeflals, _gtool?ient, rifle' ni: Sc'tiit!t r: upOl;J aphCO('lanit'
)CAS of di) ?nii- and `atAiZing; iCl2titity iregUe; .'lt 0-c.nitli alid Sc nIr:I71r1^
VI . . ;ilt o l C l , eq i ptlli'_n7', )l
1i tf1o(l
c `.9i i1S!1!Tl_:ilt5; idcnti!'', cquiponeiit and ULoisil diCsi!n ,,id IUC ii,l;,'l
�VI !RCC_grl!Ze_ iproblC'iiis arc" r1ct-ential sol;,tions associated with. tempelaLu r: i=ontiU!;
t,oj ?k,-eufflg anc. ;E�,iiilr; arc !il leriieli`.Stl!
ii>jt7L'C IIL:i'= )i 017 i-am; Il7l[Tl�m,.nt i (C q coilt!"ol D!'oq!-i;m; ii'slp!Plll:,rlt Ci('dninq sr_h dUle..S and
011-w dilri's, im,)le ilerll ?Cit! pmeriC Arid fdfliily !ii ll!;1 Ztl ail f]!1)( ;iitl:
`Vlili I "ribl'y and I-ecuglii7fl the roods most c..olllllonl}' 13=.5�1C18C2(i "!rh "O.-�Cl i!t`rfjlf5
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TOWN OF SOUTH WINDSOR WEALTH DEPARTMENT
1�40 Sullivan: Ave.. Snut`. V%1indsor, Ci L) 0-? Mailinq Ad�res5
173' Sullivan Avel , Som-h Vdind sor, C-T 06071 - Office Adlres_,
PI-,one Rurnber: (860) 337-6173, Fax INIumbo: (860) 644-1930
i
Mobile Vendor ess Name.
- M
mioi)ile v rl�for i jGperaior Nar��e
Business Name f Base 01 Ojp
Owner of Busin for Base Of Op.: `�J11�t%L��.��:J� � �1 � c_t , _\\�-��"1
J
11 e1c.-Phe11C 1,4 r of was;: Of Opi.: - -�C (cc,- 3cp'_`
THE FOLLO NG PORTION TO BE FILLED OUT BY THE OWNER OF THE FOOD
ASLTSHMENT USED AS THE BASE OF OPERATION.
C �� ._�•_1�11 C j�il�� al_Test ijlal iti�'' lic_cl?�E'G fL) ?Si.d�7i!Stlnit'I li-
C„NL9 •.)?r:7:ad J'.5:;,;r�
kr,ovvrl as \ is available as Ule
base of opel ns for �"� `J Z�'�b�l awned by
gl{US [ de a copy a. 1=f1 '- Base of C)L�e;atlon food f�2i flit I-ssued by �:f"lE' local i]i d!!_i t
ceparTment.
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ServSafe
National Restaurant Association
ServSafee
CERTIFICATION
MACKENZIE PARRISH
for successfully completing the standards set forth for the ServSafe®Food Protection Manager Certification Examination,
which is accredited by the American National Standards Institute(ANSI}-Conference for Food Protection(CFP).
4""IIIIIIIIIIII%��
942810 5243
CE TI UMBER EXAM FORM NUMBER
4/4/2017 4/4/2022
DATE OF i=XAMINATION DATE OF EXPIRATION
Local laws apply "_back with your looal regulatory Negc, for recertification requirements.
_ " I
°.hcrman Brown
SVP, National Rantouranl Association Solutions
#0655 "
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W02901 Y.1101 Contod us wilt queslims at 175 W Jockron Blvd Ste 15W,Chicogo,L.6060A or SevSafe@reskmca org.