HomeMy WebLinkAboutApplication 150 Nevers Road (43) ^ 0 re
TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
1540 Sullivan Ave., South Windsor, CT 06074
Phone Number: (860) 644-2511 x250, Fax Number: (860) 644-7280
TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION
***Must be submitted 2 weeks prior to event,No fees charged***
Event Name: Vic. �-i l L jv�k
Event Date(s): I I I I �i Event Time:
Event Location
PERSON IN CHARGE INFORMATION
Last Name: L�I-K First: -- Date:
Street�Vldiess: co —vim ��a Apartment/Unit#:
City: 4 °� � State: C_T Zip:
Phone &Cell R,
Q E-mail �M�, @ {I -
Phone: 9 l � Address: V � t � � U(�C� � c.,-\
ORGANIZATION YOUR REPRESENTING (IF ANY)
Representing:
Street Address: Apartment/Unit#:
City: State: Zip:
Phone: E-mail Address:
QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) YES NO
Name: ,`` L-(—;-
Certificate#. u \ �6 tj�- f Date:
ADDITIONAL INFORMATION l
Water Supply: YES NOV e- Wastewater Disposal YES NO t/
Electrical: YES NO If other,please
explain:
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 Inspec�gl„t�icQrilp,ted hr!her inspection.
Applicant Name ft Ef IrI EG
(Please Print): 4� � � � � � L �
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Applicant Signature: �-
� — SOUTH WINDSOR
HEALTH DEPT.
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OFFICE USE ONLY
Inspector Name:
(Please Print):
Inspector Date:
Signature:
Food Class: 1❑ 2[I 3 ! 14 i
Temporary Food License#: Expiration Date:
Notes: Date Received:
own Olve� 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.
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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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 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(s1anitizers be stored?
9. How`` will condiments and single service items(cups,plates,utensils,etc.) be dispensed? AT-02 c IA
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10. What method of garbage disposal will be used? 1
FOODS NATIONAL REGISTRY OF
FOOD SAFETY PROFESSIONALS®
' CERTIFIES
ref
o CO) ZHI LE CHEN
HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE
CERTIFI FOOD SAFETY MANAGER
P R UNDER THE
CONFERENCE FOR FOOD PROTECTION STANDARDS
PRESIDENT:
LAWRENCE J.LYNCH,CAE
ii
ISSUE DATE:JULY 2,2017
EXPIRATION DATE:JULY 2,2022
a0656 CERTIFICATE No:21365821
6751 Forum Drive,Suite 220,Orlando,FL 32821 TEST FORM: EZS36
This cer[ificale is nol valid for more
P(800)446-0257 F(407)352-3603 www.NRFSP.com Than five years from dale of issue.
National Registry of Food Safety Professionals'