HomeMy WebLinkAboutTemp Food Inspection 1175 Ellington Road • VENDOR APPLICATION FOR TEMPORARY FOOD EVENT
The VENDOR of each temporary food event must complete this application and must be filed 14 days
prior to the opening event. This application must be submitted to the Town of South Windsor
Health Department, 1540 Sullivan Avenue, South Windsor,CT 06074.
This application is not a license.Temporary food permits will not exceed a period of 1 to 5 days.
Today's Date
Name of Event -*A W i
Date of Event C--�-JAIO - JV
Time of Events
Location of EventT--LLi--
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Event Coordinator Event Coordinator Coordinator Address. tea ,;se
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Event Coordinator Phone# -1 o
Event Coordinator E-Mail Address �—"--
Event Coordinator Phone#(cell,work&homer q 6 DA
Name of Applicant - .>��C.` �j ".zi dl�,
Name of Applicants Business(please indicate if mobile vendor)
Applicants Address
Applicants E-Mail Address �, �+-i �10�•��an
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Applicants Phone#(cell, work&home)
Set up time .
Please provide the following: (If any of the following does not apply to you put NIA)
ow t all food and beverage items to be prepared and served(menu). Attach a separate sheet if
necessary.
NOTE: Any changes to the menu must be submitted to the Health Department 10 days prior to the
event.
RECEIVED
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C � MAR 18 2010
SOUTH WINDSOR
ENGINEERING DEPT.
2
TEMPORARY FOOD SERVICE EVENT
COORDINATOR' S APPLICATION
This form must be filed 14 days prior to opening event.Application must be submitted to the
Town of South Windsor Health Department
at 1540 Sullivan Avenue,South Windsor,Connecticut 06074
Phone 860-644-2511 Extension 248 Fax 860-644-7280
This form is not a license.
Temporary food events will not exceed of 1 to 5 days
Name of Event �} �aso� ���43��A"2�AA�QEA
Date(s)of Event IS,-)&vt) - "�ZVO
Hours of Event "'26 a t^, - Q,.
Number of Food Vendors ,kjh
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Name of Event Coordinator , �: , �' ���► ti ><Mew �.�3ti� ���b
Address of Event Coordinator
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Cell Phone# Home Phone# JZ`b ' 3 Work Phone#
E-Mail �-
Name of On-Site Coordinator-• ; A Dom.
QFO (please check if On site coordinator is QFO and provide a copy of QFO certificate)
List of Vendors attending event
Each vendor must complete the Temporary Food Service Event Vendor Application.Application not received
fourteen days prior to the event will not be accepted and the vendors will not be allowed to open for business.
The Event coordinator must make arrangements 5 days in advance with the Town of South Windsor Health
Department to determine the time of pre-will comply with the Connecticut Public Health Code and the Town of
South Windsor Code of Ordin
Signature of Event Coordinate
Date 0 °
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2. Describe specifically how frozen,cold, and hot foods will be transported to the event.
3. List all places(name&address)where meats,poultry, seafood, shellfish, and ice will be purchased.
4. List names,phone numbers, addresses, and shifts to be worked of all employees. See.attachment#1.
--------------------
5. Use attachment#2 in this packet to sketch a drawing showing the event area and where your
operation will be. �--- S L4.) .V—,
6. Describe the number, location and set up of handwashing facilities to be used by employees.
7. Describe how and where utensil/equipment washing will take place. If no facilities are available,
describe how alternate steps will be taken.
2
8. Describe how wastewater will be collected, stored and disposed.
9. Describe the number and location of garbage containers.
10. Describe what heat source will be used to keep hot foods h 140 d ees and above).
11. Describe how colds foods will be kept cold(45 degrees and below).
12. Describe how food temperatures are monitored.
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13.Will foods be prepped on sit ? If no,where will foods be purchased? (enclose a copy of food
license)
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NAME OF EMPLOYEE PHONE# ADDRESS SHIFT
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