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Home My WebLink About280 Sullivan Avenue (2) sf TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT 1540 Sullivan Ave., South Windsor, CT 06074- Mailing Address r - 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: Mailing t�J617�> s 6i or}n5, n£ ll C Address: 1/ /Vor-M14-a S j Telephone#: 9 F;� cj l 1 MA" 1,r s-i ra c' od o sr" Fax#: ( ) Cell Phone#: Email Address: Operator Name: Mailing S;e✓r.y �� ,jam,1, Address: 64 /V,4 j c1. Telephone#: rd 2 e A C" MA'�yet-es;" e n�c,'fin Fax#: ( ) Cell Phone#: (gGo ) 9 pia End 41 Email Address: ��,�� r�x Qualified Food Operator Required: YES NO ❑ Certificate#: Name: S'J�. GJc)yc iL IDate: Please submit latest copy of the Food Operator certificate to the office. Name of Business/Unit: (,)y�c7)S allay;,fit j, Water Supply: Public L� Private Well El License Plate# A 14 &Y9g3v CT Wastewater Disposal: Public On-Site ❑ Site Location: 3-�'v SCllt,l.�tia Avg Electricity Available: YES NO ❑ c U6i,7y If Other, Please Explain: Ir-e drf2l1,1-6 n 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) St-e vT 1'4z" ) RECEIVED DEC 2 0 2017 Agreement and Signature HEALTH DEPT 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: ,f Date: 7 Office Use Onl Inspector Name (Print): ,� ) Inspector Signature: Date: IZ Ib Food Class: 1 ❑ 2 ❑ 3 B-4 ❑ FEE: $100 Application ❑ QFO Cert ❑ Base of Ops ❑ Zoning ❑ Fire ❑ Expiration Date: lZ `&�� =V\ ((3 m Swo TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT n° «Ndy, 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 Name of Establishment: _-, , 1. What foods will be prepared on and served out of the unit? S 1 n' i"A re,l 2. What is the source of the food to be dispensed? Provide the name and address of the food distribution facility. 5eawrll seA-Pso 3. How will foods be kept hot or cold on the unit? What type of thermometer will be used? How will they be sanitized? 4. How and where will utensils, pans, etc. be cleaned at the end of the day? Be specific. i ,' ?:7 nr� :e L✓J�SI,� s �/ ►+ii,1-� w ,1. �fn�� 5. Describe the method of handwashing used at the /u/nit. 1-/r*S110 R J";-iS - S. aH,v i�'z r 0 LJ 0 l� �_ �sh�e{4 s w 1` ��J� (eJ llJ �✓.Y,v_'� :.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). USy 7. How are water tanks filled? Where is wastewater disposed? AT 1-7-, l,7fl.t't c), z .2,. R i,d,,S 8. Where will excess food and paper products be stored? n 11 f �a [' J►n i r�� +--t i3 i !he 6J3IL-z Ci J` iC'f:(_ ,,L rrf 9. How will garbage be disposed on the unit and at the Base of Operations? A CvrnMtrc, ( 1�i�i�, !'yMks>t2,Z Qrc %2 /-rr> /)-/so j7Q,kL (>3"'4 iLF j7, 12r4sZ 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 TIMEJEMPERATURE 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 I 9 t vt74 6,007c i L attest that S i t��-� 4jo 7e+ L (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 wner/Operator of the Establishment) Signature and Title Date (Signed by Qualified Food Operator) Name of Establishment CJQ jr2 s Eonos�6� Address of Establishment ** 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)(B) and 19-13- 1349(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 19-13-1342(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 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. ..................................................■.............................■ C-)oT attest that Sc )-I NoTe (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. ` - _ �/ /✓ Date: I� ��Signature and Title: (Signed by Own/r/Operator of the Establishment) Signature and Title: Date: (Signed by Alternate Person in Charge) Name of Establishment: Address of Establishment: �''►i atic�'`S� r� C ' r� 6 d �/U •N N S • �K 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 DECLARATION OF BASE OF OPERATION This form must be submitted with your application for permit. Mobile Vendor Business Name: CJv�d s ADlyo s•l), 'L4 C Mobile Vendor Owner/Operator Name: S��-�i C" T, :L Business Name of Base Of Op.: � S -� L Address of Base Of Op.: Owner of Business for Base Of Op.: Telephone Number of Base Of Op.: L)&U.,r.A�'�--- 756 THE FOLLOWING PORTION TO BE FILLED OUT BY THE OWNER OF THE FOOD ESTABLISHMENT USED AS THE BASE OF OPERATION. I, ' �-S4-414-- 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 fortY61sty owned by / ! Name of Mobile Vendor Business Owner of Mobile Vendor Business Signature of Owner of Food Establishment "Please include a copy of the Base of Operation food permit issued by the local health department." Wojo's Roadside Breakfast or Bacon or Sausage egg sandwich----------- 3.50 Add cheese to sandwich-----------' -----------------$4.00 Egg and Cheese sand—---------------'--'____ Tator Coffee,water,soda or Hot Cocoa------—-------------$2.00 LUNCH Grill Cheese with lobster---- --- --- $12.00 Grill Cheese - ---------- ---- - --------$5:00 Grill Cheese with tomato-- $8.00 Grill Cheese with bacon------- ----- --- $8.00 Grill Cheese with ham-----__ -$8.00 Lobster Roll ---- - — ----$10.00 Lobster Roll with fries $15.00 Poutine (fries with gravy and cheese curds)------$7.00 I I I 1 ServSafe National Restaurant Association SleEry nfe CERTIFICA'=T' ION STEVEN WOJCIK For successfully completing the standards set Forth For the Se-•Safe""Food Protection Manager Certification Examination, which is accredited by the American National Standards I .stitut._ (ANSI)-Confer.nee For Food Protection(CFP). 73313 5282 UMBER EXAM FORM NUMBER 8/14/2022 DATE OF DATE OF EXPIRATION Local laws apply. ' for recertification requirements. -.IiEaITEa PIIaGIIIIM - ..�Natlnay SL�nduds Instllule ho Gonhnmce Ia 1 ood Protnalon � #0655 w1n3c=Dr dam with Maritime C015, ,Mr " am Iradenwrks of the NRAEF Mali Contact us with questions at 175 W Jackson BW.Ste 1500,Chicago,IL.60604 or ServSate@resta Mobile Food Vendor Application sect. 4.1.1 Address of Proposed Food Cart/Truck,q Su/<<hw-r Ate. Sv .Zr✓ ��s� c r� Size (max. 8'x 221 Zone 1. Name of Applicant ej-6;a s fo r, .4,4 c. Address 1(6 pl ormr�,i o eo yv Phone Number Yd a �� 2. Starting date Dr..- 3 Is 1-7 Ending date ® 3/ 'q-b / F 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 or 10 feet from the road, whichever is farther. Max. of 12 sq ft of signage allowed. b. The food cart/truck, trash container (required) and all temporary signage for the food cart/truck are to be removed at the end of each workday or by 9:00 pm (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. f Applicant Signature Property Owner's Name n(r-� JEn Property Owner's Signature Reviewed and approved by: ,� .,, A"K a. ��,,� Date Zoning Enforcement Officer r Reviewed and approved by: �l Date Town Sanitarian rev.12/16/16 ir.