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Home My WebLink About1370 John Fitch Blvd. (2) 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 �14.501R• APPLICATION FOR ITINERANT FOOD SERVICE LICENSE Owner Name: np Mailing �rA�►n, 4, cSpu,-z� Address: 1 Telephone#: Fax#: Cell Phone#: /3 Email Address: Operator Name: Mailing ('y Address: Telephone#: ( ) Fax#: ( ) Cell Phone#: ( ) Email Address: Qualified Food Operator Required: I YES W NO ❑ Certificate#: Name: ��c �, _ Date:- Please submit latest copy of the Food Operator certificate to the office, 1 Name of Business/Unit: A4 7 Water Supply: Public P ' ate Well ❑ License Plate# I astewater Disposal: Public On-Site ❑ Site Location: a�T li�' , �f a� Electricity Available: YES NO +- f Other, Please Explain: Propane Use: YESV NO ❑ *Please contact Fire Ma al 8 282- 69* Menu: (Note"P/ease list items in as much detail as possible, or a copy of a menu attached is applica e) �G''Ll(, 0-' /4'/&1 JL• RECEIVED�� ,1, oL 1- r7- DEC 15 2017 SOUTH WINDSOR Agreement and Signature HEALTH DEPT. 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: Date: _ o' Office Use Only Inspector Name (Print): A �s Inspector Signature: Date: i2,lj6\1'1 Food Class: 1 ❑ 2 ❑ 3 ❑ 4 ❑ FEE: $100 Application Eve' QFO Cert a Base of Ops ❑ Zoning ❑ Fire ❑ Expiration Date: kl( On ,? c,,; � I (Go -43-v3 TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT n°u;10N Be41 1540 Sullivan Ave., South Windsor, CT 06074 - Mailing Address A 1530 Sullivan Ave., South Windsor, CT 06074 - Office Address Phone Number: (860) 337-6173, Fax Number: (860) 644-1930 ".,�a•� ITINERANT VENDOR QUESTIONNAIRE � /,, Name of Establishment: lei i i 1. What foods will be prepared on and served out-of t e unit? J zxf < :ell ej' i, : 4 Y44t- 2. What is the source of the food to be dispensed? Provide the name and address of the food _ distributi L'A', facility. ? ';a i 7 r fit` 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 4. How and where Zvi u ensilss ans, tc. be cleaned at the end of the day? Be specific. 5. Describe the method of handwash'ng used at the unit. 6. Describe how food will be protected. (Note: in large units where food is prepared inside, screening is'required to pr vent the entrance insects). 7. How are water tanks filled? Whe-r� is wastewater disposed? 8. Where will excess fogd and paper products be stored? 9. How will garbage be dispo //en�d 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. of dye TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT .es 1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address �+ 1530 Sullivan Ave., South Windsor, CT 06074—Office Address i" Phone Number: (860) 337-6173, Fax Number: (860) 644-1930 OR C DECLARATION OF BASE OF OPERATION This form must be submitted with your application for permit Mobile Vendor Business Name: Mobile Vendor Owner/Operator Name: Business Name of Base Of Op.: � �W Address of Base Of Op.: Owner of Business for Base Of Op.: /1 'C Telephone Number of Base Of Op.: 1 = �' - THE FOLLOWING PORTION TO BE FILLED OUT BY THE OWNER OF THE FOOD ESTABLISHMENT USED AS THE BASE OF OPERATION. 2 E= attest that my licensed food establishment Owner of Food Establishment used as ba e known as mcowe [8z5� is available as the Name of Food Establishment l�J base of operations for y eiiz, s � � owned by Name of Mobile Vendor Business 1 i; Owner of Mobile Vendor Business ature of Owner of Food Establish nt "Please include a copy of the Base of Operation food permit issued by the local health department." ServSafe National Restaurant ciation e ry afe CERTIFICATION LINDA SOUZA for successfully completing the standards set forth for the ServSafe®Food Protection Manager Certification Examinalion, which is accredited by the American National Standards Institute(ANSIKonference for Food Protection(CFP). 3069780 5102 ERTIFICATE NUMBER EXAM FORM NUMBER 12/8/2015 12/8/2020 DATE OF !- XAMINATION DATE OF EXPIRATION Local laws apply. "heck with your local regu6tory ovene;for recertification requirements. i Sk:rrnan Brown WP. Nalsonal Restaurant Associalion Solution: #0655 0 a In«ordonce with Marifitne Lal>—, uwa+eon 2006,Qmrh n ADM N 066-2013 IRegJonon 32.SFondvd A3.1; 0� t• - m2015 nlo`oaol Fduastior i Fowdanon f NtAFFI AA.vIk reu—"SwAu6d?and ire 5-- f. tuali the arc design art kadmwola d*w Nalcwel M.oamor, omens aennw be ropea�reed e•abured 1 CanW us with questions at 175 W Jackson Blvd Ste 1500,Chicogo,IL 6060A o SemSaWmskiumnt org Mobile Food Vendor Application sect. 4.1.1 Address of Proposed Food Cart ruck � J�A l�- -i� #� �tj SOL"rG �r- Size max. 8'x 22� Y, Zone Cc;, 1. Name of Applic nt v Cr p&o Address ivL Phone Number D7NAI 2. Starting dateEnding date u G I A plot plan must be submitted with the application showi 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. S. 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 or 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 temporary signage for the food cart/truck are to be removed at the end of each workday or by 9:00 pm (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 bide by the above requirements. Applicant Signature Property Owner's Name Property Owner's Signature Reviewed and approved by: Date 4-44/ 7 Zoning Enforcement Officer AReviewed and approved by:4 .I Date Town Sanitari rev. 12/16/16 �_7 Breakfast Menu Call (413) 544-1524 to order Egg & Cheese $3.25 Add bacon, ham or sausage $4.25 Steak Egg & Cheese $5.50 Kielbasa Egg & Cheese $5.50 Pancake Breakfast Sandwich $5.00 Wake Up Burger $5.50 Ultimate breakfast sandwich $5.75 2 eggs/bacon/sausage/ham with cheese on a Kaiser Roll Breakfast Chppotle Wrap $4.25 With chipotle mayo, egg, sausage and cheddar Linda's special for yolk lovers, yolk will not be broken until it's put on your ch9ice of bread. This will be drippy & messy but great! Lunch Menu Regular Hot Dog $2.00 Add Cheese for $2.50 Hot Dog with Cheese & Bacon $3.00 Hot Dog with Sauerkraut $3.00 Chili Cheese Dog with onions $3.50 Linda's Pit Dog $3.50 (Chipotle mayo, cheese, grilled onions & peppers & jalapenos.) Kielbasa Dog with cheese, grilled onions & peppers $4.00 Add Sauerkraut or Chili $4.50 Hamburg/ Cheeseburger $4.75 Double Cheeseburger $6.00 Add Bacon to any sandwich acid $.50 (Mayo, ketchup, pickles, onions, lettuce and tomato.) Grilled Chicken Wrap or Buffalo.Chicken $3.75 (Ranch dressing, shredded cheddar cheese, tomato and lettuce) Grilled Chicken or Buffalo Sandwich $4.75 (Ranch dressing, provolone cheese, tomato and lettuce) Lunch Menu Veggie Burger on Kaiser Roll $4.75 (Provolone cheese, mayo, ketchup.) Cup of Chili with cheese $3.75 BLT on Texas Toast $4.50 Grilled Cheese on Texas Toast $3.50 Grilled Bacon & Cheese $4.50 Grilled Ham & Cheese on Texas Toast $4.50 Steak & Cheese with grilled onions & peppers (on a grilled Kaiser roll) $7.50 Baked Potatoes Sour Cream and Chive Potato $3.00 Cheese Potato $3.50 Bacon & Cheese Potato $4.00 Chili & Cheese Potato $4.00 Fully Loaded $5.00 Drinks & Chips Reg & Decafe Coffee, Tea, Hot Chocolate $1.00 Coke, Diet Coke, Sprite and OJ $1.25 Bottle Water or Gatorade $1.25 Lemonade & Iced Tea $1.25 Chips $1.00 Homemade Cookies 2 for $1 .25