HomeMy WebLinkAbout1530 Sullivan Avenue (12) '0"* lot., Town of South Windsor — Health Department
1540 Sullivan Ave., South Windsor.CT 06074-Mailing Address
I S30 Sullivan Avenue,South Windsor,CT 06074 -Office Address
Phone Nwnber:(860)337.6173 Fax:(860)644-1930
Nmperl twp=11 Renewal
Type: Mobile/Itinerant Vendor Temporary Event 0 Pe'n'woent Food Service Estab*dmtent
(plea"Prim Clearly)*4* CLASS. FEE DUE:
Name of Establishment: 1'i4p '4K' 4-
Name of Person in Charge: &f-0
Establishment Street Address: ff f 0 f f-ViVe
City, State, Zip Code: oio i 6
Ptioneir: CJ 4;0 Cell PhoneO: kir-O
Fax*: JF-4;0 F-70 F1 S-0
E-Mail Address: 7evyt&tWkAj,.t$b6rct#q capacity:
Certified Food Protection Manager YES b'�M 0 Certificateii:
(CFPM)
Name: Expiration Date:
Testing Organization: I Ptwe#:
E-Mad Address: AfternatePhoner,
Atternate Person In Charge Phor**.
Restaurant Own'er cont at-, Inforfflatior
Owner's Name: 5t-- 6;7C74- 5 - Pt"w- ctv,-c*arw of RA~9 frr owrw,0%p
staws.Mailing Address: 4ak- IndivW"0 Assedatim 0
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City, State,Zip Code: C 7 mer LepCorporation i Entity 07 z 4 r
Phoneg: y' A Fax #:
?Ice J%( fe- rb/-o P?op'lro
E,Mari Address: ypewvye(f AV,* j-0W Call Phone At
Renovations
Were there any renovations made last year? YES 0 100 Will there be any renovations? YES Yr— C) r/-4&
If Yes, please list al renovations
that were done)tD be done:
ReStau'a "t c-f All lti=r*ls
Latest Meft Attached? YES[1 140 1-1 N-2
Please WAff_MgnV_*&M in as much detail as possible a copy of a menu attached is applocab4e.
C-tj 4:10
Res"ura""t F d pr p [beck ad that ar'r,4y,
-NSC*ok to order ONLY PrAdvanced catering for specific quantities [I Los"Time as a Public Health Control
hot of cold holding WreParet food to serve at another site
Prepares food for Highly Susceptible PoputstWri(praschoolers or"eld")
D Prepackaged neon TCS Food Only n Win TCS Food only(food that do"not require refrigimbon),
Please check all that apply:
State Licenses: 0 Bakeiry 5,sqiw Pen"a mom
Water Supply ,.-Pe*oriv me): — Public Private Well
Wastewater Disposal ic"erx oriv ore i: Publlc Septic Other(please use space below W evolam)
Agmement and Signature,
By sub"wthrig dvs I affirm that it*f"set for"in it are bw and complete and that I*MR axr4*y with the
ordinances and requWxns of the Town of South Windsor and State of Coninect;cut. I also affirm to allow the Town of South
`Mndwr Healih Department access to the establishment as required. I understarid that any false statements of other
misrepresentations made on Ovs application may result in tmirriediate srwMown or revocation of Inv FOW Service License tor
the TO"Of South wirXISM
Date of Bwth: /, I/, 7,4 Applicant.Name(Print).
Applicant Address: tr 6jT4 't Ph
Applicant Signature: Date: jz
Office Use Only
Inspector Name(Print):
Inspector Signature., i Date.-
Food Class: Expiration Date:
Date Recermd. Date Approved:
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TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
1540 Sullivan Ave,, South Windsor, CT 06074-Malhnq Address
1530 Sullivan Ave., So*Ab Windsor, CT 06074 _O tte Addrm
i Phone Number: (860)337-6173. Fax Number (860)644-1430
WA
ITINERANT VENDOR QUESTIONNAIRE
Name of Establishment: �.� � A 1 dl' ((Y.
1. 1�hat f x ill be epa a nd ened out of the it'
2. What is the source of the food to be dispensed) Provide the name and address of the food
distri join f li�+
3. How will foods be kept hot or cold on the unit? What type of thermometer will be used-)
How will they•aesanitized? ,
4. How and where will utemils, pans, tc. cleaned qt the end of the day7 Be sPwfiWAX
tpod
unit
S, ri e the rnlef h17
9vsed at the
. Describe how food will be protected. (Note: in large units where food is prepared inside,
screening is required to prevent theentra%e4 insects).
7. How are water tanks filled? Wliere is wastewater disposed7
8. Where will�' excess food and paper�produ be stored7
__ !—'if Cat t3t (A-0 tko r
9. will garbage be clrd on the unit arxi t the Base of Operations?
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TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
LW Whvan Ave., South Windsor, Cr 06074- Matkng Address
1530 SA00 Ave., South YY a Cr 06074-Ofte Address
sPtov Number<( )337-6173, Fax :($ )644-1930
Mob
`le Vendor Business Name: '- � all,
Mobile Vendor Owner/Operator Fume �`o 4 -1 M
Business a of Base Of Op.. t
Addressof Base Of Op.: ,, 1(
Owner of Business for Base Of .: '
Telephone Nurnber of Base Cep.. k-4 = ( 1 , 3
THE FOLLOWING PORTION TO BE FILLED OUT BY THE OWNER OF THE FOOO
MMKISHIMENT USED AS THE SM Of OPERATION.
attest t my licensed food establishment
t
knownasf 4� !0�k' is availatite as the
%vreafr
base of operations for by
Name of .
s ct 0WW
�. . eaaotovw
**Please Include a copy of the Base of Operation food permit Issued byhealth
department-**