HomeMy WebLinkAboutApplication 150 Nevers Road (19) °wM s`'< � TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
1530 Sullivan Ave., South Windsor, CT 06074—Office Address
Phone Number: (860) 337-6173, Fax Number: (860) 644-1930
APPLICATION FOR ITINERANT FOOD SERVICE LICENSE
Owner Name: V 1 N c' � �O'Y��$'� ' Mailing
Address: C�`° l L ILL.
Telephone#: 0-7 G 6 63 7
Fax#:
Cell Phone#: _( -2. S
Email Address: 6E rq Wl7ac•c�� Sr', �On•
Operator Name: '1�)Er( vi Mailing
_ Address:
`Telephone#: ( )
Fax#: ( )
Cell Phone#: ( )
Email Address:
Qualified Food Operator Required: I YES NO ❑ Certificate#:
Name: IDate:
Please submit latest copy of the Food Operator certificate to the office.
Name of --�
Business/Unit: Water Supply: Public Private Well ❑
License Plate# Wastewater Disposal: Public On-Site ❑
Site Location: Electricity Available: YES❑ 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)
RECEIVED
— Tj a,U
APR 13 Z018
SOUTH
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):
Applicant Signature: Date:
Office Use Only '.s ;`;
f Inspector Name (Print):
Inspector Signature: Date:
Food Class: 1 ❑ 2 ❑ 3 ❑ 4 ❑ FEE: $100
Application ❑ QFO Cert ❑ Base of Ops ❑ Zoning ❑ Fire ❑ Expiration Date:
W, �. Aid() — 4� 314f1�
pK', TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
1530 Sullivan Ave., South Windsor, CT 06074— Office Address
Phone Number: (860) 337-6173, Fax Number: (860) 644-1930
ITINERANT VENDOR QUESTIONNAIRE
Na
me of Establishment:
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 ` c_..-r—
3. How will foods be kept hot or cold on the unit? What type of thermometer will be used?
How will they be sanitized? oo\< T S C-CL O (LO G
1 e - 01, L.J . as
4. How and where will utensils, pans, etc. be cleaned at the end of the day? Be specific.
- -
5. Describe the rrp�ethod of andwashingg 4s d at the u i . tom,
�.r 4 �aLD "-Ia z - L i eQ u 1 O o S OPPP �
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).
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7. How are water tanks filled? V
here i w tewa r dis osed?
8. Where will excess food and paper products be stored?
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9. How wild bage 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
` l
C�`� attest that ' r-4. t'
(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.
Signature and Title Date
(Signed by Owner/Operator of the Establishment)
Signature and Title Date
(Signed by Qualified Food Operator)
Na of Establishment
m
V '-LC-i C±0+-t-e—C S S i 0.1-C S.
Address of Establishment
** Please attach corresponding certificate of completion for approved training course.**
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TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
0 1530 Sullivan Ave., South Windsor, CT 06074—Office Address
c
Phone Number: (860) 337-6173, Fax Number: (860) 644-1930
SOR.` w DECLARATION OF BASE OF OPERATION
This form must be submitted with your application for permit.
Mobile Vendor Business Name: �� a`"`L.c Ss i+o r-1
Mobile Vendor Owner/Operator Name: �'"� 1yi
Business Name of Base Of Op.:
Address of Base Of Op.: ► a �-�"
1
Owner of Business for Base Of Op.:
Telephone Number of Base Of Op.:
THE FOLLOWING PORTION TO BE FILLED OUT BY THE OWNER OF THE FOOD
ESTABLISHMENT USED AS THE BASE OF OPERATION.
I, attest that my licensed food establishment
Owner of Food Establishment used as base
known as is available as the
Name of Food Establishment
base of operations for ` owned by
Name of Mobile Vendor Business
Owner of Mobile Vendor Business
e
Signature of Owner of Food Establishment
"Please include a copy of the Base of Operation food permit issued by the local health
department."
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CERTIFICATION
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