HomeMy WebLinkAboutInspection 150 Nevers Road (11) ^° N •��� 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
'6S X-C TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION
***Must be submitted 2 weeks prior to event***
EVENT INFORMATION
Event Name: In 4- '' P cj , K—
Event Date(s): fyI Y h Event Time: I. 3 mA
Event Location: � 5 LS 7 K6 d K A e-I U 'S` - �U U+ k W last s0r- CT U l� o 1 y
PERSON IN CHARGE INFORMATION
Last Name: N`(AI CIL,v First: � �I S MI.:
Street Address: '7 0q 5, (f l l u4 Apartment/Unit#:
City: �` 1 U r State: C T Z;� O Co 1 1 I
Phone:I 8106) -1 l� -l'C-5 e Address: .es �a C i cI o(_j J -Gear,
ORGANIZATION REPRESENTED (IF ANY) RECEIV D
Representing:
Street Address: Apartment/unit APR 15 2018
City: State: Zip. SOUTH WINDSOR
Phone: E-mail Address: HEALTH DEPT.
QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) I YES 71 NO
Name:
Certificate;;. Date:
ADDITIONAL INFORMATION
Water Supply:i YES '✓ NO Wastewater Disposal YES _V-'NO
GLY\pL
Electrical: YE 1, S NO Base of L 1- 1
Operations: (-\ I Z z
MFAU "(PLEASE LIST ALL MENU rM4-, IN AS MUCH DETAIL AS POSSIBLE)**
� � ,✓K r ; led C -r' �1 � ll
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****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 Tnspector has completed his/her inspection.
Applicant Name
(Please Print):
Applicant Signature: f Date: l/f 1 /f Q
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