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TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
1540 Sullivan Ave., South Windsor, CT 06074- Mailing Address
1530 Sullivan Ave., South Windsor, CT 06074—Office Address
'�f r Phone Number: (860) 337-6173, Fax Number: (860) 644-1930
V"sOR TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION
***Must be subnjitted a weeks prior to event***
Event Name: v V{l V"lr.U ....._/ I&, R O{ti St 1
Event Date(s): �`I� .tr aay S�.�I I Z CD) oll Event Time:
Event Location. -)O v R(q�n� U1 1 1{ � � � Sup��� / � � �t��n�So(� �� (oQ�" ►
PERSON IN CHARGE INFORMATION
Last Name: I( � e First: t+�y C _ M.L.
Street Address: '>I^U P�P w.+ U'I`1 t� A 04 Apartment/Unit#: �v 11
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City: S_cw�S�n �nr��c� ��(1 _ State: C-V- Zip: UUv�Ll
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Phone: �p � 1�'31,(b_... ._...__ Addre E-mail ss: fi��1 0v �....(nM•tii� •COM
ORGANIZATION REPRESENTED (IF ANY) t JJ
Representing:
Street Address: Apartment/Unit#:
City: State: Zip:
Phone: E-mail Address:
QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) iZYES E'] NO
Name: Wa�� �CGiv��YH .
Certificate#: [ 1 40 (PC) 9 Z Date: 2-0 17
ADDITIONAL INFORMATION
Water Supply. YES NO Fj Wastewater Disposal YES [ NO
........... _
Electrical: YES NO 0 Base of
Operations: V 1111\ R is ,hf j\r ur O OgS'
MENU 11 **(PLEASE tjff 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 FireMarshal'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 revoca ieaaf-my tem r_a Food Service License for the Town
of South Windsor. Temporary Food Service License will be issued after the Food Inspectr has completed his;her inspection.
Applicant Name i ram, �tU�C��H t
(Please Print): _ JA
Applicant Signature: /r 1 Date: ` 7 (01
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tso HEALTH DEPARTMENT
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OFFICE USE ONLY
Inspector Name:
(Please Print):
Inspector
Signature: Date:
Food Class: 1 El 2 f 3 El 4 E FEE: $50, Nonprofits exempt
Temporary Food License#: Expiration Date:
Payment: Date Received:
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CERTIFICATION
WALTER BEAULIEU
for successfully completing the standards set forth For the ServSafe®Food Protection Akwi* r Certification Examination,
which is accredited 6y the American National Standards Institute(ANSO-Conference for Food Protection(CFP).
706082 10537
UMBER EXAM FORM NUMIIER
2/15 2/15/2022
DATE OF EI DATE OF EXPIRATION
Local laws apply.C ency for recertification requirements.
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Coafad us with quedions at 175 W lodaon BW-Ste 1500,Chicago,1.60604 or ServSa66redaurmt.org
*N�� Town of South Windsor Health Department
fQp 41 , Temporary Food Event Questionnaire Form
y.,t ,�� Please complete all questions and return to the Health Department with your application.
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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 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 sanitizers be stored? 11
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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? 11
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