HomeMy WebLinkAboutApplication 1175 Ellington Road (2) ww. far TOWN OF SOUTH
n° H 1NINDSOR HEALTH DEPARTMENT
O - 154o Sullivan Ave., South Windsor, CT 06074
Phone Number: (860) 644-2511 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: � '
Event Da s: er Evt TIC f - 'r"1'
Evert Location: t A'd b..e- f rQ s� 11a/t
PERSON IN CHARGE INFORMATION
Last Name: First: S�Ir� M.I.: Date:
Street Address: Apartment/Unit#:
city, Ir��A" ^ �/l State: Zp: ill
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Phone 'L Cell g : E-mail 1
Phone o )2(3 '6�1 Address:
ORGANIZATION REPRESENTED Q(IF A"
Representing:
' Street Address:' TS-6 k. !n is+ X 1�gpartmerM/Unit#:B� rv1
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City. � �\1, I : State: Cfi ' 7JP- . .
Phone:(�03� Email Address: .1 `n�`-
QUALIFIED FOOD OPERATOR (INCLUDE. DY OF CERTIFICATE) : ; 5
Name:
Certificate#: Date:
ADDITIONAL INFORMATION
Water Supply: YES I_ NO Wastewater Disposal YES ❑ NO ;
YES NO 0 if other,please
Electrical: explain: -
MENU i**(PLEAS!LIST ALL MCNU rWMS IN AS MUCH DIETAIL'ASPOSSIBLE)*x
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****PLEASE DRAW A DETAII DIAGRAM OF FOOD BOOTkI ON THE BACK OF.THIS FORM:
USING THE GRAPH .ICTURE ON THE BACK•OF THIS APPLICATION."''""
The food preparation and storage a�Fas 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 skmitting this application,I affirm that the fads forth In it are true and complete. I understand mat any tatse stabemenl5 or other
misrepresentations made on this appiicAoon may m5uttin immediate shubdown or revocation of my temporary Food Service Llmnse for the Town
of South Windsor. Temporary Food Service Ucense will be issued after the Food Inspector has completed his/her inspection.
Applicant Name
(Plem Print):
Applicant Signature: te:
; Da �/��
Town f South Windsor Health Department
o �►.. `� 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 servedldlspensed? (Please Include nAme/address of source)
Foods must be from an approved source. w;eat 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 dugng transport and how it is kept hot or cold as needed.
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*Iity to be used.
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