HomeMy WebLinkAboutApplication 677 Rye Street t hA �o
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
`14SMI.01 TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION
***Must be submitted 2 weeks prior to event***
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Event Name:
Event Date(s): I V` 1 1 Event Time: m
Event Location: 1 �, - �`�- arm G-V , ,S- W„rt��U
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PERSON IN CHARGE INFORMATION
Last Name: First: ' 1�_w�� M.I.:
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Street Address: o�,l C, Apartment/Unit#:
State: C T Zip: 0(9 0 r6
City: �
Phone: E-mail �Lh 1
Address:
ORGANIZATION REPRESENTED (IF ANY)
Representing:
Street Address: a� j rnh d I I Sfi Apartment/Unit#:
City: Irk
l State: Zip: Ou I S
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Phone: X-AL_I aa. UU E-mail Address: ,�j b C 1 fi- S L7- • uor-,
QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) ❑ YES ❑ NO ❑
Name: Q �L"Ulu(7\ PJ yj v!Y`n
Certificate#: I S S3 S �)11 "1 Date:
ADDITIONAL INFORMATION
Water Supply:
YES NO ❑ Wastewater Disposal YE NO ❑
Electrical: YES NO ❑ Base Operations:
MENU **(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.
RECEIVED
Applicant Name 1 1
(Please Print): Lax 4-U �'�` 1� �NV1 y
Applicant Signature: /)��j Krov-,_ BUG 1 � 2018 Date:
SOUTH W NpSOR
HEALTF- DEPT.
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OFFICE USE ONLY
Inspector Name:
(Please Print):
Inspector Date:
Signature:
Food Class: 1 ❑ 2❑ 3 ❑ 4 ❑ FEE: $50, Nonprofits exempt
Temporary Food License#: Expiration Date:
Notes: Date Received:
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SW 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.
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.
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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.
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4. Please describe the type of hand washing facility to be used.
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S. How wilt the food be protected?
Food must be protected during storage, preparation, display,service and transportation. Cooking to order will
lessen thechance 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? I
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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?
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9. How will condiments and single service items(cups,plates,utensils,etc.) be dispensed?
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10. What method of garbage disposal will be used?
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Additional Information
""Q Contact the local Fire Marshal (860-282-0669)to ensure compliance with the Fire Code.
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.
'�'9I Wastewater must be disposed of in a sanitary sewer or other approved sewage disposal system.
Equipment and tables must be clean, smooth, washable, durable, non-absorbent and in good
repair.
Dust must be controlled (i.e. dry fields) by watering down.
U All workers at the food booth must sign a log sheet indicating the date,their name,address and
telephone number and the hours that they worked. Please retain the log sheet after the event.
�I If gloves are used,they must be a food grade quality glove and must be used for only one task
(such as working with ready-to-eat foods or with raw animal food). You must wash your hands
after removing the gloves and prior to putting on a new pair of gloves. Gloves must be discarded
when damaged or soiled, or when interruptions to use occur.
Food employees may not wear nail polish or artificial nails unless wearing intact gloves in good
repair.
Pre-Event Self-Inspection Checklist
"Prior to your event,take a moment to go through this checklist The checklist should be completed for each temporary food site
FACI LITY
❑ Storage of dry goods(shelves and/or crates for off the ground/floor storage)
❑ Cold storage(refrigerators/coolers)at 40 degrees F. or below.
❑ Hand wash station that includes warm potable water,soap and paper towels
❑ Potable water supply(hot and cold)
❑ Food preparation area
❑ Wet and dry garbage disposal
❑ Dishwashing facility(wash, rinse, sanitize)
❑ Area to clean and sanitize utensils
❑ Ice and ice storage (freezers/coolers)
❑ Facility free of pests and rodents
❑ Method of wastewater disposal
EQUIPMENT AND SUPPLIES
❑ Calibrated metal-probe thermometer (0-220 F degree ranee)
❑ Plastic wrap
❑ Extra utensils including tongs,spatula,spoons,etc.
❑ Plastic disposable gloves
❑ Bleach/Quaternary Ammonia for sanitizing
❑ Test strips for testing sanitizing solution
❑ Clean wiping cloths and containers for sanitizing solution/spray bottles
❑ Food-grade storage containers
❑ Hair restraints
❑ Log Book
❑ Garbage containers/plastic bags
FOOD SUPPLIES
❑ Shellfish tags must be kept for 90 days after purchase.
❑ No horne-prepared or home-canned foods can be used in the preparation of any item.
❑ All meats and poultry must be USDA-inspected and come from an approved source.
❑ All preparation must be done onsite or in a licensed commissary or kitchen.
❑ Check temperatures of foodstuffs when they arrive at the site.
❑ Meat,eggs, poultry,fish,shellfish,and milk should be at 40 degrees F or below.
Se vSafe
National Restaurant Association foe
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CERTIFICATION
ALEXANDRA BROWN
for successfully completing the standards set Forth For the ServSafe®Food Protection Manager Certification Examination,
which is accredited 6y the American National Standards Institute(ANSI}-Conference for Food Protection(CFP).
15585694 10555
CERTIFICA' E NUMBER EXAM FORM NUMBER
9/26I2017 9/26/2022
DATE OF cXAnnINATION DATE OF EXPIRATION
Local laws apply =heck with your local regulatory oiler--.,For recertification requirements.
Sher n
SVP, National Rsxtourant Association Solutions
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