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HomeMy WebLinkAbout2017-4-27 - 150 Nevers Road - Temp Food License Alexis Ice Cream Truck RECEIVED n° q' `C4, TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT pR 27 N17 1540 Sullivan Ave., South Windsor, CT 06074 SOUTW WINDSGR Phone Number: (860)644-2S11 x2SO, Fax Number: (860) 644-72801EA1-V OEPT TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION ***Must be submitted 2 weeks prior to event,No fees charged*** EVENT INFORMATION Event Name: _A 0 o n A_v y ,� Event Date(s): �1R� '1\II �� EventTime: f Ahrt Event Location: ,f\ QACI_'� `, —s'011 Z PERSON IN CHARGE INFORMATION Last Name:C` r First: ��1 G(k M.I.: Date: Street Address: Apartment/Unit#: City: State: Zip: Phone &Cell E-mail Phone: / Address: ORGANIZATION YOUR REPRESENTING (IF ANY) Representing: � /S / C e C0 e GYJ T �l C 1� Street Address: —"� /-f / Apartrnent/Unit#: City:: `�/ �� State: C4 Zip: Phone: Email Address: m S q.' [Q ho QUALIFIED FOOD OPERATOR (INCLUDE CO F CE;explain: �� YES NO Name: Certificate#: Date: ADDITIONAL INFORMATION / Water Supply: YES NO V YES _ NO `y✓ Electrical: YES NO `rn� MENU `` **(PLEASE LIST ALL MENU ITEMS IN AS MUCH DETAILT!OSSIBLE)** r 2 C tl C e ✓� e �(/1� -e 5 vl C e J V14/ �Z�r1;Cal ****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 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 (Please Print): - /� `` ,, n Applicant Signature: A P P R O U. Ej-a TOWN OF SOUTH WINDSOR HEAtLJTI- DEP TMENT DATE: SIG: Lllct e sue Hawk„dyed Town of South Windsor Health Department Temporary 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 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. 141 4—ca C VW4 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 ref erator, 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 thermom er to monitor food temperature is required. If thin patties are being cooked,a thermocouple may be nee o accurately check temperatures. 4. Please describe the type of hand wa g facility to be used. 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. 6. How will the all utensils and food contact surfaces be washed,rinsed and sanitized? 7. Where will excess food(Potentially hazardous and non-potentially hazardous foods),dry goods,and single service items be stored? B. Where will ware wash detergents and sani�be stored? 9. How will condiments and single service items(cups,plates,utensils,etc.)be dispensed? 10. What method of garbage disposal will be used? FOOD PERMIT N° 3213 WINDSOR HEALTH DEPARTMENT DATE: T UA)C ZP,Iol( OWNER: �ALtvs M15KIA1 ESTABUSHMENM Al"15 !:CC I i2ke>,c WINDSOR, CT 06095 CLASSlTYPE: for MNDSOR HEALTH OEPA EXPIRES T 1 Y r, aa17 wpartrnenr a A Q„„o s , Sales and Use License Number_ 1029196 i o wnw si'�" Tax Permit ,4art6rd C T 06 i 014-543, FJW3(Rwv.07M) F;�Q�at This LoctfBon: 'ro pQman ruwnmd boron.h hmwd under ft Sslsssd6UwT=P4a The )AHMAO ALEXIS pem.t Is good ooy ea ro rvirnsd po'.0m and at ft-I P I n shown- It L 1SKIN AHMAD ALEXIS ewe a my dww In ownerv*,vo pwd Is roA red void. 156 kW N 5 T v 8 Eapr.rron 9 twrom TeRacommComagm+�^w&r BROJID BROOK CT 0601fi 9765 ;g�1]306l3012018 07121I2006 45034964001 L ISION AHMAD ALEXIS MIST IN AHMAD ALDUS 155 MAIN ST 18 BROAD©SOOK CT 09016-WM _ InLp..Il.11,1uLM1llh11d� 111htil,l,iy611�h..�I..h. �n e. This license may not be trarahrred or assignod. mis er ofReM+w Stir►,css