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Home My WebLink About2017-1-3 - 1175 Ellington Road - Temporary Food License Application SOUTH WIND HEALTH D E---, PA R, TMENT '(OW N seq TEMPORARY FOOD PERMIT ORX- EVENT : PANCAKE BREAKFAST FUNDRAISER LOCATION : SW FIRE STATION , ELLINGTON RD APPLICANT : BOY SCOUT TROOP 62 VALID : 1114I 17 TO 1 / 28 / 17 THE RECIPIENT OF THIS PERMIT SHALL OPERATE IN ACCORDANCE WITH THE REGULATIONS OF THE SOUTH WINDSOR HEALTH DEPARTMENT AND THE CONNECTICUT PUBLIC HEALTH CODE. 1I512017 DIANE L. COLLELO, REHS, DATE SIGNED: ENVIRONMENTAL HEALTH SPECIALIST THIS PERMIT MUST BE DISPLAYED IN AN AREA VISIBLE TO EVENT PATRONS AND IS NONTRANSFERABLE * PERMIT ONLY VALID IF SIGNED BY HEALTH OFFICIAL TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT 1540 Sullivan Ave. South Windsor CT 06074—Mailing Address 1530 Sullivan Ave., South Windsor, CT 06074—Office Address Phone Number: (860)337-6173, Fax Number: (860)644-1930 '4yR)R TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION ***Must be submitted 2 weeks prior to event,No ..___ Event Name: �0 � 4.. 7"_Ae- Event Date(s): _3p n u a r /y p,/�' Event Time: Sa 7� A01�� Event Location: 0;,f z IV,,9 1/S u r %�i'G ��X/l' /�iilC �+ sov[Y�Ltf/i it alld r PERSON IN rCIiARGE INFORMATION Last Name: 1,/I _ L _ First: !/•n!C,n M.I.: 14 Date: Street Address: Idl 1116 Grrt,`/�j t6 1 Apartment/Unit#: / °ty: s o u }'� W l, �so� 0� state: G Z'p: Phone B Cell E-mail Phone: sJ4 D 'S� '0 6 35 / Db'0 7( Address: Twi Cis 0 tf @ 0 and i Dyyl. ORGANIZATION REPRESENTED (IF ANY) Representing: f3 0 Se o u �- -rl-.)d/b l0 CU S-e- /w,�y'S a J� a y 0 U G) Street Address: )� Apartment/Unit#: City: 5,o U � �l/I d So State: Zip: Q 7l' Phone: g6 j ?G 9 , b 0 76 E-mail Address: Tr u l� //U� D� QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) 9 YES ❑ NO Name: 0 C 4 o r"a-� / , SrY►'/7 L Certificate#: 6 5 �"G D3 Date: 4/- 9617 ADDITIONAL INFORMATION / �/ Water Supply: YES NO ❑ Wastewater Disposal YES [1 NO C] Electrical: YES UX NO ❑ If othe{, please explain: MENU "(PLEASE LIST ALL MkNU IftMS IN AS MUCH MAIL AS POSSIBLE)** b u7 � C i +r .S ' 0 ZAsu 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. Der the South Windsor Fire Marshal's offiWCEIVED 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 otl ► 2 Q 7 misrepresentations made on this application may result in Immediate shutdown or revocation of my temporary Food Service License f of South Windsor. Temporary Food Service License will be issued after the Food Inspector has completed his/her inspection. Applicant Name n SOUTH WINDSOR (Please Print): tv) �f HEALTH DEPT. Applicant Signature: �� / C' / /_ Date: /1 -9//� / v 11 Di A a e- OFFICE USE ONLY Inspector Name: (Please Print): Inspector Date: Signature: Food Bass: 1❑ 2❑3❑4❑ FEE: N/A Temporary Food License*,. Expiration Date: Notes: Date Received: RECEIVED DFC 0 5 2016 d G � nlJTH WINDSOR ,c N „ //o�`` n° TOWN OF SOUTH WINDSOR HEALTH DEPARTMENTrI_TH DEPT. G� ' 1540 Sullivan Ave.,South Windsor, Cr 06074—Mailing Address r 1530 Sullivan Ave.,South Windsor, CT 06074—Office Address Phone Number: (860)337-6173, Fax Number: (860)644-1930 iAPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION ***Must be submitted 2 weeks..... .. .Event Name: Event Date(s): C r✓e 1 ] v/ Event Time: S —�0 a Event Location: Sv y� G v/,,7 d S - PERSON IN CHARGE INFORMATION Last Name: W/� First: / .17 e— M.I.: /'/ Date: Street Address:I J ✓hC --m /` Vd Apartment/Unit#: city: e t/ State: C Zip: it 6 Q'711 Phone A Cel E-mail Phone: 0 5 ,e G 3-5l $G 0 86 p$47�i Address: TW/G�S/l0 �f ,It �% ORGANIZATION fR�EPRESENTED (IF ANY) Representing: s�p vl �/'—d �U �d f0e—✓ C Street Address: Apartment/Unit#: Gty' U State: Zip: Q 6 Q / y Phone/� Vi4S Smolt E-mail Address: QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) YES NO Name: L/ PO 4Q rifA f Certificate#: 6 -5 Ll9 3 Date: ADDITIONAL INFORMATION / / / Water Supply: YES P NO ElWastewater Disposal YES C NO ❑ Electrical: YES L� NO ❑ If other,please explain: MENU **(PLEASE LIST ALL MENU ITEMS IN AS MUCH DETAIL AS POSSIBLE)** U Z x S' Z El G / iS S�(9�2 {rce. Sys /✓ •'•s PL W A/DUET/AIL DAI-et RA Od EASE 1 OIIi O E 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. Der 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 License for the Town of South Windsor. Temporary Food Service License will be Issued after the Food Inspector has completed his/her inspection. Applicant Name /�R=�Cy� //(Please Print): Applicant Signature: J q►M/ CL/yl ey Date: Wows M01�� Town of South Windsor Health Department r+ Temporary Food Event Questionnaire Form Please complete all questions and the Health Department ith X --r appicrnf* �n.enH,�•o� 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. S e s �e 1- 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. -C Y 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 beneeded to accurately check temperatures. L e I&C Al--i _<�,�Ile 7 S 43n d ,�/�sL _�k. Pgo_� /kg 24,,_ ./L_ l!// AP-- e G c /OLt--i� ll P Ire/ �/J�� r"Pi /41` lx- e lipfn_ l _ ,cam 1�� AyP � 4. Please describe the type of hand washing facility to be used. rs:7:' EXAM FORM NO. 4455 CERTIFICATE NO. 6548603 Se#irSafeo TO DEBORAH P SMITH for successfully completing the standards set forth for the ServSafe®Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute ANSI)—Conference for Food Protection (CFP). 6/24/2009 DATE OF EXAMINATION 6/24/2014 DATE OF EXPIRATION Local laws apply.Check with your local regulatory agency for recertification requirements. • NATIONAL ACCREDITED PROGRAPA RESTAURANT ConferenceAmema, National rFoodStandards ® David Gilbert ASSOCIATION Chief Operating Officer,National Restaurant Association #0655 Executive Director,National Restaurant Association Solutions 02009 National Restaurant Association Educational Foundation.All rights reserved.ServSafe and the ServSafe logo are registered trademarks of the National Restaurant Association Educational Foundation, and used under license by National Restaurant Association Solutions,LLC,a wholly owned subsidiary of the National Restaurant Association. This document cannot be reproduced or altered. 00121102 v.0906 S. How will the food be protected? Food must be protected during storage,preparation,display,service and transportation. Cooking to order will lessen the chance for bacterial growth,which //may occur prior to service. // b-e Uc� /E /2 . 1�71Q4 , �i�.��.6- ��Li .l 6. How will the all utensils and food contact surfaces be washed,rinsed and sanitized? .V 7. Where will excess food(Potentially hazardous and non-potentially hazardous foods),dry goods,and single service Items be stored? /> l - a Lf is 3 // b-e. rX, t ,// -P /' , � S. Where will ware wash detergents and sanitizers be storedY 9. How will condiments and single service items(cups,plates,ute sils,etc.)be dispensed? 10. What method of garbage disposal will be used? Ir,,( (' C+/,, /1 0, G//✓e�p Additional Information I/Contact the local Fire Marshal (860-282-0669)to ensure compliance with the Fire,Code. f Q 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. /Q'If a/Wastewater must be disposed of in a sanitary sewer or other approved sewage disposal system. W! Equipment and tables must be clean, smooth,washable, durable, non-absorbent and in good repair. v Dust must be controlled(i.e. dry fields) by watering down. *r 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. C/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.