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Home My WebLink AboutApplication 150 Nevers Road =_- - - TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT - - 1540 Sullivan Ave., South Windsor, CT 06074 Phone Number: (860)644-2S11 x250, Fax Number: (860)644-7280 TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION ***Must be submitted 2 weeks prior to event,No fees charged*** Event Name:S�v Ie 1 10n '.S /�)Wityr �'N a EventDate(s): IJLG /l, 261L Event Time: h7m-3pm EventLocation:Uar/,es 6eS Ca"mr-ly Cen3 ier /5J0 4 i�f'r rsP_ A/ C��(// V-6b7y PERSON IN CHARGE INFOR"ATION �/ Last Name: �f OV� First: M&1155 a M.I.: Date: Street Address:7y//?d43t//�/ Avle)W3 Apartment/Unit#: City: saw �l State: lyre Zip:0q0V Phone &Cell //,, 44�' E-mail p� Phone: 2%Q� / !� Z� Address: hWS �/ A1�r � ORGANIZATION YOUR REPRESENTING (IF ANY) Representing:ram` `aikevi ,� C4,De�—P oeivL-'S 11 n Street Address: ,(,//�j,��n/ fell � � ) Apartment/Unit#: City:i1 � (J� L4 /`r State: PTC Zip:�L�o��/ Phone::J[/'(��,1�(J v�` r yI E-mail Address: QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) YES ❑ NO Name: Certificate#: 10 3 09 100 Date: ADDITIONAL INFORMATION ./ Water Supply: YES ❑ NO L-10K Wastewater Disposal YES ❑ NO Cp Electrical: YES ❑ NO W,,,- If other,please 1 explain: MENU **(PLEASE LIST ALL MENU ITEMS IN AS MUCH DETAIL AS POSSIBLE)** Litey=(Ihye Ullsydjbec-) ****PLEASE DRAW A DETAIL DIAGRAM OF FOOD BOOTH ON THE BACK OF THIS FORM. USING THE GRAPH PICTURE ON THE BACK OF THIS APPLICATION**** The food preparation and storage areas must be covered if event is outdoors. Be sure that the tents used for overhead cover are fire-rated. Der the South Windsor Fire Marshal's office. AGREEMENT AND SIGNATURE 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 temporary Food Service license for the Town of South Windsor. Temporary Food Service License will be issued after the Food Inspector has completed his/her inspection. Applicant Name (Please Print): � �� i Applicant Signature: `` RECEIVED �7 I� Date: �Z—J®1J,. i ' n 052016 SOUTH WINDSOR HEALTH DEPT. W o,. Town of South Windsor Health Department n n Temporary Food Event Questionnaire Form = -- Please complete all questions and return to the Health Department with your application. 1. What is the source of the food to be served/dispensed? (Please include name/address of source) Foods must be from an approved source. Meat and dairy products must come from a government-inspected source. If it is necessary to bring in foods that are prepared at a licensed facility other than the temporary site,you must indicate how the food is protected during transport and how it is kept hot or cold as needed. LO 111"1161 r7 00if Le— C'L 7q l nyai 1' icy 11��;rL �. 2. How will the food items be kept cold/frozen? Ice must be from an approved potable source. Frozen foods cannot be thawed at room temperature. Proper thawing can be done in a refrigerator,under cool running water,or as part of the cooking process. 3. How will the food items be cooked and/or hot held? A sanitized metal stemmed,calibrated probe thermometer to monitor food temperature is required. If thin patties are being cooked,a thermocouple may be needed to accurately check temperatures. 4. Please describe the type of hand washing facility to be used. > er S. How will the food be protected? Food must be protected during storage,preparation,display,service and transportation. Cooking to order will lessen the chance for bacterial growth,which may occur prior to service. 6. How will the all utensils and food contact surfaces be washed,rinsed and sanitized? 7. Where will excess food(Potentially hazardous and non-potentially hazardous foods),dry goods,and single service items be stored? 8. Where will ware wash detergents and sanitizers be stored? 9. How will condiments and single service items(cups,plates,utensils,etc.)be dispensed? 10. What method of garbage disposal will be used? n)OV 7 - -- - - Y I `�/ tr � 1 �) j w v OFFICE USE ONLY Inspector Name: (Please Print): Inspector Signature: : Food Class:1 ' 2 3 Temporary Food License#: ExpIrat1on Date: Notes: Date Received: Additional Information ❑ Contact the local Fire Marshal (860-282-0669)to ensure compliance with the Fire Code. ❑ The food preparation and storage areas must be covered if event is outdoors. Be sure that the tents used for overhead cover are fire-rated, per the South Windsor Fire Marshal's office. ❑ Wastewater must be disposed of in a sanitary sewer or other approved sewage disposal system. ❑ Equipment and tables must be clean, smooth,washable, durable, non-absorbent and in good repair. ❑ Dust must be controlled (i.e. dry fields) by watering down. ❑ All workers at the food booth must sign a log sheet indicating the date,their name, address and telephone number and the hours that they worked. Please retain the log sheet after the event. ❑ If gloves are used,they must be a food grade quality glove and must be used for only one task (such as working with ready-to-eat foods or with raw animal food). You must wash your hands after removing the gloves and prior to putting on a new pair of gloves. Gloves must be discarded when damaged or soiled, or when interruptions to use occur. ❑ Food employees may not wear nail polish or artificial nails unless wearing intact gloves in good repair. EXAM FORM NO. 10359 CERTIFICATE NO. 10430918 ServSafe National Restaurant Association S ry afe CERTIFICATION TO JENNIFER L HOMEN zT for successfully completing the standards set forth for the ServSafe"Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute(ANSI)-Conference for Food Protection(CFP). DATE 0 10/18/2 0 DATE OF EX Local laws apply. recertification requirements. i � Association #0655 CO2012 National Retts of the NRAEF,used under license by National Restaurant Association Solutions,I.I.C. The IORo i.: - - *tate of ivatrle SERIAL NUMBER Department of Agriculture,Conservation&Forestry Division of Quality Assurance&Regulations 103810 28 State House Station,Augusta,ME 04333-0028 (207)287-3841 2-30074 October 3,2016 October 25,2017 This certificate is valid only between the date issued and expiration date appearing LICENSE NUMBER DATE OF ISSUE DATE OF EXPIRATION herein. Only the named holder at the location for which issued may use it. This certifies that The person named herein is authorized Lakonia Greek Products LLC to sell or manufacture food products, MOBILE VENDOR fuel and/or sell or repair weighing and Melissa Rioux measuring devices as permitted by law 74 Industrial Park RD,Sui for the listed authorizations. This certificate and/or each type of 74 Industrial Park RD Suite 3 authorization represented is subject to Saco,ME 04072- Location: ' ' suspension,revocation or cancellation as Saco authorized by Maine Revised Statutes. LICENSE TYPE DESCRIPTION OF LICENSE AUTHORIZATIONS FEE License Type Authorizations Fee Retail 1-4,ud Iistablishment 0 to 10 Prepackaged Food 20.00 Mobile Vendor 0 to 10 20.00 Commercial Food Processor Fruits,Vegetables 50.00 Other Type Herbs&Olives TOTAL: 90.00 Department of Agriculture,Conservation& Division of Quality Assurance Forestry ,41A- &W J V�" 44AU Commissioner Acting Director