HomeMy WebLinkAbout2018-5-25 - 150 Nevers Road - Temp Food License Application Soulier d
n <�-� s�•,-� TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address
s 1530 Sullivan Ave., South Windsor, CT 06074—Office Address
Phone Number: (860) 337-6173, Fax Number: (860) 644-1930
T EMPORARYISPECIAL EVENT FOOD SERVICE LICENSE APPLICATION
**14Must be submitted 2 weeks prior to event***
EVENT INFORMATION
Event Name:5 ��3U �\ - `�
Event Date(s): I y C Event Time:
Event Location:
PERSON IN CHARGE INFORMATION
Last Name: ` �1,�f First M.I.:
Street Address: \ �-\ 1, - Apartment/Unit#:
City: N Sys c__ State: L T Zip: O(D&S5
Phone: , ���. )��- E-mal V Addrless: �J A1 x:o•V.�l)
ORGANIZATION REPRESENTED (IF ANY) I
Representing:
Street Address: Apartment/Unit#:
City: State: Zip:
Phone: E-mail Address:
QUALIFIED FOOD OPERATOR ((INCLUDE COPY OF CERTIFICATE) YES NO ..
Name:
Certificate#: A Date:
ADDITIONAL INFORMATION
Water Supply: YES __. NO Wastewater Disposal YES NO
Electrical: YES NO Base of
- Operations:
MENU **(PLEASE LIST ALL MENU ITEMS IN AS MUCH DETAIL AS POSSIBLE)**
ec� r
****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 m temporary Food Service License for the Town
of South Windsor. Temporary Food Service License will be issued after the Foai� 9rro&Dieted his/her inspection.
Na
me
Applicant me (1 - �1 MAY 2 5 2018
(Please Na �i�
Applicant Signature: Date: �� 12-'
SOUTH WINDSOR UU
HEALTH DEPT.
I I
i
I i
I I i I
- - I
I
I I I I I I I
IF T
I I I
I
i
OFFICE USE ONLY
Inspector Name:
(Please Print):
Inspector Date:
Signature:
Food(lass: 1 2❑3 4 FEE:$50, Nonprofits 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.
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.
Ond Cp\e� I c 0
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.
` l\ XA Wpc)-'� ` -
4. Please describe the type of hand washing facility to be used.
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.
Cote tD C'O WTP_6 CCU i,IXOS
6. How will the all utensils and food contact surfaces be washed,rinsed and sanitized?
r
7. Where will excess food(Potentially hazardous and non-potentially hazardous foods),dry goods,and single service
items be stored?
. ..�7� or) -1 rf�1Prs wI ��p �
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?
K_�
ServSafe
ServSnfe
mad CERTIFICATION
GLENN ALDRICH
3, , r
for successfully completing the standards set forth for Iha ServSafee Food Pr ,t ►ificatian Examination,
the American National Standards Institute (AN�I�,.. ,
br -ood Protection ON.
which is accredited by
601099 51
r. :. .
UMBER E X A
DATE OF EXPIRATI
DATE OF C.
Local laws apply. en_y for recertiRcution requirements.
� � I 5
rtu of the NkOF
r:
Conti,cl u�w�ih qu�iow,�17ti W 1«kwn Btid Sie 1500.Chx,,p,il.,b(ld(w:»S.ivSat� wtiVunh•.I,twy.