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HomeMy WebLinkAboutApplication 150 Nevers Road (18) K o're TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT j v _ 1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address - 1530 Sullivan Ave., South Windsor, CT 06074—Office Address Phone Number: (860) 337-6173, Fax Number: (860) 644-1930 TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION ***Must be submitted 2 weeks prior to event*** �EVENTINFOCMATION Event Name: )(L) Event Date(s): /O , /7 Event Time: /Q -- 3 Event Location: /C,Ic tl c lI plq 0 ✓ PERSON IN CHARGE INFORMATION Last Name: kAybc-•' , First: �NCY M.I.: Street Address: /10 R_%Vnt4j1 AC_1` (1,4p 41\G r Ilf Apartment/Unit#: City: QPUMA1,60A 1 �( f State: C7 Zip: ©(a 053 Phone: O1/_b, L /�j M ftJTg E-mail U�% 0 0 V Address: ORGANIZATION REPRESENTED (IF ANY) Representing: Cmaee_ �P/C&65 00 Street Address: 6,4me Apartment/Unit# City: .541vE State Zip: Phone: .5A4me E-mail Address: /��� /Ct��K �044k QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) (�J YES NO Name: 4raf A1 f ' Certificate#: Date: ADDITIONAL INFORMATION Water Supply: YES NO ✓ Wastewater Disposal YES NO ' Electrical: YES NO ;_ Base k Operations: MENU "(PLEASE LIST ALL MENU ITEMS IN AS MUCH DETAIL AS POSSIBLE)** Pfr__A91C_1C 14C.b Con &5 ****PLEASE DRAW A DETAIL DIAGRAM OF FOOD BOOTH ON THE BACK OF THIS FORM. USING THE GRAPH PICTURE ON THE BACK OF THIS 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. Der the South Windsor Fire Marshal's office. AGREEMENT AND SIGNATURE 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 _/4 i'n (Please Print): N IVV1 dRYWd Applicant tiign ure: p, , Date: b " oKQ� Town of South Windsor Health Department '0M S, 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. rO%JL5 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. 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. 4. Please describe the type of hand washing facility to be used. 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. ❑ Dust must be controlled (i.e. dry fields) by watering down ❑ 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.