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Home My WebLink About9 Arthur Drive �°*" Sf"< Town of South Windsor — Health Department 1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address y 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address Phone Number: (860) 337-6173 Fax: (860) 644-1930 /1bso -Co.." Establishment rorratio� N w Permit❑ Permit Renewal ElType: Mobile/Itinerant Vendor Temporary Event Permanent Food Service Establishment El Print Clearly)*** CLASS: yI yy,, FEE DUE: Name of Establishment: C�u{-TrrJI vb(l Name of Person in Charge: ; Establishment Street Address: Imo.-�Nw V, 6 Gt(l City, State, Zip Code: _V)irlu SUS _ G f Q 1P 0? el Phone#: �031—��b �(o S� Cell Phone#: Fax#: f E-Mail Address: C f dt�6,;fd!otection 0d"( Seating Capacity:Please submit latest copy of the Certifie `�ood ffi i e vSafe certificates to the office. Certified Food Protection Manager YES NO ❑ Certificate#: (CFPM) (Required for ALL Class 2,3&4) Name: �L Expiration Date: Testing Organization: `3j" SMR Phone#: E-Mail Address: Alternate Phone#: Alternate Person In Charge Phone#: Restaurant t er Contact Information Owners Name: ( ' �(�( � d { ) Please check one of the following for ownership � status: Mailing Address: `T—vu U, Individual ❑ Association❑ City State Zip Code. Corporation ❑ Partnership El Other Legal Entity El Phone# Fax #: E-Mail Address Cell Phone#: Renovations Were there any renovations made last year? YES❑ NO Will there be any renovations? YES❑ NO If Yes, please list all renovations that were done/to be done: Supplemental Questionnaires For Itinerant and Temporary Event applications, please complete the supplemental questionnaire form �v W Na TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT f 1540 Sullivan Ave., South Windsor, CT 06074 — Mailing Address 1 1530 Sullivan Ave., South Windsor, CT 06074 —Office Address Phone Number: (860) 337-6173, Fax Number: (860) 644-1930 �asox.ro' ITINERANT VENDOR QUESTIONNAIRE Name of Establishment: O C Ct(�T 6 1 6 I7)L) TM OL 1. What foods will be prepared on and served out of the unit? C ;roc)-eT i-el 2. What is the source of the food to be dispensed? Provide the name and address of the food distribution facility. p0� (M 3. How will foods be kept hot or cold on the unit? What type of thermometer will be used? How will they be sanitized? 1 D iLC� 4. How and where will utensils, pans, etc. be cleaned at the end of the day? Be specific. K) UnA i H ZP d (A f- OCYY)V14 i5!� 5. Describe the method of handwashing useI at the unit. WL IA S >>^ S b h p fit�— -�"g 1j 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). TZC ( l (A z7",-Cl (n b OA,M!.A-�-, 7. How arq wate tanks filled? Wher is wastewater disposed? J u , 1 i'(- - >� � mires 8. Where will a ess food and paper products be stored? �6 9. How will garbage be disposed on the unit and at the Base of Operations? canX FIJ v 0 Rev.7/16/18 TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT f fi 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 1US`aR- o' DECLARATION OF BASE OF OPERATION This form must be submitted with your application for permit. Mobile Vendor Business Name: (ICA `r� 12(,� ,�l I� Mobile Vendor Owner/Operator Name: E r l c- ST NCT-� Business Name of Base Of Op.: �Gf ► �� Address of Base Of Op.: 8-7 C k �C �` S�, �'r,S� wv t v< �1 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. S18EI� attest that my licensed food establishment wwner of Food Establishment used as base known as Cf C'e-TIP, i e is available as the Name of Food Establishment base of operations for Cct �-Tfb I(-� � �' owned by Name of Mobile Vendor Business Owner of Mobile Venab6r Business s of Owner of Food Establi ment "Please include a copy of the Base of Operation food permit issued by the local health department." Restaurant Menu/List Of All Items Served/Sold Latest Menu Attached? YES❑ NO ❑ NOTE*"(Must have latest copy on file) Please list all menu items in as much detail as possible or a copy of a menu attached is applicable. %T ► C (v q o-e+-Wf Wcook taurant Foci Prep (check all that apply) to order ONLY ❑ Advanced catering for specific quantities ❑ Uses Time as a Public Health Control ❑ Cooking/cooling/reheating/thawing/freezing/hot or cold holding ❑ Prepares food to serve at another site ❑ Prepares food for Highly Susceptible Population(preschoolers or the elderly) ❑ Prepackaged non TCS Food Only ❑ Non TCS Food only(food that does not require refrigeration) Additional Information Please check all that apply: State Licenses: ❑ Bakery ❑ Liquor Permit ❑ None Water Supply (check only one): Ypublic _ Private Well Wastewater Disposal (check only one): ublic _Septic _Other (please use space below to explain) Agreement and Signature By submitting this application, I affirm that the facts set forth in it are true and complete and that I will comply with the ordinances and regulations of the Town of South Windsor and State of Connecticut. I also affirm to allow the Town of South Windsor Health Department access to the establishment as required. 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. Applicant Name (Print) Date of Birth: 6 -2 Applicant Address: - pY ; S(; C f Phone#: ZC4( —Gq5�; Applicant Signature: Date: / It) Office Use Only Inspector Name (Print): Inspector Signature: Date: Food Class: Expiration Date: Date Received: Date Approved: SOUTH WINDSOR FIRE MARSHAL'S OFFICE 2019 MOBILE FOOD VENDOR I'SORA<� PERMIT APPLICATION TYPE (check all that apply) Truck ❑Trailer ❑Tent ❑ Other setup CONTACT INFO Business Name: b Business Owner: Address: d Sol- City, State, Zip: C-f LO Z Phone 1: _ ��2 Phone 2: E-Mail: T'� r b i I C COOKING EQUIPMENT (check all that apply) eep Fryer ❑Griddle a4en (conventional) ❑Oven (wood-fired) ❑Grill (solid fuel) ❑Grill (gas) ❑ Other FIRE SAFETY (check all that apply) Exhaust Hood Last Cleaned ( l s ❑ Extinguishing system Last Inspected Class K Extinguisher Last Serviced 1-4 ABC Extinguisher(s) Last Serviced p Tent NFPA 701 label? ❑ Yes ❑ No AGREEMENT/SIGNATURE By submitting this application, I affirm that the facts set forth in it are true and complete and that I will comply with the ordinances and regulations of the Town of South Windsor and State of Connecticut. I also affirm to allow the South Windsor Fire Marshal's Office access to the establishment as required. I understand that any false statements or misrepresentations made on this application may result in immediate shutdown or revocation of my Mobile Food Vendor Permit. Name (Print):_ du a Signature: Date: Mailing Address: 1540 Sullivan Ave, South Windsor, CT 06074 Office Address: 232 West Road, South Windsor, CT 06074 Date received: Phone: 860.282.0669 Fax: 860.282.0666 Reviewed by: