HomeMy WebLinkAbout1530 Sullivan Ave (7) TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
Sg'- 1540 Sullivan Ave., South Windsor, CT 06074- Mailing Address
= 1530 Sullivan Ave., South Windsor, Cr 06074-Office Address
Phone Number: (860) 337-6173, Fax Number: (860) 644-1930
APPLICATION FOR ITINERANT FOOD SERVICE LICENSE
Owner Name: Mailing
w/'Iffn ! Address: Po 1Z1C /I rtr
Telephone#: 3 ) 12 3 0 300 'ANC-17TWX C1 nG 77'J
Fax#:
Cell Phone#: Uri 7 � - �
Email Address: Lu�y�p�%,-lli�P;)Nc4'ctSaN uit Ljrq
Operator Name: Mailing
Address:
Telephone#: ( O 3 ) 7 Z 3 -O 30 O e n d
Fax#: ( )
Cell Phone#: S&S 113 9
Email Address: I I I i,yS t'G7yjL-,A IYcAV'j S
Qualified Food Operator Required: I YES M NO ❑ Certificate#: i(�(
Name: !�AKOt 104- PD;OC+rN— Date: 5"
Please submit latest copy of the Food Operator certificate to the office.
Name of
Business/Unit: ZU G 15 �b i! i D ���NK S water Supply: Public Private well El
License Plate# Wastewater Disposal: Public On-Site
Site Location: Electricity Available: YES Fk] NO ❑
If Other,Please Explain:
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)
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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): i L OZNI l 1
Applicant Signature: Date:
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Gass: 1 ❑ 2 ❑ 3❑ 4 ❑ FEE: $100 lU L(3
Application ❑ QFO Cert❑ Base of Ops ❑ Zoning ❑ Fire ❑ Expiration DateREC:EIVED
MAY 01 2018
SOUTH WINDSOR
HEALTH DEPT.
d TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
�1°�'o•K 8� -� 1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
A 1530 Sullivan Ave., South Windsor, Cr 06074—Office Address
Phone Number: (860) 337-6173, Fax Number: (860) 644-1930
ITINERANT VENDOR QUESTIONNAIRE
Name of Establishment: i , j y S rD/Ar o
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
d,'nbution facility.
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 where will utensils, pans, etc. be cleaned at the end of the day? Be specific.
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5. Describe the method of handwashing used at the unit.
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6. Describe how food will be protected. (Note: in large units where food is prepared inside,
screening is required to revent the entrance of insects).
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7. How are water tanks filled? Where is wastewater dis
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8. Where will excess food and paper products be stored?
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9. How will garbage be disposed 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.
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 TIME/TEMPERATURE 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 LU(.Yr(P W 02 M C.-k! attest that L i ffq Pin(4-1 IV c y
(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 i Date 0�10 f /
( igned by Owner/Operator of the Establishment)
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Signature and Title ,1.,;rL .0, 1 n�� Date 7 O
(Signed by Qualified Food Operator)
Name of Establishment
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Address of Establishment
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** 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)(13) and 19-13-
1349(t)(7)(13),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 foodbome 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.
.................................................................................
I l UC`1 KD IA;�Z(V"U-/- attest that 4 n?Z�� w O 2 m C(c /
(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.
Signature and Title. 0 WWA Date:
be—
(§gndd by Owner/Operator of the Establishment)
Signature and Ti Date• �� /r
igned by Alternate Person in Charge)
Name of Establishment:
Address of Establishment:
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"` TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address
= w 1530 Sullivan Ave., South Windsor, CT 06074—Office Address
Phone Number: (860)337-6173, Fax Number: (860) 644-1930
y�
tU O R DECLARATION OF BASE OF OPERATION
This form must be submitted with your application for permit.
Mobile Vendor Business Name: 11 C'I S PD iPT' #041c"c-j
Mobile Vendor Owner/Operator Name: LUC-10 !, ,9-2 lCrf i
Business Name of Base Of Op.:
Address of Base Of Op.: � C ?R K Art N4 U G-9Ki GIG CT CC Pb
Owner of Business for Base Of Op.:
Telephone Number of Base Of Op.: 9,Q 7 2 3-0 3 Q-2
THE FOLLOWING PORTION TO BE FILLED OUT BY THE OWNER OF THE FOOD
ESTABLISHMENT USED AS THE BASE OF OPERATION.
I, I I IF 4 rfr-,� N nZ (YIC,K i attest that my licensed food establishment
v Owner of'Food Establishment used as base
known as 1.0C-15 is available as the
Name of Food Establishment
base of operations for k i C I s >o in OG44�S owned by
Name of Mobile Vendor Business
1 r G (s O Z►(; GK 1
Owner of Mobile Vendor Business
'1
dig ature of ner of Establi d9nt
"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
Size (Max. 8'x 22� i Zone
1. Name of Applicant l C`1 lY Q L/J 0 Z rYj GK i
Address 3r!}Q tC f
Phone Number ?,U 3 13 6 3 aQ
2. Starting Date )jC)l / I
Ending Date ! D L2 /
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 9:00pm (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.
Applicant SignatureL•
Property Owner's Name
Property Owner's Signature
Reviewed and approved by: Date
Zoning Enforcement Officer
iA
ServSafe A
ry af
CERTIFICATION
KAROLINA POTOCHNEY
for successfully completing Ike standards set forth for the ServSafem Food Protection Manager Certification Examination,
which is accredited by the American National Standards Institute IANSIKonference for Food Protection OR
12384489 10430
CERTIFICATE NUMBER EXAM FORM NUMBER
5/27/2015 5/27/2020
DATE OF EXAMINATION DATE OF EXPIRATION
Local laws apply.Check with your local regulatory agency for mcerliflcation requirements.
Sherman Brown
SVP, National Restaurant Association Solulions
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Food Service License
Naugatuck Valley Health District
LUCY'S POTATO PANCAKES - ITINERANT
ITINERANT
NAUGATUCK
OPERATOR
LUCYNA WOZNICKI
EXPIRES: DECEMBER 31, 2018
THIS LICENSE EXPIRES ON THE EXPIRATION DATE ABOVE AND MAY BE REVOKED BY THE DIRECTOR
OF HEALTH FOR FAILURE TO COMPLY WITH APPLICABLE DISTRICT AND STATE REGULATIONS.
THIS LICENSE IS NOT TRANSFERABLE BETWEEN PERSONS OR PLACES, FEE IS NOT REFUNDABLE .
VALID ONLY WHEN SIGNED BY
License Glass: J-3 THE DIRECTOR OF HEALTH
OR AGENT
J6FFREY DUSSETSCHELEGER, DDS, MPH
DISPLAY IN A PROMINENT PLACE Director of Health