HomeMy WebLinkAbout2017-10-27 - 1175 Ellington Road - Temporary Food License Application Oct 26 17 07:50a Donaldpadegimas 8605283240 p.1
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n °W" 5t,� � TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT_
-1540 Sullivan Ave., South Windsor, CT 06074 Mailing Address
1530 Sullivan Ave., South Windsor, CT 06074—Office Address
s J Phone Number: (860) 337-6173, Fax Number: (860)644-1930
'°s^M TEMPORARYISPECIAL EVENT FOOD SERVICE LICENSE APPLICATION
***Must be submitted 2 weeks prior to event***
Event Name: ' J
Event Date(s): Event Time:
Event Location: rl /� /� rl F I/7y �t1Ps
PERSON IN CHARGE INFORMATION
Last Name: O d r 1, {.L First: J M.I.:
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Street Address:_----! l -tJ c0r cA Apartment/Unit*d:/
City: I State: — . _.... ZIP:C 6— Q 7
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Phone: & � (o / (����, Y Address: J. ce.n �.�' rod t'`l .e Ile- Gojmas7'. ti
ORGANIZATION REPRESENTED (if ANY)
Representing: I J!Oki 5 C0
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Street AddreSS: , t f,L 1 .�,^ Apartment/Unit#
City: l/ i� 1LI State: zip.
Phone: ca,�� 5 �� 3_— E-mail Address: D. P,rI� ��f`r71C�S �oo
QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) ❑ YES ❑ NO ❑
Name.
Certificate#: Date:
ADDITIONAL INFORMATION
Water Supply YES ET" NO ❑ Wastewater Disposal YES IY NO ❑
Electrical: YES L� NO =1 Base of
Operations:
MENU ^ **(PLEASE LIST ALL MENU ITEMS IN 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 be covered if event is outdoors. Be sf
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tents used for overhead cover are fire-rated. Der the South Windsor Fire Marshal's solce.
AGREEMENT AND SIGNATURE
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By submitting this application,I affirm that the facts set forth in it are true and complete.I understand that any false statements or abler
misrepresentations made on this application may resutt in immediate shutdown or revocation of my temporary Food Service Lcens W%w R
of South Windsor. Temporary Food Service Ucense will be issued after the Food Inspector has completed h�sjher inspection. �1EALTH GEi .
I Applicant Name
(Please Print):Applicant Signature: n e Date: 17
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Oct 26 1707:50a Donaldpadegimas 8605283240 p.2
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OFFICE USE ONLY
Inspector Name: -
(please Print)_ �a��— c -`_I
:nspector 1
Signature: ��{/� Date: ((J�Z 1 \l
Food Class:1 ❑ 2❑ 3 EI'4❑ FEE: $50, Nonprofits exempt
Temporary Food License*: Expiration Date:
Notes: PVV� � of y\,e, L„.\l Date Received:
Oct26 1707:50a Donaldpadegimas 8605283240 p.3
1 Town of South Windsor Health De artment
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 then food is protected during transport and how it is kept hot or cold as needed.
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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 coo( 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 maybe needed to accurately check temperatures.l
4. Please describe the type of hand washing facility to be used.
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Oct 26 17 07:50a Donaldpadegimas 8605283240 p.4
S. How will the food be protected?
Food must be protected during storage, preparation, display,service and transportation_ Cooking to order wilt
lessen the chance for bacterial growth,which may occur prior to service
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6. How will the all utensils and food contact surfaces be washed, rinsed and sanitized?
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7. Where will excess food(potentially hazardous and non-potentially hazardous hoods), dry goods,and single service
items be stored?
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8. Where lwill ware wash detergents and sanitizers 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?
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