HomeMy WebLinkAbout1530 Sullivan Ave (4) It d0�'e
"" sC4< TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
' r 1S40 Sullivan Ave., South Windsor, CT 06074- Mailing Address
� = r; �0 1530 Sullivan Ave., South Windsor, CT 06074-Office Address
- Phone Number: (860) 337-6173, Fax Number: (860) 644-1930
ORnR-0) APPLICATION FOR ITINERANT FOOD SERVICE LICENSE
Owner Name: 1 � ' Mailing
V 1 �'•'� i f �� Address: t ueox.,
Telephone#: "��q I'C�L-kJ M EAC.fI CA,0
Fax#:
Cell Phone#: -
Email Address: ��.IJ "►�1 � �Ut- ��cv�
Operator Name: 1 Mailing
A W l( Address: 41 t1 s—'
Telephone#: ( )
Fax#: ( )
Cell Phone#: L_ )
Email Address:
Qualified Food Operator Required: YES M NO ❑ Certificate#: ;3cx4(;,-11 q "
Name: ,(I r i�� �h�( 1 Date: _,c7 �cla,
Please submit latest copy of the Food Operator certificate to the office.
Name of }� + Water Supply: Public Private Well ElBusiness/Unit: S 4 M�I� Ls HC�i L L
License Plate# t - Ivy 13 f\1 4 Wastewater Disposal: Public❑ On-Site
Site Location: Electricity Available: YES❑ NO • -'
f 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)
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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. Foqd Service License will be ued after the Food Inspector has completed his/her inspection.
Applicant Name (Print):
Applicant Signature: Date: 1�'�Lj I�S
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: 1 ❑ 2 ❑ 3 ❑ 4 ❑
Application ❑ OFO Cert❑ Base of Ops ❑ Zoning ❑ Fire ❑ Expiration wecrawn
MAY 14 2018
SOUTH W INDSOR
HMTH DEFT
6 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) 6"-1930
R ITINERANT VENDOR QUESTIONNAIRE
Name of Establishment: ` V i-S c 'r L l C
1. What foods will be prepared on and served out of the unit?
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2. What is the source of the food to be dispensed? Provide the name and address of the food
distribution facility.
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3. How will foods be kept hot or cold on the unit? What type of thermometer will be used?
How will they be sanitized?
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4: How and where will utensils, pans, etc. be cleaned at the end of the day? Be specific.
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5. Describe the method of handwashing used at the unit.
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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? Where is wastewater disposed?
8. Where will excess food and pa r products be stored?
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9. ^How will garbage be disposed on the unit and at the Base of Operations?
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PLEASE CONTACT THE TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT AT LEAST 48 HOURS
IN ADVANCE TQ 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
(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
attest that er('O_ Ake
(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
(Signed by Owner/operator of the Establishment)
Signature and Title Date
(Signed b�,Qualified Food Operator)
Name of Establishment
"4 as
Address of Establishment
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** 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-B42(s)(8)(B) and 19-13-
1149(t)(7)(B), 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 19-13-842(s)(6), 19-
13-649(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
roods; 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 peronal 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 )otential hazards prior to delivery
and during delivery; identify potential hazards and mth ds 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) Peecognize problems and potential solutions associated v;m, temperature control,
preventing cross contamination, housekeeping and maintenance— mplernent self
insoection 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.
t� �
I Ix- 1—T l �c attest that -?IC urn u-T ��' r r I
(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:
(S ned by Owner/Operator of the Establishment)
Signature and Title: Date: -� 1''` k `
(Signed by Alternat Person in Charge)
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Name of Establishment:
Address of Esstablishment`:,-,
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Mobile Food Vendor Application Sect. 4.1.1
Address of Proposed Food Cart/Truck
Size (Max. 8'x 22� Zone
1. Name of Applicant V alf r(4�, be( / ,
Address 1-�'I vi-- II C-L -k- L-,)y( n«co cti 111!� o lam„
Phone Number _ U i e5(z---4 5
2. Starting Date
Ending Date
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:OOpm (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 aide by the above requirements.
Applicant Signature
Property Owner's Name
Property Owner's Signature
.................................................................................
Reviewed and approved by: Date
Zoning Enforcement Officer
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--> TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
� v 1540 Sullivan Ave., South Windsor, Cr 06074—Mailing Address
' 1530 Sullivan Ave., South Windsor, Cr 06074—Office Address
Phone Number: (860) 337-6173, Fax Number: (860) 644-1930
t�soR•c �
DECLARATION OF BASE OF OPERATION
This form muu be submitted with your application for permit.
Mobile Vendor Business Name: "I Ji k67 L ��
Mobile Vendor Owner/Operator Name: _ IT(2
11 `pBusiness Name of Base Of Op.: t !�'(�'��S 17 2
Address of Base Of Op.: 71
VflOwner of Business for Base Of Op.: r 1 S
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
Food used as base
known as is available as the
Name of Food Establishment II
base of operations for IA' 14S 1^ owned by
y of Mobile Vendor Business
Owner of Mobile Vendor Business
Sign�atuof ner of Food Establishment
**Please include a copy of the Base of Operation food permit issued by the local health
department.**
y�%,u it cZot aCOre: YJ
Candidate Status: Pass �•••.. "`...."'._.".
Test Date: March 29, 2014
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yyw�y NRFSP�4.- Date Mark 29,20
Congratulations!Attached is your certificate - -
and at*Wlet�'Ply notif
the National R
y ROBERT N ABELIN
egistry of name or address changes tthe address below_ 47 BELLEV[TE AVE
LONG MEADOW_MA 01106
Preventing Contamination and Cross Contamination(Mastereo)
Ensurelg Personal Hygien,and Errployee HMM Active M in (Competent)
Controls n a Food Establishment(Competent)
NotificatiOn of Test Resulty National Registry of Food Safety Prafessiona
CEEMFIED FOOD SAFETY MANAGE
ID#: xxx-XX- _
Scaled Test Score: 84
Candidate Status: Pass,x vwl:ERi -;Y {ate;
Test Date:March 29, 2014 -
76W unhersaj Biw..
Suite 550
.R 32819. -- _
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Phone(407)3�s83O. --- -==�it7xate Ncr 20962176
Frei t40713 -3W3 43-Date Mach 20.2014
wwu+NRFSP_{ Expiration Date Mach 29.2019
CongrawlatiOns!Attached is your certificate and wallet card Please notify the National Registry of name or address changcs at the address below. VALERIE J ABELIN
47 BELLEVUE AVE
LONG MEADOW_MA 01106
Preventing Conte and Cross
Ensuring PErsbnal H �rrnatron(Compelenfj
Yg a and&rVoyee Health(Competent)
Mo�nttori ety Managing Controls in a Food Establishment(Competent)
g the Flow of Foods(Competent)
Ensuring Product Tune and Temperature(Competent)
Conducting Cleaning and Sanitizing(Competent)
Managing-Physical Facility Design&Maintenance:Preventing&Controlling pests
(Mastered)
NatioaWRqgihyofFoodS,*tyPratesmnals® 1 7680Univer-ABWStc550 1 Orlando.FL32819 1 F90=407323930
1 Face 4073523603
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C CERTIFIES--
O O
Z ROBERT N ABELIN
HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE
CERTIFIED
Faop ", � t3 FOOD SAFETY MANAGER
UNDER THE
CONFERENCE FOR FOOD PROTECTION STANDARDS
Training by A-F811
1-800-723-3873
267-975-6442
PRESIDENT:7i5o
LAWRENCE J.LyNcK CAE
ISSUE DATE: MARCH 29, 201 4
Yor`w EXPIRATION DATE: MARCH 29, 2019
CERTIFICATE NO: 209621 82
380 Univprna:Blvd.Salle 55%Odando.FL2=9
TEST FORM:EZS]9
3OM 4464M F(40i'I 3%--4W3 WIV v NRFSP-00m Tho cafdimte k not nrd for moR
tional Registry of Food Safely Professionals® th=rre s—r m daft of iaoc
e' t000 r� National Regis"ofFood Sakes PtofessiOnWst
Notification of Test Result U CERTIFIED FOOD SAFETY MANAGER
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II?#:7IICC--XX- -ROBSRT V*MUN
Scaled Test Score: 90 CERTIFIED
Candidate Status.Pass -
Test Date:March 29,2014 76M UnWera r Bhrd-
Suge550
o Odardo,FL32819
I Teri Free(!)446.0257 — - _' Ccrtificatc Ntx 20962182
Phone(407)3523MO Live Date~March 29,2014
Fax(407)352-3603 Frpiratino Data March 29.2019
cnnv.NRFSP.can
Congratulations!Attached is your certificate and wallet card Please notify ROBERT N ABELIN
the Nationl Registry of na ne or address changes at the address below_ 47 BELLEVUE AVE
LONG MEADOW,MA 01106
Preventing Contamination and Cross Contarnination ffiftslufe4
Ensuring Personal HWmm and Employee Health(CompetenQ
Actively Managing Controls in a Food Establishment(Competent)
Monitoring the Flow of Foods(hlastereO
Ensuring Product Tom and Temperature(Compete"
Condudirq;Cleaning and Sanitizing(btastered)
Managing:Physical FaaTdy Design&Mairdenanee:Preventing&Controlling Pests(Masbred)
National R e^_. of Food SaSety Professionnls,& 1 76M Universal Blvd Ste 550 1 Cd odo.FL 32819 1 Phone:407352.3830 1 Fwc 4073§2.3f03
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CERTIFICATE OF {
�F ALLERGEN AwARENESS
p
Name of Recipient: VALERIE ABELIN
Certificate Number: 2263470
Date of Completion: 3/23/2016
Date of Expiration: 3/23/2021 �+1
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R/ �((e.
�1 Iasued By:
?he above—!lamed person is hereby issued this certificate [� _
.for completing an allergen awareness trainingprograin 1l� NATIONAL .
/ / P�.,: RESTAURANT �t
recognized by the Massachusetts Department of Public Health ASSOCIATION,,
in arrordance with 105 CMR 590.009(C)(3)(a). Massachusetts Restaurant Association 800.765.2122
333 Turnpike Road,Suite 102 uwwv.restaurant.org
Southborough,NIA 01772
71ris certificate will be valid for five(S)years firom date of completion. 508-303-9905
r www wrestaurantassoc.org ( �pr