HomeMy WebLinkAbout1530 Sullivan Ave w nec,
W M se
4 �� TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
v% 1530 Sullivan Ave., South Windsor, CT 06074—Office Address
Phone Number: (860) 337-6173, Fax Number: (860) 644-1930
o'ioIR �'
APPLICATION FOR ITINERANT FOOD SERVICE LICENSE
Owner Name: W I \`.`l `'� '_�" tr Mailing � �11
Address: (pZ_ �j--n✓K:.�� IBC f'�T-�
Telephone#: ( 53(pQ ) �yG— 3?_ �.•� --e 4:4— CT
Fax#: ( ) _ Q'oo Z
Cell Phone#: L(,9— 32, c7
S
Email Address: _R?A)- wi 'l Ce-TT n �;'c�ilC� ((vr?
Operator Name: W l\'c,V4'A LA, e r g
Mailin
Address: (��. $�m wry APT y64
Telephone#: J(2) )
Fax#: �� V"
Cell Phone#: ci —
Email Address: , (( t(^n 1,1.E
Qualified Food Operator Required: YES V NO ❑ Certificate#: I U`((p3 S
Name: Date: (U 23
Please submit latest copy of the Food Operator certificate to the office.
�'a �l�
Name of Q�• � S I
Business/Unit: 17� 01tM� �� Cf(-' `l Water Supply: Public 2/private Well ❑
License Plate# Wastewater Disposal: Public Er On-Site ❑
Site Location: k)�eJ_ikN 1C.— Electricity Available: F YES❑ NO
If Other, Please Explain:
�p�uy ��r GM•.-�.� �
Propane Use: YES LZ 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)
RECE VED
APR 05 ?0;R
SOUTH Vv,
HEALTH DEPT.
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): t&), .� 1{
Applicant Signature: Date:
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: 1 ❑ 2 ❑ 3 ❑ 4 ❑ FEE: $100
Application 0 QFO Cert ❑ Base of Ops 0 Zoning 0 Fire ❑ Expiration Date:
o�.a die
TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
1540 Sullivan Ave., South Windsor, CT 06074 Mailing Address
= - ft 1530 Sullivan Ave., South Windsor, CT 06074—Office Address
�= Phone Number: (860) 337-6173, Fax Number: (860) 644-1930
DECLARATION OF BASE OF OPERATION
This form must be submitted with your application for permit
Mobile Vendor Business Name:
Mobile Vendor Owner/Operator Name: WN C'
Business Name of Base Of Op.: vl
Address of Base Of Op.: 19 q (,to, J—k,4 a�(
Owner of Business for Base Of Op.: �1�-►�
Telephone Number of Base Of Op.: Z&
THE FOLLOWING PORTION TO BE FILLED OUT BY THE OWNER OF THE FOOD
ESTABLISHMENT USED AS THE BASE OF OPERATION.
I, c Ulm attest that my licensed food establishment
Own f Food Establishment used as bases
known as ��vJ All,ee4555-1 is available as the
Name of Food Establishment base of operations for CLS 914
&Ve�DL161- 1 � owned by
Name of Mobile Vendor Businev
'664v � �
er of Mobile Vendor Business
Signature of 0wR Food Establishment
"Please include a copy of the Base of Operation food permit issued by the local health
department."
EXAM FORM NO. 4887
CERTIFICATE NO. 10463358
a..,,. fe
ery
CERTIFICATION
WI LLIAM SAWYER
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).
0/23/2013
DATE OF AMINATION
10/23/2018
DATE vF tXPIRATION
Local laws,ppi. r.f,tck With your Iof:al regulatory ax,fj,cy f. , recertification requirements.
t
Paul Nufenwn
#0855 Executive Vics President,National Restaurant qs;
_ OC!dtl Oil
10WRI�Mtin.,; .NK�,1���IIrf•dllr fWpV'g1(Iall wabf'�Ml 'i,ry'jal•Ki,�;xe,�f/sd.. ,�
W °`nrnw'"'r �Mwol •,Wilk ,
t
❑ �o D
0
D
D a 4
IrS All Abe The 38COl
Bacon Tater Tots — Hot or Not - Tater Tots, Nacho
Cheese Sauce, Chopped Bacon, and Scallions. $ 8.00
Mozzarella Cheese Cubes — Dill or Ranch Dressing, Chopped
Bacon, Chopped Roasted Red Peppers, and Scallions. $ 9.00
Deers Fried Bacon Wrapped Grilled Cheese Sandwich -
French Style - $ 12.00
Bacon Mac & Cheese — Very Cheesy with lots of Bacon $ 5.00
Cheesy Fries with Bacon $ 5.00
Bacon Cheesy Onion Rings - $ 7.00
X Ib Chocolate Covered Bacon Slice ( before cooked ) Laced with White
Chocolate
Candied Bacon %lb ( before cooked )
$ 6.00 EACH or2 for$ 10.00
Assorted Soda's or Bottled Water- $ 2.00 Each or 2 for$ 3.00
f '
f te'G" partitiotimill f
fire MWI-,%itwt
wodws fre pug motorise Ultx) l'f�" : 'V r lost,
t0,Hood
Will
r t n.K rxroulfN�tM t d"4-lxmj 18"Ow )4 O-Alle fryer fryer F -
I ntol roof 3f"Witiex3d"f triple-
Vent
i—J Ibtit,x �t ! will )
�.• !'lit��t �i'light ! � I � �w ti�►t �
- % Phase calm drover :drove dmr%
IIU - ftn fill
rultk�l jgdk�t ,Artb1 txr ,rear •.i,nt Urttlrl }�,ltKl '
Ut' IW ,
i,nlh I r Ingh IIM ,
draft shell
r�In•It Inrn r dlgltHl Irt�.irat pn j, �VE'rhE'rjEi�'dl?ItIE't}, lai,;
�ittl(5
li�� ►+.a',llllir�