HomeMy WebLinkAbout2018-5-11 - 150 Nevers Road - Temp Food License Application Meadowstone Farm u.� TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
1530 Sullivan Ave., South Windsor, CT 06074—Office Address
t0 Phone Number: (860) 337-6173, Fax Number: (860) 644-1930
FARMER'S MARKET FOOD SERVICE LICENSE APPLICATION
***Must be submitted 2 weeks prior to event
EVEIfI�INFOAMATION
Event Name: I '.ir � (�o n �(
Business w; w� �CJ�n A
Representing: I �I�aus� 2�N�
Event Date(s): 1.,I _ G I�] Event Time:
Event Location: �b `�(' NL v,�_ /Pd I v -W1 vidw
PERSON IN CHARGE INFORMATION r 1 c
Last Name: ���� First: ^ li II I� M.I.: Date:
Business Address:�� �� vU Unit#: I
City: couvrf_rbl"l State: CT Zip:
Phone&Cell Phone: II E-mail
�-0 -U �g Address: nr' ,5�t �r_ @ 19L��CA�S�'1(IQ��Cple�l C�Y1�
OTHER LICENSES (IF ANY) V
Temporary Event LI Milk Producer/Distributor Bird/Poultry Livestock
(Other Health Dept.)
Egg Distributor r_I Food Manufacturing Frozen Desserts Bakery
QUALIFIED FOOD OPERATOR (MUST INCLUDE COPY OF CERTIFICATE) YES NO NON-PROFIT
Name: i n►^p(� *&L—
Certificate#:` �I/ �_ a!j(C 0 S(� p Date:
ADDITIONAL INFORMATION `1
Water Supply: YES '__ NO �_ Wastewater Disposal �ix l }� YES NO
Electrical: YES - NO If other,please
explain:
MENU **(PLEASE LIST ALL MENU ITEMS IN AS MUCH DETAIL AS POSSIBLE)**
****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, per 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. Tempo�ary Food Service Li will be issued after the Food Inspector has completed his/her inspection.
Applicant Name
(Please Print):
RECEIVED
Applicant Signature: V4ln Cu Date:
MAY 112018
SOUTH WINDSOR
HEALTH DEPT.
� ���� Town of South Windsor Health Department
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Temporary Food Event Questionnaire Form
Please complete all questions and return to the Health Department with your application.
S'IIR S �~
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.
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 therm oco a 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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CERTIFICATION
JULIE LAMOTHE,
for successfully completing the standards set forth for th I ServSa(e®Food Protection Manager Certification Examination,
which is accredited by the American National Standards Institule(ANSI)-Conference For Food Protection (CFP).
1628.8683 10591
{-CERTIFICATE NUMBER EXAM "FORM NUMBER
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4/10/2018 4/10/2023
AMMU659 DATE OF EXAMIPJAIICJt`I DATE OF EXPIRATION
CaliRwrolswar Local laws apply.Chekitli your 6'ml reaulaloiy ag cy for recertification requirements.
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Executive Vice Presideni, Nalicnal Restaurrm;Associntion Solutions
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171 10d I i s•.17t 1 Conla i us wilh questions at 233 S.Wacker Drive,Suite 3600,Chicago,IL 60606-6383 or ServSahs®raslaurant.org.
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Additional Information
❑ Contact the local Fire Marshal (860-282-0669)to ensure compliance with the Fire Code.
❑ 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, per the South Windsor Fire Marshal's office.
❑ Wastewater must be disposed of in a sanitary sewer or other approved sewage disposal system.
❑ Equipment and tables must be clean, smooth, washable, durable, non-absorbent and in good
repair.
❑ Dust must be controlled (i.e. dry fields) by watering down.
❑ All workers at the food booth must sign a log sheet indicating the date,their name, address and
telephone number and the hours that they worked. Please retain the log sheet after the event.
❑ If gloves are used,they must be a food grade quality glove and must be used for only one task
(such as working with ready-to-eat foods or with raw animal food). You must wash your hands
after removing the gloves and prior to putting on a new pair of gloves. Gloves must be discarded
when damaged or soiled, or when interruptions to use occur.
❑ Food employees may not wear nail polish or artificial nails unless wearing intact gloves in good
repair.