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HomeMy WebLinkAboutApplication 501 Evergreen Way (8) TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT 1540 Sullivan Ave., South Windsor, Cr 06074— Mailing Address 1530 Sullivan Ave., South Windsor, CT 06074—Office Address Phone Number: (860) 337-6173, Fax Number: (860) 644-1930 `"VOR.."�- TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION ***Must be submitted 2 weeks prior to event*** EVENT INEQg L , Event Name: l9i-thflP— r pT�49 �D r�-U� f�Sr dEJi Y Event Date(s): ' 6/,�3 ,�� l (j t Event Time: 'I Q `� PV4 Event Location: I t e- r20 Mew APE PJ PT (X_ PERSON IN CHARGE INFORMATION Last Name: 11fitJ�.�M�N�C�[ First: "I%0GRIV M.I.: Street Address: 5q ��('gn/P L � Apartment/Unit#: City: l l' t Y State: C Zip: 06 � Phone: q� Y E-mail d0'j 6(tB O q 4 l Address: TttA ORGANIZATION REPRESENTED (IF ANY) `,t c/ Representing: W OOCtf-.PM6-PAVE P01J / �� K�f&,^J Street Address: 5 i, (4 /`-(— Apartment(Unit#: City: ( 1—_)6 / State: C-7— Zip: 06 S-t Phone: 3o 3 6`f o 0 q } I E-mail Address: OtH 1eJ"6,1VAr0- fl"N C QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) [I YES [-I i 1 Name:-- -A0PAP�OIt-N K_.( f1N64V1AVEC Certificate#: Date: ADDITIONAL INFORMATION Water Supply: YES i� NO [I Wastewater Disposal YES IAA NO D Electrical: YES ❑ NO Ell Base of Operations: MENU **(PLEASE LIST ALL MENU ITEMS IN AS MUCH DETAIL AS POSSIBLE)** P"t"­'1_`LffWQ 5_ i SSE CMXX . M&x- _'�4PeLE Fghw ****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. Appl(Plealse cant Print): n/�14/}fU2>r►/ame �G �✓�RECEIVED Applicant Signature: ` n 7 Z013 Date: 6/5 1, 11 / ( 3 so TM DEPT- i i i i f l � I I OFFICE USE ONLY Inspector Name: (Please Print): Inspector Date: Signature: Food Class: 1 ❑ 2❑ 3 C] 4❑ Temporary Food License#: Expiration Date: Notes: Date Received: Town of South Windsor Health Department Temporary Food Event Questionnaire Form o j Please complete all questions and return to the Health Department with your application. '1USOR COS 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. 'D of t i A�-�r� e1 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. �4tep IN 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. F-600 FMS &F W0V- YTt l-` PrNO PU.Ncc- ��l TA �� o 0 � v;- 4. Please describe the type of hand washing facility to be used. Owd oK 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 is kept hot or cold as needed. cl 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 w, t36 CoyV_- AT wo 1L S`bu-c AND L4(e Qn! �Rh 1 l LE o ° F1 t 4- ABv-C- 4. Please describe the type of hand washing facility to be used. fO�J L 6N"r J CaLTPAEAL w1V A-VJ-60 L Aar 2 1,Ve7_ 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. v-&)g M S i V-V W ( 6 t 460umrR . fr ShRF I A ' 6. How will the all utensils and food contact surfaces be washed,rinsed and sanitized? ©IMP'N-AT k j „� E. �� E ��v 1SAW'fti 7. Where will excess food(Potentially hazardous and non-potentially hazardous foods),dry goods,and single service items be stored? fay 5 D1. M1D s�N t�t,a�` S L>"X S t-t llr ' O k?- Jai' (.F." A (/ bF'r � FL.00L S. Where will ware wash detergents and sanitizers be stored? 9. How will condiments and single service items(cups,plates, utensils,etc.) be dispensed? I 4 10. What method of garbage disposal will be used? Ake y -! 71! M CITY OF WEST HAVEN _ FIVE RIVERS LLC-FRANKIE, FOOD SERVICE - POST ROAD -• _ 1151 BOSTON LICENSE 2018-2019 BALWINDER SINGH ;9 i EXPIRES: July 1, 2019 FEE $375 This license expires as noted above. ; This license may be revoked by the Department of Health for failure , ` to comply with applicable City and State regulations. , •' �� This license is not transferable. y :a DISPLAY IN A PROMINENT PLACE ' 6, ; Mry DlfeCtOf 0f-� � NATIONAL. REGISTRY OF FOOD SAFETY PROFESSIONALS® CERTIFIES p NIPAPORN KLANGMANEE i HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE FOOD SAFETY MANAGER R UNDER THE CONFERENCE FOR FOOD PROTECTION STANDARDS Training by AT-I , w 1-800-723-3873 2�7-975-6442 PRESMENT: all , r LAWRENCE J. LYNCH,CAE it ISSUE DATE: MARCH 20, 2018 #0656 EXPIRATION DATE: MARCH 20, 2023 CERTIFICATE NO:21444674 6751 Forum Drive,Suite 220,Orlando,FL 32821 TEST FORM: EZS38 P'(800)446-0257 F(407)352-3603 vnvw.NRFSP.Com This certificate is not valid for more National Registry of Food Safety Professionals' than five years from date of issue.