HomeMy WebLinkAboutApplication 150 Nevers Road (41) TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT � s�
1540 Sullivan Ave., South Windsor, Cr 06074-Mailing Address
?� 1530 Sullivan Ave., South Windsor, Cr 06074-Office Address
sy �' Phone Number: (860)337-6173, Fax Number: (860) 644-1930
."R.L0 TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION
***Must be submitted 2 weeks prior to event***
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Event Name:4,1,&Lp_e �w`A l c_)i_i0JCir Aep tk 4es i,ocL L
Event Date(s): 10 C T aU 1 p Event Time: 1 I
Event Location: ow-v's po,'4-
PERSON IN CHARGE INFORMATION
Last Name: ty) C'G r a�� First: i M.I.:
Street Add re:s ,3 1 0 Lt) LeRa,��v'1 U no Apartment/Unit
City' cJ►Jao r S 1 State: �� ZIP: p 6(39 Cv
p E-mail
Phone: ��_ 7 �O [/ Address: L ✓Ylxv—] e �00 Zc() VClAt,�> . Com
ORGANIZATION REPRESENTED (IF ANY)
Representing:
L?u /C�a CJ<0L.t7
Street Address: '7 7 ( l cu� /_r•,JL; I c ti' :J �� Apartmo+t/Unit#:
City` G� J rJ;3 v r State: ��I +p: C.)609 61
Phone: ;(� 7,�� •t/ZS t E-mail Address: G(llC<�• ( e /�-C
QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) YES , 40
Name:
Certificate#: t 3_T 9 g y 9(,, Date:
ADDITIONAL INFORMATION /
Water Supply: YES rie NO LJ Wastewater Disposal YES 11�' NO _i
Electrical: 1 YES '---,"'NO ❑ Base of /� r�}lyl�i1�/1�11} Operations: ►Jf�s G ct l U�c3J' Sf e e� m F-�-ipw
MENU //,J "(PLEASE LIST ALL MENU ITEMS IN AS MUCH DETAIL AS POSSIBLE)**
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****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.
Applicant Name '
(Please Print):
Applicant Signature: D� Date: /S iq U^ o 0 1 g
RECE� ED
AUG 16 20 i:3
SOUTH WINDSOR
HEALTH DEPT,
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OFFICE USE ONLY
Inspector Name:
(Please Print):
Inspector Date:
Signature:
Food class: 1 ❑ 2❑ 3 CI 4❑ FEE:$50, Nonprofits exempt
Temporary Food License#: Expiration Date:
Notes: Date Received:
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dve Town of South Windsor Health Department
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Temporary Food Event Questionnaire Form
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 the food is protected during 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.
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.
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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.
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? ( (7
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10. What method of garbage disposal will be used?
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North Central District Health Department
East Windsor - Enfield - Ellington - Suffield -Vernon -Windham -Windsor Locks - Stafford
Food Service License
JLM Knockout Dogs
200 Oid County Rd., Windsor Locks
Mobile
Owner:
Linda TO,c,"�'3' rath
Number 2545 Est.Code MV-1 Class 4
This License Expires On The Expiration Date Above And May Be Revoked By The Department Of
Health For Failure To Comply With Applicable District And/or State Regulations.
This License is Not Transferab:-e.
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EXPIRES O
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0, 2018 ��
Director OF Health ' G�
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DISPLAY IN A PROMINENT PLACE
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NationalAssociation
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CERTIFICATION
LNDA MCGRATH
for successfully completing the standards set forth for the ServSafee Food Protection Manager Certification Examination,
which is accredited by the American National Standards Institute(ANSIKonference for Food Protection(CFP).
13589496 5158
CERTIFICATE NUMBER EXAM FORM NUMBER
frainin r and E_xanl 5/2/2016 5/2/2021
DATE OF EXAMINATION DATE OF EXPIRATION
Local laws apply.Cho&wA your local rogAdory agency for recertification requirements.
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Sheeran Brown
SVP,national PAdaurant Asweiolon 3*60ons
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rS,2015 National Raeawant Amarstion fi I+miiv- FaurdnGar P►*AB! AN r4*neared.SwAcki t1!and 1n Snedofe boo ae trademarks of the NRAEF
Naional aermrart AwocdaMD and**are demo on tradenaks of M?,Ic*6 d Riau nt Aeeooa6an
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IA102901 v.1401 Contacl us with questions at 175 W Jackson Blvd Ste 1500,Chicago,IL 60604 or 5-56-O. urant.org.
North Central ' District Health Department
East Windsor - Enfield - Ellington - Suffield -Vernon -Windham -Windsor Locks -Stafford
Food Service License
BT's Grill
5 Ucar Street
Suffield
Owner:
Than--as ,�'upec & a rian `�.,onneau
Number 2790 Est. Code R-4 Class 4
This License Expires On The Expiration Date Above And May Be Revoked By The Department Of
Health For Failure To Comply With Applicable District And/or State Regulations.
This License Is Not Transferable.
G�.�►.�. -00
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Q �< = EXPIRES O� N OCT. 31 W
2018 ��
Director Of Health �
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IN A PROMINENT PLACE