HomeMy WebLinkAboutApplication 80 Haynes Road From:BEAR'S 660 436 2822 10/11/2016 11:17 #109 P.001/004
Q TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
r _ 1540 Sullivan Ave., South Windsor, CT 06074
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Phone Number: (860) 644-2S11 x2S0, Fax Number: (860)644-7280
'�-5'6N•i�� TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION
**'Must be submitted 2 weeks prior to event,No Fees charged***
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Event Name:
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Event Date(s): Event Time:,�r; . ��6 A
Event Location:
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.PERSNINCHA GE INF
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Last Name: �`�' � _ ....... ........ ..:... ....... . .........First: --� ----.. . ..............,:.:•M.I.: \,A`. ..Date: k o" 1 I..�,..•.
Street Address: ` L. �' r' �C
L L.Lti }C,T��j `�' Apartment/Unit#:
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City. G -�j;H •lt►'t. �` c�rL.... . . .... State: C..1.. Zip' Q, (�I
Phone &Cell E-mail
Phone: b Address: 5
ORGANIZATION REPRESENTED. f.
Representing: - �•, :_ .: _..__............. :_...._;�...;...,;._.;.
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Street Address: \_ �L_k Apartment/Unit#:
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City: state: Zip:
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Phone: E-mail Address:
QUALIFIED FO.q..0 R/TOR. ':IINCLUDE C.OPT(-OF•.CERTIFICATE} YES.:rya
Name:
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Certificate#: ' Date:
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AD O D I N L INFORM T=O IT A A n
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Water Supply: YES NO Y' Wastewater Disposal YES L; NO
Electrical: C3 Q use
MEN �:.. ' . . ,,::. :t'•`•'`'�'''•�• �•�`»*N ..•**...
U ,..:.:;:•;} ti `:;'; PLEASE LIST MENIf~ITEMS IN MUCH DET BtECr
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4!. `.PLEASE DRAW:A.DETAILDIAGRAM.OF:FOOp,.1BOQ7H.:gN THE,DACK Of:TH.IS F,ORM..
SItYG TFiE GRI#PH PICTv.RE O}1t TFIE BACK OF.ThS APPLICATION!*#•�
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, oer the South Windsor Fire Marshal's office.
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• G RE E �i'=N D S TUR E .AIM .I. E:.
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.
Applicant Name
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(Please Print): ;•� ~- .- _.r ��,_
Applicant Signature: �� i-fLpc�L. OCT Date:
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SOUTH WINDSOR
HEALTH bEPT.
From:BEAR'S 860 436 2822 10/11/2016 11:17 #109 P_0O2/004
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oiFfICE USE ONLY
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(Pleas,`Print): ... �TIG.I�.�_:.,.0(/l�f• .. ... ..,.......,.........
Inspector Nam
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Inspector Date:
Signature: ....
Food Class: 101 2 LJ 3 L 14 i_.1 FEE: N/A
Temporary Food License#: Expiration Date:
Notes: Date Received:
From:BEAR'S 860 436 2822 10/11/2016 11:16 #109 P.003/004
Town of South Windsor Health Department
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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 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.
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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.
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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 facility to be used.
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Fram.BEAR'S 860 436 2622 10/11/2016 11:1B #109 P.004/004
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.
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6. How will the all utensils and food contact surfaces be washed, rinsed and sanitized?
7. Where will excess food(Potentially hazardous and non-potentially hazardous foods),dry goods,and single service
items be stored?
S. Where will ware wash detergents and sanitizes be stored?
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?