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Home My WebLink AboutApplication 150 Nevers Road (12) To: South Windsor Health Dept Page 2 of 6 2016-09-21 13:52:06(GMT) From: Mike Welsh �N s - TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT 1540 Sullivan Ave., South Windsor, CT 06074 Phone Number: (860)644-2511 x250, Fax Number: (860) 644-7280 y 1��S3k•�UK v TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION ***TvIust be submitted 2 weeks prior to event,No fees charnei—W* =r% Event Name: South Windsor Apple Harvest Festival _........................._............._........-... ................_..............----..._..................................."-_. ........._........ ...._,...........-..... ..---........ .... ......... . :'.......................... ..__ _....__.._.,_..._:........,._ Event Date(s): October 2, 2016 i EventTime: 11:00am-4!00pm i....._............... _..-_..:._..............................................._........_...,_,.._..............._.....................,_...;.................. ...............................__........__....,......<....._.................................�..... .._.:_ .. _ .::............_..._., Event Location: Nevers Park Rotary Pavillion \ rA+ - y. ,.... ....... .:.....�,..� .... .._ .ti..... ._.C.....r...�.`,.•�:,', .X .4in�� JiiXY[ .:t.' ..\-, ::v4•-:.��:,r::1:.r...:):y<�r_:�:__,::v.,�.: :-,.,...,.:.•:a;;..::'....o-::.�::..::...:::...:<.......,::_-..:: __..r.,.--..,-_-:::.:...�..::..x..:..:" .. :.. .,n.... ,. .,:, ,.,.,,..,r - ,.... . ,::l,�yc":.. ..+r ,M,S> . ..,,a..,.: ..<.or:.:�,rr...:rarr:yv;S:.. Last Name: Welsh F First: Carol i M.I.: Hate: r.......... ..... ..... .._.......... __.,,.._........>....,,_..,..... .... ,,,.,.,.... ............. _..,,_....,....... ... ....... .._=..._...__._.,_. ..._...._....... _..., ....,........_..........._...x..._........._._._.,...J_,.,........................_....._. ..... ._.._...... : 3 Street Address: 17 WindWood Dr Apartment/Unit#: City: Glastonbury 1 State: CT Zip: 06033 Phone &Cell 860-209-8296 / E-mail theroastedbeanct@ gmail,com Phone: Address: •i`ra� y� .._<._-_.- -.. _.,.. :.r:.._, .,.:c,. .-,,.r�.._......G,. :::si:,, r,,.e;:. ..:..n:r....._..,... :A•..._:. .:.<6.` ..aa, T:,....i.,.?5�.y+i,.:, -::a;-:::a'...:::. --�:,.<...._,..:_......:,!....:..:............�-_< ..:.,..,.•- .. a,. ,w .:----..� ,r:...+ fn:,:4FS'�'r.*r ,�`.ti,.r �-t-fl,:.:, r:Si:'ti,R,,:RIirt:;r7�.>, .:.,..:r :fn> ,;"'n'.i;�i: ,r,:wY.'fkit r�a7,:aE;:;,,. , 1 ' I Representing: The Roasted Bean i Street Address: same as above ;Apartment/Unit#: i.............:.,,.:rr,,....,,.,,. .,............r:...•,_,,.........:_:.,.<:..:..................r,,::: .._.,,:...:......rrr,.:,rr..::. ..........................r.:_..-_..,r..:....., ,,,::..rrr::.r....:r..r,.:.,:.::...::.:::rr.:,:.rrrrrr....r,.,,rr..:r,............... _,. .....,:.,.,.....,:,. City: State: Zip: : Phone: E-mail Address: �{ s•r:T.7:;''ye1:/ .,:.. is 4, :.ati _ „ °i!i,F!+NrM'.Ma:�'LY�,:wi$,iYYwfu... z+.�':>;nJ_s._�.�'..:,4,::w:..,,�:. ................... ..........._- ...._.-_. ._....... ...-..... ..-........ ... .._-. •....__._.. �, '`L'.t--�Y-'>`,"v___ti. i:x3"c.'.:�:: Name: Certificate#: i Date: i•-. [+{:Y'yu�'1,"�•y::k-+'"' 1. �y x`f7'?%^7 �� y .!i":yy. u:r1:> ,,1:+ �:f•-•--• t`_.:..,.::._.. ,.a,YG.e v.,:.. ,...,,1.,L,.....e-.,',ATi i{.-..r ...vrcn,..,Nh'n.a♦ _.o, -.-...,:..., tY....:r. ...:,Y... ..,wJ ...........N.. .Y - r.,...—.. ..n...r w ,... .< .. ......e ._ ... _ Water Supply; bottled water YES NO `1 Wastewater Disposal YES r.j NO ..........._..._..................................-......................_........................-.------.-----------------..._----_..._..-------...-..._....._..........--..........-....--...--.-...-.-........... -.<.....-_.............................:........................................................,......,................... Electrical: generator YES NO If other,please explain: i. _ ::.,✓ /.;.�is [•f:^ �•� _ r.....,.. ...':t,.f r,r9.2 ... ^,....q,.: ... ..4::::Y.: :.y-: .: e r � - C ■� - �aS":ti:M'J:,'.m,•;1 ' :eav3,✓r..,tt.;f. r.,.•u:...J,?"..�.. ......: .e:.ee..., <.,f.J.;- ,.1, �'T .'�i- - - ::.�:;:::.::::.—::::_w:..�:,::�•::....:..:.:.:... ......____._'�:::,.:.�:.,,:,.,..u-,.:.r<:....;u�:A'8�+..fr..,-:r:.F.t::r—,.T..,:,:5 :`3ia Jam,:'! .-�,�...... .,,?+�.F.,:`YA.+Mh.Y;,.rt!...N�4.undf I,:ayrt� ,Yv.W.�+ ''€iTi<'!, m:Yr`.,?r;:":.�.r... locally roasted coffee-fresh brewed(hot&iced) 12oz bags of ground coffee i i 1 � 7 i ty. :Y, W .C., ..f.,+Y..-, /.,. if .R,a v✓ - - - _ r::,+;.,:,lr,„J.:,l �s �':;.,€f� ;,� ,� t:,�<.,1�.,,,.�t<;:,,;11,�.r'I.NX{i'rll♦��1�1RiF1,%it'«E I�+t�' {(�_�� IF�I�'yAS�`�'�3!-::��y� ,j�/�yj1n}' � s .. ,. <-.. _• ,.,�_.....�.4:,M.«F ....<..;.rr....r...` `....�.rr.e1k..'.,1:=i,:..Yn......:.. :.*:G.."' ..,...,,.AE...I e.,. ..,..,b:lnXif ....x X.'.., ...r'],..,f , The food preparation and storage areas must be careered if event is outdoors. Be sure that the tents used for overhead cover are fire-rated, ver the South Windsor Fire Marshal's office �:nn ..d•� :a ra.�;r7 tea:'. >;!!. .a ,�. - .,f.'s,r'.;i4a,e:.,,�<:'p:'�•ti,F�e :,Yi 4 .::e..n..,tr,•ir.,+n!r..,:.n,,::>:,.r.::..r..•::,,1s�..., cr.....r.,.A,...••.rn+';.....5!,,v...,•; ..y;d ,�.,, *,.a.,�..i . '� .,..:��.;.`:: 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. 1 ......................._........................_........................_..._................_.._........ -.....__..._....._...._.._...._............._............_............_............................................................................................................................. Applicant Name i {Please Print: Carol Welsh ..................,_._....._.-......__..:_r,,,.r,,,..,.a...,,.r,....rr,r.,:::.:..,.:.:...,:,.,,,a„r,.,,,r.rr,,..,.:r.,,,,..r....,ra----.":r..:.,,. _._...r...:r...,,,:,,...,::,..rr,....,r:,.,r,.,:,.„rr,.,,ra,rra„r,.,, Applicant Signature: Date: 9-.12-16 1......,_,.._.............._............._........... _.«.:.,._..,r.,..:.,.:,...:,:,..r-..=....._..:...:,..:...;..-:...,...,w......._.._..__._._......_................................._._................_......_...._......._......_........_......_.._.........................._............._._... TO:South Windsor Health Dept Page 3 of 6 2016-09-21 13:52:06(GMT) From: Mike Welsh f I T- 1K Inspector Name: Print: ........... ....................... Inspector Date: Signature: ............... ............ ............. .......................................................................................................... ....................------ Food Class: 1 2 3 4 FEE: N/A ............ ............. ............................ ............ Temporary Food License*: Expiration Date: ............ ............................ .............. ......... ...............—................................... ................................ ................................................. Notes,. Date Recelved! r ...................... .............................................................. ....... ....................... ............... To: South Windsor Health Dept Page 4p,g 2018-09-21 13:52:06(3MT) From: Mike Welsh Town of South Windsor Health Department Temporary Food Event Questionnaire Form Please complete all questions and return to the Health Department with your application. 1. What is the source nf the food h»beserxed/dispemsed? (Please include name/address ofsource) Foods must be from an approved source. Meat and dairy products must come from agovernment-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. locally roasted coffee -fresh brewed (hot&1cedcoffee 2. How will the food Items be kept cm|d/froaem? 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. milk & cream to be stored in portable coolerwith ice `- 3. How will the food items 6e 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. 4. Please describe the type of hand washing facility tobeused. pot2ble waterin dispenser, with excess catchbucket, hand soap & hand sanitizerincluded To: South Windsor Health Dept Page 5 of 6 2016-09-21 13:52:06(GMT) From: Mike Welsh S. 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. NIA 6. How will the all utensils and food contact surfaces be washed, rinsed and sanitized? tables are washed with clorox beach wipes 7. Where will excess food(Potentially hazardous and non-potentially hazardous foods),dry goods,and single service items be stored? N/A 8. Where will ware wash detergents and sanitizers be stored? 9. How will condiments and single service items(cups,plates, utensils, etc.) be dispensed? cups are placed on holder or in plastic stoarge bag to be dispensed one at a time by vendor 10. What method of garbage disposal will be used? trash can with trash bag To: South Windsor Health Dept Page 6 of 6 2016-09-21 13:52:06 (GMT) From: Mike Welsh Additional Information ❑ Contact the local Fire Marshal (860-282-0669) to ensure compliance with the Fire Code. ❑ The food preparation and storage areas must be covered if event is outdoors. Be sure that the tents used for overhead cover are fire-rated, per the South Windsor Fire Marshal's office. ❑ Wastewater must be disposed of in a sanitary sewer or other approved sewage disposal system. ❑ Equipment and tables must be clean, smooth, washable, durable, non-absorbent and in good repair. ❑ Gust must be controlled (i.e. dry fields) by watering down. I ❑ All workers at the food booth must sign a log sheet indicating the date,their name, address and telephone number and the hours that they worked. Please retain the log sheet after the event. ❑ If gloves are used, they must be a food grade quality glove and must be used for only:one task (such as working with ready-to-eat foods or with raw animal food). You must wash your hands after removing the gloves and prior to putting on a new pair of gloves. Gloves must be discarded when damaged or soiled, or when interruptions to use occur. ❑ Food employees may not wear nail polish or artificial nails unless wearing intact gloves in good repair.