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Home My WebLink About2018-4-13 - 150 Nevers Road - Temp Food License Application Titi's Tasty Treats d,r,-� 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 OR•O' TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION ***Must be submitted 2 weeks prior to event*** Event Name: Event Date(s): , /, S d-�/40 /I ') �/� �� Event Time: 9, �� Event Location: w T/(. C/v c� s cc PERSON IN CHARGE INFORMATION Last Name: b i 510Y First: J-e-n�/ Street Address: J, Apartment/Unit#: City: �/�S ,b�- State: 6477 Zip:0G,03 3 Phone: ��0_ �3 y_ l �. / E-mail Address: �i f/5 1-45 e hrew-S t!lahoG ORGANIZATION REPRESENTED (IF ANY) v Representing: Street Address: Apartment/Unit#: City: State: Zip: Phone: E-mail Address: QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) YES =.1 NO i_1 Name: Certiricate#: Date: ADDITIONAL INFORMATION Water Supply: YES Cl NO Wastewater Disposal YES NO LJ Electrical: YES L_ NO BaseOperations: MENU **(PLEASE 1ST ALL MENU ITEMS IN AS MUCH DETAIL AS POSSIBLE)** Cc�c� Kos , Gti kes,� �'�oKr�s�. lTS,i �✓/v�n, '�5, L'�k.G�op.S , Gv' 1a�o S cnn�lie) Ir�e�-NIV .. ****PLEASE DRAW A DETAIL DIAGRAM OF FOOD BOOTH ON THE BACK OF THIS FORM. APR 13 2018 USING THE GRAPH PICTURE ON THE BACK OF THIS APPLICATION**** SOUTH WIN SOR The food preparation and storage areas must be covered if event is outdoors. Be surethatji 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 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 Lam / (Please Print): Applicant Signature: Date: 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. c-,Lc oY' �v c1G CLS e 6. How will the all utensils and food contact surfaces be washed,rinsed and sanitized? t-v L' l l Y\O -�- re c�!'�Y� P o c-/ �-' O -� O o w; VIO 7. Where will excess food(Potentially hazardous and non-potentially hazardous foods),dry goods,and single service items be stored? 8. Where will 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? pcf ash CCl a„nr�- Town of South Windsor Health Department h Temporary Food Event Questionnaire Form Planea ramnlole all questions and return to the Health Department witn 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. 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. r\ c_oc l-Qc' w , —ic e �KS. 5eYi5 I t V e 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. n o ho 4. Please describe the type of hand washing facility to be used. _ Ioves o. Z- eAC w : 11 bDe 0Se� (jc'A eA - — 0 s ETT I F1 OFFICE USE ONLY Inspector Name: (Please Print): Inspector Signature: Date: Food Class: 1 ❑ 2❑3❑4❑ FEE: $50, Nonprofits exempt Temporary Food License#: Expiration Date: Notes: Date Received: ` --_ :-E--�-- -a-ned below k 0r Q Me d under the Son and[l8e Tex AcL s good"for the Waned perm-.ttee&W al ft location shown. -y= i a:,.-change In ownerdV%the permit is n um end void. TITIS TASTY TREATS LLC TITIS TASTY TREATS LLC _�=e_- iphallon Business i Conneeftut NI 41 CLUB RE)w-- _�: Date start Date MllNL�hlAM CT 062t�-1007 2017. 05J31/?A22 06/30/2017 ?2437692-001 TITIS TASTY TREATS LLC TITIS TASTY TREATS LLC Ile MILL ST GLASTONBURY CT 06033.1209 -- Kevin B.Sullivan 'nis license may not be transferred or assigned. Commissioner of Revenue Servim M WM STATE OF CONNECTWI T ♦ DEPARTMENT OF CONSUMER PROTECTION "Y Be it known that a- TITIS TASTY TREATS LLC 41 CLUB RD WINDHAM, CT 06280-1007 has been certified by the Department of Consumer Protection as a licensed BAKERY Number of Production ESmployew: 1 License #: BAK.0016308 Effective Date: 08/23/2017 Expiration Date: 06/30J2018 ' vez*online at www.dicense.cLgov Mkbek Sel Cwn.bWomr ®rr r I • ery nfe ,.Owm CERTIFICATION JENNIFER LABOY for successfully completing the slerxlards set forth 6t the ServSafel Fc-. Protection MWttae.�,-Certification Exorvrinetion. which is accredited by the Ametican National Standards Institute W,;'.�;)-Confera FW :,od Protection(Cf'P1. --15.220927 5262 CERT1T� ,NUMBER EXAM FORM NUMBER 6/5/2 01 6/5/2022 DATE OF IXAMINAPON DATE OF FXPIRATION Local laws apply.Chock with your!xci rog 6smy open¢;,for recertification ewpirements. ij .`VP,-t+lo an Br S _— VP; iiorol ReJtauranf Associ a';ion Solvlions •..,•'.w.w�hea 3fX18,(1rcJufw,AG.1 N OSB�2013 Gi�pl�fan:.L S�nd�d A32J. 1 �❑ >,,..ar A�oria[� fd,sesfa�ol fau.rtaiw RdUffl.N rib ev.�d.Sr,r�e/1 and�Ss•S:ti ,,, unM Aausfarin avI'6 art dwW v.ev&.gr{J ml dR tlotvfd tlwlouevr A S.Iriativt ,mvo16.npo&ml w allt& -4w I w w4h qwd"--0 1 14 W Jadm*i Nod,We I S00�C*rapo,ll.6050/or S.wklb-+rlre�Mwn�l iw�