The URL can be used to link to this page

Home My WebLink About1530 Sullivan Ave (8) w d0�re "" SC,< '� TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT 1S40 Sullivan Ave., South Windsor, CT 06074— Mailing Address 1530 Sullivan Ave., South Windsor, CT 06074—Office Address :t Phone Number: (860) 337-6173, Fax Number: (860) 644-1930 �I°s°R-Co APPLICATION FOR ITINERANT FOOD SERVICE LICENSE Owner Name: f Mailing Address: t �� ' Telephone#: Fax#: Cell 4 9. I Email Address: PrUt_ M Operator Name: 1 Mailing A W�(A 4 Address: Z h P-- Telephone#: ( ) Fax#: ( ) Cell Phone#: ( ) Email Address: Qualified Food Operator Required: YES M NO ❑ Certificate#:�C ' Name: f;1�(�� h�( i� Date: May- Please submit latest copy of the Food Operator certificate to the office. Name of Business/Unit: �V I p1S Water Supply: Public[� Private Well El License Plate# f"I f} - Wastewater Disposal: Public El On-Site Site Location: U(? Electricity Available: YES❑ 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) }0-r fire— CCK:> avcf� �.�.1•Chu � iv�u:�-�Ar�`f� Y�l�Jh J��o nj �.h�\� �r�c'S`' �c.i�r 1.:._rc;t�� C h p SaAa --� vJA re r 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' ed after the Food Inspector has completed his/her inspection. Applicant Name (Print): bc t l l`I Applicant Signature: Date: lNaw I1 Office Use Only Inspector Name (Print): Inspector Signature: Date: Food Class: 1 ❑ 2 ❑ 3 ❑ 4 ❑ Application ❑ OFO Cert❑ Base of Ops ❑ Zoning ❑ Fire ❑ Expiration MAY 14 ZQ 18 SOUTH WNDSOR HEALTH DEFT 6� TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT !� «M 5�. 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 °N C ITINERANT VENDOR QUESTIONNAIRE Name of Establishment: L' V ' t S �Iol L L C 1. What foods will be prepared on and served out of the unit? -TNN I - T uSi cu-d V-e It h 2. What is the source of the food to be dispensed? Provide the name and address of the food distribution facility. �- Cl- �� ►. - �<< - C4� c��, Mk nl 3. How will foods be kept hot or cold on the unit? What type of thermometer will be used? How will they be sanitized? �r�ral (X� _ 4-hec nny 0 4. How and where will utensils, pans, etc. be cleaned at the end of the day? Be specific. 5. Describe the method of hand,.vashing used at the unit. 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). 7. How are water tanks filled? Where is wastewater disposed? IE%ci 1�uT t- UIS %G1 C F �t urn 8. Where will excess food and Paper products be stored? t^ ; 9. How will garbage be disposed on the unit and at the Base of Operations? -_ c_t 6 t\tom PLEASE CONTACT THE TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT AT LEAST 48 HOURS IN ADVANCE TQ NAVE 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 r I,? attest that �e r i'O_ Alv-t f (d (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 Date I (Signed by-Omer perator of the Establishment) Signature and Title Date I (Signed b Qualified Food Operator) Name of Establishment las �� Jc� Address of Establishment ** 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)(B) and 19-13- B49(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 19-13-642(s)(6), 19- 13-649(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; icentity 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. ................................................................................. t I AL l 10 attest that J urn u-"T sX' r r I (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. l , Signature and Title: Date: (Signed by Own /O rator of the Establishment) I Signature and Title:�/' � Date: ( igned by Altema Person in Charge) Name of Establishment: Address of Establishment: Mobile Food Vendor Application Sect. 4.1.1 Address of Proposed Food Cart/Truck ef (D 0 0 �P1JPj+ 117 Size (Max. 8'x 22� , Zone 1. Name of Applicant 1)dl r(E- t Cl�-Oher'T ( i k Address L41 Pi-11A�t -kC-y Phone Number U_) �, . ,C---4 2. Starting Date 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 information is true to the best of my knowledge and that I agree to aide7b -lhe-above requirements. Applicant Signature Property Owner's Name Property Owner's Signature ................................................................................. Reviewed and approved by: Date Zoning Enforcement Officer 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 ''. DECLARATION OF BASE OF OPERATION This form must be submitted with your application for permit. �1 Mobile Vendor Business Name: k67 p C LL(L Mobile Vendor Owner/Operator Name: �� fT( _ }- h -0 T �- I Business Name of Base Of Op.: _ y I - �Q r `P 72 Address of Base Of Op.: � �I ft t I I C� �� cQ j��-C" (r( �' Owner of Business for Base Of Op.: Telephone Number of Base Of Op.: l� (UCi �� Cwb? j THE FOLLOWING PORTION TO BE FILLED OUT BY THE OWNER OF THE FOOD n. ESTABLISHMENT USED AS THE BASE OF OPERATION. I- - attest that my licensed food establishment jwneftf Food used as base known as is available as the Name of Food Establishment base of operations for 1�' 14S 1 S owned by ` of Mobile Vendor Business lbe( -x-i_. Owner of Mobile Vendor Business c Signatu of Owner of Food Establishment **Please include a copy of the Base of Operation food permit issued by the local health department.** y � J Ubt i3Core: _9() Candidate Status: Pass A.. Test Date: March 29, 2014 nseo UnkW&*aIwd_.. swe 550 yY• _ PhD-(407)3523M -_Ctitifcafe No.209621 Fim(4M 9i52,3603 Issw Data March 29.20 typWyNRFSPtw Egtuation Date March 29,20 Congratulations!Attached is your certificate w d wallet card.please n tif the National Registry of name or address changes at*e address bel° ROBERT N ABELIN 47 BELLEVUE AVE LONG MEADOW_MA 01106 Preventing Contamination and Cross Contamination(Mastered? Ensuft Per Fp99�and�Pbyee 1 eOM(Competent) Active in Controller a Food Establishment(Competent) Notification of Test Result y�%ft 1`labonal Registry of Food Safety profismona a CERTIFIED FOOD SAFETY MANAGE Scaled Test Score: 84 Candidate Status: Pass vim_ _sJF Test Date:March 29, 2014 � 76W t, Suite550 odmdo,FL=Bi9 Phckne(4071352S83O Fax(4071 A52-01603 'SSW Va(c Mxrth 20.2614 —.NRF,riPOwn EVintim Data March 29.21119 Congratulations!Attached is your certificate and wallet card_Please the!National notify Regis[r},of name or address changes at the address below- VALEME J ABELIN 47 BELLEVUE AVE LONG MEADOW.MA 01106 Preventing Contarnkrftn and Cross (Ensuring P �bna!H Contamination(Competent) Ygiene and Employee Health(Competent)Actively Mana�urg Cone in a Food Establishment(Competent Monitoring the Flow of Foods ) Ensuring Product Time and Temperature ( ConductingC Perattrre{Competent) leaning and Sanitizing(Competent) Managing-Physical Facility Design&Mairitenance:Preventing&Controlling Pest(Mastered) National Registry ofFaodSafely Prof eccswnals® 1 7681Un1versal131vdSte550 1 Orlando.lT-32819 1Pho=407323&30 I Face 407352.3603 4 r a vva... rraa a.r a s a��a a..yvvavaiAa..y.G� a CERTIFIES ' cn 0 o ROBERT N ABEUN HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE CERTIFIED p � R FOOD SAFETY MANAGER UNDER THE CONFERENCE FOR FOOD PROTECTION STANDARDS Training by A-FS1 1-800-723-3873 267-975-6442 PRESIDENT: I LAWRENCE J.LyNcK CAE ISSUE DATE: MARCH 29, 2014 YO6S6 EXPIRATION DATE: MARCH 29, 2019 CERTIFICATE NO: 209621$2 380 Universal Blvd..Soft 55%Oriando.FL32919 TEST FORM: P7 19 300I44"M F(407)i%--4 03 ,.vnnv.NRFSPcorn Tsa evtirKate is not valid Tor eon- botlal Registry of Food Safety ProfessionaLSO Lhao fire yca s frim date or issva National Rory of Food SafM ProfewionaLX Notification of Test Result CERTIFIED FOOD SAFETY MANAGER � F K G Z -ROBERT V.AB_ELM Scaled Test Score: 90 Candidate Status:Pass Test Date:March 29,2014 76M unwarag wage 550 - - - 0dando,FL32819 i Tag F.(800)44&0257 - - =. cerdKeneNa 20962182 fpPhone(407)3523830 lsmD Date March 29,2014 4 Fax(407)352-3603 Expiration Data March 29,2019 fFcmnv.NRFSP.can CongratuMons!A ttached is your certificate and wallet card Please notify ROBERT N ABELIN the National Registry of nalne or address changes at the address below_ 47 BELLEVUE AVE LONG MEADOW,MA 01106 Preventing Contamination and Cross Contamination Ensuring Personal Hygiene and Employee Health(Competent) Actively Managing Controls in a Food Establishment(Competent) Monitoring the Flow of Foods(MastereO Ensuring product Tom and Temperature(Compete" CondudbV Cleaning and Sanitizing(btaste-d) Managing:Physical FaaTdy Design&Mairdenanee:Preventing&Controlling Pests(Afste►ed) National Re^i5-,rn-ofFood Safety Pmf—do-Isf9 1 76M Universal Blvd Ste 50 I Orlando~FL 32819 I Phak:4073523830 I F=4073§2.3f03 r r r ►� #r ` G �`I i CERTIFICATE OF { N ALLERGEN AwARENESS TRAINING ^ ` N -I�i 1 Name of Recipient: VALERIE ABELIN Certificate Number: 2263470 Date of Completion: 3/23/2016 Date of Expiration: 3/23/2021 a ;o p , Issued By: ?he above-named person is hereby issued this certificate for completing an allergen awareness training program �3 � ., NATIONAL. . l RESTAURANT recognizes'by they Massacbmetts Department of Public Health ASSOCIATION in accordance with 105 CMR 590.009(C)(3)(it). Massachusetts Restaurant Association 800.765.2122 333 Turnpike Road,Suite 102 uwwv.restaurant.org Southborough,NIA 01772 71ris certificate will be valid for five(5J years firom date of completion. 508-303-9905 r www wrestaurantassoc.org / pr J