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HomeMy WebLinkAboutApplication 501 Evergreen Way (4) Ma,y. 29. 2018 1 . 09FM N,D. 0414 F. 2 —�_ TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT 1540 Sullivan Ave., South Windsor, CT 06074-Mailing Address L 1530 Sullivan Ave., South Windsor,CT 06074—Office Address Phone Number: (860)337-6173, Fax Number; (860) 644-1930 `'s°o a°1 TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION ***Must be submitted 2 weeks prior to event*** Event Name: Greater Hartford Food Truck Festival � Event Date(s): 6/23/18 and 6/24118- -_ -- — — -- EventTlme: - Event Location: Evergreen Wak EvergreeaWaq,South Windsor Cr 06074 PERSON IN CHARGE INFORMATION Lass Name: $ruff — Firs[: George - M.L:•----- _ - -.....__ Street Address: 227 Turnpike Rd Apartment/Unit#: City'_Westborough ~H - Stlte MA I zip: 015B1 Phone: 5N-329-1795 / E-mail_Address: gbtttff®redheattavern.com _ _ ORGANIZATION REPRESENTED (IF ANY) Representing: Red HeaL Tavern Street Address: T Apamnent/Unit#' City: State: Zip: Phone: E-mail Address: QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) - -� EX YES ❑ NO ❑ Name: Certificate#: Date: ADDITIONAL INFORMATION M — _ _ _ _ _ Water Supply: - _------ YES ❑ NO 11 Wastewater Disposal YES ❑ NO L Electrical: — - — -- - YES EN NO ❑ Hose of -------- -- ,--- - -- Ooeratlons_ _-- -- . MENU **(PLEASE LIST ALL MENU ITEMS IN AS MUCH DETAILAS POSSIBLE)" pulled Work.tune and cheese-china _ --- - -_- --- --J---`, _•I ****PLEASE bRAW A DETAIL DIAGRAM OF FOOD BOOTH ON THE BACK OF THIS FORM. USING THE GRAPH PICTURE ON THE BACK OF THIS APPLICATION The food preparatlon and storage areas must be covered if event is outdoors. Be sure that the 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. (Please P Appa Print)-. George Bruff AppllcantSlgnature; / - Date: 4/1711B May. 29. 201 a 1 ; 09FM No. 0414 F. '�,u► �° � Town of South Windsor Health Department Temporary Food Event Questionnaire Form Please complete all questions and return to the Health Department with your application. ^uSGP Gor 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. Source of food will be Sysco z. 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. Anv food that needs to be kept cold will be stored in an iced cooler below 40 degrees 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. Any food required to be kept hot will be stored in a hot box and/or a electric steam well above 145 degrees 4. Please describe the type of hand washing facility to be used. A portable handwashing station will be setup if required witb hot water,soap,papertowls,hand sanitizes,and a waste water bracket. May. 29. 2C 1 ' : 09PM No, 0414 P 4 I ll �l APO 1 L , I � ` - I- A OFFICE USE ONLY Inspector Name: Please Prints Inspector Signature: -- -- — — -- — — Yw^�Da[e: _ Food class:i❑2❑3❑4 Cl FEE:$50, Nonprofits exempt Temporary Food License#: Expiration Date: Notes: Dabe Received: May. 29. 201 QU 1 : (19PM N,-J. 0414 r. 5 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. AU food will be kept covered and all staff will have hair restraints and gloves used at all times_ 6. How will the all utensils and food contact surfaces be washed,rinsed and sanitized? Sanitizer will be brought from the restaurant and stored in spray bottles and red sanitizes buckets.Sanitized and rinsed utensils,will be stored seperately.All food contact surfaces will be sanitized prior to and during service every 2 hours. 7. Where will excess food(Potentially hazardous and non-potentially hazardous foods),dry goods,and single service Items be stored? Excess food will be stored under the tent in Hotboxes or Coolers depending on tern perature requirements. 8. Where will ware wash detergents and sanitizers be stored? Sanitizer will be stored in sprav bottles and red buckets. 9. How will condiments and single service Items(cups,plates,utensils,etc.)be dispensed? No condiments will be dipensed and single service items will be given to the public by a staff member. 10. What method of garbage disposal will be used? Garbage will be disposed of in the restaurants garbage disposal unit May, 29, 20180 1 , 10PM No, 041.4 P, b 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 goad repair. May. 29. 2018 1 : 10FM U. 0414 P. 7 Pre-Event Self-Inspection Checklist "Prior to your event,take a moment to go through this checklist.The checklist should hp completed for each temporary food she. FACILITY ❑ Storage of dry goods(shelves and/or crates for off the ground/floor storage) ❑ Cold storage(refrigerators/coolers)at 40 degrees F.or below. ❑ Hand wash station that includes warm potable water,soap and paper towels ❑ Potable water supply(hot and cold) ❑ Food preparation area O Wet and dry garbage disposal ❑ Dishwashing facility(wash, rinse,sanitize) ❑ Area to clean and sanitize utensils ❑ Ice and ice storage(freezers/coolers) ❑ Facility free of pests and rodents ❑ Method of wastewater disposal EQUIPMENT AND SUPPLIES CI Calibrated metal-probe thermometer(0-220 F degree range) ❑ Plastic wrap ❑ Extra utensils including tongs,spatula,spoons,etc. ❑ Plastic disposable gloves ❑ Bleach/Quaternary Ammonia for sanitizing O Test strips for testing sanitizing solution ❑ Clean wiping cloths and containers for sanitizing solution/spray bottles ❑ Food-grade storage containers ❑ Hair restraints ❑ log Book ❑ Garbage containers/plastic bags FOOD SUPPLIES ❑ Shellfish tags must be kept for 90 days after purchase. ❑ No home-prepared or home-canned foods can be used in the preparation of any item. 1] All meats and poultry must be USDA-inspected and come from an approved source. ❑ All preparation must be done onslte or in a licensed commissary or kitchen. ❑ Check temperatures of foodstuffs when they arrive at the site. ❑ Meat,eggs, poultry,fish,shellfish,and milk should be at 40 degrees F or below.