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HomeMy WebLinkAbout2016-9-13 - 150 Nevers Road - Temp Food License Application SWDTC d TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT 1540 Sullivan Ave.,South Windsor,CT 06074 h; W Phone Number: (860)644-2511 x250, Fax Number: (860)644-7280 y�soe:ca�' TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION ***Must be submitted 2 weeks prior to event,No fees charged***1 ���19�V1� ;d� ���'1�� •v4` .-����'� �::�s''k�t`��'�.`ti � ����s.'� �^e* �` s=i�� fk�i� .?�"��e� nr�.�.�rv���n� +,� 1 Event Name: A1`.._.. ��� U-.}�1._..__. V PS'� r Event Time: <<06 A�'(_..`- .._` -•:...6✓ ..�" ..._..._.......' Event Date(s): ,� i Event Location: � e oe oa V>O,. _.. ._.._. .. . .. . ................. ........c . __:......._._...... I. PERSON IN CHARGE INFORMATION. • ' I Last Name First: Date: I E Street Address: {� Apartment/Unit#: I (Sty: state: ( zip: � (� C) ( t ............. . o( f1._. _ ..t�V'1�to CZ. ...._....._....�. . _.. ...._.�� _...... -- - - - ...._....._...... Phone &Cell ''// �—H E-mail Phone: ��-��Y'"J (� Address: ASS O O.Mo'd C I._...................: .-........ ....... - (� ORGANIZATION REPRESENTED (IF MY) Representing: / Street Address: Apartment/Unit#: ! 1.------._...-.............._............._....... _ . ..,., .. ........_._..., i City: r I State: CT 'Zip: lS . Phone. t[� po a(-L L 6� 9 S Ql C(�,E-mail Address: Act QUALIFIED.FOOD.OPERATOR (INCLUDE COPY OF CERTIFICATE) } ❑ YES ❑ NO ❑ i Name: Certificate#: Data., I ADDITIONAL INFORMATION Water Supply: YES NO ❑ Wastewater Disposal YES NO ❑ ; ...-......._...................... ------ , _..................._.,..........-.................................._..........,....._.............._.............-._.................... ..._._......... ................_........1 Electrical: YES i$( NO © If other,please _........__._.._ . .. _._........ .. . explain:... . MENU "(PLEASE LISTA L M§jNU UJMS IN AS MUCH DETAIL AS POSSIBLE)** I .... . . I ****PLEASE DRAW A DETAIL DIAGRAM OF FOOD BOOTH ON THE BACK OF THIS FORM. � USING THE GRAPH PICTURE ON THE BACK,OF THIS.APPLICATIO[it****.: 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 ................................:..........................................-........_..__...._..__....._ ._._..._._...:._.....:..... .__............... " v_. ... ...._.:.._.. ..._......... .._.:.....__............:_.._..._....._..I 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 of South Windsor. Temporary Food Service License will be issued after the Food Inspector has completed his/her inspection. I �9Applicant Name + (Ple --)::7� K -,*�* 3., ase Print): �I Applicant Signature. _ I Date: 13 - - _..............., -... � Rd Town of South Windsor Health Department �► Temporary Food Event Questionnaire Form Please complete all questions and return to the Health Department with your application. '1DSOR.CO'`. 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 nee ed. ` An C 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. �U 4. Please describe the type of hand washing facility to be used. a: 2 v�� - y Y -f-T I I [W- rot. OFFICE USE ONLY Inspector Name: (Please Print); _-__-- Inspector I Date: Food Class: 1®2®3©4 D FEE. N/A i i i Temporary Food License#: Expiration Date: i j Notes: Date Received: j s i i are TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT - 1540 Sullivan Ave., South Windsor, CT 06074 Phone Number: (860) 644-2511 x250, Fax Number: (860)644-7280 :coyr TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION ***Must be submitted 2 weeks prior to event,No fees charged*** Event Name: �(� (J _ ►�ICKJ ,A f.._ —c -F — ��-+ Event Date(s): I0 Ig A Event Time: Event Location: PERSON IN C RGE INFORMATION _ Last Name: !e\ M.I.: - Date: — Street Address: l ` 1�— Apartment/Unit#; City: Sam 11!V f ✓?or%J C-' - State: - Zip: Phone &Cell �i/f °�J / E-mails V Phone: .. -------(1 W`-'"F!_ _� ld - Address `--- S S P @ _. --l—=L -- - - ORGANIZATION REPRESENTED (IF ANY) _ Representing: L� —` —� -00-3✓ ------- Street Address: W i ,0�1 �,r Plj — Apartment/Unit#: ] City: ,State: — �� —_ �Zip; �� ��`.'( Phone: E-mail Address: QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) T — ❑ YES ❑ NO Name: Certificate#: Date: — ADDITIONAL INFORMATION Water Supply: YES ❑^ NO ❑ Wastewater Disposal YES ❑ NO ❑-- Electrical: YES ❑ NO El explain: other,please explain; -- MENU **(PLEASE LIST ALL MENU ITEMS IN AS MUCH DETAIL AS POSSIBLE)** ------- -- - - --.._. - - -------- --._.................. _........--- -- ._.... ****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, per the South Windsor Fire Marshal's office. AGREEMENT AND SIGNATURE — __ _—REMWE D 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 Lice�fpr�eGTg, of South Windsor. Temporary Food Service License will be issued after the Food Inspector has completed his/her inspection. Applicant Name SOUTH WINDSO (Please Print); Applicant Signature: Date: o Town of South Windsor Health Department Temporary Food Event Questionnaire Form emu. 4` Please complete all questions and return to the Health Department with your application. sna-co�'� 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. c41,2a IOU - 060 (14 CSC (96 I a2 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 wafter, 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 maybe needed to accurately check temperatures. b 4. Please describe the type of hand washing facility to be used. VD) il 1, 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 fire-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.