HomeMy WebLinkAboutApplication 150 Nevers Road (20) are
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
'"ZRAk' TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION
10 ***Must be submitted 2 weeks prior to event***
NATION
Event Name:
Event Date(s): , /,/40
/I` S d-�') �/� �� Event Time: 9, ��
Event Location: w C/v
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PERSON IN CHARGE INFORMATION
Last Name: b i 510Y First: J-e-n�/
Street Address: J, Apartment/Unit#:
City: �/�Sb�- State: 6477 Zip:0G,03 3
Phone: �3y_ � � / E-mail
Address: �i f/5 1-45 e /rew-S t!lahoG
ORGANIZATION REPRESENTED (IF ANY) v
Representing:
Street Address: Apartment/Unit#:
City: State: Zip:
Phone: E-mail Address:
QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) YES =.1 NO i_1
Certificate#: Date:
ADDITIONAL INFORMATION
Water Supply: YES Cl NO Wastewater Disposal YES NO LJ
Electrical: YES C_ NO BaseOperations:
MENU **(PLEASE LIST ALL MENU ITEMS IN AS MUCH DETAIL AS POSSIBLE)**
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****PLEASE DRAW A DETAIL DIAGRAM OF FOOD BOOTH ON THE BACK OF THIS FORM. APR 13 2018
USING THE GRAPH PICTURE ON THE BACK OF THIS APPLICATION****
SOUTH WINpSpR
`-he food preparation and storage areas must be covered if event is outdoors. Be suwAhati irr
tents used for overhead cover are fire-rated. oer 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
(Please Print):
Applicant Signature:
Date:
S. 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.
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?
8. Where will ware wash detergents and sanitizers be stored?
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?
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Town of South Windsor Health Department
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.
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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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OFFICE USE ONLY
Inspector Name:
(Please Print):
Inspector
Signature: Date:
Food Class: 1 ❑ 2❑3❑4❑ FEE: $50, Nonprofits exempt
Temporary Food License#: Expiration Date:
Notes: Date Received:
>�364M r'- I blow Is Or a as d under I n Sales and Use Tax AcL
Zia pis good orryr for the nenied perm-tree and at ft Iowdon shown.
00m s wq change In owrmdi%to permit is rNA and void. TITIS TASTY TREATS LLC
Dab TITIS TASTY TREATS LLC
>�Irza>ion Business Cormecuad Tax 41 CLUB RD
s Data Start Date Ntattber WINDHAM CT 06200-1007
07A)M171 ousiP2022 06/30/2017 72437892-001
TITIS TASTY TREATS--LLC
TITIS TASTY TREATS LLC
98 MuST
` Gt STUFiY CT 06033-1209
Kevin S.Sullivan
Tnis license ma not be transferred or assi ned. Commissioner of Revenue Sen�ces
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STATE OF CONNECTWI T ♦ DEPARTMENT OF CONSUMER PROTECTION �
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Be it known that j
TITIS TASTY TREATS LLC
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41 CLUB RD
WINDHAM, CT 06280-1007
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-% has been certified by the Department of Consumer Protection as a licensed
a.: BAKERY
Number of Production Employees: 1
License #: BAK.0016308
Effective Date: 08/23/2017
r I Expiration Date: 06/30/2018
verify online at www.dicenee.ct.gov MkbekSeftvV.Cmm6dmw
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CERTIFICATION
JENNIFER LABOY
for successfully ownpleting the slt:tnclards set forth kyt the ServSafe* Protection Mar• Ceriificctio,, o,ion
which is accredited by the Ametican National Standards Institute I )--Conferencr od Protect;(:
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CERTIFICATE t,.UMBER EXAM FORM NUMBER
6/5/2017 6/5/2022
DATE OF FXAMINAT ION DATE OF EXPIRATION
L-1 laws aPPV i,ocic with your!uaI rog 6wy N, for recertification i'ftpiremonts.
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