HomeMy WebLinkAbout2016-3-16 - 150 Nevers Road - Temp Food License Application Jeff's Kettle Corn rG^� TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
1540 Sullivan Ave., South Windsor, CT 0604
Phone Number: (860)644-2511 x250, Fax Number: 860) 644-7280
M All FOOD SERVICE LICENSE A LICATION
ale<t he •., . : ..t,'r!2 I%s prior to vvent!Nu ft,. „ . _ct "
EVENTDVFORMATION 1 1 p
Event Name: So ,� ( n �1,..(
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EventDate(s): dLL� $1 Q.5 i �1 nna--ln1 `��i�'3O Event Time: I b'
Event Location: �1�'9. c`) j ap f_ A 10)111XLf i ocW- I I$
PERSON IN CHARGE INFORMATION 1 �/�
Last Name: S�( First: ! i n t r . M.I.: ClDate: ?, I
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Street Addres�:l I ^ Apartment/Unit#.
Cam: �d���v V( 1 i State: CJ Zip: n6co s
Phone &Cell E-mail �c ��
Phone: �lQ 0-Li 0 a— `� `�� � �r Address:
ORGANIZATION REPRESENTED (IF ANY)
Representing: v
Street Address:
Apartment/Unit#:
City: State: Zip:
•
Phone: E-mail Address:
QUALIFIED FOOD OPERATOR Y(INCLUDE C'PY OF CERTIFICATE) YES NO
Name:
Certificate#: `J ��I �� Date:
1"•
ADDITIONAL INFORMATION
Water Supply: YES NO Wastewater Disposal YES J No
Electrical: YES NO If other,please
explaln:
MENU **(PLEASE i IS f-At[—r_IiFNIH r I FN5 IN AS MUCH DETAIL AS POSSIBLE)**
****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 the covered if event is outdoors. Be sure that the
tents used for overhead cover are fire-rated, ner 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 /1
(Please Print): Ql
Applicant Signature: ' Date:
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South Windsor Farmers Market —Regulations 2016
Market regulations are listed below. By signing this document you agree that you have read and understand
these staternents. Please direct any questions to Sou thWi ndsorl'ootl n eniail.c„nt
1.State of Connecticut of Agriculture Fanners'Market Guide.All state gu idelines in the State of
Connecticut Agriculture Farmers' Market Guide shall be followed.The Fanners' Market Guide:
htt111iy_��_��_.r.t.eov/done/lih/dna� marketing Filrs/Complete FM Rut. Guide 014.25_201?.pol
2.Set-up tune—mint be completed by 9:30AM. NO sales before 10:00 AM.
3.Booth Break-down—should be completed by 2:00 PM.Vendors must dispose of/take all trash with theta.
4.Market Absence. If you are unable to attend a scheduled Market,you MUST notify the Market Master
before Thursday,7:00PM,on Market Week. Exceptions are made for emergency or last—minute
situations. Failure to notify MAY result in a loss of Market Privileges.
5.Market Cancellations. In the unlikely event that the Market is cancelled due to severe weather,
infortnation will be posted on www.swtood.org AND Facebook by 7AM on Market day.
6. Connecticut Grown/Made--Farm/Food Vendors:All produce must be grown in CT, food must be made
by the Vendor in CT.Artisans:All items must be made by the vendor in CT.
7.Non transferrable—Thus Market booth is NOT transferable to other vendors.
8. Registered Business—Vendors must be a registered business with the State of Connecticut,have a CT
license AND provide a certificate of liability insurance with a minitnum liability limit of$500,000.
Liability Insurance-MUST NAME:Town of South Windsor as additional insured.
9.Sales Tax Certificate/Kitchen Certificate—ALL FOOD VENDORS tnust submit copies.
10. Food Vendor Permit Information. Farmers Market health and safety regulations are ivandated by the
State of Connecticut and administered by the Town of South Windsor Health Department.
IT 1S THE RESPONSIBILITY OF FOOD VENDORS TO APPLY FOR A FOOD PERMIT.
Forms available at:-.vw-.v.s%vfood.or and should be sent directly to the SW Health Dept at:
heather.oatis@soiitliwindsor
11.The South Windsor Farmers Market is a WIC Certified Market
12.Suoblemental Nutrition Assistance Pro¢ram(SNAP)--The SWFM is a SNAP-Certified Market.
Slioppeis with SNAP Cards may use their benefits at the Market using$1 Tokens provided by
Market Managers. More information will be provided to vendors at the start of the Market season.
Market Fees—paid by check, mast be received by April 15, 201G
Mail this signed Regulations Fornt with your Application&Check to:
SW Farmers Market/Summer 2016
75 Miuielle Dr.South Windsor, CT 06074
Market Master Phone: 860-373-7403
Email: southwindsorfood@gmail.com
Name of Fann/Vendor.
Vendor Signature: _ _ Date: _
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sot i Windsor Farmers Market 1 2016 Summer Market Application
www.swfood.org 1860TRESH.03 I Facebook&Instagram: SouthWindsorFannersMarket
fr�bc.°"'Aj " S`44 TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
1540 Sullivan Ave., South Windsor, CT 06074
Phone Number: (860) 644-2511 x250, Fax Number: (860) 644-7280
DECLARATION OF BASE OF OPERATION
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This Form mu+r he wbmit[cd with your application fo;permit.
Vendor Name: U IP.- S Vc4hP Corn
Vendor Owner/Operator Name:
Business Name of Base Of Op.: c 'torn
Address of Base Of Op.: f� 1 f� T(-1 QA-) T()1a0254
Owner of Business for Base Of Op.: Siva CQ
Telephone Number of Base Of Op.:
THE FOLLOWING PORTION TO BE FILLED OUT BY THE OWNER OF THE FOOD
ESTABLISHMENT USED AS THE BASE OF OPERATION.
I, (J S attest that my licensed food establishment
Owner of Food Establishment used as hase
�l
known as ( � �S P �P. �0� is available as the
Name of Food Establishment
base of operations for �� .S Corn owned by
Vendor
Owner of Business
I` ',^51 rCZf owner of Food Estal invent
**Please include a copy of the Base of Operation food permit issued by the local health
department.**
5. 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.
Food supply kept in NSA approved plastic bins
with snap lids
6. How will the all utensils and food contact surfaces be washed,rinsed and sanitized?
Utensils to be washed in our portable 4 bay sink
with hot water under pressure. Sanitized with a
solution of Santimine 150
7. Where will excess food(Potentially hazardous and non-potentially hazardous foods),dry goods,and single service
items be stored?
Food stored in 1.5 mil poly bags with twist ties
8. Where will ware wash detergents and sanitizers be stored?
Under sink
9. How will condiments and single service items(cups,plates,utensils,etc.)be dispensed?
Not applicable
10. What method of garbage disposal will be used?
30 gallon plastic garbage can with plastic bag
and snap lids. Disposed of at our base of
operation
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