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INSPECTION REPORT STATE OF CONNECTICUT
FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH
CONTINUATION SHEET
NAME OF ESTABLISHMEN`\\T \ TOWN n DATE OF INSPECTION
,!S.W- ar-
INSPECTION REMARKS
FORM#
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INITIAL(INSPECTOR) INITIAL(PERSON IN CHARGE)
Distribution: 1 st-White-Health Department 2nd-Yellow-Owner/Manager
' NDOR APPLICATION FOR TMI&ORARY FOOD EVENT
The VENDOR of each 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,Cr 06074.
This ay
alieation is not a liter.Temporary food permits will not exceed a period of 1 to 5 days.
Toda 's Date '' `�"9/7-�'�,'
Name of Event �u '�V11�^ 1a1�. �. �'S ��•�o�a'aC� t Q`�
Date of Event
Time of Events
Location of Event ls�---.
Event Coordinator
Event Coordinator Address U% ' �`�
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Event Coordinator Phone#
Event Coordinator E-Mail Address
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Event coor+drnator lame (Dell, �'"""—
Name of Applicant W •vS,S �-� , ��-"
Name of Applicants Business(please indicate if mobile vendor)
Applicants Address %0\ `��1'}0�•��. So.l lT�N4seR C'�• -
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Applicants E=Mad Address �. � �,
1hr�a Q'arW
Applicants Phone#(cell,work&home)
Set up time M• .
Please provide the following:(If any of the following does not apply to you put N/A)
�ll food and beverage items to be prepared and served(menu).Attach a separate sheet if
necessary.
NOTE: Any clnnges to the menu must be submitted to the Health Department 10 days prior to the
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TEMPORARY FOOD NICE EVENT
COORDINAT 'S APPLICATION
This form m be filed 14 days ba .Application mostbe submitted to the
Town of Wit
at 1540 3ulivsn Avenues '� ,Connecticut 06074
Phone 960-644-2511 248-Fax 860-644-7280
Temponuy food evens wM notemceed of t1 to 5 days
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Date(s)of Event S. A-*AA
Hours of Event 4% +^ �Z.. +�aa.�
Number of Food Vendors ,tg*
Name of Even Cooldfid6r" +
Address of Event Coordinator
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Cell Phone# r' Home Phone# J�`b� Work Phone#
E-Mail /
Name of On—Site Coordinator 1�ww' -
QFO (per dhedk if ew site comic or is QP0 a4od"a copy of QFO certificate)
List of Vendors attending event
Each vendor most comphft the Temporay Jkj6 i ti' t Venom Application.Application not received
fourteen days prior to the event will not be accepW and thavendors will not be allowed to open for business.
The Event coordinator must nine anang ateg 5'-dW4&ad6Awwith 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 Ozdiimpjw& - -
Signatwe ofEventC ► ._ .
Date2_ ae}tl
=V [eWl Tempoc uaty pow Coondmnw Application 2007 be
2.Describe Specifically how fiOMD,told,and but foods will be transported to the event.
3.List all places(name&address)where meats,poultry,seafood,shellfish,and ice will be purchased.
4.Iast names,phone numbers,addr ,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. 5.� . jj3�� ��.i �
b6.Descxte the number,location and set up of hand8 facilities to be used by employees.
7.Describe how and where utensiltequipment wasbing will take place.If no facilities are available,
dessarbe how alternate steps will be taken.
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8.Describe how wastewater will be collecied,stored and disposed-
9.Describe the number and location of goba ge containers.
10.Desc n what heat will be used to keep hot foods naR,�`"degrees and above).
11.Describe how colds foods Will be kept cad(45`des and below).
`�a,�E"F• ate. �ate. "'�'E
12.Describe how food temper are monitared.
13.Will foods be p t1 an s f Nuo, be peed?(enclose a copy of food
license) `'--�
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NAME OF EMPLOYEE PHONE# ADDRESS SHIFT
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2.
3.
4.
5.
6.
7.
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