HomeMy WebLinkAboutApplication 90 Foster Street ut twre
5'•� - 5- TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
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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
'"NOR k"' i ilIY= i .r!;%�;�')'jSPECIAL EVENT FOOD SERVICE LICENSE APPLICATION
` 'Must be submitted 2 weeks prior to event"*"
EVENT INFORMATION '^^
Event Name: F o S T e a- Fig P_ m (f V a N rm o}-Z L_
Event Date(s): sze4 2cl Q C,+ Zg-rh Event Time: WCQ e-ev-J S
Event Location: F63-f2f2" - I j S v t—JM—A
PERSON IN CHARGE INFORMATION
Last Name: G I T lq '4 FS First: C rD (,J Arz"0 M.I.: S
Street Address: Z C'7 >F0 S j 2. S Apartment/Unit#
City: 5. W k No 5c��(L State: C-T Zip:
Phone: �6 Q 5l Z / E-mail Address wc�,d C. v�•3 �
Address aC{ d C,O 1
ORGANIZATION REPRESENTED (IF ANY)
Representing:
Street Address: Apartment/Unit#:
City: State: Zip:
Phone: E-mail Address:
QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) YES NO
Name:
Certificate#: Date:
ADDITIONAL INFORMATION
Water Supply: YES NO (�Wastewater Disposal YES 1 ' NO
Electrical: YES NO l Base of
Operations:
MENU **(PLEASE t_!ST 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****
i h - food preparation and storage areas must be covered if event is outdoors. Be sure that the
used tot overhead coves are fire-rated, uer 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 Dw A J2 0 S
(Please Print): � C���
Applicant Signature: Date: /Z
EC�V/
ED
SEP 19 Z018
SOUTH WINDSOR
HEALTH DEPT.
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AAP-
OFFICE USE ONLY
Inspector Name:
(Please Print):
Inspector
Signature: Date:
Food Class: 1 0 2 0 3 P?(4❑ FEE: $50, Nonprofits exempt
Temporary Food License#: Expiration Date:
Payment Date Received:
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�Qwn„6',e� Town of South Windsor Health Department
�G Temporary Food Event Questionnaire Form
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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 tool 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, un ier 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 will the food be protected?
Food must be protected during storage, preparation,display,service and transportation. Cooking to order will
lessen the chance for bacterialgrrowtth,h, 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 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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ServSafe ,
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ServScl- f e
CERTIFICATION
EDWARD CHAVES
for successfully completing the standards set forth for the Serv&Ae Food FFoloclion Manager Certification Examination,
which is accredited by the American National Standards In k4a(A -Conference for Food Protection (CFP).
ER EXAM FORA+! NUMBER
9/20/2018 9/20/2023
DATE OF E `' AMINATION DATE OF EXPIRATION
Local laws apply wttlt your locel tvWototy aua: -,for recertification requirements.
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o ServSaFe logo are trademarks of the NRAEF National Restaurant Assoclation®R and the arc design
Contact us with questions at 233 S Wacker Drive,Suite 3600,Chicago,IL 60606-6383 or ServSafe@res1auran1.crg.