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Home My WebLink About1370 John Fitch Blvd. 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 8OR•01� APPLICATION FOR ITINERANT FOOD SERVICE LICENSE Owner Name: Mailing �(H � 4, C50u<< Address: j Telephone#: Fax#: Cell Phone#: Email Address: 10Aj��.�{�j;&, Oel Operator Name: Mailing S( 4f Address: Telephone#: ( } Fax#: ( ) Cell Phone#: ( ) Email Address: oe Qualified Food Operator Required: YES W NO ❑ Certificate#: 5')Q_4 Name: Lko,,A& � Date:• t Please submit latest copy of the Food Operator certificate to the offir_e_ Name of —/ Business/Unit: � S 84 Skp Water Supply: Public J2 P ' ate Well ❑ License Plate# astewater Disposal: Public On-Site ❑ Site Location: �' EhJI T7 1 i. Electricity Available: YES❑ NO �L ^f` 1� '�� 'Y('G•Lt^�)f Other, Please Explain: Propane Use: YESW NO ❑ Please contact Fire Mars al 8�p 282- 69 _IF"F i"1 d I (J. ar' b4 Menu: (Note"Please list items in as much detail as possible, or a copy of a menu attached is applica e) YtLtF-HIC c'' ��' /� �rr,��, RECEIVED �S��tr�Gsf �� cl: Oi�� r7- DEC 15 2017 �>uUTH WINDSOR 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): 11,41.1 z ' UI Applicant Signature: A Date: _ o' Office Use Only Inspector Name (Print): Inspector Signature: Date: ijkj6 1'1 Food Class: 1 ❑ 2 ❑ 3 ❑ 4 ❑ FEE: $100 Application Eve' QFO Cert a Base of Ops ❑ Zoning ❑ Fire ❑ Expiration Date: k'(,kOn ,? c,,; � I (Go -43-v3 TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT n°�;�N�c,e 1540 Sullivan Ave., South Windsor, CT 06074 — Mailing Address R 1530 Sullivan Ave., South Windsor, CT 06074 — Office Address O = 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_o�'t a unit? % r 2. What is the source of the food to be dispensed? Provide the name and address of the food _ distribute n facility.^ �rQ . _ _ l�/! L L f 3. How will foods be kept hot or cold on the unit? What type of thermometer will be used? How will they be sanitized? i i 4. How and where VvilJ utensils pans, etc. be cleaned at the end of the day? Be specific. 5. Describe the method of handwashjng used at the unit. 6. Describe how food will be protected. (Note: in large units where food is prepared inside, screens is rgquired_�o prevent the entrance QfAnse j firs r� % > L ��i!t' �„cc�► 2 7. How are water tanks filled? Where is wastewater disposed? 8. Where will excess food and paper products be stored? , 9. How will garbage be dispo ed 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. 0 K nre � °WH 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 t`>>r!R•t � DECLARATION OF BASE OF OPERATION This form must be submitted with your application for permit r Mobile Vendor Business Name: Mobile Vendor Owner/Operator Name: Business Name of Base Of Op.: 1 d. to[hg` Address of Base Of Op.: SU-109 l Owner of Business for Base Of Op.: klsee-4 Telephone Number of Base Of Op.: 0(..o THE FOLLOWING PORTION TO BE FILLED OUT BY THE OWNER OF THE FOOD ESTABLISHMENT USED AS THE BASE OF OPERATION. I, - Miree I P" attest that my licensed food establishment Owner of Food Establishment used as bake known as mcowe 8155 is available as the Name of Food Establishment base of operations for L�j,, owned by Name of Mobile Vendor Business Owner of Mobile Vendor Business / ature of Owner of Food Establish nt "Please include a copy of the Base of Operation food permit issued by the local health department." i S ervSafe National Restaurant Association Se ry afe -- CERTIFICATION LINDA SOUZA for successfully completing the standards set forth for the ServSafe®Food Protection Manager Certification Examinalion, which is accredited by the American National Standards Institute(ANSIKonference for Food Protection(CFP). 13069780 5102 CERTIFICAIE riUMBER EXAM FORMA NUMBER 12/8/2015 12/8/2020 DATE OF XAMINATION DATE OF EXPIRATION Local laws apply. -keck with your local r gukatory agt i:. for recertification requirements. k:rman Brown WP. National Restaurant A.socialion Solution; In«ordonce with Maritime _ w,.Vsan 2006,Rrolawr,ALCM N 060-20131%@Aoemr 32 Stoecbd A3-2! V if 4=15 -,,,,,r,am Arodakm Eduocelyd Fourdanen(hWA 9 A2 riles reser el SwAnInO and dr 5,— f. — are trademarks of the NRAEF R,,,rn,aw A*xx *n0 ad fire arc druign are hadenstv6 eJ*w Nolsnel lcoom aw Asaecidssn T1,16 dowma)enn,w,Ix rorwodxed e•csh-,sd 14102W I v 1401 Conlod us with questions at 175 W Jadaon aW Ste 1500,Chicogo,IL 6060A or SemSaWraskiumnt org i J Mobile Food Vendor Application Sect. 4.1.1 Address of Proposed Food Cart ruck I A170 �;,T6�" -�,�u i� i L4 Size (max. 8'x 22� Zone 1. Name of Applic nt Address L l &It Phone Number 2. Starting date V I Ending date u G WiNDSOR p�N�NG DEP1. 3. A plot plan must be submitted with the application showi 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. S. 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. 6. 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 agrelto bide by the above requirements. Applicant Signature Property Owner's NameA�-01_ Property Owner's Signature r Reviewed and approved by: i}>vl.'e y �� (� '��,� Date Zoning Enforcement Officer Reviewed and approved by: Date Town Sanitari rev. 12/16/16 i Breakfast Menu Call (413) 544-1524 to order Egg & Cheese $3.25 Add bacon, ham or sausage $4.25 Steak Egg & Cheese $5.50 Kielbasa Egg & Cheese $5.50 Pancake Breakfast Sandwich $5.00 Wake Up Burger $5.50 Ultimate breakfast sandwich $5.75 2 eggs/bacon/sausage/ham with cheese on a Kaiser Roll Breakfast Chppotle Wrap $4.25 With chipotle mayo, egg, sausage and cheddar Linda's special for yolk lovers, yolk will not be broken until it's put on your ch9ice of bread. This will be drippy & messy but great! Lunch Menu Regular Hot Dog $2.00 Add Cheese for $2.50 Hot Dog with Cheese & Bacon $3.00 Hot Dog with Sauerkraut $3.00 Chili Cheese Dog with onions $3.50 Linda's Pit Dog $3.50 (Chipotle mayo, cheese, grilled onions & peppers & jalapenos.) Kielbasa Dog with cheese, grilled onions & peppers $4.00 Add Sauerkraut or Chili $4.50 Hamburg/ Cheeseburger $4.75 Double Cheeseburger $6.00 Add Bacon to any sandwich acid $.50 (Mayo, ketchup, pickles, onions, lettuce and tomato.) Grilled Chicken Wrap or Buffalo.Chicken $3.75 (Ranch dressing, shredded cheddar cheese, tomato and lettuce) Grille(I Chicken or Buffalo San(iwich $4.75 (lZanch dressing, provolone cheese, tomato and lettuce) Lunch Menu Veggie Burger on Kaiser Roll $4.75 (Provolone cheese, mayo, ketchup.) Cup of Chili with cheese $3.75 BLT on Texas Toast $4.50 Grilled Cheese on Texas Toast $3.50 Grilled Bacon & Cheese $4.50 Grilled Ham & Cheese on Texas Toast $4.50 Steak & Cheese with grilled onions & peppers (on a grilled Kaiser roll) $7.50 Baked Potatoes Sour Cream and Chive Potato $3.00 Cheese Potato $3.50 Bacon & Cheese Potato $4.00 Chili & Cheese Potato $4.00 Fully Loaded $5.00 Drinks & Chips Reg & Decafe Coffee, Tea, Hot Chocolate $1.00 Coke, Diet Coke, Sprite and OJ $1.25 Bottle Water or Gatorade $1.25 Lemonade & Iced Tea $1.25 Chips $1.00 Homemade Cookies 2 for $ 1 .25