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HomeMy WebLinkAboutApplication 65 Rye Street Oct 20 16,02:07p p.1 `ll'�`L`i''e TOWN OF SOUTH WI NDSOR HEALTH DEPARTMENT 1540 Sullivan Ave., South Windsor, CT 06074 Phone Number: (860) 644-2511 x250, Fax Number: (860) 644-7280 ' '•- SPECI AL EVENT FOOD SERVI CE LI CENSE APPLI CATION "`Must besubmitted 2 weeks prior to event, No fees charged*'* EVENT.I NFORMATION Event Name: OCT 2 4 2016 Event Date(s): f I // „ Event Tame: r� Event Location: SOUTH WINDSOR.. .._F.Lj.�1C ' IC+}�� __���+a^t/': .:...._.►.<.c.C..+..l.t.I� . ... .. ..._. ffEAITHDEPT PERSON.-I N CHARGE 1 NFORM.. TI ON Last Name: '� �IGiC First: Ce'� M.I.. Date: Street Address: Ap nt1Un CjG City: ;':E Slate: �a lap: ./v( f Phone &Cell E-mail 1 f _1 f-ti I II Phone: _ r_,� r Address fir✓ 1 cr,l: I�?�i a� . a..., G' t ORGANIZATION REPRESENTED (I F ANY) €. Representing. , r- .Street Address: i Apartment/Unit City: �1 fi Sate ..._ ' Zip- Phone: ^r - �i 'J� E-mail Address: QUALI FI ED FOOD OPERATOR (I NCLUDE COPY OF CERTI Ft CATE) ✓YES 3 NO f_I Nam a: Certificate#: Date: ADDITIONAL INFORMATION Water Supply: YES .J NO .;�Wastewaler Disposal YES NO r ©ec rival: YES �! NO %�I f other,please explain: MEN U "`(PLEASE:';' :_ - "'•,I N AS MUCH DETAI L AS POSSI BLE) "•'•PLEASE DRAW A DETAIL DIAGRAM OF FOOD 800TH ON THE BACK CF TH I S FORM. USING THE GRAPH PI CTURE ON TH E BACK OF THIS APFLI CATION' i AGREEMENT AND SI GNATURE By submitting this application,I affirm that the fads set forth in it are true and complete. I understand that any false statements or other misrepresentations made on this application may resutt 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 hisiher inspection. Applicant Name P r 11 { (Please Print): . , Applicant Signature: ;...._ _. Date: t f Oct 20 16,02:07p p.2 I i i l I t i �(. I I i s-- ' ! �ti I ' �«'i •' I I� - �_ I ! , s i l _ OFFI CE USE ONLY Inspector Name: (Please Print): Inspector Date: Signature: Food Gass: 1 I_. 2 : 3 4 Temporary Food License#: Expiration Date. Notes: Date Received: Oct 2016,02:07p p.4 5. How will the food be protected? Food must be protected during storage, preparation,display,service and transportation. Cbokingto order will lessen the chance for bacterial growth,which may occur prior to service. 6. How will the all utensils and food contact surfaces be washed,rinsed and sanitized? yy � 7. Where will excess food(Potentially hazardous and non-potentially hazardous foods),dry goods,and single service it ems be stored? 8. Where will ware wash detergents and sanitizers be stored? t f 9. How will condiments and single service items(cups, plates,utensils,etc.)be dispensed? 10. What method of garbage disposal will be used? ,, j `� Oct 20 16,02:07p p.5 Additional Information Qontact 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'scffice. r Wastewater must be disposed of in a sanitary sewer or other approved sewage disposal system. -� Equipment and tables must be dean, smooth,washable,durable, non-absorbent and in good repair. Dust must be controlled(i.e.dry fields)by watering down. Fi All workers at the food booth must sign a log sheet indicating the date, their name,address and telephone number and the hoursthat they worked. Rease 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 anew pair of gloves. Gloves must be discarded when damaged or soiled, or when interruptionsto use occur. r- Food employees may not wear nail polish or artificial nails unlesswearing intact gloves in good repai r.