HomeMy WebLinkAboutApplication 65 Rye Street (2) Oct 2016, 02:07p p.1
w., TOWN OF SOUTH WI NDSOR HEALTH DEPARTMENT
- -_ — - 1540 Sullivan Ave., South Windsor, CT 06074
Phone Number: (860) 644-2511 x250, Fax Number: (660) 644-7280
SPEC!AL EVENT FOOD SERVI CE LI CENSE APPLI CATI ON
`**M ust be submitted 2 weeksprior to event, No fees charged* '
_.. . . RECEIVED..
EVENT)NFORMATION
Event Name:
2 4 2016
Event Date(s): I f Event Time:
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Event Location: e ! EA
H WINpSOR�'
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1 — {� ii ii HEALTH DEPT.PERSON I N CHARGE 1 NFORM./TI ON
Last Name: J !� First: M.I.: ! Date: en
Street Address: + ` _ Aparlmenn it
City: State Zip:
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Prone &Cell E-mail
Phone: _%�_ -`r_: ��' Address: �t�.e1-1`�v,C ... -C li i�" +_r.��G' t
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ORGAN IZATI ON REPRESENTED (i F ANY) l
f;epresenting:
Street Address: 1� 4 -ten '� f } 1 Apartment/Unit
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City: S . �. State: � Zip:
Phone: ^ �f^ E-mail Address:
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QUALI FI ED FOOD OPERATOR (I NCLUDE COPY OF CERTI FI CATE:) S-e"YES ri NO LJ
Name:---- `tJ .• i� 1^.. . .. .
Certificate#: ` s v� -� Date:
ADD TI ONAL I NFORMATI ON
Water Supply: YES .J NO Wastewater Disposal YES NO y
Electrical: Yl —1 NO If other, please
explain:
MENU t "`(PLEASE. 'r'-..: • _ ,I N AS MUCH DETAI L AS POSSi BLE)"
PLEASE DRAW A DETAI L DI AGRAM OF FOOD BOOTH ON THE BACK OF THI S FORM,
USI NG THE.GRAPH PI CTURE ON TH E BACK OF THI S APFLI CATI ON'
AGREEMENT AND SIGNATURE
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 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 I nspedor has completed hislher inspection.
Applicant Name
(Please Print): t?J�• �. i
..Applicant Signature: . ..
. Date:: ..�.
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Oct 20 16,02:07p p.2
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OFFI CE USE ONLY
Inspector Name:
' (Please Print):
Inspector Date:
Sgnalure:
Food Gass: 1 lW 2 3 4
Tempofary Food license#: Expiration Date:
Notes: Date Received:
Oct 2016, 02:07p p.3
Town d SNA VYndsor HmIth QMgdnmrit
TaTpaary Food Event Qjesti onnai re Form
1. What is the source of the food to be served/dispensed? (Please include namel 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 foodsthat are prepared at a licensed facility other than the temporary site,you
must indicate how the food is protected durirgtransport and how it iskept hot or cold as needed.
2- How will the food items be kept cold/frozer?
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 isrequired. If thin patties
are being cooked, a thermocouple maybe needed to accurately check temperatures
4. Please describe the type of hand washing facility to be used.
Oct 2016,02:07p p.4
5. How will the food be protected?
Food must be protected during storage, preparation,display, service and transportation. Gboking to order will
lessen the chance for bacterial growth,which may occur prior to service.
6. Flow 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?
8_ Where will ware wash detergents and sanitizersbe stored?
9. Flow will condiments and single service items(cups,plates,utensils,etc.)be dispensed?
41
10. What method of garbage disposal will be used?
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Oct 20 16, 02:07p p.5
Additional Information
Cbntad the locai Fire Marshal (860-282-0669)to ensure compliance with the Fire Code.
u The food preparation and storage areas must be covered if event is outdoors. Be sure that the
tents used for overhead cover are f ire-rated, per the South Windsor Fire M arshal's office.
r: Wastewater must be disposed of in a sanitary sewer or other approved sewage disposal system.
D 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.
n 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 removi ng t he gloves and prior to putting on anew pair of gloves. Coves must be discarded
when damaged or soiled, or when interruptionsto use occur.
E Food employees may not wear nail polish or artificial nails unlesswearing intact gloves in good
repair.