HomeMy WebLinkAbout2016-9-18 - 150 Nevers Road - Temp Food License Application Sylvias Hot Dogs TOWN OF SOUTH WINDSOR HEALTH
DEPARTMENT
1540 Sullivan Ave.,South Windsor, CT 06074
Phone Number: (860)644-25I1 x248, Fax Number. (860)644.7280
".'MPORAIWSPECIAL EVENT FOOD SERVICE LICENSE APPLICATION
::::::::Must be:subs fitted!.Weeks,prior to event***
-Event Name
Event Date(s): �,(� f f rr C" -: Event Time: :n r.
Event Location: �E j �y� r 1�57 (D
PERSON IN CHARGE INFORMATION r
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Last Name: hr,k Fist: Va
M.L: Date:
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Street Address: rl j r-�f� {t Apartment/Unit#:
City: q State: zip: 6,1 lC"Jlp
Phone &Tel E-mail /►�. 1
Phone: -L (3 `['��` /�il�-}� � � Address: �1f 1�15 [ rid° A0 lam- �(�+
ORGANIZATION YOUR REPRESENTING (IFANY) "
Representing:
Street Address: S{� Apartment/Unit#:
Tt
City: State: Zip:
Phone: E-mail Addrpr5z -
QUALIFIED FOOD OPERATOR Y1;5 NO
NON-PROFIT
Name: t j LEe(e '� {l� R(),6 ��T ft�6 u 1C� ..._ .
Certificate#: ¢ r ., . . . '..-... _. ....
ADDITIONAL INFORMATION
Water Supply: YES NO l Wastewater Disposal YES, NO
If other lease
Electrical- YES I_ NO •p
explain:
MENU **(PLEASE LIST ALL memo ITgms sm 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 he covered if event is outdoovse Be stare'that the
tents used for overhead cover are fire-rated. oer 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 stateme
misrepresentations made on this application may result in immediate shutdown or revocation of my temporary Food Service LUMVED
of South Windsor. Temporary Food Service License will be issued after the Food Inspector has completed his/her inspection.
Applicant Name
( SEP 16 2016
(Please Print)- t� �t ei r 'Vj
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Applicant Signature: Date: ,..w r
Y R. t i1Y
Town of South Windsor Health Department
a g Temporary Food Event Questionnaire Form
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Please cOmPlete all questions Owl return to the Houlti, Depariinent witi,your application,
I. 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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Z. 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.
I
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.
4. Please describe the type of hand washing facility to be used.
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