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HomeMy WebLinkAboutApplication 150 Nevers Road (9) 7.4 'FQ1NNF0�JTH '11 �NtS4R HEAt,Tf QEPARTNIET' 1540.Sullivan.Ava,', SotltF►Windsor.CT'{ffip74 .. .L ... Phone Number; (860)644 251 x294, Fax Number: (860):644-7280 TEMPORARY/SPECIAL EVEN':MD1 SERVICE LICENSE APPLICATION ***rvlvst to submittedt 2 weeks prior to event,No fees charged**,' , Event Name ve t.:b s': Even t; n . �iinE 6 Event I.acatton; ``"C,�V li GNl~ RMAITIQI! P. 1 Last Name: First M.I.: gate911 F Aparlrra;ntlU Address riit#.;' .'...,..''treet...... .._: _�...._�_.,...,�!...... .;:�_:....�� _ . . .... .......,.. _ .<....._..__.,... - _ ......................_..._....�...ti-. State.: `:Phane..:ic i"eli *' E•mai3: y. "�°i�Rt"i�1NI211'{"Ib1��R1�P6E13� {�P�'Y'� f Representing Street Address t if if'aVY`►1ent/Unik# a., .. ... 1 ... i. :.._. ......... ,... err Phone; - aEl Address: ' ..YI . ;.lfii . hxEQ SOD QREIIA`rOt ,thlCd.UE(OPY 0 CER 1" ICA'#E) r " 4rIQ G'! Name: >:: .:..::..:.,..:......;..... �T. 9_.._.:...............,.:..._.........., ....,._a...... �..:....,.,..n- :::.:....... . . , .-.._.__.. .,__.._._....._.... ._. .t ertiiicatieM Date;: water .SUPO.' YES :o NO:� 'llltastEv+ta..ter bi posal YES Wl N i Eieebilcal's. Y Nt}., :Ifother;;please MEN4! * {pit trsr d itf+t �c�t IPJ* _. ._ ,ALL�iyMEN its '�pliK p>E`t'AXI.AS- All 3 t i i�Sllri�x�iEt �PIRA�iw'T#1�'�t!�K AF ��ill�'ItTI�c�N���t , 1 I 'the food:p.r*parotioti:and'-torap..:areas must he coverad:if event Is�d.0ars B sure: at the tents.used for overhead c©vet are f re rated.aer the.Southtindsar Eire Marshal's office. �'-AGili<EEMi AN©st6tntita 4:.•-.. :_...,...N _....,n_.,.'.1 .,...,_cn:'.., t .: v,.....t.... .,....:.... .:..- .- ..,:: ,..v.t.. ., ....... ,<.... r .. .,. ...... ....r. ..i.•:.a .. .. ffy submiWng this application,I atyllr r that the facts set forth in.w arestruearid complete.I understand that any,false statements or other rtiisrepresentatton5 made on this.application may result in immediate shutdown or fevocatlon of my temporary:Food Serves License,for the town of South Windsor, Temporary Fooj.Service.License wlil be'issued after the Food=inspector has completed tils/[rer iAspecdori: •plirBi�tNaii� .i AppNcarnt s�rtature: Date; , Gown of Soatb Windsor Reelth ..�1.. . artment Temporary Food Event Questionnaire Form r 1 �dj iw,, r Ileple�sa caraplato all questions and-raituro o they Houlth Department with Your application. 1, What is the source of th+e`fpgd to:.be.sewed/di5pen5ed? (Please include name/address of source) Foods must be.from an approved.source:; Meat.and dairy ptoducts:must comefrom a goverrtnient-irtispecte.cl .source. if it is necessary to bring].n foods that are.pf`epared at e:licensed facility other than the temporary site,:you ust indicate how the food is protected during transport:and how it i5:kept hot or cold.as rie m edo& , YP P g an�'s�:lub. Mtn,`.: : ra acka a..corn;as P ro tics in owstate licensed food mane acturng facility 2: Hover Will the food items be kept cold/fr!oaen'T ice must be from a`n approved potable sour-ce. Frozen foods ac nnot he:thavOid at room temperature. Proper thaw[ng can be done in:.a refrigerator,under cool running water,or a.s Part of the coaking process, Not applica+bJa 3 lioW vulll the food items be cooked and/or-hot held? A saititi ed metal stemmed,callbr . probe thermometer:to monitor food temperature is required.. If-thin patties. are beirfg cocked;a.:thet7nocauple°may.be needed tQ:accurately checIc temperatures. 00oked in a 160 lit propane fired — stainless$tet kettle d. easg describe the type of hand washing famlity`to be used, Portable-sink with ho, .water under pressure �. .--.. .. 5 How will the;food be proteftd? Fdod:mtast:be. pfotected during, rage,preparation,display,service and transpartatlorM. Coo*-I rg to order i ll lessen the chanGe:ftsr baeteria[growth.,vyhich.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 :...............:.::.. . ..:.::.:. ..... ... . .. ...... .. : WO hod s#er under pressure: anitze wit a -solution of Santirrline 150 T. Where will excess food(potentially hazardous and nonwpotentiaily hazardous foods);dry goods,and:single service litems be stared?: Foad sfared in.1.-rnff pOly bags with twist ties S. Where will ware wash detergents:.arid:senitmers be::stored? Under sink 9. `How will.condiments and single service items(cups,plates utensils,etc.)be dispensed?, Not applicable 10. what method Of 980*04 sposal:vi►ill be.;ow? .. ... ....... .. .. .. :... . ....... . ...:.. gallon plan#tG gar.age Iran with plasfre ag and snap'lids. Disposed Of-at. Our base of operati n I oo .�k1. 'k.'`-'�i1•� It '� s�#':. I .. �f*,a. �'K-9r� 1 a `�r�� r 77. •..\.�` 's,*j��� �^""�':k L�Y� l of� �:Z i'�7}'F }+Y� fi5'; Y � y �•.f�:y�Yzv.1Y1`k� � ,` „ - ,f �-.tNh.�^"t'J �➢ ,,.�. k{ xiv d; sAbN lis ol ` .:y";�arv,°��4�' `Y-f�� R,.c;?` t YES�•' t' ''� s' r'�' ' f �t � r •L 11 Y'yR�u y^t ... . . . ...:: w4 - _ — 2: • i .T «_ ..r a. .. ... .. .. t`' 71 _ . T. . .. : .-Y w : w7 try 77 • © us : r _ y. y IMP.Odac Name; lospector .. „. .. 5 nature: _..__.._._.. . ........_.. ...m_.r. _ load Cta 1; C3.3 ,4. �1 .. Expiration Date:. 7'egrs Food Ucensa#K .._ .,_ ,. _ . ., _..._.. _...._... ... E.Nds: ate Received: 522265 STATE Or, C'.ONN CTICUT DEPARTMENT .0.F C 04N SIj M 1E R P.R0 TE .1 p A t G"I A.1 C 11 U C + H&:r t f o r d O>A il CI.0 t I, 1. .0 6 t Q IIS your license certificate:. Such license:shall bepogiod in a conspicuous location and'shown to any properly interested .person on request. Donot attemptta make any dhanges or aIter this certificate m.any way: license. trans.&rable; We A*fhafY ti keep Yollt email inkrmati ith_our office.currey-it. All,renewal nqtificatbns an&cattificateg.will oul y eMailad to:the last reported email on.record. Questions regarding this;.license can be directed to the Food and.Standards Division ai.do...f.00dandstandardg@dt.y,.o Mhd.Ingad I dress.- EMAI on foie tube usea Far receiving notices from WS Office. 1 9.FPS'nTTLE CORN jcstrong@snet.net 31 HALE VXMT EXr VERNON ROCKMLE,tT 060"-3748 :U' .0 M T ON STATE O. CONN CTIC..T + EPAWYMENT OV'CONSIJ ERPROTEW I Be it Upow#That, JEFFS'KETTLE CORN A T4UA3M�CT�06004=fiW has certified by the VOCO MV��VRTNGESTABLISHMENT Ucetise F-M.E.0000154, Efffto":Deft... 01/01/2016 tlxpirafion Date: 06/30/2017 Jo athnnA�.I3a:eisiCawm�saioner