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Home My WebLink AboutApplication 150 Nevers Road (4) nee TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT S. q 1540 Sullivan Ave., /South Windsor CT 06074 J Phone Number: (860) 644-2511 x250, Fax Number: (860) 644-7280 �uSOR.Co. FARMER'S MAKET FOOD SERVICE LICENSE APPLICATION ***Must be submitted 2 weeks prior to event,No fees charged*** EVENT INFORMATION = AL __ Event Name: South Windsor Farmers Market Event Date(s): Event Time: Event Location: PERSON IN CHARGE INFORMATION Last Name: Welsh First: Carol M.I.: Date: 6/21/2016 Street Address: 17 WINDWOOD DR L , Apartment/Unit#: city: Glastonbury State: CT Zip: 06033_ Phone &cell g60-209-8296 / Email roastedbeanct@ gmail.com Phone: _ Address: 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: Certificate# Date: ADDITIONAL INFORMATION Water Supply: YES ❑ NO [X Wastewater Disposal YES ❑ NO ❑ Electrical: YES ❑ NO R If other, please explain: _ MENU "(PLEASE LIST ALL MENU ITEMS IN AS MUCH DETAIL AS POSSIBLE)** locally roasted coffee-fresh brewed (hot&iced) 12oz bags of ground coffee ****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): Carol Welsh Applicant Signature: �� Date: 6/22/2016 owe d 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. locally roasted coffee 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. cooler 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. brewed coffee with coffee maker 4. Please describe the type of hand washing facility to be used. .00l .r with fresh water soa) and oaner towels 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. Collelo, Diane From: Collelo, Diane Sent: Wednesday,June 22, 2016 9:09 AM To: 'Carol Welsh' Cc: Oatis, Heather Subject: RE: South Windsor Farmer's Market Good Morning, Thank you for your quick response. Your application has been approved. I will be there Saturday to perform a preoperational inspection of your booth. Should you have any further questions, please do not hesitate to contact me. Regards, Diane L. Collelo Environmental Health Inspector Town of Windsor, Health Department 1540 Sullivan Avenue South Windsor, CT06074 Ph. 860-644-2511 ext. 248 Fax 860-644-7280 Website: www.southwindsor.org From: Carol Welsh [mailto:roastedbeanct@gmail.com] Sent:Tuesday,June 21, 2016 5:30 PM To: Collelo, Diane<Diane.Collelo@southwindsor.org> Subject: Re: South Windsor Farmer's Market Hello Diane, My apologies... Here is the information you requested. 1) yes, I will have milk&creamer I have thermos pitchers to keep them cold for customers and the extra cream &milk I have in a cooler. 2)the water I use to brew with is spring water from one of those giant jugs they sell 3)the coffee beans(ground) are from a company in Westport CT called Solude Coffee. They get the beans and roast & grind them at their facility in Westport. 4) 1 keep the paper cups in their plastic sleeve and take them out one by one. I am working on getting a cup dispenser. Same with the lids. The stirrers are in container cup on the table for people to grab as they wish. 5) with my hand washing station I do have hand sanitizer as well as soap and I use Clorox wipes to clean my stations/tables Thank you, please let me know if you need anything else. Carol Welsh (860) 209-8296 On Jun 21, 2016, at 3:07 PM, Collelo, Diane<Diane.Collelo@southwindsor.org>wrote: 1 Good Afternoon, I have reviewed your application for the SW Farmer's Market. I have a few questions: 1. Will you have milk/creamers? Where are they from,are they aseptic? How will you keep them cold? 2. Where are you getting the water to brew your coffee? 3. You state locally roasted coffee, but what is your source? 4. Where will you keep your single use cups,stirrers, etc.? You put N/A on the form. 5. You will need sanitizer on site,your application states N/A. Please let me know the answer to these questions, in order to expedite the approval of your application. I can approve the application if you submit the answers to me by Thursday June 23,2016. 1 look forward to hearing from you. Regards, Diane L. Collelo Environmental Health Inspector Town of Windsor, Health Department 1540 Sullivan Avenue South Windsor, CT 06074 Ph. 860-644-2511 ext. 248 Fax 860-644-7280 Website: www.southwindsor.org z Temporary Event Form Q�yo Ndyc� Event Name: `Jug FMAt-6& AI A-n-.k — Date: nIZ- Event Location: fez• /Ui/t�lf_ �� Time: QFO: Vendor Name/Organization 411 d't Esc% e-�- ��•�,N•��' Food Source &Temperature: Food from approved sources �,�,,�� v No home canned/home prepared foods Ice from potable water source Food prepared offf site in approved food service facility Cold holding<450 r./- Personnel: Hot holding> 1400 `� � '�"�` v (fed ...JZ 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 ±20, alcohol wipes Food protected from outside contaminants, sneeze guards p e 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 Cleanin Ware washing set up adequate to wash, rinse, sanitize Sanitizer available; test strips available Wiping cloths stored in sanitizing solution Water Supply&Wasteater Disposal: Adequate supply of potable water Backflow preventer and food grade hoses when needed Wastewater disposed in approved disposal system (sanitary sewer, blueboy) tPreises: All food contact surfaces easlily cleanable, intact Floors clean, easliy cleanable Walls and ceilings protect against contaminants Garbages adequate, rodent proof, non-absorbant Toilet facilities adequate, clean materials prop r beled and stored Inspector Food Operator Temporary Event Form n coa 6K,� Event Name: � � O�� if Date: �'�W Event Location:s( � •tc 4 Time: �D• ` � O �' ,mil QFO: _'= ►' Vendor Name/Organization Food Source&Temperature: Food from approved sources No home canned/home prepared foods Ice from potable water source Food prepared offf site in a roved food service facility r/ Cold holding<450 Hot holding> 1401 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: 4 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> 1401 _ Thermometers available and adequate; calibrated ±21, alcohol wipes L / Food protected from outside contaminants, sneeze guards Food prep areas protected from contamination J/"' Utensil storage approprate, clean Food protected from cross contamination during storage, prep, display Utensils cleaned and sanitized afer use or every 4 hours Cleaning: b_ Ware washing set up adequate to wash, rinse, sanitize Sanitizer available;test strips available Wiping cloths stored in sanitizing solution Water Supply&Wasteater Disposal: C/ Adequate supply of potable water �G Backflow preventer and food grade hoses when needed Wastewater disposed in approved disposal system (sanitary sewer, blueboy) Premises: All food contact surfaces easlily cleanable, intact f Floors clean, easliy cleanable Walls and ceilings protect against contaminants -� Garbages adequate, rodent proof, non-absorbant f Toilet facilities adequate, clean Tox' materials Fu rl d stored 11-- s� I ector Food Operator