HomeMy WebLinkAboutApplication 476 Rye Street 0jo
n°0' "4, - TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
x a 1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
co 1530 Sullivan Ave., South Windsor, CT 06074—Office Address
Z _ Phone Number: (860) 337-6173, Fax Number: (860)644-1930
"10w-CL` TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION
***Must be submitted 2 weeks prior to event***
EVENT INFORMATION
�f_Event Name: / <<j
Event Date(s): g/_J C?_ j (� Event Time: 6A'_1
- e *e 4
Event Location: /7 c,/` :�; r—
PERSON IN CHARGE INFORMATION
Last Name: ! ,A /A U.S1-c-AS First: Sc M.I.:
Street Address: �SUll u^j AUC Apartment/Unit#:n
City: SCiV71-� �a,�CC$o. State: Cr Zip: 06C)7Y
Phone: 6� 7 6 yo / E-mail -�/�uC c-i l/�lt'�y �� �O•f�
Address: 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 1 NO
Name: -- l L)iUNt'�TC✓T �Az[ic, / 7�c Jl ll'
Certificate#: Date:
ADDITIONAL INFORMATION
Water Supply: YES J NO� Wastewater Disposal YES 1-1 N0,"�
Electrical: YES I- j NO � i;`'"` `'f
Op(vi--Mons:
MENU **(PLEASE LIST ALL MENU ITEMS IN AS MUCH DETAIL AS POSSIBLE)**
It'la r �3/�,z� ��- Sc av�O Faari A eA-v i,,� A Gvl'0
****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.
Appllcant Name / k4i RECEIVED
(Please Print): JT ` ' �>
Applicant Signature: ' SEP 2 6 2018 Date: - -/g
SOUTH WINDSOR
HEALTH DEPT.