HomeMy WebLinkAbout2016-9-7 - 1175 Ellington Road - Temporary Food License Application O
TOWN OF SOUS' WINDSOR HEALTH.DEPARTMENT
....",-
154o 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 cbarged***
Event Name: �puie� r X)i to
Event Date(s):
Event Locabori; urn tx_i�
PERSON IN C14ARGE INFORMATIONLast Nam: First: S'�Ir� Date;
AklArtMerit/Unit
Street Address: 4 ,,
city, da/L State: 7Jp:. C(e(
E-mail
Phone Cell 6W%V� CL)'r_7
Phone: Address:
ORGANIZATION REPRESENTED (IF A"
Representing:
Apar"entfUnit SY-AR: 3C
S"ek Address:5 lC N. AA st
OtV: State, C_r ZJP-. J
E-mail Address Uf
Phone:(dD
NO
QUALIMD FOOD OPERATOR (INCLUDE AY OF CERTIFICATE
Name: 7 Date:
Cerdficate#:
ADDITIONAL INFORMATION
w suppty, YES I NO �& Wastewater Disposal YES ❑ NO ;X
aw
if other,please
Dectricat YES NO 0 o(olaln:
MENU
*!#(PLEASII LIST ALL M CNU rWMS IN AS MUCH DETAIL I S POSSIBLE)"
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****'P.LEAS*f DRAW A DETAI 'DIAGRAM OF FOOD soM ON THE BACK OFTHIS FORM.'
USING THE GRAPH i licrURE ON T"E BACK'00 THIS APPLICATION!'*
The food preparation and storage at Pas must be covered if event is outdoors. Be sure that the
tents used for overhead cover are fit'e-rated, Der the South Windsor Fire Marshal's office.
AGREEMENT AND SIGNATURE
gy sibmitft ttils appikatim,I affirm that the facts forth to it are true and complete-I understand that any N&statements or other
vwn or revocation OF my temporary Food seroce Ucense for the Town
misrepresentations made on this application may resA'n immediate shutdown
of South Windsor. Temporary Food Service Ucense will�be issued&IbBr the Food Inspector has completed his/her inspection,
Applicant Name
(Please Print);
Applicant Signature; Date:
Town f South Windsor Health D®partment
Temp?rory Food Event Questionnaire Form
Please complete all questions and return to the Health Department with your application.
1. What is the source of the food to be servedJospensed7 (Please Include nAme/address of source)
Foods must be from an approved source. lv,eat 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 aLs needed.
2. How will the food items be kept cold/froter?
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 neededto accurately check temperatures.
LJ, l(_/ Al" _ CJ;1
4. Please describe the type of hand washing*Iity to be used.
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