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HomeMy WebLinkAbout2018-7-7 - 150 Nevers Road - Temp Food License Application Van Dana Farm n ` � � TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT °'M '`'<a 1540 Sullivan Ave., South Windsor, Cr 06074— Mailing Address O 1530 Sullivan Ave., South Windsor, Cr 06074—Office Address . . y Phone Number: (860) 337-6173, Fax Number: (860) 644-1930 FOOD SERVICE LICENSE APPLICATION ***Must be submitted 2 weeks prior to event*** Event Name: sd v `l W t 1 r L�r�►►�cr� �yl�c,,�c� Business j'� •►� Representing: Gtn 4/G�/IG� C ct/r►7 Event Date(s):({,b3 71y 71 B 9/ 9�! g�s ��s q/s� Event Time: Event th �(r1 d /- f C r 150 O',S19 — Location: 04' r7 SCE Lt�rx,*fvn�>/ tom/ C( �s�l.`ir3 SGcr7�1 PERSON IN CHARGE INFORMATION /Last Name: _R clanrLn5� First: / ►^<U M.I.: �' Date: 6 YAP r4I/)-/ Business Address: d� 7 ? Unit 9: Cam: l C't State: Zip: 060!'y E-mail Phone&Cell Phone: ��0•�7)- �//(P 90"$$d'o17 7y Address: OTHER LICENSES (IF ANY) Temporary Event Poi&Producer/Distributor ❑ Bird/Pout r Livestock (Other Health Dept.) Egg Distributor ❑ Food Manufacturing ❑ Frozen Desserts ❑ Bakery ❑ QUALIFIED FOOD OPERATOR (MUST INCLUDE COPY OF CERTIFICATE) ❑ YES f8 NO ❑ NON-PROFIT Name: Certificate#: Date: ADDITIONAL INFORMATION Water Supply: YES ❑ NO ❑ Wastewater Disposal YES ❑ NO ❑ Electrical: t YES � NO ❑ If other,please ` explain: MENU 1 **(PLEASE LIST ALL MEP. JM�IN AS MUCH DETAIL AS POSSIBLE)** 4- .P.P 9ck.."p4s Cc;nQy ****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 -/ `/ RECEIVED (Please Print): /`01-7c-ls r\J�!nl ASn1 Applicant Signature: � JUN 07 2018Date: 61-1 SOUTH WINDSOR HEALTH DEPT. 4 t kA k t • Inc t'. � cs 1 � d r OFFICE USE ONLY Inspector Name: (Please Print): Inspector Date: Signature: Food Class: 1❑ 2❑ 3❑4❑ FEE:$50,Non-Profits exempt Temporary Food License*: Expiration Date: Notes: Date Received: a, f I -i► �oMa � Town of South Windsor Health Department o^ Temporary Food Event Questionnaire Form 11C and return fn thr 'n.ti,W.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 ind' ate how the food is protected during transport and how it is kept hot or cold as needed. Ran �o,,�c� f��r� 5� �. S�a�l� 0� 77 !duns -2d To CT 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. 1114 3. Now 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 ther to couple may be needed to accurately check temperatures. 4. Please describe the type of hand washing facility to be /used. / / _NCOo i% W , « L- riZ lose � r` Cll J�c t;' 4 / �v�T��. - 50-P spcysiw Jr/c ((c 7`/� e UJ �j i G✓o� r 1"2S� f9�� t'Gf � LISz n t✓ 74 1, 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. C� o 1 C'a.'7 a 9) �( L<< 1'3rtc ��y s d r Ley �yf 7' 6. How will/the /all utensils and food contact surfaces be washed,rinsed and sanitized? 7. Where will excess food(Potentially hazardous and non-potentially hazardous foods),dry goods,and single service items be stored? 17lA�- S. Where will ware wash detergents and sanitizers be stored?` 9. How will condiments and single service items(cups,plates, utensils,etc.)be dispensed? I& 10. What method of garbage disposal will be used?w o - 'Vtss roc s -13, cy�?L_ hei CLr �L_ XL�`r 011 4-1 �rL� ln �PG1� © � L- 5-xLLI` difPiOS 74 L 5'a—y 4