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Home My WebLink About2018-5-25 - 150 Nevers Road - Temp Food License Granny's Pie Factory �O�e TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT A 1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address � ti 1530 Sullivan Ave., South Windsor, CT 06074—Office Address r fi !' f° 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**"` EVENT INFORMATION /�,� 1' Event Name: Sa ct,-�-V) W i,VIC60 1- Fa(-W_r-S /V 4 f V_4? L p Bess !___ n n(�S Re f C Far.C-T� Representing: (�7�t,. Event Date(s): C0 116 I /a0 l e} _ q jA% 1 a 0 f g Event Time: Srxf urcl""`� `r r S / I Oa� 1 em Event U Location: 15a Ale( er,5 Rd, Som. h Wixd5c 'l CT ()6071( PERSON IN CHARGE INFORMATION Last Name: �{a,f-av LI C Cl! First: Al c k a I a t M.I.: Date: S7 l 1 0 I 145 Business Address: 'd 3 S ch ft t 5 rz4t Unit#: 1 l City: Eas 1 1a, �� 1P f-4 State: 6 T Zip: � 4 f 0 g Phone&Cell Phone: g 7 / E-mail Sfo4 j (0�� rcv1n1.5 �dm �LO�e�-q f 1��{ cu rn w CC" SQ,rV►G C �1 OTHER LICENSES (IF ANY) Temporary Event I I Milk Producer/Distributor i Bird/Poultry I, Livestock J 1 (Other Health Dept.) Egg Distributor J Food Manufacturing ] Frozen Desserts Bakery +� QUALIFIED FOOD OPERATOR (MUST INCLUDE COPY OF CERTIFICATE) i YES 'J NO `J NON-PROFIT Name: Certificate#: Date: ADDITIONAL INFORMATION / Water Supply: YES NO _/ Wastewater Disposal YES l.Ji NO [ Electrical: YES i.. NO ':/ If other, please explain: MENU **(PLEASE LIST ALL MENU ITEMS IN AS MUCH DETAIL AS POSSIBLE)** r 7-M 4,J aT ,o leas-a e�-Z l2c�rlGc_ ****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 Inspector has completed his/her inspection. Applicant Name (Please Print): Ni t H V0,5 RECEIVED Applicant Signature: Date: MAY 25 ?,l�z ✓✓ SOUTH"NDSOR 2� � HEALTH DEPT. n°tow"are=�,< TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT 1530 Sullivan Ave., South Windsor, CT 06074 Phone Number: (860) 337-6173, Fax Number: (860) 644-1930 ''�,.5.„H.�.•'' DECLARATION OF BASE OF OPERATION This form must be submitted with your application for permit. Vendor Name: (--i-VAY7h V S e CTCJ�L/ Vendor Owner/Operator Name: A] Cc,i Business Name of Base Of Op.: Zy ✓1 in U 5 t` i e Lih C� OY-L( Address of Base Of Op.: 1 b,-3 5c V?oo l S -�r4z+ 4-6k;5+ HG r44�5 -cl )--Icr aro f 0 K Owner of Business for Base Of Op.: Tom n Ha,rOVa'- 1 All Y) IG.t Hay- OL-s Telephone Number of Base Of Op.: :6 C) -- / — //6 THE FOLLOWING PORTION TO BE FILLED OUT BY THE OWNER OF THE FOOD ESTABLISHMENT USED AS THE BASE OF OPERATION. I, A Lo H a ro V&3 attest that my licensed food establishment Owner of Food Establishment used as base known as CT►'�c✓1 S Ple �C�C / is available as the Name bf Food Establishment base of operations for 6M 0 n u s P`e c owned by endor r Owner of Business Signatur of wner of Food Establishment **Please include a copy of the Base of Op ion food permit issued by the local health depart ent.** 103 School Street Hours East Hartford, CT cpMautiMon.- Fri. : 8 - 5 06108 Sat. : 8-1 Sun. : Closed 860-291-1164 ems PIE-ITUORY» grannyspiefactory.com Fruit Pies Apple Apple Sugar Free Apple Raspberry Apple Cranberry Dutch Apple French Apple Blueberry Dutch Blueberry Cherry Dutch Cherry Coconut Custard Custard Key Lime Meringue Lemon Meringue Peach Pecan Mince Pineapple Pumpkin Raspberry Strawberry Rhubarb Very Berry Frozen Pie Shells - . 6" Pie Shells 8" Pie Shells 10" Pie Shells 10" Custards or Quiche Shells t•L-V.>KC%'40 13 STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION This is your license certificate. This certificate shall be posted in a conspicuous location where business is to be conducted and shown to any properly interested person on request. Do not attempt to make any changes or alter this certificate in any way. This license is not transferable. In an effort to be more efficient and Go Green, the department asks that you keep your email information with our office current. All renewal notifications and certificates will only be emailed to your last reported email on record. Questions regarding this license can be directed to the Food & Standards Division at dcp.foodandstandards@ct.gov. Mailing address: Email on file to be used for receiving all notices from this office: GRANNY'S PIE FACTORY customerservice@grannyspiefactory.com 103 SCHOOL STREET EAST HARTFORD, CT 06108 .��y `•�>,. :y,:k,. ` •+��' moo-, 'i;/- `•'Fy ill: "4q �)', N 7•'t'•'11 "'417-1 ;:`' 1i� --- ---t — STATE OF CONNECTICUT ♦ DEPARTMENT OF CONSUMER PROTECTION I . >' Be it known that GRANNY'S PIE FACTORY ! 103 SCHOOL STREET EAST HARTFORD, CT 06108 has been certified by the Department of Consumer Protection as a licensed ! BAKERY y Number of Production Employees: 6 License #: BAK.0000631 '< . Effective Date: 07/01/2017 i 'z Expiration Date: 06/30/2018 I r verify online at Www.elicense.ct.gov Michelle Seagull,commissioner 1 _� Oil '�H .J < .. `.'�/:1 ! `� ",•. .,•. Ji.<`ii •Aup"",wR 't� . tD C' 3;iC• • � - 'fie: i: s;.• a'. 'rs.: ''4,.