HomeMy WebLinkAboutApplication 765 Sullivan Ave TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
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
'O110R G"` TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION
'"'"Must be submitted 3 weeks prior to event*11"'
EVENT INFORMATION
Event Name: C-r i tc,`1 p_t_
Event Date(s): .rT�,` I Lil Event Time:
Event Location: G (-j f,
PERSON IN CHARGE INFORMATION
Last Name: `�(�ttil. fj First: ,k M.I.
Street Address: -7� �Z S Zt k C� �� 2 Apartment/Unit#:
City: \�.I�� r State: C
C�/_ 1 E-mail
Phone: Oli O q�l G( �j�p�j c� l Address:
ORGANIZATION REPRESENTED (IF ANY)
Representing r G,6 C.,T(/
Street Address: Apartment/Unit#:
City: State: Zip
Phone: E-mail Address:
QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) CI YES ❑ NO
Name: AA i 1 k(A4_ (:AIL-
Certificate#: Y Ll 1 6 Li C Date:
ADDITIONAL INFORMATION
Water Supply: ES NO ❑ Wastewater Disposal YES ® NO ❑ \_o y
Electrical: YES l NO n Base of z C (cr t-L ,> 9 G V"
Operations:
MENU **(PLEASE LIST ALL MENU ITEMS IN AS MUCH DETAIL AS POSSIBLE)*
****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 n/� �, -yam�'(Please Print): \J
Applicant Signature: Date:
RECE"D
MAR 2 9 z016
SO( ►VINDSOR
HEALTH DEPT.
OFFICE USE ONLY
Inspector Name:
(Please Print):
Inspector Date:
Signature:
Food Class: I ❑ 2❑3❑4❑ FEE:$50, Nonprofits exempt
Temporary Food License#: Expiration Date:
Notes: Date Received:
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Brasato- Michael Damato
_ Serving window 64" long
7' exhaust hood
4 buirner
SSv,. A# ,* SS Steam
Prepstovetop oven Peps. Table
Table Griddle Vable
fncr
8.5'Wide
Single door
hand sink fridge SS`'
3 tiay�is sink= ' Prep`'
Table
----16' Long------
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Italian Food Truck&Catering Company
• Burrata, Prosciutto, Tomato, Basil Pesto, Pistachios, & Fig Balsamic $8
• Fried Mozzarella with Marinara $6
• Handmade Ricotta Gnocchi with Sausage & Broccoli Rabe $7
• Beef & Pork Meatballs over Polenta with Roasted Red Pepper Pesto $7
• Crispy Brussel Sprouts with Goat Cheese & Crushed Pistachio $6
• Pea & Mozz Arancini with Marinara $6
• Fried Mozz, Soppressata, Apricot Jam, Cherry Peppers, & Spring Mix
Sandwich on a Brioche Bun $8
Italian Food Truck &Catering Company
• Burrata, Prosciutto, Tomato, Basil Pesto, Pistachios, & Fig Balsamic $8
• Fried Mozzarella with Marinara $6
• Handmade Ricotta Gnocchi with Sausage & Broccoli Rabe $7
• Beef & Pork Meatballs over Polenta with Roasted Red Pepper Pesto $7
• Crispy Brussel Sprouts with Goat Cheese & Crushed Pistachio $6
• Pea & Mozz Arancini with Marinara $6
• Fried Mozz, Soppressata, Apricot Jam, Cherry Peppers, & Spring Mix
Sandwich on a Brioche Bun $8
ate` , 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.
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 iaccurately check temperatures.
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4. Please describe the type of hand washing facility to be used. r /'
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5. 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?
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7. Where will excess food(Potentially hazardous and non-potentially hazardous foods),dry goods,and single service
items be stored?
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8. Where will ware wash detergents and sanitizers be stored?
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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?
ciation
ServSafe
National Restaurant
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CERTIFICATION
M I C HAE L DAMATO
for successfully completing the standards set forth for the ServSafee Food Protection Manager Certification Examination,
which is accredited 6y the American National Standards Institute(ANSO--Conference for Food Protection(CFP).
4176413 5180
ERTIFICATE NUMBER EXAM FORM NUMBER
9/19/2016 9/19/2021
DATE OF LXAMINATION DATE OF EXPIRATION
Local laws apply.Check with your local rogulatory ogcnc, for recertification requirements.
Shc•;man Brown
SVP, National Restaurant Association Solutiom
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