The URL can be used to link to this page

Home My WebLink About2016-6-21 - 150 Nevers Road - Temp Food License Application Bakery on Main TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT 1540 Sullivan Ave., South Windsor, CT 06074 Phone Number: (860)644-2511 x250, Fax Number: (860) 644-7280 TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION *"Must be submitted 2 weeks prior to event,No fees charged,1*21 Event Name: Event Date(s): duly V`, Z3, t91 2O Event Time: See -3: /-I ,- 0 c-4- I Event Location: ",-oWG I -)5 Yu" Lc PERSON ry� IN CHARGE INFORMATION Last Name: 0 a 113 First: C M.I.: 6 Date: (p 2 to Street Address: 1 2 7 I' 0.lk- /JL,-c_ ( a O Apartment/Unit#: City: a-4� 1 d 1 State: C"'- Zip: C)la( 0 Phone &Cell 86 o E-mail Phone: ] 6 6-` -1 If, 13161 9 8 Address: Cv-f4 t3 d @ 6e mn ry a�a h ORGANIZATION REPRESENTED (IF ANY) Representing: P, 0/1 MCLf`n Street Address: /-z _j l p� Apartment/Unit#: City: OQ �i l ✓f' V� State: C--C ZIP: O U L a $ Phone: 1 3 l to E-mail Address: Cj_,, -j ck®Io rL ANz-t f.+I QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) - ` ❑ YES ❑ NO ✓ Name: Certificate#: Date: ADDITIONAL INFORMATION Water Supply: YES ❑ NO ❑ Wastewater Disposal YES ❑ NO ❑ Electrical: YES ❑ NO V If other,please explain: MENU **(PLEASE LIST ALL MENU ITEMS IN AS MUCH DETAIL AS POSSIBLE)** QLL v,_U-e..S X C.r y....i k-'—s ****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. ver 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 Ucense for the Town of South Windsor. Temporary Food Service License will be issued after the Food Inspector has completed his/her inspection. Applicant Name /1 (Please Print): (ill Q CQ 1 Udl Applicant Signature: 04 Date: Co l 2 l / / b � M0 Town of South Windsor Health Department Temporary Food Event Questionnaire Form o � Please complete all questions and return to the Health Department with your application. 2. 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. / n fAw"n 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 an 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 Abeing cooked,a thermocouple may be needed to accurately check temperatures. l 1A 4. Please describe the type of hand washing facility to be used. (,(�u-f"e ✓ ) �G LUr '�1,-- S(2�u+ . �1cswd SCkn �i2 So n . � c� "a4_ 4{ 6 C�L 4-C�W��-+� 0.yN�� cl� Additional Information ❑ Contact the local Fire Marshal (860-282-0669)to ensure compliance with the Fire Code. ❑ The food preparation and storage areas must be covered if event is outdoors. Be sure that the tents used for overhead cover are fir -rated, per the South Windsor Fire Marshal's office. ❑ Wastewater must be disposed of in a sanitary sewer or other approved sewage disposal system. ❑ Equipment and tables must be clean, smooth, washable,durable, non-absorbent and in good repair. ❑ Dust must be controlled (i.e. dry fields) by watering down. ❑ 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. ❑ 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. Temporary Event Form ovt 6 � Event Name: _ ,fl��ar'/� `S Ir1 flL.�'i Date: !v/S / tom"" Se'` Event Location: A)&Vk: X; Time: QFO: Vendor Name/Organization �,4 Lev- i c)rt A /,,t ) �'a,�a•�•�' Food Source &Temperature: Food from approved sources ,�„�� GvUti No home canned/home prepared foods del, X' Ice from potable water source Food prepared off site in approved food service facility Cold holding<450 Hot holding > 1400 �ersonneL, , �. �'hpprop it ate handwashing facilites (warm water, dispenser with hands free spigot, liquid soap, paper towels,waste water container, trash can) No employees with communicable diseases; cut and sores covered Qjean outer garments, no smoking, eating or drinking in prep area �, - - ndwashing at appropriate times �- Minimize bare hand contact Food & Utensil Storage, Handling: i Dry storage of all goods, utensils, single serve items protected and not on ground Cold storage: units clean, have working thermometers, internal temp<450 Hot holding: units clean, ability to keep foods> 1400 Thermometers available and adequate; calibrated ±20, alcohol wipes Food protected from outside contaminants, sneeze guards Food prep areas protected from contamination ✓" Utensil storage approprate, clean Food protected from cross contamination during storage, prep, display Utensils cleaned and sanitized afer use or every 4 hours Cleaning: Ware washing set up adequate to wash, rinse, sanitize Sanitizer available; test strips available Wiping cloths stored in sanitizing solution Water Supply&Wasteater Disposal: Adequate supply of potable water ,i Backflow preventer and food grade hoses when needed Wastewater disposed in approved disposal system (sanitary sewer, blueboy) Premises: All food contact surfaces easlily cleanable, intact Floors clean, easliy cleanable Walls and ceilings protect against contaminants Garbages adequate, rodent proof, non-absorbant Toilet facilities adequate, clean Toxic materials properI labeled and stored pector F.