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Home My WebLink AboutApplication 80 Hayes Road (2) nab w ��ea� TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT y , 1540 Sullivan Ave., South Windsor, CT 06074 Phone Number: (860) 644-2511 x250, Fax Number: (860) 644-7280 ' 'Rt4_ER� i LAKE T FOOD SERVICE LICENSE APPLICATION ***Must be submitted 2 weeks prior to event,No fees charged -*:',: EVENT INFORMATION `` G /��,�" Event Name: SOI,I.'47 tN,tjcjsVf Lvg7ktl' f LLj�►n6js I�r�-i(ket Event Date(s): Event Time: Event Location: If , ,t 1140, 1 � 071JAII Crime H&V eS Si PERSON IN CHARGE INFORMATION 3 V 1 J T Last Name: ( I First: L�I HC(, M.I.: Date: Ill —to ./(j Street Address:`) I Apartment/Unit#: City: State: C_r Zip: v Phone &Ceu E-m3 / j '1(D7Z�� Address: u l IQr10 I28�@ hL�•LEI Phone: ,_t, ` Lo Y7 �� ORGANIZATION REPRESENTED , (IF ANY) Representing: Mac O�UTf&4.5 �L F�S UC- _ _ Street Address: Lo I C I I ll � �� Apartment/Unit#I: City: If� State: Phone: E-mail Address: l nj t, m(�b1R 4�U/1 t "JL � Corn QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) J YES NO Name: Certificate#: Date: ADDITIONAL INFORMATION Water Supply: YES NO Wastewater Disposal YES FA NO Electrical: YES ?_ NO If other, please explain: MENU **(PLEASE LIST ALL zAENU d'-EMS IN AS MUCH DETAIL AS POSSIBLE)* hot- SCI,i i s ****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 he 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 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 k1spector hapaompleted his/her inspection. Applicant Name — � I• (Please Print): ,I MA �1 Applicant Signature: n Date: 9U, u• X)UTH WINDS01' �� ==JEALTH DEP-l'. I I- f I -iQ-- i I � _ I _ I I I I �I TV 1 OFFICE USE ONLY Inspector Name: (Please Pint): Inspector Date: Signature: Food Class: 1❑ 2 Q 3 0 4❑ Temporary Food License#: Expiration Date: Notes: Date Received: a 0Ye� Town of South Windsor Health Department 7 �0• " $CAS Temporary Food Event Questionnaire Form Please complete all questions and return to the Health Department with your application. ORA" 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. R-bdi I I. k C11 e- 111"L(-, d jil Cf O)JIVU 1<1 khtn 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. 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. n) ,0 4. Please describe the type of hand washing facility to be used. W144'9100,117 art Z)VT l Our' T�u�s l�l 1_)� D(Ll f k ('li 1 S )PA kd O ) 4 b4e_11S1 1 5j2DOr7-5 ECOTE N S I L • 0 Q 0 O f O C O• • O� N 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. LID 6. How will the all utensils and food contact surfaces be washed,rinsed and sanitized? /U' Iq 7. Where will excess food(Potentially hazardous and non-potentially hazardous foods),dry goods,and single service items be stored? a) 6 8. Where will ware wash detergents and sanitizers be stored? 9. How will condiments and single service items(cups,plates,utensils,etc.) be dispensed? 10. What method of garbage disposal will be used? wit. 01tc, TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT V 1540 Sullivan Ave., South Windsor, CT 06074 - '► �' Phone Number: (860) 644-2511 x250, Fax Number: (860) 644-7280 Q. .5'OR•l.0~ DECLARATION OF BASE OF OPERATION This form must be submitted with your application for permit. Vendor Name: IvQ(`8CbP, h0,i/:SALL✓ Me �' L Ck /1r Vendor Owner/Operator Name: Gar� 111[, Business Name of Base Of Op.: I11(jG GDU.Lp2U.f' &odS LL( Address of Base Of Op.: (- 1 H l (Irzs. �r Me;-iGuji Owner of Business for Base Of Op.: Galki r I l L Telephone Number of Base Of Op.: &1) ^ 9�110 — I/�� THE FOLLOWING PORTION TO BE FILLED OUT BY THE OWNER OF THE FOOD ESTABLISHMENT USED AS THE BASE OF OPERATION. I, CIO attest that my licensed food establishment Owner df Food Establishment used as base known ass Gyu,? C�SLLC is available as the Name of Food Establishrfient base of operations for Out'. 6I7) 1 -s C ou'312U_t /QS owned by Vendor caner bf Business Signatur caner of Food Establishment "Please include a copy of the Base of Operation food permit issued by the local health department." EHS.106-Rev.11105 INSPECTION REPORT STATE OF CONNECTICUT ROUTINE INSPECTION ❑ REINSPECTION FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH ❑ PREOPERATIONAL ❑ OTHER 410 Capitol Avenue,MS#11 FDP,Hartford,CT 06134 NAME OF A ESTABLISHMENT ESTABLISHMENT /r 1 A C ? 1,( CLASS STREET ADDRESS l Wirt TOWN OWNER or � f INSPECTION 1` OPERATOR ✓y yVl C �y.Q 4�( DATE and TIME -3/ Based on an inspection this day,the items marked below identify the violations in operation or facilities which must be corrected by the date specified below. SOURCES OF FOOD EQUIPMENT&UTENSILS:CLEANLINESS VERMIN CONTROL 1 Approved source,wholesome, 4 21 Preflushed,scraped,soaked and racked 42 Presence of insectstrodents 2 nonadulterated 22 Wash water clean,proper temperature 1 43 Outer openings protected against entrance of 1 2 Odginal container,property labeled 1 23 Accurate thermometers provided,dish basket,If usd insects/rodents 24 Sanitization rinse(hot water-chemical) 2 FOOD PROTECTION 25 Clean wiping cloths 1 FLOORS,WALLS&CEILINGS 3 Potentially hazardous food meets 4 26 Food-contact surfaces of utensils& 2 44 Floors:floor covering installed, temperature requirements during storage, equipment dean constructed as required,good repair,dean preparation,display,service,and transportation 'Nonfood-contact surfs s of utensils& 1 45 Floors,graded,drained as required 1 e uipment clean i ' OF 46 Floor,wall juncture covered 4 Adequate facilities to maintain product 2 28 Equipment/utensils,storage,handling 1 47 Mats removable,good repair,clean temperature,thermometers Drovided 5 Potentially hazardous food property thawed 2 C 1�es�. j i' �„r d wt r cL^1k 48 Exterior walking,driving surfaces, 1 6 Unwrapped or potentially hazardous food 4 WATER SUPPLY _, good repair,dean not re served 29 Water source adequate,safe 4 / 49 Walls,ceilings attached,equipment property �] 7 Food protected during storage,preparation. 30 Hot and cold water under pressure, 2 constructed,good repair,de n. Wall&ceiling display,service&transport lion t � Sl� �,( .2 provided as required surfacesas req 8 Food containers stored off flo-of 50 Dustless cleaning methods used, 1 SEWAGE DISPOSAL cleaning equipment property stored 9 Handling of food minimized 2 31 Sewage disposal approved 4 10 Food dispensing utensils property stored 1 32 Proper disposal of waste water 1 LIGHTING&VENTILATION 11 Toxic items properly stored,labeled,used 4 51 Adequate lighting provided as required 1 PLUMBING 52 Room free of steam,smoke odors 1 PERSONNEL 33 Location,installation,maintenance 1 53 Room&equipment hoods,ducts,vented as required 12 1 Personnel with infection restricted 14 34 Nodes connection,back siphonage,badkflow 4 DRESSING ROOMS&LOCKERS CLEANLINESS OF PERSONNEL TOILET FACILITIES 54 Rooms adequate,dean,adequate lockers 1 13 Handwashing facilities provided, 4 35 Adequate,convenient,accessible,designed, 4 provided,facilities dean personnel hands washed,clean installed 14 Clean outer clothes,effective hair restraints 1 36 Toilet rooms enclosed with self-closing door 1 15 Good hygienic practices,smoking restricted 2 37 Proper fixtures provided,good repair,dean HOUSEKEEPING 55 Establishment and premises free of litter,no 1 EQUIPMENT&UTENSILS: DESIGN, UANDWASHING FACILITIES 11 insect/rodentharborage,no unnecessary articles CONSTRUCTION &INSTALLATION Suitable hand cleaner and sam!ary towels or 1 56 Complete separation from living/sleeping quarters 1 16 Food-contact surfaces designed,constructed, 2 ✓ apPro:A hand ' ic:r devices nro,,77— and laundry maintained,installed,looted tissue waste receptacles provided 57 Clean/soiled linens stored property 1 17 Nonfood-contact surfaces designed, 1 58 No live birds,turtles,or other animals 1 constructed,maintained,installed,located GARBAGEfRUBBISH STORAGE&DISPOSAL (except guide dogs) 18 Single service articles,storage,dispensing 2 39 Approved containers,adequate number, 1 19 No reuse of single service article covered,rodent proof,dean SMOKING PROHIBITED 20 Dishwashing facilities approved design,adequately 2 40 Storage arealrooms,enclosures— 59 1 Smoking prohibited,signs posted at each 3 constructed,maintained,installed,located property constructed,dean entrance 1 41 Garbage disposed of in an approved manner, at approved frequency QUALIFIED FOOD OPERATOR DEMERIT SCORE 60 Qualified Food Operator 3 4 3 2 1 RISK FACTOR VIOLATIONS IN RED 61 Designated alternate 2 62 Written documentation of training program 2 Signature of Pelson in charge TOTAL RATING Date Corrections Due SIGNED(in�ctor) DESCRIBE DEFICIENCIES ON CONTINUATION STREETS DISTRIBUTION:1" -White—Health Department 2Id—Yellow—Owner/Operator