HomeMy WebLinkAboutApplication 150 Nevers Road (3) 11-29-16;03: 38PM;cbs ;860-286-8836 # 1/ 2
TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
' 1540 Sullivan Ave., South Windsor,CT 06074- Mailing Address
10 1530 Sullivan Ave., South Windsor, CT 06074-Office Address
11 it Phone Number: (860) 337-6173, Fax Number: (860) 644-1930
�''�'�r�M•<<'`� TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION
*'"Must be submitted 2 weeks prior to event,No fees charged""
Event Name: S 0 t..LLIv_1�_S_O_rL—v�GLT
Event Date(s): L went Time: 9 tW
Event Locatlona `,h
PERSON IN CHARGE INFORMATION
Last Name: First: M.I,: I Date:
Street Address: / - /LI S _ Apartment/Unit#: / G
city L.00 M ICE Stated^ Zip:
Phone &Cell E-mail
Phone: _ 6 6,(r
ORGANIZATION REPRESENTED (IF ANY)
Representing: —�
Street Address: Apartment/Unit#:
City: State: Zlp:
Phone: l E-mail Address:
QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) ❑ YES ❑ NO O
Name:
Certificate#: Date:
ADDITIONAL INFORMATION _ \
Water Supply: — —YES ❑ NO O Wastewater Disposal YES ❑ N01�10
ElectriCal: YES ❑ NO , If other,please
explain:
MENU **(PLEASE Y MENU M IN AS MUCK DETAIL AS PASSIBLE)"* t
r 6/7
I ****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. oer the South Windsor Fire Marshal's office.
AGREEMENT AND SIGNATURE
By submitting this application,I affirm that the fags 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 C
(Please Print): Q`rr
Applicant Signature: RECEIVED Date:
NOV 3 0 2016 _ 440SOR
HEALT DEPT.
SOUTH WINDSOR
HEALTH DEPT.
11-29-16;03: 38PM;cbs ;860-286-8836 # 2/ 2
o'r, Town of South Windsor Health Department
. ` � `� "temporary Food Event Questionnaire Form
Q c� d �;
,y Please complete all questions and return to the Health Department with your application.
I. 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 Ind71L
ow the food Is protected during transport and how it is kept hot or cold as needed.
-b (-C. 0-7— &o y7`Z E Z) A-T .
2. Mow 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. Now 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.