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TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
1540 Sullivan Ave., South Windsor, CT 06074 Mailing Address
1530 Sullivan Ave., South Windsor, CT 06074—Office Address
"y Phone Number: (860) 337-6173, Fax Number: (860) 644-1930
TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION
***Must be submitted 2 weeks prior to event***
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Event Name: Gr 2,a 5 6S) 7vz,,C
Event Date(s): ( Z 3 ((o Z Event Time: +Q _T,ow�Sa. jr IRS4p•/v'� SI-0
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Event Location: imcv% \\C PCB F. y\,1c4n L,L. �a✓� �^2 PAo Slops at�E�av�t�.(�
PERSON IN CHARGE INFORMATION
Last Name: �i�N-�c� First: ccvtyz-AV 1
Street A&f,:s': �j 3S �u 2�2 W 0,/ Apartment/Unit#:
City: W r C�S l State: C7— Zip: 6(0 0 3-�
Phone: O LO t4'�a C'1�0 C7 / E-mail (�
Address: 1'v10�S + SO��w�,�NSB'l� �OAc CBvu
ORGANIZATION REPRESENTED (IF ANY)
Representing:
Street Address: `S�.'�?J '�1 �,v���{�P� C,y Apartment/Unit#:
City: State: C I (��� l�d7�
Phone: �a 9 PLC E-mail Address rN�S. S O,� ci:v.�yl,� AA4,1 C-Y,\ n
QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) �<YES -I NO
Name: Cc,vze-,r LAWS
Certificate#: Date: l2oi� IIIz,120Z?_
ADDITIONAL INFORMATION
Water Supply: YES NO Wastewater Disposal YES NO
Electrical: YES i_ NO
MENU **(PLEASE LIST ALL MENU ITEMS IN AS MUCH DETAIL AS POSSIBLE)**
****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. per 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 c� �
(Please Print): �Qvc� J �nw�S y RECEIVED
Applicant Signature: \ GV JUN Date
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018
r -Cox , SOUTH WINDSOR
H�LTH DEPT.
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 Received:
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Town of South Windsor Health Department
Temporary Food Event Questionnaire Form
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Please complete all questions and return to the Health Department with your application.
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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 t�Ehe,food is protected lduring transport and how it is kept hot or cold as needed.
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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.
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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.
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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.
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6. How will the all utensils and food contact surfaces be washed,rinsed and sanitized?
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7. Where will excess food(Potentially hazardous and non-potentially hazardous foods),dry goods,and single service
items be stored?
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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 used?
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ServSafe
National Resta:irant Association
ServSnfee
-� CERTIFICATION
CARRIN LAWS
for successfully completing the standards set forth For the ServSafe®Food Protedion Manager Certification .Examination,
which is accredited by the American National Standards Institute(ANSI-C ference for Food Protection OR
1�745507 10555
tlIIMBER EXAM FORM NUMBER
11/8 11/8/2022
DATE OF E -MINATION DATE OF EXPIRATION
Local laws apply.Ch wirtt ymr local ngulalory oy , for recertification requirements.
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