HomeMy WebLinkAboutApplication 150 Nevers Road (37) 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
***Must be submitted 2-weeks prior to event'***
EVENT INFORMATJCI'
Event Name:
Event Date(s): / q A." _/ Event Time:��
Event Location:•/�� �•/4��' �.-����Lw� rS/���..'a!/��/��� �.�i�
PERSON IN CHARGE INFORMATION
Last Name: ������ / � First:
Street Address: �C�; �/ D � Apartment/Unit#:
City: �" >`"� G��i.ii Las�,�_ State: zip: Glc C
Phone: E-mail
Address:
ORGANIZATION REPRESENTED (IF ANY)
Representing:
Street Address: / /�Ly �r .� Apartment/Unit#:
City: State: ��� Zip: QIpLj ;7
Phone: U c/' ��yli' �/ E-mail Address: ,,
QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) YES NO
Name:
Certificate#: -5 e-_3Xe-95,,e Date:
ADDITIONAL INFORMATION G�
Water Supply: a Wastewater Disposal YES ;/ NO
Base of
Electrical: YE `!
Operations:
MENU **(.PLEASE =ST ALL MENU ITEMS IN AS MUCH IDETAXAS 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. 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 be issued after the Food Inspector has completed his/her inspection.
Applicant Name
(Please Print):
Applicant Signature Date:
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ServSafe
National Restaurant Association
Certificate of Ac ievement
This certificate is awarded to
KATHLEEN DAUGHERTY
M Congratulations I You have completed
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ASTM E2659 ServF Safe® Food Handier
Cer6ficale Issuer
Inhine (-ourse an'd xarn
.-Mployee ood- Safety
National Restaurant Association Certificate Number 3303184 Date 3/13/2018
233 S. Wacker Drive, Suite 3600 Exl2fration Dote 3/13/2021
Chicago, IL 60606-6383
800.765.2122 in Chicago area 312.715.1010
Restourant,org I ServSafe.com
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OFFI CE USE ONLY
Inspector Name:
(Please Print):
I nspedor Date:
Signature:
Food Gass: 1 " 2 'WW. 3 4 m FEE $50, Nonprofits exempt
Temporary Food License# Expiration Date:
Notes: Date Received:
Town d Sx th Wndsor Health D4partment
Temporary Food Cent Chi onnai re Form
Please co rpletealI questions and return to the Health Department with your application.
1. What is the source of the food to be served/dispensed? (Please indude 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.
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. Roper
thawing can be done in a refrigerator, under cool running water, or as part of the cooking process.
z/a/'1�l%9,C� S 3. How will the food items be cooked and/or hot held?
Asanitized metal stemmed, calibrated probe thermometer to monitor food temperature is required. If thin patties
are being cooked, a thermocouple maybe needed to accurately check temperatures.
4. Please describe the type of hand washing facility to be used.
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.
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6. How will the all utensiIsand food contact surf aces be washed, rinsed and sanitized?
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7. Where will excess food (lbtentially 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?
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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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