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Home My WebLink About1530 Sullivan Ave (3) k 0'�re n "" S'r'4< TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT 1540 Sullivan Ave., South Windsor, CT 06074- Mailing Address = 1530 Sullivan Ave., South Windsor, Cr 06074-Office Address Phone Number: (860) 337-6173, Fax Number: (860) 644-1930 IpSOR-Cu� APPLICATION FOR ITINERANT FOOD SERVICE LICENSE Owner Name: Mailing I ffn 111)TN1CK! Address: C, Pi)I?X- Telephone#: CWQ3 .2 3 6 300 `N,C-17iIiix CI r)G -77'J Fax#: Cell Phone#: (I Email Address: u A;)Nc4�s a14 j.)it c-,")11 Operator Name: Mailing Z w, Address: Telephone#: ( O 7 2 3 -u 30 0 0 r 1 y Fax#: Cell Phone#: 9 ►i Email Address: S Qualified Food Operator Required: I YES M NO ❑ Certificate#: - ` ' Li V( Name: j�AKOIi104- pci—loc r fY►=y Date: 5" Please submit latest copy of the Food Operator certificate to the office. Name of Business/Unit: ZU G/5 1?6 t(Li r-) Pl1 IVCA1(' S Water Supply: Public Private Well El 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) fig;(�(O FA C��K� ` O��rvc-� 5 D i-A Q C Fvt q-r n C Z�iZ+Ki �U c'� i Gou L.��S✓l 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 Inspector Name (Print): Inspector Signature: Date: Food Gass: 1 ❑ 2 ❑ 3❑ 4 ❑ FEE: $100 toL(3 Application ❑ QFO Cert❑ Base of Ops ❑ Zoning ❑ Fire ❑ Expiration DateREC:EIVED MAY 01 2018 SOUTH WINDSOR HEALTH DEPT. d TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT 1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address A 1530 Sullivan Ave., South Windsor, Cr 06074—Office Address r Phone Number: (860) 337-6173, Fax Number: (860) 644-1930 ITINERANT VENDOR QUESTIONNAIRE Name of Establishment: i . i t /Af O eANc44115E;;S' 1. What foods will be prepared on and I,s�eprved out of the unit? IJi p _ �t��Qt�7 i�ilf►t-{ L�Iit� � P/JVC'ci / f�. 1. CA/lJ 1 ��I 2l(�i >i A-4CX' �� ;r_c r C-oUL84,el 2. What is the source of the food to be dispensed? Provide the name and address of the food dbitri'bution facility. _" I _ ��n��/�� W()�pnl ', A 3. How will foods be kept hot or cold on the unit? What type of thermometer will be used? How will they be sanitized? z C PRcP Pal 4. How and where will utensils, pans, etc. be cleaned at the end of the day? Be specific. �tf\V _IH&S 130+ 3 USES) f=02 y+ASN)YG- , -StiNF�G,�NG 5. Describe the method of handwashing used at the unit. ►�4jF 1n1G- 'hlr�, st'Ic-�; ��aP �f►Pt�Z ' rf�? Pr D�sc�r�> I�uc.;k�i 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 U C1 - �, �Z - - cam; i9 NSeOR 1L21 i ti Isr'l a, AI I _►f.LS 7. How are water tanks filled? Where is wastewater di(s sed? 8. Where will excess food and paper products be stored? ivPl SiiC L0 9. How will garbage be disposed on the unit and at the Base of Operations? BRAS+-] P?A 1CL 1/\)I;/,-I L_ r N 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: 19-13-1342(s)(6), 19-13-1348(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 BETWEEN TIME/TEMPERATURE AND MICROORGANISIMS(SURVIVAL, GROWTH, AND TOXIN PRODUCTION); DESCRIBE THE USE OF THERMOMETERS IN MONITORING FOOD 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 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. (B) DEMONSTRABLE ELEMENTS OF COMPETENCY 0) 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. (H) 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 W02ly/C-A ) attest that K4R.OLi f(q i n(4.1lVr Y (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 QL? (210 1 ( igned by Owner/Operator of the Establishment) Signature and Title LV a,a. � O r� n�ti Date :,' 7 1 / (Signed by Qualified Food Operator) Name of Establishment L u c ti s Address of Establishment -Z?;.c Mc- A-r � UChltc�K C.T no -7-710 ** Please attach corresponding certificate of completion for approved training course.** ALTERNATE PERSON IN CHARGE DEMONSTRATED KNOWLEDGE STATEMENT Pursuant to Public Health Code (PHC) Section: 19-13-1342(s)(8)(13) and 19-13- 1349(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 foodbome 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. ................................................................................. ILUC`1KD IA;?Z0;U --/! attest that (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., Date:0 1 60 be (%Ad by Owner/Operator of the Establishment) Signature and Tit Date• igned by Alternate Person in Charge) Name of Establishment: LOU ��a l� ��, I> Address of Establishment: °tea are 5`'< TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT a 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address w�' = 1530 Sullivan Ave., South Windsor, CT 06074—Office Address l` Phone Number: (860)337-6173, Fax Number: (860) 644-1930 y!tQSAR-1 i"�11v DECLARATION OF BASE OF OPERATION This form must be submitted with your application for permit. Mobile Vendor Business Name: ( l� I S PD�Q� f�kC►��5 Mobile Vendor Owner/Operator Name: lLi( .1 iY� 1 fJ21yiCi Business Name of Base Of Op.: Address of Base Of Op.: _2;-� C MR �� A yi 11//�l i�'.-��!� i�� " ! C 77 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. 4 rfr—,� w nZ (Ylo<i attest that my licensed food establishment v Owner of'Food Establishment used as base known as 1.UC-1 S -Pn o Civi('US is available as the Name of Food Establishment base of operations for h I C I s ?o p i j Pia owned by Name of Mobile Vendor Business 1 l r C it 0% Inl O Z.►,�( � Owner of Mobile Vendor Business ture oflowner of o Establis ment "Please include a copy of the Base of Operation food permit issued by the local health department." Mobile Food Vendor Application Sect. 4.1.1 Address of Proposed Food Cart/Truck Size (Max. 8'x 22� ! c) /'-C / Zone 1. Name of Applicant C 7 n W 0 Z rrI CK i Address P,iC Phone Number ?.03 713 63 aQ 2. Starting Date 4-�'j G/ l l Ending Date I D Z .3 n / I Y 3. A plot plan must be submitted with the application showing the proposed location of the food cart/truck along with any signage related to it. Food cart/truck must be a minimum of 20 feet from a street line. 4. A safe pull off and parking area must be provided. The food cart/truck and parking shall be located to not pose a safety hazard or obscure sight lines. 5. Temporary signage related to the food cart/truck is to be kept to a minimum. Sign(s) are to be located on the property where the food cart/truck is located and must be behind the property line of 10 feet from the road, whichever is farther. Max. of 12 sq ft of signage allowed. 6. The food cart/truck, trash container (required), and all the temporary signage for the food cart/truck are to be removed at the end of each workday or by 9:00pm (whichever is earlier). 7. This application must be renewed on an annual basis. I, the undersigned, acknowledge that the above information is true to the best of my knowledge and that I agree to abide by the above requirements. Applicant Signature '"�� Property Owner's Name Property Owner's Signature ................................................................................. Reviewed and approved by: Date Zoning Enforcement Officer ServSafe , ti,itnn.il Rr ;l.i,lr,ull t� '.•,,,r'GtUgr Sery af CERTIFICATION KAROLINA POTOCHNEY for successfully completing the standards set forth for the SerVSafem Food Prole-lion Manugei Cei lificuiion Examination, which is accredited by the American National Standards Institute lANSIK0 1 foronce for Food Protection OR 12384489 10430 FRTIFICATE NUMBER EXAM FORM NUMBER 5/27/2015 5/27/2020 DATE OF EXAMINATION DATE OF EXPIRATION Local laws apply.Chock with your local regulam y agency for mcerlificallon requirements. Sherman Brown SVp, Nallonal Restaurant Association Soluliow. a. a #0666 S6 In 0ccomd m wllh Morldms LGL,w(G•n�ntun 20oG,Rewltttxt AIk.S M 4F9:ot U�e9�lalia�3 2.Stun lwd a+ll l!Jlb g2o1S Nal000l Rov :,:M Awxlohan Fsluv>1R+tt11 Nxjo"INRAEFLA 1plrst*wv%d bwvSdvVa'v1 the Sei Sc&k9^c��kadNnarbchheNRAEP, Ndio�1 Red.'rh%A A t• 711tNYT wd the UiC Wt rxe fi 1dMKth1 ul t'k wxA Re0aulpA)Aw.:Mvm 111m dxamnl mitm W teptoduad or ahvod v.lAd I Comact ut wuh gmllons d 175 w Jackson Blvd,Ste 1S00,Chktteo,IL,60604 or SuvSak&odaum 1.1107"1 Food Service License Naugatuck Valley Health District LUCY'S POTATO PANCAKES - ITINERANT ITINERANT NAUGATUCK OPERATOR LUCYNA WOZNICKI EXPIRES: DECEMBER 31, 2018 THIS LICENSE EXPIRES ON THE EXPIRATION DATE ABOVE AND MAY BE REVOKED BY THE DIRECTOR OF HEALTH FOR FAILURE TO COMPLY WITH APPLICABLE DISTRICT AND STATE REGULATIONS. THIS LICENSE IS NOT TRANSFERABLE BETWEEN PERSONS OR PLACES, FEE IS NOT REFUNDABLE , VALID ONLY WHEN SIGNED BY License Class: J_3 THE DIRECTOR OF HEALTH At4i OR AGENT AFFREY DUSSETSCHELEGER, DDS, MPH DISPLAY IN A PROMINENT PLACE Director of Health