HomeMy WebLinkAbout2018 - 150 Nevers Road - Temp Food License Application CT Gourmet AN10�4�e � TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
1530 Sullivan Ave., South Windsor, CT 06074—Office Address
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 INFOR _
Event Name:
Business f
Representing: C� 60,p,M r
Event Date(s): � Event Time: /0 —/
Event �!
Location: Pao&,4 e— P/ ��--
PERSON IN CHARGE INFORMATION
Last Name: First: ^, M.I.: Date:
Business Address: Unit#:
City: State: Zip:
Phone&Cell Phone: E-mail @
Address:
OTHER LICENSES (IF ANY)
Temporary Event Milk Producer/Distributor B rd/Poultry Livestock
(Other Health Dept.) /
Egg Distributor Food Manufacturing (! Frozen Desserts Bakery
QUALIFIED FOOD OPERATOR (MUST INCLUDE COPY OF CERTIFICATE) ' YES NO NON-PROFIT
Name:
Certificate#: Date:
ADDITIONAL INFORMATION -/
Water Supply: YES NO!V Wastewater Disposal YES 1,/ 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. 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):
Applicant Signature: Date:
I
OFFICE USE ONLY
Inspector Name:
(Please Print):
Inspector Date:
Signature:
Food Class: 1 i,i 2 'i_! 3 '_]4' '. FEE: 50, n-Profits exempt
Temporary Food License#: n Date:
Notes: Date Received:
Tam of SxAh VVndsor Health Department
_- - Te T puary Food Event Q,esti onnai re Form
_= Tease oxrplete 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 foodsthat 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. Roper
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 maybe 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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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.
6. How will the all utensils and food contact surfaces be washed,rinsed and sanitized?
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7. Where will excess food (Potentially hazardous and non-potentially hazardous foods),dry goods,and single service
items be stored?
8. Where will ware wash detergents and sanitizers be stored?
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9. How will condiments and single service items(cups, plates,utensils,etc.) be dispensed?
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10. What method of garbage disposal will be used?
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Additional Information
0 Contact the local Fire Marshal (860-282-0669)to ensure compliance with the Fire Code.
0 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.
0 Wastewater must be disposed of in a sanitary sewer or other approved sewage disposal system.
0 Equipment and tables must be dean, smooth,washable, durable, non-absorbent and in good
repair.
0 Dust must be controlled(i.e. dry fields)by watering down.
0 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 anew pair of gloves. Gloves must be discarded
when damaged or soiled, or when interruptionsto use occur.
El Food employees may not wear nail polish or art ifidal nai Is unless wearing intact gloves in good
repai r.
C`PL113 k2.ri&'L3
616W2
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 Careen,the department asks that you keep your email information with our office
current. All renewal notifications and certificates will only be emailed to the last reported email on record.
Questions regarding this.license can be directed to the Food&Standards Division at dcp.foodandstandards@ct.aov.
Mailing address: Email on file to be used for receiving all notices from this office:
CONNECTICUT GOURMET BISCUIT COMPANY
10 WINDE"CENTER RD
WINDE",CT 06280-1339
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STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION
F Be it known that
CONNECTICUT GOURMET BISCUIT COMPANY
I 351 BOSTON POST RD t '
i NORTH W NDHAM, CT 06256-1037
t
j has been certified by the Department of Consumer Protection as a licensed
FOOD MANUFACTURING ESTABLISHMENT
! License #: FME.0000577
Effective Date: 01/29/2018
Expiration Date: 06/30/2018 _
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