HomeMy WebLinkAbout2019-1-8 - 1175 Ellington Road - Temporary Food License Application TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
1540 Sullivan Ave., South Windsor,CT 06074--Mailing Address
u 1530 Sullivan Ave., South Windsor, CT 06074—Office Address
�t. Phone Number: (860) 337-6173, Fax Number: (860) 644-1930
,M1�SOR-c�^`y TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION
***Must be submitted 2 weeks prior to event***
VE(�TINFORMq,TION �` l
Event Name:
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Event Date(s): �,G4c,G �Ct,(1q&� �r� ZLl EventTime J ,�� /� 5/�Gt tcG�� ��7�f�
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Event Location: !"�-V(4 r 0", 5 C9 , Gv- C 7
PERSON IN CHARGE INFORMATION
Last Name: t' 1 l-\ First: ' -400 f-ril M.I.:
Street Address: -_ Apartment/Unit#:
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City: r, Email t Zip__
Phone: ,Ct t I (�s � y Address:_ _S () e 4— --
ORGANIZATION REPRESENTED (IF ANY)
Representing: r p o --- -
Street Address: — t Apartment/Unit#:
City: ���C%�1__. � C� � State:� � �� Zip..
Phone: E-mail Address:
QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) YES ❑ NO ❑
Name: J tv"31 \_t 9 J-...
Certificate#: 6 � 0 � Date:
ADDITIONAL INFORMATION
w t YES NO ❑ Waseater Disposal YES L�' NO ❑
Water Supply: p
Electrical: YES NO ❑ Base 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 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
j of South Windsor. Temporary Food Service License will be issued after the Food Inspector has completed his/her inspection. j
Applicant a
(Plea Print):
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Applicant Signature: Date:
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Town of South Windsor Health Department
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Temporary Food Event Questionnaire Form
1At 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 washe , rinse 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? �--
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?
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CERTIFICATION
DEBORAH SMITH .
for successfully completing the standards set forth for the ServSafe®Food Protection Manager Certification Examination,
which is accredited by the American National Standards'lnsfitute(ANSI)-Conference for Food Protection(CFP).
10658'.
ER EXAM FORM NUMBER
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7/18/2018 7/18/2023
DATE OF EX DATE OF EXPIRATION
Local laws apply.Che cy for recertification requirements.
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PROGRAMACCREDITED
American allonal Standards Institute
and the Nerence for Food Protection
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#0655 ciation Solutions o •❑
In accordance wi
e ServSafe logo are trademarks of the NRAEF.National Restaurant Association®and the arc design
Contact us with questions at 233 S.Wacker Drive,Suite 3600,Chicago,IL 60606-6383 or ServSafe@restourant.org.
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OFFICE USE ONLY
Inspector Name:
(Please Print):
Inspector ---• ate:
Signature: _
Food Class i ❑ 2® 3❑4❑ FEE:$ , Nonprofits exempt
Temporary Food License#: Expiration Dater
---- ------ --- --------
Payment: Date Received: