HomeMy WebLinkAboutTemp Food Inspection 1739 Ellington Road � Cc>kN
-3/08/2010 TUE 11:13 FAX 210 349 2464 ERCC OFFICE c�(�(,6C �]003/008
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TEMPORARY FOOD SERVICE EVENT
COORDINATOR' S APPLICATION
ThisfbimmustbefilqdN awminrnin eve must be submitted to the
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• - X eiiSiOn 248
This forin is not a license.
Temporary food eve.Uts will not exceed of t to 5 days
Name of Event
Date(s)of Event f p1v
Hours-of Event —
NWUNar of Food Vendors
Name of Event Coordinator
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Address of Event Coordinator � (as+ ew D,-A i at Gl@ r
E Mail ell one# Home Phone# Work Phone# t �(�S 5 o.
t�i V1 P,VOL " Vvt 0`c
Name of 011.—Site Coordinator 01
QF 0_ (please check if on site coordinator is QFO and provide a copy oEQFO certificate)
List of Vendors attending event
Each vendor must complete the Temporary Food Service Event irendor 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 arrang is 5 days in advance with the Town of South Windsor Health
Department to determine the time of pre' 1 comply 'th the Connecticut Public Health Code and the Hartford
Municipal Code
Date tv
9/08/2010 TUE 11:14 FAX 210 349 2464 ERCC OFFICE U 004/008
VENDOR.APPLICATION NOR, TEMPORARY•FOOD EVENT '
The VENDOR of each temporary food event must complete this application be filed 4 a s
nor to the o enin event.This application the
C
This application is not a license.Temporary food events will not sz� M a period of i to 5 days.
Today's Date 10
Name of Even Fn:,n' �1� �v c �-��p &Wk Shva# 6q .
Date of Event 6 b y
Time of Event t`a yv► p r
Location of Event 39 E(11 va on 0CLd• ��i ,r\dSor Ca. 060��
Event Coordinator_-
Event Coordinator Address i S. TZ,77 v,�;_
..Event Coordinator Phone# (3 y> 4U!5-6 2 Q
Event Coordinator E-Mail Address Y lk i\e��n eZ Yy\oS�
Event Coordinator Phone#(cell;work&.home)("l t y� �,S- SO
4•y
Name of Applicant D aA a N Paf 1
Name of Applicants Business(please indicate if mobile vendor)
Applicants Address U 17-0 Cost Wtw pci (�s ae, " San-la A f12 , C �12_70S-
Applicants E-Mail Address f k V,% a ri zh z`(�yvu,( e`E'{cc4t o-n Ga
Applicants Phone#(Ml,-work.&home). I t y )y l 5 -T!
Set-up time. I a Gtyn
06/08/2010 TUE 11:14 FAX 210 349 2464 ERCC OFFICE IM005/008
Please provide the following:(If any of the following does not apply to you put NIA)
1. List 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.
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2.Deset;ibe specifically how frozen,cold,and hot foods will be transported to.the event.-
I List all'places(name&address)where meats,poultry,seafood,shellfish,.and ice will be purchased.
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4.List names,phone numbers,addresses,and.shifts to be worked of all employees. See attachment#1.
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5.Use Attachtzzent#2 in this packet to sketch a drawing showing the event area and where your
operation will be.
See 0.-E+aGhn dQCkAYVA
06/08/2010 TUE 11:14 FAX 210 349 2464 ERCC OFFICE IM 006/008
6.Describe the number,location and set up of handwashing facilities to be used by employees.
Vol�atole h(cr,r� was�nvnq s+cc�Ior, tvca�{erJ, on-site
7.Describe how and where utensil/equipment washing will take place.If no facilities are available,
describe how alternate steps will be taken.
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S.Describe how wastewater will be collected,stored and disposed.
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collected � o reds �n C1Qn-kkVr\er wt 3 crM��-gym s��k
9.Describe the number and location of garbage containers.
10.Describe what heat source will be used to keep hot foods hot(140 degrees and above).
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11.Describe how cold foods will be kept cold(45 degrees and below).
12.Describe how food temperatures are monitored,cleaned and sanitized.
lecLOP'Tt C JOLA
13.WiH foods be prepared on site?If no,where will foods be purchased? (enclose copy of food license)
06/08/2010 TUE 11:14 FAX 210 349 2464 ERCC OFFICE U 007/008
ATTACHMENT #1
NAIyIE QF EMPLOYEE P QNE# ADDRESS SIFT
.1. Walter spencer (ISO) -12a- -
oo5y Seca Ana, CA 9z1�.s
2. La 'Ao Ode.
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10.
06/08/2010 TUE 11:15 FAX 210 349 2464 ERCC OFFICE Q 008/008
ATTACT3NMNT #2
CHECKLIST FOR FOOD BOOTHIVENDOR OPERATORS
Metal probe thermometer(0—2.20 degrees F range).
y Thermometers for all refrigerators
Coolers and ice packs(if ice is to be used for cooling of foods,where is water to be drained) -
Plastic wrap/Altuninum foil .
Extra utensils:tongs,spatulas,spoons,and lrnives
Water source
✓. Buckets/tubs for washing,rinsing,sanitizing;food equipment
Bleach for sanitizing,test strips for checking
Waste water disposal container
Container(s)for grease collection
Clean wiping cloths and a container to store there in
Garbage containers and plastic bags
Hats/hair restraints
Crates,shelves to store food.off of the ground,
Gloves for food handling
V/ Hand washing station
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Fage Sampling—More Information
• We have a refrigerated van that will be keeping the yogurt stored at a temperature of 41
degrees Fahrenheit.
• We will be setting up a 10x10 plastic washable vinyl tent outside the front entrances of these
stores.
• There will be 3 food tables that line the interior of the tent.
• Nothing will be covering the tables but the team has sanitized wipes to keep the surfaces clean.
• The tent itself will be covered on top and will have 3 covered sides.
• We will be storing the yogurt inside the refrigerated van and we will be scooping from 1 quart
containers of Fage Yogurt that will be provided to us by Fage Headquarters.
• Passersby will receive 2 ounce samples of yogurt(0%, 2%or 10%) and 1 ounce samples of the
topping(fruit: strawberry, peach, and cherry; or honey) into individual 3 ounce souffle cups,
with individually wrapped utensils.
• Toppings will be pumped out of industrial condiment pumps.
• We have 3 ice cream scoops(one for each percentage yogurt)that will be used to distribute the
product.These utensils will be held in designated containers.
• We also will be handing out dollar off coupons and collateral material.
• We have a hand wash station on site and also have a 3 separate compartment sink with hot
water.
• Trash disposal will be determined on site.
• Restrooms will be provided in-store.
• Water will be disposed off-site.
• We have 3 coolers that we use for storing the product
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STATE OF NEW YORK
DEPARTMENT OF AGRICULTURE AND MARKETS
10B AIRLINE DRIVE
ALBANY, NEW YORK 12235
DIVISION OF MILK CONTROL
AND DAIRY SERVICES
Far,(518)485-8730
LICENSE NOTICE
The lower portion of this notice is your Milk Dealer License.
A new license will be necessary if there is a change in your business entity; for example,
individual (sole proprietorship) to corporation, corporation to limited liability company, individual
to partnership, etc.
If you decide to purchase or merge with an existing milk dealer or engage in a different activity
for which you are not authorized, you need to notify the Department and obtain approval prior to
completing the acquisition or engaging in the new activity.
If you change/add locations or plan to sell/discontinue your business, please contact us so we
can update our records
Your license must be renewed each year. A renewal application will be mailed to you, If you
have any questions concerning your milk dealer's license, please call this office at(518) 457-4142.
Date Issued: 0 3/01/2 010 Nw York State Control No.: 003750
Expires: 0 2/2 8/2 011 Department of Agriculture;u►d Aiarkets Estab No, 0129
Pea$ 100 iVbmiy;N-Y,I2235-A.= License No.: 00571
Receipt No. 0412
,MILK DEA
t &ICEN$�
t Prusuantto.Aiiiele 21 of the A 'iculture and�Iaciie't,� ait! tlis:li iisze'ss autlionzed tR perform those activities requested in its
application for this Iicemse.
<MANUFACTtR`9
This license cannot be sold or tralisferred. a t#;tj;t:^i M1`f •.•.+4:••._ , < r.,s•
i:t' •;`•Z.1. r.t4`; !;,}lfitly•'1?t'i �!
�' ;, •tip .c�,' ;:`^; k' ?,� ,'�
FAGS USA DAIRY INDUSTRY .TNC:``Y'+'` =:•:' t:,-
1 OPPORTUNITY DRIVE ' '
JOHNSTOWN NY 12 09 5- Patrick I IOoler
,� Commissioner