HomeMy WebLinkAbout2018-4-26 - 150 Nevers Road - Temp Food License Application Keifer's Kettle Corn re
� -1> TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
y 1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
1530 Sullivan Ave., South Windsor, CT 06074—Office Address
f Phone Number: (860) 337-6173, Fax Number: (860) 644-1930
TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION
***Must be submitted 2 weeks prior to event***
Event Name:
Event Date(s): Ulu ( gQ 13 Event Time:
Event Location: ��{k-CA 3 R �. 0 t 6 -
PERSON IN CHARGE INFORMATION
Last Name: S -,(12( o r)1 First:
Street Address: Y 1 �2t D Apartment/Unit#:
City: `1 ILi 5(,'`' C� State: C� . P-W&
Zip: I/Phone: �(e Q O / E-mail , +� IC.I-M Ke 2tU- G d1-t-I
c � �3�� Address: C.U-i"�� l�
ORGANIZATION REPRESENTED (IF ANY)
Representing: ��"' klS K� � �n an, L ��
Street Address: Apartment/Unit#:
City: State: C� r Zip: o&-335 /
Phone:S'L G E-mail AddressQN*rl G Lv. e � y2s�m e f..G,2 G c
QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) I _ �G YES ❑ NO ❑
Name' s C� �T C ZI�C1�41 %
Certificate#: n 6 3 'j •1 r1 _0 Date: 41 {q I ZO iD
ADDITIONAL INFORMATION
Water Supply: YES NO ❑ Wastewater Disposal
_ YES l NO El
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Base of
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Electrical: -" i YES ❑ NO Operations: I ) pec�0 eo-((- y�C� U0_6wn Q{C3�57
MENU **(PLEASE IN AS MUCH DETAIL AS POSSIBLE)**
RECEIU9&
****PLEASE DRAW A DETAIL DIAGRAM OF FOOD BOOTH ON THE BACK OF THIS FORMSOUTH MNDSOR
USING THE GRAPH PICTURE ON THE BACK OF THIS APPLICATION**"* HEALTH DEPT.
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 Nam QQ
(Please Print):
Applicant Signature. k `` ,,C y cat �� a
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OFFICE USE ONLY
Inspector Name:
(Please Print):
Inspector Date:
Siqnature:
Food class: i❑ 2❑3 114❑ FEE: 50, N nprofits exempt
Temporary Food License#: Expiration Date:
Notes: Date Received:
Town of South Windsor Health Department
Temporary Food Event Questionnaire Form
"., Please complete all questions and return to the Health Department with your application.
�G.tiOR.Co�'
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.
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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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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.
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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 azardous foods),dry goods,and single service
items be stored?
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S. 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?
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EXAM FORM NO. 4530
"'Sery
CERTIFIdRTF NO. 703R?2-0
Sery S- afe. Gertiricatioll
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Toi sumessf;illy compieting tho sia;-dards sat forth for the Sen,,Safe'Food f'r jftctlo!l imanage! C-ei t! n N>;arnirl8!!or
which!s accreditei;by !'m- Am.-,!ICBR Matio!lal Standards ir;st!tUtB iANSIi-Conh-i-n,-a for I prOtF.Ctl(p? (i-FP).
4/! /2010
4/19/2015
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