HomeMy WebLinkAbout2018-6-7 - 150 Nevers Road - Temp Food License Application Pullo TOWN OF SOUTH WI NDSOR HEALTH DEPARTMENT
1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address
1530 Sullivan Ave., South Windsor, CT 06074—Office Address
Rhone Number: (860) 337-6173, Fax Number: (860) 644-1930
TEMPORARY/ SPECI AL EVENT FOOD SERVI CE LI CENSE APPLI CATI ON
***M ust be submitted 2 weeks prior to event***
EVENT 11;MAT1 O
Event Name:
Event Date(s): r Event Time:
LID A JA - 1 v o V-M
Event Location:
PERSON I N CHARGE I NFORMATI ON
Last Name: v \\ First: q
Street Address: `\ l'c Apartment/Unit#:
Oty: —Ysz'\-k-, State: C Zip:
E-mail
Phone:Q L c to Lk ci L, ate; Address: `1 Q— -j c-A M P�\L CO f A
ORGANI ZATI ON REPRESENTED (I F ANY)
Representing:
Street Address: Apartment/Unit#:
Oty: State: Zip:
Phone: E-mail Address:
QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTI FI CATE) -YES . NO
Name: d
Certificate#: 12-3 _5 3 a- 9 Date:
ADDITI ONAL I NFORMATI ON
Water Supply: YES _ NO Wastewater Disposal YES NO
Electrical: YES NO Base of
Operations: Sol ��r .r C,Z V e N
MENU "*(PLEASE LIST ALL MENU ITEMS I N AS MUCH DETAI L AS POSSIBLE)"
ky.T
_e c
-49
tC + Lit
�e-e�c5 (��T- �e�) ►3��1s11 P �4��' Cyr:• S
PLEASE DRAW A DETAI L DI AGRAMrt� OF FOO _�.-TH ON THE BACK OF THI S FORM
USI NG THE GRAPH PI CTURE ON THE BACK OF THI S APPLI CATI ON****
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 Are Marshal's off ice.
AGREEMENT AND SI GNATURE
By submitting this application, I affirm that the fads 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
(Rease Print):
Applicant Signature: �� $ JUN 0 7 2018 Date. -5
SOUTH WINDSOR
HEALTH DEPT.
-7..ryt9d cl-ee b.
V-2? 01- 31 M
CY
a �
s d
iLj
EE
OFFI CE USE ONLY
Inspector Name:
(Please Print):
I nspector Date:
Signature:
Food Class: 1 E 2 3 4 FEE$50, Nonprofits exempt
Temporary Food Lioense#: Expiration Date:
Notes: Date Received:
Tom of SbtAh W ndsor Health D 4?@rtmerYt
Temporary Food Bent Qjesti omai re Form
R ease wipl eke ail questi ens and return to the Health C@partment wi th yo r appl i c 3ti on.
1. What is the source of the food to be served/dispensed? (Please include nametaddress 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.
B R5 M,t�"c. Ht5r1; a z!k. ,,� C,,:- 1, _3'IC, �_' -C Sty ;Ll�vch���� ZycT
T 1`� tJ ���'�-"► AL-iJ ��e -e c c� Ntc z v �^�1 a-a—�+ } Cry ecl C i
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 thermocouple may be needed to accurately check temperatures.
4. Please describe the type of hand washing facility to be used.
5. How will the food be protected?
Food must be protected during storage, preparation,display,service and transportation. C.boking to order will
lessen the chance for bacterial growth,which may occur prior to service.
IN c'
c. �C 72 s ►�l Cc�v�y' �S
6. How will the all utensils and food contact surfaces be washed, rinsed and sanitized?
�
A ' z r 2 S AO } + d Y\
0
7. Wherewill excessfood(Potentially hazardousand non-potentially hazardous foods),dry goods,and single service
items be stored?
8. Where will ware wash detergents and sanitizers be stored?
t r A_-o. I rc "l eon" C-1
9. How will condiments and single service items(cups,plates, utensils,etc)be dispensed?
V-CLC
T
10. What method of garbage disposal will be used?
A
t 1
C�1.:�l \� \ `C 1�Lz .'t<. Jl.,�l�1 \-L_�k�CC--�w �y--� �`-• -
i� Ch
ServSai7fe Y
,.-.,,Atery a e
ad CERTIFICATION
ANNE PULLO
for Rxc ssf*axrp6ng&sbmklr(s set forth 6 the S—Safes Food Probdion MarKxjw Certification Exa nine+ion.
whisk is occredded by to Arnoxm National Stan�hej*L*e(AN51}{onfer 4x Food Prdodion(CFP).
353279 5042
ATE NUMBER EXAM FORM NUMBER
5111 15 5/11/2020
DATE OF EXAMINATION DATE OF EXPIRATION
load 6m gWly_C1,.A wah your local n pA&k ry opemy for recai4cofi o�ieroeaR
slr,,,00 a.
SVP,Noti .l lb k--t A.—c t—solidi«
_ 2
._ _._ _ .a.w...��,.::�...�.zr>a,e..r.v..o.+noeazouf�+...12•. �w27t
J7aT901 v.ltlt Gdf�.i6q.d..•a VSw�dsoLd 9e 1304Ci:masleowa>Sa '- -so