HomeMy WebLinkAbout2018-4-16 - 150 Nevers Road - Temp Food License Application Dee's Flavors 0
^° OWN •� -� 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
1°s°a-rkl ` TEMPORARY)SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION
***Must be submitted 2 weeks prior to event***
IVEN11OFFORMATION
Event Name: ,I C" 5 i n. + , P CI..I K—
Event Date(s): fYI Ck V � '-"' Event Time: I. mA
Event Location: � 5 LS )/0 6)(T-l e-I U-1 'S` - �U U+ k W lact s0r- C:T U (3 0 1 y
PERSON IN CHARGE INFORMATION
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Last Name: a I a v e- First: -C)Wrzk�I
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Street Address: '7 Q� 5 UrrU4 Apartment/Unit#:
City: H Cx r }- r State: C T Zip: O to l
(� � E-mail j
Phone:l rOL -1 -�C Address: Les I Ct L'��i Cl o L)J -CC,rn
ORGANIZATION REPRESENTED (IF ANY) RECEIVED
Representing:
Street Address: Apartment/unit APR 15 2018
City: State: Zip: SOUTH WINDSOR
Phone: E-mail Address: HEALTH DEPT.
QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) V4ES NO
Name: QyYY�I r.)5 P\G16ue,
Certificate#: Date:
ADDITIONAL INFORMATION /
Water Supply:G I YES NO Wastewater Disposal YES VI"'
Electrical: L, YES NO Base of }�1 � 1
Operations: I Z 7- J� I ,t C C
MFMU "(PLEASE LIST A"r.,i-NU 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 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 Tnspector has completed his/her inspection.
Applicant Name
11(Please Print): L� (r I �� �V, UVe
%Applicant Signature: Date: f f Q
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