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HomeMy WebLinkAboutApplication 150 Nevers Road (31) TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT 1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address 1530 Sullivan Ave., South Windsor, CT 06074—Office Address Phone Number: (860) 337-6173, Fax Number: (860) 644-1930 -SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION "dust be stibiillitled ? weeks prior to eceul** EVENT INFORMATION II� 1_ .S r. I Event Name: J T 1 Q �l "t W d l,� U �7 Y- rs 4 r a W )" / r S- Event Date(s): �J N (: C l Event Time: Event Location: ` V CI 1 (—U 1 lk j,J Cj"Vt CT PERSON IN CHARGE INFORMATION U 1 Last Name: 1 I, t� }� nn First: U ,� M.I.: Street Address: I �/{,c �/ I'`(j �, Apartment/Unit#: city trN Vj H (f C- 6 b 1 l Statc: CT + i' © G V 11 l Phone: 2G Z I S- �-/ a 4 a E-mail Addr,ss: a 1.1 u, I _ �, 1r i m LA f l C C,L" VV�` ORGANIZATION REPRESENTED (IF ANY) ARepresenting: Vt � -� t y N c; 4Street Address: � r 0 J ( V1n G (�c. C1 Apartment/Unit# City: v+ V 1 %.A State: C Ck I ) 'C �' Y`� Zip C4 Z J Phone: I V eo n ! E-mail Address: t. QUALIFIED FOOD OPERA�OR (INCLUDE COPY OF CERTIFICATE) YES NO Name: Certificate#: Date ADDITIONAL INFORMATION / Water Supply: YES NO ✓/ Wastewater Disposal YES NO Electrical: YES NO ✓ Base of Operations MENU **(PLEASE 1.[Si.. 3i ri�U L'i�i IN AS MUCH DETAIL AS POSSIBLE)** vv\ \A CA 1 I' r ****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, ner 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 Ibe issued after the Food Inspector has completed his/her inspection. Applicant Name (Please Print): J Applicant Signature: 1 Date G I Lf