HomeMy WebLinkAboutApplication 301 Evergreen Way (2) 10r105,+2015 10:21 (FAX) P,001/005
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-- TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
�. 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address
a 1530 Sullivan Ave., South Windsor, Cr 06074—Office Address
Phone Number: (860)337-6173 Fax Number: (860)644-1930
y�^Os°■ *W TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION
***Must be submitted 2 weep prior to event***
_EVENT TNFOftMATION - -
Event Name: bN T 2-0M 6 N,dVP
iEvent Date(s): Event Time:
Event Location:
PERSON IN CHARGE INFORMATION
Last Name: QCt_v�v 9u ' First L _.. M.I..
j Street Address: Apartment/unit
City" � state: 7Jp:
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Phone: p �'Sp / Oar. I Address: a'� `�d1(
ORGANIZATION REPRESENTED (IF ANY)
i Representing* pf..l�(a��i�_ MTCTE_:; Yv
Street Address: �v�� � I Apartmenttg,
1J ...--A.. State: ZIP: O("Cq
Phone: i E-mail Address:
' QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) iT. YES
Name:
Certificate#: [ �� I Date:
ADDITIONAL INFORMATION v /'
vh:ter Supply: YES ❑ NO Wastewater Disposal YES ❑ NO Ind
Electrical: YES ElNO 9ase of
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 OP 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, per 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 Ueense will be Issued after the Food Inspector has completed his/her Inspection.
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Applicant Nama ( �
I (Please Print):
Appitcant Signature: Date:
10+05i'2018 10:21 (FAX) P,002 005
Town of South Windsor Health Department
A Temporary Food Event Questionnaire Form
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Please complete all questions and return to the Health Department with your applitaf Ion.
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. Now will the food Items be cooked and/or hot heldi"
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.
4. Please describe the type of hand washing facility to be used.
10e'05+2018 10:21 (FAX) P,003f005
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?
8. Where will were wash detergents and sanitlzers 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?
10 r 05/2018 10;22 (FAX) P,004?005
Additional Information
Yf Contact the local Fire Marshal (860-282-0669)to ensure compliance with the Fire Code.
I/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.
C7 Wastewater must be disposed of In a sanitary sewer or ther approved sewage disposal system.
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�1 Equipment and tables must be clean, smooth, washable, durable, non-absorbent and in good
repair. H Pt LA--
t� Dust must be controlled(i.e. dry fields) by watering down. N
M/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.
ad/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,
10;'05I2018 10;22 (FAX) P.005+005
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OFFICE USE ONLY
Inspector Name:
Please Print):
Inspector Date:
5lgnature,�____�
Food lass: 1❑ 2❑ 3 ❑4❑ FEE:$50,Nonprofits exempt
Temporary Food License#: Expiration Date:
Payment: —------ — Date Received: