HomeMy WebLinkAboutApplication 1175 Ellington Road (6) Nov. 29. 2017 9 : 00AM No. 4696 P. 1
NC� TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
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c L i 15�40 Sullivan Ave., South Windsor, CT 06074 Mailing Address
s . _ 1530 Sullivan Ave., South Windsor, CT 06074—Office Address
PhuriF- Number: (860) 337-6173, Fax Number: (800) 644-1930
TEMPORARYISPECIAL EVENT FOOD SERVICE LICENSE APPLICATION
***Must be submitted 2 weeks prior to event***
Event Kame._._..3r�lilk-Fyi;�l _ .► ,. 41n (/�
Event Date(s) Event Time
Event Location;
PERSON IN.CHARGEJNFORMATi N p
Last Name; � �� _..._ __._..__._.._..--.,. .• First: uL I I _• _ _M.L--M� _-... -.__.... . .
Street Address: 1 Apartment/Unit#: '
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City.ji, Sl._�Sl_!._l !Y �. .��` State; �T Zip: b�
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ORGANIZATION REPRESENTED (IF ANY•)' .
! Representing; So 1 �Jo_r V,V l_c:s _.
i Street Address: 1� A artmen Unit#:
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Phone: .Qj^.o � �� E-mail Address: Corn rn an.'ii
',QUALIFIED FOOD OPERATOR. (INCLUDE COPY OF CERTIFICATE) YE9 NO
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j Name! 1
Certificate#: Date:
ADD�LTIONAL-INFORMATION•.=`:-. ._'_:.- _ - _ - _ _ - _ _ •
Water Supply: YES 1JI NO Wastewater disposal YES NO 4 i
t lectrical:— YES [� NO Base of I
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N�ENiJ (P.l_EASE.LZST A•LL MIENU ITEMS IN;AS MUCH:DETAIL AS POSSIBLE)'''
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U`.'.ING Tlir: 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 oveiiI cover are fire-rated. 0(,r tfic SU Ith Windsor Fire IVlarshai's office.
AGRII MENT AND:SIGNATURE
By submitting this application,I affirm that the facts set forth in It are true and complete,I understand that any false s:ctements or other j
misrepresentations made on this application may result in immediate shutdown or revocation of my temporary Food Servlce License for the Town ; I
of South Windsor. Temporary Food Service License will be issued after the Food Inspector has completed his/her inspection.
i Applicant% e
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Applicant Signature: -- —� � _._-...•._..._.._....__.. ,•Date: �
Nov, 29, 2017 9: 01AM No- 4696 P. 2
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Inspector Name,
Inspector
Signature: Date-
Food Gass: 10 2 C' 3 E2 4 ❑ FEE, $5D, Nonprofits exempt
Temporary Food License#; Expiration Date:
Notes; pate Received;
Nov, 29. N17 9: 01AM No, 4696 P. 3
Town of South Windsor Health Departlment
Temporary Food Event Questionnaire Form
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- Please complelo all questions and return to the Health Deparimenf wifh 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 necessao/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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Nov, 29, 2017 9. 01AM No. 4696 P. 4
5. How will the food be'protected?
ation, display, service and transportation. Cooking to order will
Food must be protected during storage, prepar
lessen the chance for bacterial growth,which may occur prior to service. I
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6. How will the all utensils and food contact surfaces
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7. Where will excess ood (potentially hazardous and non-potentially hazardous foods),dry goods,and single service
items be stored?
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S. Where will ware wash detergents and sanitizers be stored? I n I
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9. How will condiments and single service items (cups, plates, utensils,etc.) be dispensed?n ahL11-4,
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10. What method of garbage disposal will be used.
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