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Home My WebLink AboutApplication 501 Evergreen Way 0', TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address Y 1530 Sullivan Ave.,South Windsor,CT 06074—Office Address Phone Number: (860)337-6173, Fax Number: (860)644-1930 :°.•w? _ate.'_ ? u.�,•4a= FOOD SERVICE LICENSE APPLICATION .I__'-"Must be submitted 2 weeks prior to event*'"* EVENT INFORMATION Event Name: 'So w fl,lBusiness (} VV I�� Representing: I r ltkCi &b Y Q VS C__Q bIAY L� Rjvd_s Event Date(s): U 13 /Z Z��I CI Z Z Event Time: /� ,�✓Y! P/)') Event 1 1 ,- Location: %S-D /V e Irks K 4 &,,u*h 1 L;Yl&Si(- PERSON IN CHARGE INFORMATION Last Name: V LA LC( First: C71 no— Business Addddres�s: (PI H j I J CAS f �� City: State: 7. -7 c Phone&Cell Phone: E-mail ZO 3 7I -7Z�' I Address: /tl fv @ �aL �/u4_s OTHER LICENSES (IF ANY) �! Temporary Event -- Milk Producer/Distributor Bird/Poultry _ Livestock (Other Health Dept.) --- Egg Distributor Food Manufacturing Frozen Desserts Bakery QUALIFIED FOOD OPERATOR (MUST INCLUDE COPY OF CERTIFICATE)rYES _ NO NON-PROFIT Name: �0.L �v ti C7DI t/1 y)lzi�' la p CLS ) LL f! certificate#: rM L * D DD D5 j y Date: q 11-J 7 ADDITIONAL INFORMATION Water Supply: YES NO Wastewater Disposal NO Electrical: YES NOP If other,please explain: MENU **(PLEASE I ITT ALL MENU ITEMS IN AS MUCH DETAIL AS POSSIBLE)** N ut L9uL6z, ****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 (Please Print): G IVitt J l,d la. n C Applicant Signature: 7 _ RECEIVED °ate: 5�-7 hr MAY 1 i SOUTH WINDSOR HEALTH DEPT. 0 e, c&tri so m 1C- A(bM -etc) n51 I Spoons , OFFICE USE ONLY Inspector Name: (Please Print): Inspector Date: Signature: Food Class: 1❑2❑3❑4❑ FEE:$50,Non-Profits exempt Temporary Food License#: Expiration Date: Notes: Date oww OKe� Town of South Windsor Health Department n4�W� Eft Temporary Food Event Questionnaire Form Please complete all questions and return to the Health Department with your application. ��tiOq•�O>� 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. 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. 4. Please describe the type of hand washing facility to be used. au 5 I G� 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? 7. Where will excess food(Potentially hazardous and non-potentially hazardous foods),dry goods,and single service items be stored? S. Where will ware wash detergents and sanitizers be stored? 9. How will condiments and single service items(cups,plates,utensils,etc.)be dispensed? 10. What method of garbage disposal will be used? Q cv�-b l r a_ h� S +o Id yi `A-)L1 441 hQ k1 IAW �f ct 1/e, U. a lkyj[�c- �a d� n 4QW TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT tp 1530 Sullivan Ave.,South Windsor,Cr 06074 r 1 r Phone Number: (860)337-6173, Fax Number: (860)644-1930 'tosoe.c<�� DECLARATION OF BASE OF OPERATION This form must be submitted with your application for permit Vendor Name: r i Vendor Owner/Operator Name: C a eu M('1 i% D Business Name of Base of op.: Hong i 1 ' LAar comffw-4ciaL Address of Base Of Op.: (0I HI I jC/ys� -w McA,It h t,;I D(ogS--b Owner of Business for Base Of Op.: Telephone Number of Base Of Op.: 274 — / `��' 32U i THE FOLLOWING PORTION TO BE FILLED OUT BY THE OWNER OF THE FOOD ESTABLISHMENT USED AS THE BASE OF OPERATION. I, Gb= C-107a ,.Lbja t?I` attest that my licensed food establishment Oww4f Food Establishment used as base known as (Y)U.f, k(DfNA C Q L.�JYI�. �O(ls is available as the Name of Food Ester fig rent base of operations for mum rJr✓J' Aw �OU-,fr&i owned by Vendor 1)na JJawrIo Owner of Business Signatu of ,fiww of Food Establ rent **Please include a copy of the Base of Operation food permit issued by the local health department.** Additional Information ❑ Contact the local Fire Marshal(860-282-0669)to ensure compliance with the Fire Code. ❑ 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,per the South Windsor Fire Marshal's office. ❑ Wastewater must be disposed of in a sanitary sewer or other approved sewage disposal system. ❑ Equipment and tables must be clean,smooth,washable,durable, non-absorbent and in good repair. ❑ Dust must be controlled (i.e.dry fields)by watering down. ❑ All workers at the food booth must sign a log sheet indicating the date,their name,address and telephone number and the hours that they worked. Please retain the log sheet after the event. ❑ If gloves are used,they must be a food grade quality glove and must be used for only one task (such as working with ready-to-eat foods or with raw animal food). You must wash your hands after removing the gloves and prior to putting on a new pair of gloves. Gloves must be discarded when damaged or soiled,or when interruptions to use occur. ❑ Food employees may not wear nail polish or artificial nails unless wearing intact gloves in good repair. 596729 C PL-03 Rev 0613 STATE OF CONNECTICUT DEPART V ENT OF CONSUMER PROTECTION This is your license certificate. This certificate shall be posted in a conspicuous location where business is to be conducted and shown to any properly interested person on request. Do not attempt to make any changes or alter this certificate in any way. This license is not transferable. In an effort to be more efficient and Go Green,the department asks that you keep your email information with our office current. All renewal notifications and certificates will only be emailed to the last reported email on record. Questions regarding this license can be directed to the Food&Standards Division at dcp.foodandstandards(a et.gov. Mailing address: Email on file to be used for receiving all notices from this office: MAC BROTHERS GOURMET FOODS,LLC info@macbrothersgourrnetfoods.com 61 HILLCREST TER MERIDEN,CT 06450 IN STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION Be it known that MAC BROTHERS GOURMET FOODS, LLC 61 HE-LCREST'TER MERIDEN, CT 06450 has been certified by the Departmenir of Consumer Protection as a licensed FOOD MANUFACTURING.ESTABLISHMENT License #: FME.0000519 Y Effective Date: 09/12/2017 Expiration Date: 06/30/2018 verify onlincat«i,«.cIiccnx.cJ.g, MkheBeSeaga4Commiefoner t •'r 1 1 1 1 1 7 r1-1 - 1 1W L 1 ' 1 - 1 7 lil 1311 A ' _ II Lcul ■ 1 r ■ ■ /1 L Its 1 r- 1 11t 1 11 I 1 I•1 - 1 11 LI 1 1 II 1 1 111 1 11 11 L 11 II 1 h II - � 1 11 11111►� II 1 1 1 I I• 1 1 + I I 1 1 1 I I h 1' 1 1 1 1