HomeMy WebLinkAboutApplication 771 Ellington Road 6
TOWN.OF SOUTH WINDSOR HEALTH .DEPARTMENT.
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1540 Sullivan Ave,, South Windsor,CT 06074
Phone Number; (860) 644-2511 x250, Fax Number: (860)644-7280
r��SOQ•C°�� TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATIO
""Must be submitted 2 weeks Prior to eveaL No tees charged***
Event Name: 1 A
Event Date S : 016
Event Time:
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Event Location: A �1
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Last Name rv71✓1 First M.Z.: Date:
l Street-Addres5: _� �i0✓) n_ -- .... _.._._._ ' ApartmentlUnit#: _______
State:__...,.. �.., = zip- 6
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1 Phone.• `i ! y d Address: y V)V1 @ �-O v f, U�( L
Representing: _. ... _. .. r. —D�-a"I ��_✓_y_�__-'-.•••�.�ff. �i�
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Street Address: 1 1 F' ^y? _`!'_�-- I Apartment/Unit
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b Phone: 7 �� 5 � ., ,� E-mail Add1'ressf : -�� M,. r�l 1 1 1� / L
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4 Name:
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Certificate#; a o�a s 3� Date:
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? Water Supply: W�jV4� YE5 NO ❑ Wastewater Disposal YES {� D ❑
Electrical YES .�.ryo. If other,please _ ___...........__...�.-------�—.�.. ,,,_, ,,w..v.•f
explain:
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The food preparation and storage areas must be covered if event is outdoors. Be sure t at the-
tents used for overhead cover are fire-rated, per the South Windsor Fire Marshal's office.
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By sUbrnitting this application,I affirm that the facts set forth In It are true and complete, I understand that any false statements i misrepresentatlons made on this application may result in immediate shutdown or revocatlon of my temporary Food Service License for the Town
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-M --—��——�� r inspection, SEE
: of South Windsor. Temporary Food Service License will be issued after the Food Inspector has completed his/he
Applicant Nama
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-ApplicantµM i natur HEALTH DE Signature-. � Date; �T
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Town of South Windsor Health Department
Temporary Food Event Questionnaire Form
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,A �G Please complete all questions and return to the Health Department with your application.
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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-inspe ed
source. If it is necessary to bring in foods that are prepared at a licensed facility other than the temporar site,you
must indicate how the food is protected during transport and how it is kept hot or cold as neededAt CA 0
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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.
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 t in patties
are being cooked, a thermocouple may be needed to accurately check temperatures.
4. Please describe the type of hand washing facility to be used.
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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.
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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 si igle service
items be stored?
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8. Where will ware wash detergents and sanitizers be stored?
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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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! Inspector Name:
(Please Print),
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iInspectorDate:
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Food Class: 1 CI 2❑3 0 4 CJ FEE; N/A l
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Temporary Food License#: Expiration Date; !
NoWS: Date Received:
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