HomeMy WebLinkAboutApplication 150 Nevers Road (21) cl,P�? i,....
TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
MENT
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
*** lust be submitted 2 weeks prior to event*
Event Name: � 30, C11v1�
Event Date(s): O�IJ( 0 I Event Time: 10—�
Event Location: —r -W0. � ,�� � 1�\Jlt
PERSON IN CHARGE INFORON
Last Name: S:e D ff-W First: S� CAM.I.: h(c�
Street Address: �� `l( Y� ( Apartment/Unit#:
City-fnlkncfv_,�J'C Statec__J Zip COvq
Phone: S ail E-mail S-1-A-u "`q, 6 I
Address: 1�
ORGANIZATION REPRESENTED (IF ANY)
Representing:PUI 0)0(JCf
Street Address: 1��� 1 �j�l•� Apartment/Unit#
City: �u�yl. State ( — Zip: ob o-Hs�
Phone: �� l�a��( j 1,, Email Address: hop)) 1
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QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) I_I YES I NO i
Name:
Certificate#: Date:
ADDITIONAL INFORMATION
Water Supply: YES I I NO Y_ Wastewater Disposal YES NO L4
Electrical: YES NO
ns:
u LE**(PASE LIST ALL MENU ITEMS IN AS MUCH DETAIL AS PO ISLE)*#
RECEIVED
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SOUTH v►WNDSOR
****PLEASE DRAW A DETAIL DIAGRAM OF FOOD BOOTH ON THE BACK OF THIS FORM. HEALTH DEPT.
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 & ,� _ 'Sem
Please Print : ���L� V
Applicant Signature: Date: D �I I+ n f I
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OFFICE USE ONL
Inspector Name: C
(Please Print):
Inspector
Signature: Date; Yo t f
Food Class: 1❑ 2[]'3 ❑ 4 D FEE �prof�tsrpt
Temporary Food License#: Expiration Date:
Notes Date Received:
'j o'te. Town of South Windsor Health Department
.opN SEA( _
rc + 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.
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 t n peratures.
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4. Please describe the type of hand washing facility to be used. —M
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 Yor bacterial growth,which may occur prior to service.
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6. How will the all utensils and flood contact surf(\ac�\ess 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?
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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?