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Home My WebLink AboutApplication 501 Evergreen Way (6) Jun. b• 2013 3: 20PM No. 53b� Z � - :•.:.:-. - OWN ._:-.—• — '-�-- T OF SOUTH WINDSOR HEALTH DEPARTMENT `_ = u"' 1540 Sulllvari Ave.,-South Windsor,CT 66074-Mailing Address ' 1530 Sullivan Ave.,South Windsor, l:'T 06074—Office Address Phone Number: (860)337-6173, Fax Number: (860) 544-1830 `=ter TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION ***Must be submitted 2 weeks prior to event"o Event Name: es.. c_r A\ x .�ior Event Date(s): 2� I Event Time: r•� Event LOGlftL `( �+ t j� ( �' � 1 i'v \• E 1 PERSON IN CMIM INFORNMON Last Name: ` =�. Frsi:V �:y M.I.. Street Address: \ 1�'` �" '�,� Apartment/Unit#: f A ;,pity' /`. !'`� P '+ State: Zip: _ v E-mail Phone: v..3 .._.i 1,. :.j Address 1 ORGANIZATION REPRESENTED (IF ANY) Representing: Street Address: �� t. J� Apartment/Unit#: I city: — State: Zip: Phone: E-mail Address?ZN�-�\ QUALIFIED FOOD OPERATOR INCLUDE COPY OF CERTIFICATE ❑ NO ❑ Name: cemficate# J '� _ ... J Day- �C c ADDITIONAL INFORMATION_ Water Supplgt��J_ �4, } ,_t_,r�YES __NO �- Wastewater Disposal - YES NO ❑-- Electrical: YES NO El ease of MENU (� �� _ C ti "(PLEASE LIW ALLY U IA^T�EMS IN AS MUCH DETAIL AS POSSIBLE)'" �..i l�:`'�� tY.1. -' N.4 ./ `�— �;.a 11:i�_ ` • `� .i-�0. _ �• -j �� '.aF 'v ,Y/ �'';<' l �� lzy,10141)(till ' f ****PLL'ASE 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 appUcation may result in immediate shutdown or revocation of my temporary food Service License for the Town of South Windsor. Temporary Food Service Llcense will be Issued after the Food Inspector has completed his/her Inspection. �Applicant Name -.�.-- ----- -- `•-,- � - ----...--- ----- - Applicant Slgnaftl : 0). I _ —- -- - - ~ Date: r - JUN 07 -?�Jjn��t So,v R H DEPT Ju �, 6. 2013 3 . 20PM No, 5369 F. 2 ,w!�°_1 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 ig kept hot or cold as needed. I 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. ~ t �G 4. Please describe the type of hand washing facility to be used. Jun, b. 2013 3 . 20PM No. 5369 P. 3 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. 1 7-� 6. Howes 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? t 1 8. 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 u3 d? VQt', - + ��4 - i,.. CO- f1S Jun. 6. 2Q18 3 . 20PM No. 5OJ69 P. 4 o f I �7r OFFICE USE ONLY Inspector Name: •- — ._... - -- ---- ------ --�----- --— - ----- (Please Print): Inspector Signature: - — -- - — - ---- _— - LDate- -—- — Faod Class: 10 2 p 3 p 4❑ _ FEE_$50, Nonprofits exempt Temporary Food Llcense#: Expiration Date: Notes: Date Received: 7 ServSafe f 7e �. e gv n r e womAg m z � CERTIFICATION JON ARRIGONE for suoo =Wly coaniWmq the omit r,ad Forth For Iha senrsare°Food Pi ;irxaiiar, Eraamnclion, which is by fie Arnerimn National Sta,darcls kwft fe Food Prokwtion(CFPI. 601102 UMBER E XAM`'; $R�4 5/9/2 5/9/2021 DATE OF DATE OF EXPIRATI -'' Local km apply. for reoerti�iaalion wqui�enrs. ': IC3 loess owls astadmabaflmNW.