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HomeMy WebLinkAbout673 Ellington Road (2) s0,0N SC,4 Town of South Windsor — Health Department _ 1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address Phone Number: (860) 337-6173 Fax: (860) 644-1930 �So R•cn� Establishment Information New Permit 4 Permit Renewal Type: Mobile/Itinerant Vendor❑ Temporary Event Permanent Food Service Establishment❑ ***(Please Print Clearly)*** CLASS: FEE DUE: Name of Establishment: 5 4yarCiS &C flSS1Si Card) Name of Person in Charge: z-_ 1 oU,1e_ 'SViemens -t Establishment Street Address: V13 F l t l City, State, Zip Code. 5p04k�A _v& _ d,NL Q f"_ b U0"7 p, Phone#: 5p �Z�� Cell Phone#: ?&D— "D LZ3 _ Fax#: _ E-Mail Address: Seating Capacity: Please submit latest copy of the Certified Food Protectio n gerJServSafe certificates to the office. Certified Food Protection Manager YES)( NO ❑ Certificate#: (CFPM) (Required for ALL Class 2,3&4) Name: _Ch eer. ml lie. Expiration Date: uI� Testing Organization: sery Phone#: ,Ov Vr E-Mail Address: Alternate Phone#: Alternate Person In Charge Wb -6YA1'4 Phone#: g' o__q�R_ (Q©04 Restaurant Owner Contact Information Owner's Name: Please check one of the following for ownership status: Mailing Address: Individual❑ Association ❑ City State, Zip e:Cod Corporation ❑ Partnership❑ Other Legal Entity❑ Phone#: Fax #: E-Mail Address: Cell Phone#: Renovations Were there any renovations made last year? YES❑ NO 1K Will there be any renovations? YES❑ NO If Yes, please list all renovations that were done/to be done: Supplemental Questionnaires For Itinerant and Temporary Event applications, please complete the supplemental questionnaire form RECEIVED FEB of I,q SOUTH iTME HEALTH DEPARTMENT �jg! Restaurant Menu/List of All Items Served/Sold Latest Menu Attached? YES❑ NO ❑ NOTE"(Must have latest copy on file) Please list all menu items in as much detail as possible or a copy of a menu attached is applicable. he4l a-t �� ►read Restaurant Food Prep (check all that apply) [:] Cook to order ONLY ❑ Advanced catering for specific quantities ❑ Uses Time as a Public Health Control ❑ Cooking/cooling/reheating/thawing/freezing/hot or cold holding ❑ Prepares food to serve at another site ❑ Prepares food for Highly Susceptible Population(preschoolers or the elderly) ❑ Prepackaged non TCS Food Only ❑ Non TCS Food only(food that does not require refrigeration) Additional Information Please check all that apply: State Licenses: ❑ Bakery ❑ Liquor Permit ❑ None Water Supply(check only one): X Public _Private Well Wastewater Disposal (check only one): X Public —Septic _Other(please use space below to explain) Agreement and Signature By submitting this application,I affirm that the facts set forth in it are true and complete and that I will comply with the ordinances and regulations of the Town of South Windsor and State of Connecticut. I also affirm to allow the Town of South Windsor Health Department access to the establishment as required. I understand that any false statements or other misrepresentations made on this application may result in immediate shutdown or revocation of my Food Service License for the Town of South Windsor. Applicant Name (Print):Q,j(de— 5h o Date of Birth: 0/-I Applicant Address: C f 00 Phone#: d-7 Z-2- Applicant Signature: Akltq Date: 9, / 3 Office Use Only Inspector Name (Print): Inspector Signature: Date: Food Class: Expiration Date: Date Received: Date Approved: � w„ SK Town of South Windsor Health Department ^� 41 Temporary Food Event Questionnaire Form yy� -" Please complete all questions and return to the Health Department with your application. SOR-C��� 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. Bw � Grw.QBI--, �IaT'4± Awl* 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. 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. ITV C r O. 4. Please describe the type of hand washing facility to be used. a n(- C, ruvwx A ' 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. S {� k o Te yu4O, aerv)'./Ic, I t 6. How will the all utensils and food contact su aces be was ed, rinsed and sanitized? s r 7. Where will excess food (Potentially hazardous and non-potentially hazardous foods),dry goods,and single service items be stored? -- dr`--L , ��na 1..Q �+�y`f' -- Cep►n 8. Where will ware wash detergents and sanitizers be stored? Q ii re UA re ✓ytQ Y 9. How will condiments and single service items(cups, plates, utensils,etc.) be dispensed? Lk fie -' l 10. What method of garbage disposal will be used? 7m,41 CC)l IP cal and Afsxaj 9�f 0 (L�U� 'S ServSafe 0 National Restaurant Association ery n e CERTIFICATION CHRISTOPHER WYLIE for successfully completing the standards set forth for the ServSafe*Food Protection',Manager Certification Examination, which is accredited by the American National Standards Institute(ANSI)-Conferenoe for Food Protection(CFP), 201324 5265 UMBER EXAM FORM NUMBER 6/2/2 6/2/2022 DATE OF E DATE OF EXPIRATION Local laws apply.C ency for recertification requirements. 10-0 She #0655 ROLM In aaordasa with Mwilime s 02015 Natural bpo are trademarks of the NRAEF. Not, Contact us w9h questions at 175 W Jackson 8W.Ste 1500,Chicogo,IL 60604 or SwvSaWrestauront.org. i