HomeMy WebLinkAbout2017-11-25 - 1175 Ellington Road - Temporary Food License Application Nov. 29. 2017 9 : 00AM No. 4696 P. 1
TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
1540 Sullivan Ave., South Windsor, CT 06074-Mailing Address
1530 Sullivan Ave., South Windsor, CT 06074—Office Address
z w' PhonF Number: (860) 337-6173, Fax Number: (800) 644-1930
02•c°'^ TEA•#PORARYISPECIAL EVENT FOOD SERVICE LICENSE APPLICATION
***Must be submitted 2 weeks prior to event***
Event Name:
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Event Date(s): r O I Event Time: O O I nti
Event Location, W���� r-�rr�n 1 I + 0(Q d
PERSON'IN:CHA�tGE.pVFORMATI N
Last Name; First: K6 I
Street Address: Apartment/Unit#: '
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ORGANIZATION REPRESENTEb (IF ANY)
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' Representlng; So� �_. _.._._......._... __
Street Address: r� ��/ � !- Apartment/Unit#:
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QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) b YE9. D,NO'
Names 1
' Certificate#: Date:
ADDITIODIAL-INFORMATION,
Water Supply:' -- - - .._-YES 1 NO Wastewater disposal - :YES f NO^,'-J` j
t lectrical: YES NO Base of
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MENU - **(PLEASE115TALL MENU LTEMS IN;As MUCH:DETAIL ASPOSSISCE)*.W.
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PLEASE DRAIN A.OELAILDIAGRAM OF'FOOD°BOQTH ON'THE.BACK OF THIS FORM:
USING THE GRAPH PICTURE ON THE BACK OF T.HIS;AP0LICA7`I0N**-
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. [)er the South Windsor Fire marshal's office.
AGREEMENT AND SIGNATURE ..:
i By submitting this application,I affirm that the facts set forth in It are true and complete,I understand that any faise=-tements or other
misrepresentations made on this application may result in immediate shutdown or revocation of my temporary Food Service license for the Town I
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of South Windsor. Temporary Food Service License will be issued after the Food Inspector has completed his/her inspection.
I licant Na
(Please P rintme- Yl 6 I
Applicant Signature: ; Date: I
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Nov, 29, 2017 9: 01AM No. 4696 P. 2
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OFFICE..USE ONLY.
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Inspector
. Signature: Date-
Food Class: I C) 2 C' 3 E2 4 -5 FEE, $5D, Nonprofits exempt
Temporary Food License#; Expiration Date:
Notes; Pate Received:
Nov, 29. N17 9: 01AM No, 4696 P. 3
Town of South Windsor Health Department
Temporary Food Event Questionnaire Form
:g Please complelo all questions and return to the Health Deparimenf wifh 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 necessao/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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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.
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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_
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4. Please describe the type of hand washing facility to be used.
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Nov. 29. 2017 9. 01AM No. 4696 P. 4
5. How will the food be'protected?
ation, display, service and transportation. Cooking to order will
Food must be protected during storage, prepar
lessen the chance for bacterial growth,which may occur prior to service. ji I
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6. How will the all utensils and food contact surfaces he as ed, rinsed an sanitized?
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7. Where will excess ood (potentially hazardous and non-potentially hazardous foods),dry goods,and single service
items be stored?
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S. Where will ware wash detergents and sanitizers be stored? I n
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9. How will condiments and single service items (cups, plates, utensils,etc.) be dispensed?
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10. What method of garbage disposal will be used. -e-�
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