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HomeMy WebLinkAboutTemp Food Correspondence 771 Main Street TOWN OF SOUTH WINDSOR TEMPORARY FOOD EVENT INSPECTION SHEET Event Name: �.tie�n`1�is'tv�c c��,,�\ Cym-3 �,�IG,I�c.�Event Date: ^a^� 0- 0X+ (, Location of Event: S. Applicant/Coord.: ,� -�`�90.l�r� - � �.. Ph.# Email Address: Fax# QFO Name: N)Ar\_,A Ph.# Email Address: Fax# METHOD: On-Site inspection Kitchen inspection Interview (Circle one) Food/Water urce �C ` U kt - S Approved source of food,wholesome, free from spoilage V-)"\t'� j Water source potable, from approved supply, food grade hoses utilized Temperature n rol Hot/cold holding equipment and temperatures adequate Dw Food cooked/reheated to correct temperature C;rer_lovrr�cg -� Metal probe food thermometer(0-220F range) available/sanitized between use Accurate thermometers for all refrigerators PPT Coolers(self draining)and ice packs/bags Hygiene/Han asking Hats or effective hair restraints for food workers �J\,j gih Hand washing station-warm water in jug w/spigot, liquid soap,paper towels Gloves for food handling, designated person to handle money Scoops to have handles!�� Records Designated person in charge of food booth for each shift-logs kept General Food P tection No extensive food preparation/handling Food protected by wrapping, sneeze guards or other effective barriers ondiments single service,pump dispensers or squeeze bottles/shakers F hot held and not sold discarded daily or at end of event ood and single service food containers stored off floor - -- Drinks-stored in ice mustbe stored in self-draining storage containers - Raw fruits and vegetables used in food prep to be washed in potable water J Toilet Facilities aste Disposal Toilet facilities adequate, clean and conveniently located Waste water disposal container—disposed of properly N I Pr Container for grease n—disposed of properly on-absorben garbage contaiA�agg tight covers, Dumpsters must be covered Garbage contain Cleaning/Sani ' ' g *,.ksx.. �„�o.�-o�ar✓�-b �^^ bS y, Buckets/tubs for washing,rinsing, sanitizing food equipment(hot water) Bleach/Quat. for sanitizing, appropriate concentration,test strips available Utensils are to be sanitized every 4 hours or as needed Moist wiping cloths to be stored in container with clean sanitizing solution Storage/FB Con uction 11 utensils/equipment to be properly stored to protect from contamination emicals to be stored separate from food products,bottles to be labeled Food booths constructed properly to protect food, adequate lighting provided COMMENTS: r1ep ck pAcW� HEALTH INSPECTOR: 11 Signature: Date: EVENT COORDINATOR: . V- S—`// ure: ' a ab Date. "A temporary food service establishment serving food or drink shall comp i ll provisions of Public (; - - - - - Health Code 19-13-B42 which are applicable to its operation." ANNEb April 2011 Y VENDOR APPLICATION ,AND GUIDELINES FOR TEMPORARY FOOD SERVICE EVENTS 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, .1.540 Sullivan Avenue,South Windsor,CT 06074. This avylication is not a license.Temporary food events will not exceed a period of 1 to 5 days. Today's Date _7171<9 1 4F Name of Event S -U)w4�'- ko-A- Date of.Event ' NJC�Ajr' Time of Event 0 J�_ Location of Event S \kd Event Coordinator A IS Event Coordinator Address Event Coordinator Phone# Event Coordinator E-Mail Address rn' I C. ckiin Event Coordinator Phone#(cell,work&home) Name of Applicant 1���NaA C-m5qa6m, A Name of Applicants Business(please indicate if mobile vend C' �ObAk Applicants Address D_,�L 6 INV" N Applicants E-Mail AddressAo-jTN't Applicants Phone#(cell,work&home) Set up timeS yY Please provide the following:(If any of the following does not apply to you put N/A) 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. CA r\r-4xIIV\S-^ 2.Describe specifically how frozen,cold,and hot foods will be transported to the event SZ 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#L 5.Use Attachment#2 in this packet to sketch a drawing showing the event area and where your ---operation-wilLbe— 6. Describe the number,location and set up of handwashing facilities to be used by efffloyees <� " <S'e-�V -%(-, 7.Describe how and where utensil/equipment washing will take place. If no facilities are available, describe how alternate steps will be taken. Ca 0 4"C.-N 4- q-s-'04� 8.Describe how wastewater will A collected,stored and disposed. 9.Describe the number and lci ation of garbage containers. o- "�, 10.Describe what heat source will be used to keep hot foods hot(140 degrees and above). A--rc, or-\ I L Describe how r Id foods will be kept cold(45 degrees and below). 12. Describe how food temperatures are monitored,cleaned and sanitized. 13.Will foods be prepared on site?If no,where will foods be purchased?(enclose copy of food license) ATTACHMENT #1 NAME OF EMPLOYEE PHONE# ADDRESS SHIFT 2. 3. x 4. 5. 6. 7. 8. 9. 10. ATTACHMENT#2 CHECKLIST FOR FOOD BOOTHIVENDOR OPERATORS Metal probe thermometer(€J 220 degrees F range) 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/Aluminum foil Extra utensils: tongs,spatulas,spoons,and knives. Water source Buckets/tubs for washing,rinsing,sanitizing food equipment Bleach for sanitizing,test strips for checking Waste water disposal container Containers)for grease collection Clean wiping cloths and a container to store them in Garbage containers and plastic bags Hats/hair restraints Crates,shelves to store food off of the ground .Gloves for food handling Hand washing station a THE NATIONAL REGISTRY OF FOQD SAFETY PROFESSIONALSO CERTIFIES 4} f, t LISA MARIE OASPARNO IE HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR Mk THE FOOD SAFETY MANAGER i b CERT[FICATION EXAMINATION 41, x rh tm#retnrJ,t�+xrzh > r , ISSUE DATE:SEPTEMBER 3,2t349 gyp° s CERTIFICATE NO:XE20413918 t �>' TEST FORM:XEDA T%b twiftute is aat rand rat more thaaAve years rrow date of bsve, Notification of Test Result g 'rational Registry ofFood Safety Preiessiona �. CERTIFIED FOOD SAFETY MANAGE lD#:XxX-xx-1955 NC} Scaled Test Score: 83 LISA MARIE GASPARI d Candidate Status: Pass Teat Date: September 3,2009 x _ Certifcate No:XE�C'd�t 139 ' Issue Date:Scptem ret 3.201 Congratulations!Attached is your certificate and wallet card.Please notify LISA MARIE GASPARINO the National Registry of name or address changes at the address below. 128 HICKORY ST SUFFIELD,CT 06078 Ensure Food Protection(You scored 91%correct),Mastered Purchase and Receive Food(You scored 91%correct).Mastered Food and Supplies Storage(You scored 91%correct),Mastered Foods Preparation.Service&Display(You scored 83%correct).Mastered Equipment&Facilities Maintenance and Cleanliness(You scored 56%correct),Competent _ Personnel Hygiene,Training and Behaviors Related to Food Safety(You scored 67%correct).Competent Legal Compliance(You scored 100%correct).Mastered National Registry of Food Safity Prot'essionalsO 1 5728 Major Blvd Ste 750 1 Orlando.FL 32919-0000 l Phone:407,352.3930 1 Feic.407.352,3603 rW, a THE NATIONAL. REGISTRY OF FOOD .SAFETY PROFESSIONAt.SO CERTIFIES , DANIEL JAMES GASPARINO X'ALl { HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE FOOD SAFETY[MANAGER GERT1FtGATtQt`i EXAMINATION President: { ; 4 ISSUE DATE:SEPTEMBER 3,2009 CERTIFICATE No:XE20413919 TEST FORM:XEDA This t"Iffiewte is ant v8W for mera y th"ttrerr.rl from ate ofhme. a; Notification IUtI U Test ResultNational€cgisuy ai'rw)d Safety Prt fess,iott€ CERTIFIED FOOD SAFETY MANACF ID#: xxx-xx-1982 Scaled Test Score:92 DANIEL JAMES GASPARINO Candidate Status:Pass Test Hate: September 3,2009 `a Certificate No:X9204139 lout Date:September 3.20, Congratulations!Attached is your cenificate and wallet card.Please notify DANIEL JAMES GASPARINO the National Registry of name or address changes at the address below, 128 I IICKORY ST SUFFIELD,CT 06078 Ensure Food Protection(You scared 82%correct).Competent Purchase and Receive Food(You scored 82%correct).Competent Food and Supplies Storage(You scored 82%correct).Competent Foods Preparation,Service 8i Display(You scored 100%correct).Mastered Equipment&Facilities Maintenance and Cleanliness(You scored 94%correct),Mastered Personnel Hygiene,Training and Behaviors Related to Food Safety(You scared 92%correct).Mastered Legal Compliance(You scored 100%correct).Mastered National Registry of Food Safety Professionalst 1 5728 Major Blvd Ste 7S0 I Orlando,FL 328Ig-tiOQO l Phone:407.3523830 1 Fax;407,332.3603 } TOWN OF SOUTH WINDSOR TEMPORARY FOOD EVENT INSPECTION SHEET Event Name: t� �„� �X\_' WA& ,I— Event Date: Lo -oc),- t ,2o t4 Location of Event: a\ Applicant/Coord.: Ph.# Email Address: L,.►_c_ Fax# QFO Name: Ph.# Email Address: Fax# METHOD: On-Site inspection Kitchen inspection nterview (Crrc[e one) Food/Water S urce 'V Approved source of food,wholesome, free from spoilage `N k Water source potable, from approved supply, food grade hoses utilized Temperature Control A Hot/cold holding equipment and temperatures adequate Food cooked/reheated to correct temperature Metal probe food thermometer(0-220F range) available/sanitized between use Accurate thermometers for all refrigerators Coolers (self draining) and ice packs/bags Hygiene/Hand, ashing ats or effective hair restraints for food workers Hand washing station-warm water in jug w/spigot, liquid soap,paper towels Gloves for food handling, designated person to handle money Scoops to have handles Records ZDesignated person in charge of food booth for each shift-logs kept General Food otection No extensive food preparation/handling Food protected by wrapping, sneeze guards or other effective barriers Condiments single service,pump dispensers or squeeze bottles/shakers PHF hot held and not sold discarded daily or at end of event Food and single service food containers stored off floor Drink stored in ice-must be-storedin self draining-sta a containers Raw faits and vegetables used in food prep to be washed in potable water L Toilet Facilities aste Disposal Toilet facilities adequate, clean and conveniently located Waste water disposal container—disposed of properly ontainer for grease collection—disposed of properly on-absorbe t garbage contai , fly tight covers, Dumpsters must be covered Garbage containers and plastic bags Cleaning/Sanitizing �1 Buckets/tubs for washing,rinsing,sanitizing food equipment(hot water) Bleach/Quat. for sanitizing, appropriate concentration,test strips available Utensils are to be sanitized every 4 hours or as needed Moist wiping cloths to be stored in container with clean sanitizing solution Storage/FB Con ction 1 utensils/equipment to be properly stored to protect from contamination — —Chemicals to be stored separate from food products,bottles to be labeled Food booths constructed properly to protect food, adequate lighting provided COMMENTS: HEALTH INSPECTOR: 1 Signature: at : EVENT COORDINATOR: Signature:(i applicable) Date. "Aempo��y food serviEe_e Zlishment serving food or drink shall comply with all provisions of Public Health Code 19-13-B42 which are applicable to its operation." April 2011 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 apulication is not a license:Temporary food events will not exceed a period of 1 to 5 days.. Today's Date Name of Event II.A l Date of Event Time of Event 10 -c2 o Location of Event___ 771 Nib T�t )�wt'°i milr,f sor f Event Coordinator >^ Event Coordinator Address` Q[,� (� p Event Coordinator Phone# (166 - -35j I g7 Event Coordinator E-Mail Address Event Coordinator Phone#(cell,work&home) Name of Applicant &Ut Name of Applicants Business(please indicate if mobile vendor)4kht'S ApphcantslAddress !o fX10 IFINVA, Aft. !fJV(fd/ik'1Ll I (�/l Applicants E-Mail Address. N -A0 _ M— Appplicants Phone#(cell,work&home) 713 "q Set up time q 50 a 4 K- Please provide the following;(If any of the following does not apply to you put N/A) 1. List all food and beverage items to be prepared and served(menu).Attach a separate sheet if necessary. NOTE:Any change_s to the menu must be submitted to the Health Department 10 days prior to the event. OU v U-wh6 eah, Scwe.3 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. 1" -R 4.List names,phone numbers,addresses,and shifts to be worked of all employees.See attachment.C.. 5.Use Attachment#2 in this packet to sketch a drawing showing the event area and where your operation will be. A 6.Describe the number,location and set up of handwashing facilities to be used by employees-. 0 7.Describe how and where utensil/equipment washing will take place.U no facilities are available, describe how alternate steps will be taken. i 8.Describe how wastewater will.be.collected,stored and disposed. P 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). INfR 11.Describe how cold foods will be Dept cold(45 degrees and below)_ WA 12.Describe how food temperatures are monitored,cleaned and sanitized. 0 i-A 13.Will foods be prepared on site?If no,where will foods be purchased?(enclose copy of food license) No J, P 11 -foods ivill mj� packaje4 4h Q b . { l1 I(eq refit� C#re— &l -Ar& Oslati-rafd- or+ Cow ed Wr oa, to, us�omer s C liq r SOUTH WINDSOR HEALTH DEPARTMENT R TEMPORARY FOOD PERMIT r,ea� e#w E 'vENT : UNION DISTRICT SCHOOL FARMER ' S MARKET LOCATION : OLD MAIM STREET , S . WINDSOR APPLICANT : 5 PLC VALID : JULY 10,4OCT. 16 , 2011 THE RECIPIENT OF THIS LICENSE ACCEPTS THE SAME WITH THE UNDERSTANDING THAT HE/SHE WILL OPERATE IN ACCORDANCE WITH THE ORDINANCES AND REGULATIONS OF THE SOUTH WINDSOR HEALTH DEPARTMENT AND THE CONNECTICUT PUBLIC HEALTH CODE. ,." SHERRY Roy, ENVIRON NTAL H OFFICER DATE SIGN o: T THIS PERMIT MUST BE DISPLAYED IN AN AREA VISIBLE TO EVENT PATRONS AND IS NON TRANSFERABLE ' PERMIT ONLY VALID IF SIGNED BY HEALTH OFFICIAL oQ TOWNT OF SOUTH WINDSOR TEMPORARY FOOD EVENT INSPECTION SHEET VQ1C^-ton^ Event Name:_ `1&, cyl s k 1,Aa,,-V-cA- Event Date: vav�\O-- r ►b)`�\+ Location of Event: t 1Lr.in^ '��� ,� 1 C•1, kmrk; S&,D&,M� Applicant/Coord.: ,�,Q�1� �C'Z .fit.. Ph.# qLp—290-911 Email Address: Fax# QFO Name: �o��c,'� � ,,n��e�., Ph.# Email Address: Fax# METHOD: n-Site inspection Kitchen inspection Interview (Circle one) Food/Water S rce Approved source of food,wholesome, free from spoilage Water source potable, from approved supply, food grade hoses utilized Temperature C trol ot/cold holding equipment and temperatures adequate " ` o`n �\ Food cooked/reheated to correct temperature +`N p D I ate -c- o_Noo.- . Metal probe food thermometer(0—220F range) available/sanitized between use x orate thermometers for all refrigerators C Coolers (self draining) and ice packsibags Hygiene/Handw,a9hing Hats or effective hair restraints for food workers Hand washing station-warm water in jug w/spigot, liquid soap,paper towels loves for food handling, designated person to handle money Scoops to have handles Records Designated person in charge of food booth for each shift—logs kept General Food Protection o extensive food preparation/handling Food protected by wrapping, sneeze guards or other effective barriers Condiments single service,pump dispensers or squeeze bottles/shakers �PHF hot held and not sold discarded daily or at end of event Food and single service food containers stored off floor - - - -- Drinks stored in must be stored in self-draining storage containers - - SZ-Raw fruits and vegetables used in food prep to be washed in potable water Toilet Facilities/Waste Disposal CA Toilet facilities adequate, clean and conveniently located Waste water disposal container—disposed of properly Container for grease collection—disposed of properly Non-absorbent garbage containers, fly tight covers, Dumpsters must be covered _Garbage containers and plastic bags Cleaning/S 'tizing Buckets/tubs for washing,rinsing,sanitizing food equipment(hot water) Bleach/Quat. for sanitizing, appropriate concentration,test strips available Utensils are to be sanitized every 4 hours or as needed PC c e� Moist wiping cloths to be stored in container with clean sanitizing solution Storage/FB Co action All utensils/equipment to be properly stored to protect from contamination emicals to be stored separate from food products,bottles to be labeled Food booths constructed properly to protect food, adequate lighting provided COMMENTS: =&,c \rc o a•!��-�- , Y� n CO HEALTH INSPECTOR: 11 Si ature: EVENT COORDINATOR: M I r, Signature (if applicable) Date. -- "A temporary-food-service establishment serving food-or drink shall comply with all provisions of Public___ Health Code 19-13-B42 which are applicable to its operation." April 2011 f NOT., NSE TO DRIVE 4"ft -14 16$ft F cos: 70 IoNt • 13� 6 a �ntll Ftl►IN 1��:: FIAR1fORD CT awe 1421.40t0 ti Exam Fam No.430 Cwt No. . i�613781 Fr R�Eg AU A�Tp10�N rvSa& Certificatan To PATRICIA HUERTA F�aroN �''��h"' tl"m'ew^1EAwRarw t«uTwanGa+inllar. Date of Exa/nination:3/25/20pg Dste of Expiration: 312WO13 Kilnyy,;RK4bt�nt AfsofiNlM L"w EIN1CATlONAL FOIINDATION , qxa yph'CMtk wiM YaxlotN ngd►Iory _WRcyfq nnrtllieRuen �AMMRN MNasxastAdotklbn Edut:nRonN �,�� RW55 FOstRtlNiRR.ANtff nntwd. . VENDOR APPLICATION AND GUIDELINES FOR TEMPORARY FOOD SERVICE EVENTS 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 events will not exceed a period of 1 to 5 days. Today's Date - Name of Event un m Date of Event Time of Event Location of Event Event Coordinator LuSV-\A Event Coordinator Address Event Coordinator Phone# ��u ^ 3 Event Coordinator E-Mail Address C t l Event Coordinator Phone#(cell,,wnorrk&home) \ Name of Applicant "VL.t �a yzu� Name of Applicants Business (please indicate if mobile vendor) Applicants Address rl n Applicants E-Mail Address ��J1Y1 \Q 1 0- wl o bon Applicants Phone#(cell, work&home) �� Set up time&- q 4�5(.L1(1� Please provide the following: (If any of the following does not apply to you put N/A) 1. List all food and beverage items to be prepared and served(menu). Attach a separate sheet if necessary.-W r ' � k e 1V V kan cx1 SITS. NOTE:Any changes to the menu must be submitted to the Health Department 10 days prior to the event. 2.Describe specifically how frozen,cold, and hot foods will be transported to the event. — ku) tp"�-6 c)n s � a1 \Oa(rn cx-�' 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. �kn'`wl �h q� � Q.i� 6. Describe the number,location and set up of handwashing facilities to be used by employees. NCO Q\�6 10�A Jh-I S kkV 7. Describe how and where utensil/equipment washing will take place. If no facilities are available, describe how alternate steps will be taken. 8.Describe how wastewater will be collected, stored and disposed. butvl'-S� 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). 11. Describe how cold foods will be kept cold(45 degrees and below). 12. Describe how food temperatures are monitored,cleaned and sanitized. 13.Will foods be prepared on site?If no, where will foods be purchased? (enclose copy of food license) ATTACHMENT #1 NAME OF EMPLOYEE PHONE# ADDRESS SHIFT 1. pa-'i Ci(A I':s "fin - .3o�9 2. �`A 3. 4. 5. 6. 7. 8. 9. 10. ATTACHMENT #2 CHECKLIST FOR FOOD BOOTH/VENDOR OPERATORS Metal probe thermometer(0—220 degrees F range) 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/Aluminum foil Extra utensils: tongs, spatulas, spoons,and knives 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 them in Garbage containers and plastic bags Hats/hair restraints Crates, shelves to store food off of the ground Gloves for food handling Hand washing station mmWVU Dur+?tos/FV'f tst an +low t0oWbw Beef, chicken, pork, or vegetarian All served with beans and rice Green and/or red salsa also sold se�ahs'�e1y Flour tortillas Red salsa (salsa roja) Green salsa (salsa verde) Beveha$es All coke products Soda and water Prises 7W RISK PLACEMENT SERVICES, INC. (MA) 84 State Street, Suite 550 FS Boston, MA 02109-2202 Phone:(617)788-3200 Risk Placement Services,. Inc. Fax: (617)367-9543 t 1�;,�i:�ortidonec To: BINDER 07/26/2010 Attn: Renewal Of:NEW From: Christian Enwright chrisfian—enwright@rpsins.com/617 788 3204 Insured: DANIELLE RUSCZYK DBA: SPECIALTY FOODS INTERNATIONAL Thank you for your order to bind.We appreciate your business!We have bound the below coverage. Policy to Follow Shortly POLICY INFORMATION '`L BILL POLICY.:'° ;:: ::>':'`:° =,. `.. ':<`<, ':;:.:;>:.,: ::;::::: ;;:: ;>:::: :.> :•::::: :;.:.::- Policy Number: CL 2578362 Policy Period: 07/23/2010 to 07/23/2011 Carrier: Mount Vernon Fire Insurance Company A.M.Best Rating: A++(Superior)-IX COPE Commercial Liability $350.00 Each Occurrence Limit $1,000,000 Personal&Advertising Injury Limit(Any One Person/Organization) $1,000,000 Medical Expense Limit(Any One Person) $5,000 Damages To Premises Rented To You(Any One Premises) $100,000 Products/Completed Operations Aggregate Limit included General Aggregate Limit $2,000,000 :P.OLICY:: , E " his emium a .iiesub'ectto ad' st' -:.:,.::::::.::.:..,,.-PR_.:MIUM.:.:CL:.::...p..C.:....:.:::m-:..Y...�:::,.,:.,..J..:::.:::::..:.:1.u.<:m:.:...:.). ,....:_.......- ..>_-.:..:........,....... . $.. :..0.... , ..__...:.... . ADD T. :':;: ... °. ;:�:<,;.::';:;::;- :::�:��;:::';: :.: �;';: ::; :_�, Surplus Lines Tax $14.00 COVERED LOCATION(S) 1 -771 Main Street,South Windsor,CT 06074 APPLICABLE FORMS & ENDORSEMENTS The following forms apply to the Commercial Liability coverage part 2110 11/99 Service of Suit CG0001 10/01 Commercial General Liability Coverage Form CG2136 01196 Exclusion-New Entities CG2144 07/98 Limitation Of Coverage To Designated Premises Or Project Please contact us with any questions regarding the terminology used or the coverages provided. 'Page 1 of 2 j i r, CG2147 12/07 Employment-Related Practices Exclusion IL0021 05104 Nuclear Energy Liability Exclusion Endorsement 1L0022 05/87 Effective Time Changes-Replacement Of 12 IL0140 11105 Connecticut Changes-Civil Union Noon IL0260 09/07 Connecticut Changes-Cancellation And L-206 10/95 Premium Fully Earned Endorsement Nonrenewal L-224 07/08 Punitive Or Exemplary Damages Exclusion L-232s 09105 Classification Limitation Endorsement L-428 10/08 Firearms Exclusion L-526 06106 Absolute War Or Terrorism Exclusion L-549 12/07 Absolute Professional Liability Exclusion L-599 10/07 Absolute Exclusion For Pollution, Organic Pathogen,Silica,Asbestos And Lead With A Hostile Fire Exception L-610 11104 Expanded Definition Of Bodily Injury L-618B 01/09 Amendment Of Premium Audit Conditions L-686 03/06 Absolute Exclusion For Liquor Liability And L-723 02/09 Blanket Additional Insured Endorsement Liability Arising Out Of Liquor Related Services L-729 08109 Exclusion-Violation Of Statutes That Govern LLQ100 07/06 Amendatory Endorsement E-Mails, Fax, Phone Calls Or Other Methods Of Sending Material Or Iflformation NTE•01/08 Notice Of Terrorism Exclusion CLJ 03/96 Commercial Liability Policy Jacket I Please contact us with any questions regarding the terminology used or the coverages provided. Page 2 of 2 { i i TOWN OF SOUTH WINDSOR TEMPORARY FOOD EVENT INSPECTION SHEET Event Name: irrrc r - — 01 �,��,,, Event Date: 1b If, — ►0 !, Location of Event: Applicant/Coord.:_C ,- t„� Ph.# Email Address: Fax# QFO Name: ) l,J - Ph.# Email Address: Fax# METHOD: n-Site inspection Kitchen inspection Interview (Circle one) Food/Water S ce C-N L-S� Approved source of food,wholesome, free from spoilage MTWater source potable, from approved supply, food grade hoses utilized Temperature Control 12L_Hot/cold holding equipment and temperatures adequate Food cooked/reheated to correct temperature Metal probe food thermometer(0—220F range)available/sanitized between use Accurate thermometers for all refrigerators Coolers(self draining)and ice packs/bags Hygiene/Handw hing Hats or effective hair restraints for food workers Hand washing station-warm water in jug w/spigot, liquid soap,paper towels Gloves for food handling, designated person to handle money IV _Scoops to have handles Records Designated person in charge of food booth for each shift—logs kept General Food P�ection v Z .extensiv e food preparation/handling d protected by wrapping, sneeze guards or other effective barriers Condiments single service,pump dispensers or squeeze bottles/shakers �PHF hot held and not sold discarded daily or at end of event Food and single service food containers stored off floor Drinks stored in ice must be stored in self-draining storage containers Raw fruits and vegetables used in food prep to be washed in potable water Toilet Facilities/W ste Disposal Toilet facilities adequate, clean and conveniently located Waste water disposal container—disposed of properly Container for grease collection—disposed of properly Non-absorbent garbage containers, fly tight covers,Dumpsters must be covered Garbage containers and plastic bags Cleaning/Sanitizing VJ Buckets/tubs for washing,rinsing, sanitizing food equipment(hot water) Bleach/Quat. for sanitizing,appropriate concentration,test strips available Utensils are to be sanitized every 4 hours or as needed Moist wiping cloths to be stored in container with clean sanitizing solution Storage/FB Construction 1�tensils/equipment to be properly stored to protect from contamination Cmicals to be stored separate from food products,bottles to be labeled L- Food booths constructed properly to protect food, adequate lighting provided COMMENTS: HEALTH INSPECTOR: Signature. Date: EVENT COORDINATOR: f\Alh— SignaVure.(if applicable) Date: "A temporary food service establishment serving food or drink shall comply with all provisions of Public Health Code 19-13-B42 which are applicable to its operation." April 2011 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 amfication is not a license. Temporary food events will not exceed a period of 1 to 5 days. Today's Date Name of Event Date of Event Time of Event Location of Event kn/M c �e� � 7 7/ . kin 7 Event Coordinator art Event Coordinator Address Event Coordinator Phone# Event Coordinator E-Mail Address Event Coordinator Phone#(cell,work&home) Name of Applicant Name of Applicants Business(p r) ",0�21.51c6d Slwc _ Vgahch Applicants Address A13 S-- Applicants E-Mail Address Gc��1 �� G'�j ✓G�rd n �� 1 jrj,�i C�v�., Applicants Phone#(cell,work&home) �tS- � d -`75(16'7Y_(C) Set up time - �G `{�� ,C�7J Please provide the following: (If any of the following does not apply to you put N/A) 1. List all food and beverage items to be prepared and served(menu). Attach a separate sheet if necessary. &oe NOTE: Any hangers ubmitte'�to the H th De artmen 0 d ys p r to the y` event. 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. 1 4— 4. List names,phone numbers,addresses,and shifts to be worked of all employees. See attachment#1. Rho - �K- PC 79 ( � '�60- 1" 5. Use Attachment#2 in this p cket to sketch a drawing showing the event area and where your . operation will be. � ���e� 6. D scrib✓�umbe r, 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. �'y(i ,��" �Q � 8. Describe how wastewater will be collected, stored and disposed. Plk 9. Describe the number and location of garbage containers. 10. Describe what heat source will be sed to keep hot foods hot(140 degrees and above). 11. Describe how cold foods will be kept cold(45 degrpees and below). 12. Describe how food temperatures are monitored,cleaned and sanitized. J .d- 13. Will foods be prepared on site?If no,where will foods be purchased? (enclose copy of food license) ftO V � r• - a ATTACHMENT #1 NAME OF EMPLOYEE PHONE# ADDRESS SHIFT 1. 2. )t 4. 5. 6. 7. 8. 9. 10. J � ATTACHMENT #2 CHECKLIST FOR FOOD BOOTH/VENDOR OPERATORS ✓ Metal probe thermometer(0-220 degrees F range) � � 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/Aluminum foil V� Extra utensils:tongs, spatulas, spoons, and knives 4 '&1&ater source �- Buckets/tubs for washing,rinsing, sanitizing food equipment !� Bleach for sanitizing,test checking Waste water disposal container Container(s) for grease collection t� Clean wiping cloths and a container to store them in _Garbage containers and plastic bags Hats air restraints Crates, shelves to store food off of the ground - 5 CIA- ,Gloves for food handling Hand washing station T 1 -71 17 11 TOWN OF SOUTH WINDSOR TEMPORARYQODE_V�ENT INSPECTION SHEET Event Name: "cVN S Event Date: r, Location of Event: Applicant/Coord.: _ h \�� 4Yv., �c r� Ph.# Email Address: Fax# QFO Name: ��n,�.,�'�r ih 1 V a•A� e� Ph.# Email Address: A Fax# METHOD: On-Site inspectio I Kitchen inspection Interview (Circle one) Food/Water S rce Approved source of food,wholesome, free from spoilage Water source potable, from approved supply, food grade hoses utilized Temperature Control hA1, Hot/cold holding equipment and temperatures adequate Food cooked/reheated to correct temperature Metal probe food thermometer(0—220F range) available/sanitized between use Accurate thermometers for all refrigerators Coolers(self draining) and ice packs/bags Hygiene/Handwashing r effective hair restraints for food workers Hand washing station-warm water in jug w/spigot, liquid soap,paper towels Gloves for food handling, designated person to handle money Scoops to have handles Records Designated person in charge of food booth for each shift—logs kept General Food Pr ction No extensive food preparation/handling Food protected by wrapping, sneeze guards or other effective barriers Condiments single service,pump dispensers or squeeze bottles/shakers 1 PHF hot held and not sold discarded daily or at end of event Food and single service food containers stored off floor Drinks stored in ice must be stored in self-draining storage containers Raw fruits and vegetables used in food prep to be washed in potable water Toilet Facilities/Waste Disposal Toilet facilities adequate, clean and conveniently located Waste water disposal container—disposed of properly _Container for grease collection—disposed of properly I Non-absorbent garbage containers, fly tight covers, Dumpsters must be covered 1.4 Garbage containers and plastic bags Cleaning/Sanitizing Buckets/tubs for washing,rinsing, sanitizing food equipment(hot water) Bleach/Quat. for sanitizing, appropriate concentration,test strips available Utensils are to be sanitized every 4 hours or as needed Moist wiping cloths to be stored in container with clean sanitizing solution Storage/FB Con ction All utensils/equipment to be properly stored to protect from contamination Chemicals to be stored separate from food products,bottles to be labeled Food booths constructed properly to protect food, adequate lighting provided COMMENTS: HEALTH INSPECTOR: 11 V Signature: Date. EVENT COORDINATOR: a A- Siknatu e:(if applicable) Date: "A temporary food service establishment serving food or drink shall comply with all provisions of Public Health Code 19-13-B42 which are applicable to its operation." April2011 WhyBuy Our Hickory Syrups? • y rrCompare These Syrups! 1. Our Shagbark Hickory Syrup and Hickory Nut Syrup are award winners in the CT KEYWOODS Specialty -Food Competition. It is a local rAizM . favorite! 2. They are New England's only Hickory Syrups: versatile alternatives to maple syrup. Award-Winning 3. It's hand-crafted syrup. It's all natural �CICOI'y Syrups with no preservatives, no artificial flavors, and DOES NOT contain corn syrup. 4. Hickory syrup is less common than maple r (FAQs) syrup; therefore, it makes a unique gift. - 5. Its high quality is backed up by 20+ years of scientific experience. 6. Hickory flavor is stronger than .maple flavor. Cooking with shagbark hickory syrup instead of maple syrup adds a deep complex flavor to the main dish. �� v 7. The best part is you do not need much of it 4 {` < k �.► Y t�5elt�, since a little bit can go a long.way! ajt�,Food Connecticut SPecl Where Can I Find Turkeywoods Hickory Syrups? Turkeywoods FarmTm hickory syrups can be '• - Turkeywoods Farm, LLC found in a variety of store and campground "New England's Only Hickory Syrups" locations throughout southeastern Connecticut Thuy-Trish Nguyen ( ). y purchased w Director of Sales and Marketing see below The can also be through our website at www.mysticsyrups.com. CONNECTICCUT 110 Haley Rd Please feel free to call 860-471-6699 for more GROWN r Mystic.CT06355 information. 860-47 i-6699 J saie@nnysticsyrups.com Mystic: Old Mystic General Store, Franklin's �, "r. ���- Www•mys"rups•com General Store, Pequotsepos Nature Center Groton: Johnson Hardware and New Asia Market E LocaL FLAvoR. Mystic Hickory Y P S ru TM Noank: Universal Foods New England's Only Hickory Syrups! Ledyard: Holdridges, Maugle-Sierra Vineyards Stonington: Fleming's Feed Westerly, RI: Dunn's 4 Corners Market TM Mystic. Hickory Syrup On-line: www.mysticsyrups.com Turkeywoods Farm, LLCICkOP� Mystic, CT © 2010 '"` What Is Hickory Syrup? fish, as a tea sweetener, etc. The syrup is tea, but also has found its way into desserts Shagbark hickory syrup, made from the bark of particularly outstanding on squash and corn and cocktails. With its characteristic spices and the shagbark hickory tree, is comparable to bread, and is an excellent holiday dinner earthy flavor, Hickory Ginger Syrup is the ideal maple syrup in makeup with similar sugar, addition. Cooking with shagbark hickory syrup ingredient in many alcoholic beverages. instead of maple syrup adds a deep complex Hickory Ginger Syrup makes a refreshing water content, and trace minerals (see Chart). While typical commercial flavor to the main dish. The best part is you do addition to these innovative drinks. yp pancake syrup not need much of it: a little bit can go a long contains corn syrup, high fructose corn syrup, way! What about Our Berry Syrups? and a host of artificial flavorings and preservatives, hickory syrup is as natural as What Is the History behind Shagbark We offer a variety of fresh berry syrups maple syrup! Syrup? including fresh Blueberry, Blueberry/Strawberry (a Mystic favorite), Red Raspberry, Blackberry, Does Hickory Syrup Come From Sap? For years, the Native Americans drank tea and Wild Grape. Since we only use freshly With maple syrup, the sap is collected from the prepared by steeping the bark in hot water and picked fruit (not frozen), these syrups are tree and water is boiled away to a sugar content sweetened the bitter tea with honey. Recipes seasonal products. of around 66%. Since the hickorytree does not for the syrup dated back to over 100 years. What Is the Shelf Life of the Syrups? produce a useable sa the a Because hickory trees are less common than p, approach for maple trees, and it takes years for the tree to We bottle our syrups at over 215 degrees processing shagbark hickory syrup is different,than maple syrup: pure natural sugar (sucrose regrow its useable bark, shagbark syrup can't Fahrenheit, so they are sterilized, not scale.roduced onlar a and fructose) is added to the water to attain a be p g pasteurized. The shelf life is indefinite provided similar sugar concentration. The unique hickory Other Hickory Syrup Products from the cap seal is not broken. However, once the flavor comes from the bark itself, which is Turkeywoods FarmT'" syrup is opened, we recommend refrigeration. pressure cooked and aged for a period of time Syrups in open bottles can stay fresh for several for enhanced flavor and maturity. Along with its trademark Shagbark Hickory months in the refrigerator. Our berry syrups Syrup, Turkeywoods FarmTm also offers Hickory should be consumed within 6 weeks for the Are Trees Damaged in the Process? Nut Syrup, which is prepared through our own freshest berry flavor. Trees are not cut or damaged in the process of proprietary method. This syrup is the only Why Are There Crystals in the Syrups? making syrup. The shagbark hickory tree begins product of its kind that has been produced. It is to naturally shed its bark at 7 years old. This made from local hickory nuts which are Like maple syrup, our hickory syrups will often bark can be harvested when it falls from the collected, cracked, and de-shelled by hand. form gem-like rock-candy crystals over time. tree, or can be carefully removed when it Because these nuts generally fall during a two- This is a natural process that occurs with syrups becomes Loose. Peeling too much bark from the Week period of the fall, and must be collected made of natural ingredients of high purity, not tree can damage it and leave it prone to insect quickly before squirrels"get them", this syrup is with corn based imitation syrups. Crystals are damage. We make every effort to preserve the available in limited quantities. Hickory nut less likely to form with our berry syrups health of our beautiful trees. syrup has a unique nutty flavor that is because of the higher concentration of natural completely different from the shagbark syrup. fruit sugar. Crystal formation does not affect What Does Shagbark Syrup Taste Like? Hickory nut syrup is distinctively light, sweet the quality of the syrup, and rather is an. Turkeywoods Farm TM Shagbark Syrup has a and nutty, and is excellent for pancakes, indication of high quality or the taste. very unique flavor, and an indescribably waffles ice cream and corn bread. What Awards Did Our Syrups Win? complex taste. Some people find it less sweet A new and rapidly growing favorite is our than maple syrup. Others have described it as Hickory Ginger Syrup. This syrup, prepared Turkeywoods Farm Hickory Syrups were woodsy, earthy, smoky, nutty, or honey-like, from the bark of the shagbark hickory tree and entered in the 10th annual, 2011 Connecticut but the only way to experience the special fresh ginger root, is generating rave reviews Specialty Foods Competition, Honey and Syrup flavor is to try it! from ginger lovers! It is a versatile sweetener Division. Our Shagbark Hickory Syrup placed that can be used in tea, sauces, marinades, or 2"d, and our Hickory Nut Syrup placed 3ra How Is Shagbark Syrup Used? combined with fruit or on ice-cream for a quick Tiezza Imports of Colchester won 1st place with Turkeywoods Farm'" Shagbark Hickory Syrup refreshing dessert. The possibilities to enjoy their;Arragucci Honey product. Thus, our two rY Ginger Hickory Gin Syrup is used like maple syrup: on waffles, pancakes, 9 Y up are endless. With its syrup winners are the #1 and #2 syrups of the oatmeal, ice cream, cheese cake, as a glaze on exotic and unique flavor, Hickory Ginger competition for 2011. hams and ribs, drizzled over baked or grilled Syrup is not only used exclusively in food and http://www.ctspecialtyfood.org/?page id=8 s e � F ' } VENDOR APPLICATION AND GUIDELINES FOR TEMPORARY FOOD SERVICE EVENTS f r t y 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 events will not exceed a period of 1 to 5 days. Today's Date ,7 t 1 /7-0 11 Name of Event 06,tif^ W v�J ,r �c Date of Event r 2 EL Time of Event !°_ 1 Location of Event Event Coordinator Event Coordinator Address Event Coordinator Phone# MA - Event Coordinator E-Mail Address Event Coordinator Phone#(cell, work&home) Name of Applicant 4 el.!- Name of Applicants Business(please indicate if mobile vendor) Applicants Address Ito G 1� _ Y 1(� C f CT CA Applicants E-Mail Address c � u ywo�Aw1 . W1rv�i Applicants Phone#(cell, work&home) 4 Set up time 1 Please provide the following: (If any of the following does not apply to you put N/A) 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. Wji S:kar-s6_-,L k 2.Describe specifically how frozen,cold,and hot foods will be transported to the event. Imo► 3.List all places(name&address)where meats,poultry, seafood, shellfish,and ice will be purchased. NI � 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. r a, 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. 8.Describe how wastewater will be collected,stored and disposed. 9.Describe the number.and location of garbage containers.0 / 10.Describe what heat source will be used to keep hot foods hot(140 degrees and above). N 1, K 11.Describe how cold foods will be kept cold(45 degrees and below). K 12.Describe how food temperatures are monitored,cleaned and sanitized. tj ( K 13.Will foods be prepared on site?If no,where will foods be purchased?(enclose copy of food license) N I� ATTACHMENT #1 NAME OF EMPLOYEE PHONE# ADDRESS SHIFT 1. 2. 3. 4. 5. 6. 7. S. 9. 10. 1 ATTACHMENT #2 CHECKLIST FOR FOOD BOOTHNENDOR OPERATORS Metal probe thermometer(0—220 degrees F range) Thermometers for all refrigerators Coolers and ice packs(if ice is to be used for cooling of foods,where is water to be drained) Flastic wrap/Aluminum foil _Extra utensils:tongs,spatulas,spoons, and knives 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 them in Garbage containers and plastic bags Hats/hair restraints Crates, shelves to store food off of the ground Gloves for food handling Hand washing station