HomeMy WebLinkAboutApplication 245 Barber Hill Road OW41 ��
n TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
1530 Sullivan Ave., South Windsor, CT 06074—Office Address
Phone Number: (860) 337-6173, Fax Number: (860) 644-1930
TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION
***Must be submitted 2 weeks prior to event,No fees charged***
Event Name: 2e n Tr�e �Ct rn , In c
Event Date(s): I i 511(0 -- la-i ay (i(.o Event Time: q C rr -
Event Location: ZLA S 6 W��n l l
PERSON IN CHARGE INFORMATION
Last Name: First: M.L: Date: 17l I�p� n P_ 1
Street Address:ZL4 S & Cbe-y- j + p,,I Apartment/Unit#:
City: S b Ut- „ ��` �,A61%CA- 1 ' ` l a�vt State: C- Zip: D oo-1(4
Phone &Cell 1pV ` E-mail
Phone: O LQ 0 y 9 O 1-3 C)o Address: D-,�erl 01— @ a b l, Lb al
ORGANIZATION REPRESENTED (IF ANY)
Representing:
Street Address: Apartment/Unit#:
City: State: Zip:
Phone: E-mail Address:
QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) YES NO
Name: C�1���f' G-eN,) a( L
Certificate#: Date:
ADDITIONAL INFORMATION
Water Supply: 120 IQ CL WC0_e YES ! NO Wastewater Disposal YES )6 NO
If other, please
Electrical: C�e_�j YES [ NO '. 1 explain:
MENU "(PLEASE LIST ALL MENU ITEMS IN AS MUCH DETAIL AS POSSIBLE)**
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Dd Q c o rn 2 i)j20ed i tt__ 016tC to n.�
****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. per 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 D_
(Please Print): v �C I1 Y-) t IJ Z r RECEIVED
Applicant Signaturl)l c _ Date: +I
�u s-/ NOV 0 `i 7016 ilo
SOUTH WINDSOR
HEALTH DEPT.
Otg"e� Town of South Windsor Health Department
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.
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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.
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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.
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4. Please describe the type of hand washing facility to be used.
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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?
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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?
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10. What method of garbage disposal will be used?
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Temporary Event Form
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Event Name: I SNy'r\ s`'
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Event Location: IJ—f Time:
QFO: C c.i r1 c C.,-e b -
Vendor Name/Organization 1�j
Food Source&Temperature:
Food from approved sources
✓ No home canned/home prepared foods
7— Ice from potable water source
'/ Food prepared offf site in approved food service facility
✓ Cold holding<450
Hot holding> 1400
Personnel:
✓ Appropriate handwashing facilites (warm water, dispenser with hands free spigot, liquid soap,
paper towels, waste water container,trash can)
✓ No employees with communicable diseases; cut and sores covered
Clean outer garments, no smoking, eating or drinking in prep area
Handwashing at appropriate times
✓ Minimize bare hand contact
Food & Utensil Storage, Handling:
Dry storage of all goods, utensils, single serve items protected and not on ground
✓ Cold storage: units clean, have working thermometers, internal temp<450
✓ Hot holding: units clean, ability to keep foods > 1400
✓ Thermometers available and adequate; calibrated ±21, alcohol wipes
✓ Food protected from outside contaminants, sneeze guards
✓ Food prep areas protected from contamination
Utensil storage approprate, clean
✓ Food protected from cross contamination during storage, prep, display
Utensils cleaned and sanitized afer use or every 4 hours
Cleaning: (� �
�— Ware 4'Ivnj'; "i�i up dequate to wash, rinse, sanitize U
V Sanitizer available; test strips available
Wiping cloths stored in sanitizing solution A-u A
Water Supply& Wasteater Disposal: J
Adequate supply of potable water C C�-k-'- ("vv
Backflow preventer and food grade hoses when needed
Wastewater disposed in approved disposal system (sanitary sewer, blueboy) '� v
Premises:
✓ All food contact surfaces easlily cleanable, intact W� G I' 1 Ck—
Floors clean, easliy cleanable J a �
Walls and ceilings protect against contaminants p(�U� �Y\
Garbages adequate, rodent proof, non-absorbant q
Toilet facilities adequate, clean
J Toxic materials properly labeled and stored
Inspector o peratcV