HomeMy WebLinkAbout1530 Sullivan Ave (6) � IMd��
TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
1540 Sullivan Ave., South Windsor, Cr 06074—Mailing Address
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
Address:
Telephone*: ( ;� �.) 1�.� 4�Ic , l
Fax#: ( ) a(n LA __
Cell Phone#:
Email Address: (m&j co pi Z�WLkie, .i p^()
Operator Name: Mailing
Address:
Telephone#: ( )
Fax#: ( )
Cell Phone#: ( )
Email Address:
Qualified Food Operator Required: YES NO ❑ Certificate#: 0,.Zci 15
Name: PMQ 1{tom Date: 3114 •—3 Z 1 "
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Please submit latest copy oft the Food Operator certificate to the office.
Name of
Business/Unit: - j cj Water Supply: Public(�] Private Well El
License Plate# Jj E ictiao Wastewater Disposal: Public® On-Site
Site Location: L c jk t_ti ���,;; ��1�, Electricity Available: YES❑ NO
If Other,Please Explain: 1C i-��
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)
RECEIVED
APR 0 6 2018
SOUTH WINOSOR
HEALTH
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. Food Service License will be issued after the Food Inspector has completed his/her inspection.
Applicant Name (Print): (-
Applicant Signature: I Date: �3 2r, 1$'
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: 1 ❑ 2 ❑ 3 ❑ 4 ❑ FEE: $100
Application ❑ OFO Cert ❑ Base of Ops ❑ Zoning ❑ Fire❑ Expiration Date:
TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
"K 8ea4 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
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'(JR-c� ITINERANT VENDOR QUESTIONNAIRE
Name of Establishment: ?) 7-z01- P, X I-e_
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 w ere will utensils, pans, etc. be cleaned it the end of the day? Be specific.
5. Descri e the method of handwashing used at the unit.
l� 1,�1:�c �- Y vr► �UC� _
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?
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8. Where will excess food.aC d paper products be stored?
9. How will garbage be disposed on the unit and at th� Base of Operatio s?
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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.
ALTERNATE PERSON IN CHARGE
DEMONSTRATED KNOWLEDGE STATEMENT
Pursuant to Public Health Code (PHC) Section: 19-13-1342(s)(8)(13) 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-
13-849(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.
.................................................................................
attest that ��
(Print Name off ner or Operator) (Print Name of Alternate Person in Charge)
is employed as the alternate person in ch a and has demonstrated to me the elements
of knowledge and demonstrable elemen o competency as described in A and B, as listed
above.
Signature and Title:
Date:
(Signed by Owner/Operator of the Establishment)
Signature and Title: Date: �h
(Signed by Alternate Person in Charge)
Name of Establishment:
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Address of Establishment:
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TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
v 1540 Sullivan Ave., South Windsor, CT 06074 Mailing Address
.d+ 1530 Sullivan Ave., South Windsor, CT 06074—Office Address
Phone Number: (860) 337-6173, Fax Number: (860) 644-1930
'tU.S'OR-CO^
DECLARATION OF BASE OF OPERATION
This form must be submitted with your application for permit.
Mobile Vendor Business Name: ?'I 2:zq - t )�Ie-
Mobile Vendor Owner/Operator Name: Ny�!td I(1-*CC
Business Name of Base Of Op.: �►n� +{S ��t , 2 attai
Address of Base Of Op.: L, (1 fl CT
Owner of Business for Base Of Op.: Lt �.
Telephone Number of Base Of Op.: eJ
THE FOLLOWING PORTION TO BE FILLED OUT BY THE OWNER OF THE FOOD
ESTABLISHMENT USED AS THE BASE OF OPERATION.
I, ��(� f1.i/l S� attest that my licensed food establishment
Owner of Fj Establishment usdU as base
known as 1L6(-ke(, ltbOOLA is available as the
Name of Food Establishment 13
base of operations for P-) Z--ZCL �04 C- owned by
Name of Mobile Vendor Business
Owner of Mobile Vendor siness
Signature of Owner stablishment
"Please include a copy of the Base of Operation food permit issued by the local health
department."
Mobile Food Vendor Application Sect. 4.1.1
Address of Proposed Food Cart/Truck C, (Cove- 6M L � I'N
Size (Max. 8'x 22� ZorLj
1. Name of Applicant Poc
tte-
Address � C i
Phone Number _ 4% `L)�,2-du tr,1
2. Starting Date ti
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 in o ation is true to the best of my
knowledge and that I agree to abide by the bove re uirements.
Applicant Signature
r
Property Owner's Name o 6 `,��'`/J�'��
Property Owner's Signature
.................................................................................
Reviewed and approved by: Date
Zoning Enforcement Officer
ServSafe
National Restaurant Association
SeakrvSafeo
CERTIFICATION
AMY PORTER
for successfully completing the standards set Forth for the ServSafe®Food Protection Manager Certification Examination,
which is accredited by the American National Standards Institute(ANSI)—Conference for Food Protection(CFP).
13291548 10471
CERTIFICATE NUMBER EXAM FORM NUMBER
3/1/2016 3/1/2021
DATE OF EXAMINATION DATE OF EXPIRATION
Local laws apply.C hed with your local regulatory og,:r.._y for recertification requirements.
ACCREDITED FR36RANI Sherman Brown
50, National Restaurant Association Solutions
#W55
In oxordanoe wilh Maritime L- 2OX RasekAon ADM N 068 2013 Pso l/me 3 2,%2%= A]21 Q
02015 Ndional Asomosm L .asrwd Fwrrdaaon 04UM Al rVhb.aw"d SenSaW and to Sam I,:.a; of dro NRAEF
�Nati A.moAai and arc door an evlswri.d!r Nnronal isrbaanr ArocAor
aoMet!»raproduad ar Ord
t 41024Dt v 1 X 1 CoNod us with tuestims d 175 W Jodcson Blvd Ste 1 S00,Chkopo,L.60604 or ServSde@radourmcorg
ServSafe
Certificate of Achievement
This certificate is awarded to
BARBARA DOVIAK
Congratulations! You have completed
fka*Issuer _ ServSafe@ Food Handler
ASTM E2659
Cerlificofe ;�' R di�..�{�✓'e�l.�'^:: � �':s����i cam ._. �'w;�'� _+,���'11 �is 1__.C..i l��u ..�L� _,t1�1'�._f �._�`'..s�.j����l
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National Restaurant Association Certificate Number 3324043 Date 3/27/2018
233 S. Wacker Drive, Suite 3600 3/27/2021
Chicago, IL 60606-6383 Expiration Date
800.765.2122 in Chicago area 312.715.1010
Restourant.org I ServSafe corn
ServS1f7
fe
National Restaurant Association
Certificate
of Achievement
This certificate is awarded to
GEORGE BRAULT
Congratulations! You have completed
ANSI ACCREDITED PROGRAM ServSafe@ Food Handier
CERTIFICATE ISSUER
#0655 Employee Food Safety Online Course and Exam
Certificate Number 2920793 5/24/2017
National Restaurant Association
175 W.Jackson Blvd, Ste.1500 Expiration Date 5/24/2020 ,0
Chicago, IL 60604-2814
800.765.2122 in Chicago area 312.715.1010 M
Restaurant.org I ServSafe.com
Para Prep Mrigerato,
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Eastern Highlands Health District
FOOD S ERVICE LICENSE
!== Eastern Highlands Health District
Establishment Name: Pizza Pixie--Itinerant Vendor
♦�" 'f Licensee: Amy Porter
Located at: Bolton CT
Is licensed to operate a food service establishment for the period beginning
April 1, 2018 and ending March 31, 2019 License # 7564
The recipient of this license accepts the same with the understanding that he/she will operate
this establishment in accordance with the ordinances and regulations of the Eastern Highlands
Health District and the Connecticut Public Health Code.
Valid only when signed by the
director of health,Robert L.Miller, .�
M.P.H., R.S.or authorized agent Date:
This license is non-transferable to any other operator,owner or establishment.
Must be on display at all times.
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CHATHAM HEALTH DISTRICT
SnuM#tfte.Daum o f&&teaten,&at Na"am,East Xanytm,Xekm,Afavc@donwo&`Jmt&utd
2018
FOOD ESTABLISHMENT LICENSE
(Class MFU)
This is to certify that Pizza Pixie
Located at: 14 Porter Road Hebron, CT 06248
Licensee: A y Porter
QFO: A y Porter
Is approved to operate a food establishment or vending machine for the year ending
December 31, 2018 under License No. 18/34
The recipient of this license accepts the same with the understanding that he/she will operate
this establishment in accordance with the ordinances and regulations of the Chatham Health
District and the Public Health Code of the State of Con icut.
i
Date Issued 12/27/2017 Signed
YL
%--- Director of Health or its Agent
This license is non-transferable in regard to location and the person to whom it was issued
This license must be displayed in the public view under a protective covering.
PIZZA PIXIE MENU
Cheese
Pepperoni
Classic White
Olive Oil, Minced Garlic, Italian Seasoning, Salt, Shredded Mozzarella, Feta, Parmesan
Honey or Maple White
Honey(Maple)Sweetened Ricotta, Fontina, Shredded Mozzarella, Salt& Pepper, Drizzle Local
Honey(Mople
Margherita
Red Sauce, Fresh Mozzarella, Garlic, Olive Oil, Basil&Seasoning
EHS-106-Rev.11105 INSPECTION REPORT STATE OF CONNECTICUT ROUTINE INSPECTION O REINSPECTION
FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH O PREOPERATIONAL O OTHER
1 410 Capitol Avenue,MS#11 FDP,Hartford,CT 06134
ESTIABLISHMENT , ,I L1 -1 �' 1 � � •�/ CLASSLISHMENT -1
STREET TOWN 1_
i
ADDRESS
OWNER or INSPECTION
OPERATOR' I DATE and TIME
Based on an inspection this day,the items marked below identify the violations in operation or facilities which must be corrected by the date specified below.
SOURCES OF FOOD EQUIPMENT&UTENSILS:CLEANLINESS VERMIN CONTROL
1 Approved source,wholesome, 4 21 Pretlushed,scraped,soaked and racked 42 Presence of insects/rodents 2
nonadulterated 22 Wash water clean,proper temperature 1 43 Outer openings protected against entrance of 1
2 Original container,properly labeled 1 23 Accurate thermometers provided,dish basket,if used insects/rodents
24 Sanitization rinse(hot water-chemical) 2
FOOD PROTECTION 25 Clean wiping cloths 1 FLOORS,WALLS&CEILINGS
3 Potentially hazardous food meets 4 26 Food-contact surfaces of utensils& 2 44 Floors:floor covering installed,
temperature requirements during storage, equipment dean constructed as required,good repair,clean
preparation,display,service,and
transportation 27 Nonfood-contact surfaces of utensils& 1 45 Floors,graded,drained as required 1
equipment clean 46 Floor,wall juncture covered
4 Adequate facilities to maintain product 2 28 Equipmentlutensils,storage,handling 1 47 Mats removable,good repair,clean
temperature.thermometers provided
5 1 Potentially hazardous food properly thawed 2 48 Exterior walking,driving surfaces, 1
6 1 Unwrapped or potentially hazardous food 4 WATER SUPPLY good repair,clean
not re-served 29 1 Water source adequate,safe 4 49 Walls,ceilings attached,equipment properly 1
7 Food protected during storage,preparation, 30 Hot and cold water under pressure, 2 constructed,good repair,clean. Wall&ceiling
display,service&transportation 2 provided as required surfaces as required.
8 Food containers stored off floor 50 Dustless cleaning methods used, 1
SEWAGE DISPOSAL cleaning equipment properly stored
9 Handling of food minimized 2 31 Sewage disposal approved 4
10 Food dispensing utensils properly stored 1 32 1 Proper disposal of waste water 1 LIGHTING&VENTILATION
11 1 Toxic items properly stored,labeled,used 4 51 Adequate lighting provided as required 1
PLUMBING 52 Room free of steam,smoke odors 1
PERSONNEL 33 1 Location,installation,maintenance 1 53 Room&equipment hoods,ducts,vented as required
12 Personnel with infection restricted4 34 No cross connection,back siphonage,backflow 4
DRESSING ROOMS&LOCKERS
CLEANLINESS OF PERSONNEL TOILET FACILITIES 54 Rooms adequate,clean,adequate lockers 1
13 Handwashing facilities provided, 4 35 Adequate,convenient,accessible,designed, 4 provided,facilities clean
personnel hands washed.clean installed
14 Clean outer clothes,effective hair restraints 1 36 Toilet rooms enclosed with self-closing door 1
15 Good hygienic practices,smoking restricted 2 37 1 Proper fixtures provided,good repair,clean HOUSEKEEPING
55 Establishment and premises free of litter,no 1
EQUIPMENT&UTENSILS: DESIGN, HANDWASHING FACILITIES insect/rodent harborage,no unnecessary articles_
38 CONSTRUCTION&INSTALLATION Scalable nand cleaner and son racy to.vels or 1 56 Complete separation from living/sleeping quarters 1
16 Food-contact surfaces designed,constructed, 2 apG roved hand drying devices provided and laundry
maintained,installed,located tissue waste receptacles provided
57 Clean/soiled linens stored properly 1
17 Nonfood-contact surfaces designed, 1 58 No live birds,turtles,or other animals 1
constructed,maintained,installed,located GARBAGEIRUBBISH STORAGE&DISPOSALI I(except guide dogs)
18 Single service articles,storage,dispensing 2 39 Approved containers,adequate number 1
19 No reuse of single service article covered,rodent proof,clean SMOKING PROHIBITED
20 Dishwashing facilities approved design,adequately 2 40 Storage area/rooms,enclosures- 59 1 Smoking prohibited,signs posted at each 3
constructed,maintained,installed,located properly constructed,clean entrance
41 Garbage disposed of in an approved manner,
at approved frequency QUALIFIED FOOD OPERATOR
DEMERIT SCORE 60 Qualified Food Operator 3
4 '� 3 f 2 1 RISK FACTOR VIOLATIONS IN RED 61 Designated alternate 2
62 Written documentation of training program 2
Signature of Peron in charge
TOTAL RATING Date Corrections Due
/ SIGNED(Inspector)
DESCRIBE DEFICIENCIES ON CONTINUATION SHEETS
DISTRIBUTION:V -White—Health Department 2nd—Yellow—Owner/Operator
Page of
INSPECTION REPORT STATE OF CONNECTICUT
FOOD SERVICE ESTABLISHMLNTS DEPARTMENT OF PUBLIC HEALTH
CONTINUATION SHEET
NAME OF ESTABLISHMENT TOWN DATE OF INSPECTION
L
INSPECTION
FORM H REMARKS
J1 i
Jbit-
INITIAL 0NSPECTO 1 10 71 \NITIAL(PERSON IN CHARGE)
,\,--1Distribution: 1st-White-Health Department 2nd-Yellow-Owner Manager