Loading...
HomeMy WebLinkAbout2018-12-8 - 1175 Ellington Road - Temporary Food License Application TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT 1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address f t° 1530 Suffivan Ave.,South:Windsor,CT 06074—Office Address, Phone Number: (860)337-6173, Fax Number: (860)644-1930 TE1114PORARYISPECIAL EVENT FOW SERVICIEUCEASE APPLICATION ***must be subinitted 2 weeks prier to event*** EVWTUQVRKAUQX Event Event►ifs): e Cdc.L j 1 ill t , Z 01 Eveent Tgne: - i I �lJ FT ITN,) Event Location: �Jvl� C �rt► �t 7rJ (I i n y Tc,� , S�,t� C fi d6eSy PEPS W IN Titer Last Name: 0C(Do 1u k l First: V'1 uvi !L Street Address: (PCL5tAApartment/Unit#: City: I�sw r1 stye: CS zip: Obi Phone: E-mail ,o- *b 3b- e l 62 Address: 1`�1 U1,e�S � �� 31©C�YYId i�_�'t�'✓� T1tiC�, (- rK, - ra,ten Representing: W u 1� 1J�,1 Street Address: £1 Apartment/Unit#: City: o� tx State: CSC Zip; 0�0� Phone: 3'/` [ E-mail Address: CC" Qv f (V#M .F C TUW E) J t 1 v V .Name: � ��kc WL `�C �1 acl Certi€ii e#: Z�I 'A b-1 S gate: q MDMCWPAL XWORMATIM Water Supply: YES V,-- r4O Wastewater Disposal YES NO YES �-'NO Base of Operations: PIEND **tP1UEAS1Ej.1ST ALL MENU ITEMS=AS AS e i�aiLf Y1czi- 11� , -�,min 1 u,'�C l 4Y�1 Q g1�ze ****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. AGREEPIMMANDSIOUTUM By submitbog bins application,I affirm that the facts set forth in at are trace and civnplete.d understand that any false staternents air other misrepresentations made on this application rnay.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(y - (Please Pant): 1 t ►l G ��Q �d (\( �� ¢ F G � Apprant Signature: 4G l l �, . . , , v t + .5 F / � .� ' c f� 1 • N1 -�44 xJ �rLs 1 I .,�J OFFICE USE ONLY Inspector Name: {Please Pr€itl: Inspector Date: 9ignabxe: Food Class: 1 Z 3 4 FEE: $50, Nonprofits exempt Temporary Food license#: €xpiration Date: Payment: Date Received: __Z> -Town of Sly Windsor.:Heath a gent Temporary Food Event Questionnaire Form Please complete all questions and return to the Health Department with your application. �DSOR-!al 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. I ic S c a rC 6f ,nu iLr e-h c( d 3 ti► 1 b r�lccnrlt�zi u . i�ua nr_ I i- bulk CQ ld LILDS 121Lz.L d -AD LL �t ,sue C"ach-iAan r -tD Paz .,c_rcx?_-d in try alk a dt c'f- 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_ 'CQ.f`r?6 lA)i(I` bZ_ ct aAZ_ems c00IaG �D lTnra es�i n d tS �1S nCa���a��- i IC-, ��cn aleQ; b� ,n �� �-�l�..l" C�l� SCR CR��� ��I I �P�'Jcer n - �►d �n �LtC,i ( �ze,,�-___ r�r 171az 1 -Hew"-Ore eed4terns-be ceei< d and/-er+t+ieid? A sanitized metal stemmed, ca9ibrated probe thermometer to monitor food temperature is required. If thin patties are'bein,g cooked,a lhermocoupie may be needed to accurately ctteck emperatures. ,�p r CIL (1G-r rf.P r o 1(t bZ cnu&. , nn ce CJ 6`1 d&LCk, d2c, —N '�S C'r7d lco d cSho,,T OaAs n OLO- Cam\ • P�I 1 i c,04:1 C 06V -hV i n ae JD)(A i.Cu.Mla f d) c yincl 4. tease describe the type of Ptand wash:farcifty to.be used. S_'fift`��cn5 k t c h,� IS (S�l w Uu; u)i th 01 hck n c1 6,I R v� L o i Y1G-t ay -a d a'>6_�4n n n C klir-mot . t" Q� iS, o d t GQ P_ 'in +Vw- I I n,rie cl i ci nz R c-t. C6 h10- clod M:�ptf__A fL n afld. &-4-\) ica OJ?L,6 kX f►v C f )CLL- . S. How will the food be protected? Food roust be protected durirtig storage,preparation,display,service arid,transportation,_ Cooking.to order.will lessen the chance for bacterial gr~h,which may occur prior to service. in •,151 0�- i i na i I 1 i � � -_6 F62A2(3, �b %2k- C.cotioA CC hb a e'h f --Ca tf z" 0 k�Na n CA \'\cSe -Co ee l ,t �fl +►�►nu tivn c c rl�;l N�c4e 6. How witi the A utensils and food contact surfaces be washed,rinsed and sanitized? �l )ttX\S 1 S �-�t 1 4 Cb �Slrcf C.i n-UT��hS L��it � L&�LQ-C h ear rinin n cp-)uc�i d- . lam ' act crcnfi P,�W �Lk.r is �i ( I dna d fl i n'1�S 7. Where will excess food(Potentially hazardous and non-potentially hazardous foodsf;dry goods,and single service items be stos-e13' 11 ►�ertT 0'�,ay►n in -4v rc&I'C f-Ztrcr(- C 4nfii i Ca lu c " AN � �-� Vk n�- -A� An v anndc 0 gkjD ea k M'Vc �cfH c o i n r-�\ Cod-pax 2ka rs;'Au— Until Klee deA i as _ _,..� i n OCA hi(IS- ceva i i u bls_ �. ssr►c^s2 iirnrt WaS►�ucieargWia"5 8nu SBCs►tLmrabe Stoi'i?m? `(fie c nrtS ce nd 5a nfi 2e'4-'�s t O M hc. SccxTA 'in fly p urn r Lts, C'Uf Ao j ac ct f"h -t-t� c5 i n L Ihy-n &b c-i CV'2'Q. �i. Xow wM-1 condiments and single serileaa i`lam"S(dips,Plates, `u``aer'siis,�sr.j L'a dispensed? Ogled; ma-n-LS CQ.nd IbIl Ed ly-I F n�;c�. `►re rrls ypi(1 �r d' any d WIkh YVM V-<e u,,P . Ce_c C& 0(U LC)i (l a wr-n CDuf to 10. What met of image 6 sposal wAl be used? vl�� u��d �nd�SOh 'DNS ��¢.t bcz-c�r� �e.3 i I l i� e�lt�C`�-a� C��i r�cl `� ►r1 . �.110D,5 NATIONAL REGISTRY OF FOOD SAFETY PROFESSIONALS® L� •o p CERTIFIES MICHELLE E VCONNELL HAs SUC CERSFULLY SAT=FIED THE REQUIREMENTs FOR THe G R11 FIEi FOOD SAFIETY MANAGER UNDER THE CONFEIRENCE FOR FOOD PROTECTION SrANDARDs PRESIDENT: _ LAWRENCE J.LYNCN.CAE ISSUE DATE: NOVEM13ER S.2017 EXPIRATION DATE: NOVEMBER S,2022 1. CERTIFICATE NO:21-407597 67 1 Forum Driw.Suite 220,Oriando,F 1,32821 TEST FORM:EXE70 P(SM)4.16-02 i'F t 107)1;2-3641 wwwN RF1;Po,m Tpb rertNeate rs snt saGd tx wwre - �Uan fisc gars&urr dale ar issue. National Registi of Fould 4atcq f'ro(esaionak' Notification of Test Result 's F IUD: XXX-xX- MICIIELLE E O'CONNELL Scaled 'Kest Score: 88 Candidate Statics: Pass Test Date: November 8, 2017 C"rti6tWe No 2t407ilf- r�x+n.;roa ..:same t,�kt)atc timrn�berR._'{Yt" Esp,ratum Date Ncnrn,ter S.'li" ( ongralulat iN xour certificate and+%allet cud_ 1'lca;c no il'N MI 11H.LE F OVONNI LL the National Rceistn o(naune or address changes at the address bolo%%. 142 GATES FARM RD G1,ASTO BITRY. CT 0603; Preventing Contamination and Cross Contamination(Competent) Ensuring Personal Hygiene and Employee Health(Mastered) Actively Managing Controls in a Food Establishment(Competent) Monitoring the Flow of Foods(Competent) Ensuring Product Time and Temperature(Mastered)