HomeMy WebLinkAbout2016-9-15 - 150 Nevers Road - Temp Food License Application Jeff's Kettle Corn 74{fly s . Tp111fN F JTH '11 INt S4R HEAt,T # DEi�ARTM� T
1540 Sullivan Ave South Windsor,CT 06p74
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t•. Phone Number: (860)ft44 2511.x24,.Fax Number: (>tGq)644�7 $0
TEMPORARY/SPECIAL�'/SPECIAL.EVENT:FDi1D SERVICE LICENSE APPLICATION
1V1ust hesubmitted 2 weeks prior to event,No fees eh€rrged***'
Event Name � h rti Liar ,�4�f✓�u' f�IGi }` ."K,
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Stnaet.Address: ApartmentJW it
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'Representing
Street Address:
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Phone: :.l =mall Address: q. ..
;Qf4; 01�QPEI .Ot YtlLhiCd.Ulir COPY OFERrICA'#lE r " 4riQ G'!
'Name;
Cerdficatie#"s. � Dbte;: �:
AQ1 >t' 1�l1fi11I.�
Water-Suppfp.' YES NO: 'llltaste.wa..ter bi posal YES z fdU�L i
'. other:please
Eteetrlial's. YES 1 N0.. expialn�
MENI! *" :irsr t1 �; c�t IlIJ*
,FILLMEN pllK pf`fAX1AS-
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N ** *PL AIN►YY DL till�(GII(1F FAllr et1tEfl lDttlNttfi#. ,
t7SIl�6 7 H 11iWlVi![1 PIR l�[�T#1111K AF I to lfCatrrl#' E
Tiefo�ad: reparatio and' oraerea muste caved if event�s outdoors. Be sure#fat the
tents.used for overhead cover area ire rated.aer tine youth 1lindsar Eire Marshal's office.
I[GIIhEEMEI
ffy submitting this.application,I affirm tliat:thefacts set fbM in.it are true,and complete.'I understand that any false statemerrts or other
rtiisrepresentatfons made on this.application may result in immediate.shutdown or.revocatlort of my temppre d6d Senrlce License,for the town
of South WtndSor. Temporary F90 .5eNice,[Onse will be issued after the Food'.Inspector has.compleW his/fter inspection:
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Applicant Name
-
J App#MAt SWature Dane':
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0* town of windsor Hoolth Awrtment
Temporary Food Event questionnaire Form
plause caraplato all questions and.faturo to they HOaM.DeparilydOnt with your aipplitnlion.
Sps
]. What is the soui`c of tFte`fogd to.be.
: sewed/dispensed? (Please include name/address of source,
Foods must be from an appr+ued source:; Meat.and dairy products:must come from a goverrtnrer�t-irrspe:ctetl
.source. if it is necessary to bring i:n foods that are prepared st a:OceAted facility other than the temporary site,yoll
rriust mcl sate haw the food is protected during transport and ltow it is kept hot or cold.as needed',
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aM's�!✓lub. MY�Pr acJ�a eta corn;as P rodUce
in our state JicenW food manabctu" faciy
2: How will the food Items be kept fold/froaed
ize rnust,be ftorn an approved potab ur le soce. RO-10b foods ac nnot be,thawed at room temperature: Proper
thaw:[ng can be done"in:a refrigerator,under cool running water,or-as Ort of the cook lilg.process,
Not applicabb
3 liow will the food items be cooked and/or-ha held?
A saniti ed metal stained,caIlWated probe thermmometer to.monitor food temperature is required.. ,If thin patties.
are being cooked;a::tiigrmocoupie°may.be needed It'accurately check temperatures.
Cooked in a 160 qJ propane fires
— #sinless$1001 kettle
d. Please describe the type of hand Wwashiag facility to be used,
f amble a�nk with hQ w►at6r underPressure �.
5 How will the food be proteMd?
Food..must be pfotected duFing storage,pre1.paration,dispI Y,service and tran5porta.tiori. Cooking to order yYill
.lessen the cha06.01tsr bacterial growth,which may.occur prior to service.
Toad supply kept in NSA:approved plastic bins
with snap lids:
6. How will the all utensils and food contact surfaces be washed,rinsed and sanitiiZW
utensils to be washed in our portably 4 bay sink
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with hot water Under pressure: Sanitized'wit a
solution:.ofSantimine 15
T. Where will excess food(potentially hazardous and nonwpotentiaily hazae ctous foods);dry gopwds,antf:single service
l Ms be stared?:
Foodsfarad in I.:5 Mff poly bags wM lost lies
S. Where will ware wash detergents:.and:senitmers be::stored?
Uh.der,$ink
9. `How wiii.condiments arid single service iterils(cups,plates utensils,etc.)be dispensed?
NO applio01
10. what methoadger:..lit►geAlsoosal:Oil be;us+ed?
anon plan#io gar.a a can with plastid bag
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and snap lids. Di}spoSed OtOt. NOW. of
operation
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In�pelot NOW
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lospector '.Do*
la road Class:
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7`egripoiait.Fgod Ucensa#K
Expiration Dabe,
E.Notds: Date Reeetvad:
Lill
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'CTICUT
STATE OF CONN .1
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D E PA Wr'W. - N T -0 f N SN.U M C 1 P.R C 10 N
p.1,1 G"I A.V C 11 U C + H wr t f o r d C 0�jl ft 01.0 t i C il 1. 6 t Q 0
e. h 11 b posted 4ndshown:to any properly interested
a e pog ,
Us.Is your Ce such license:s
.person on requeaL
Donot attempt'tQ make any d.anges or a 'r'this certificate in any way. This license trans.&rable;
We A*fhafY you keep Yoi email khoffice.ctirrerit. All,renewaln Ifi only 0
� oil information; g6l M0 x*:gmd�cartifieategwill
eMaNd to:the last reported email on.record.
Questions regarding this Ak license can be.directed to the Food and n.Standards Division at dc-n.f6odandstandards@.ct.vQ
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Md.ingad.dress.- Email on to.6 e usea for receiving 41 notices frow this office.
E.FPS'KETTLE CORN jcstrong@ignet.net
.3.1 HALE 09MT EW
VERNON ROCKMLE,CT 06004U81
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UT + DEPAWYMEN.I. N SM: R ROT]WTION
STAT E 0 F CONNMI 1 1. 0IF 0 . SU K P
e it,Y,.n That,
JEFFSKETTLE CORN
A
TOIJVM CT.060044819
has been certified by as.a licensed
by th Day wk Priot. ction
F G.RST"LISHMENT
lAcetise M F-M.E.00001541
E w F 1
$46 Date. 07/01/2m
Px0ration Date: 06/30./2017
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