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HomeMy WebLinkAbout2018-5-31 - 150 Nevers Road - Temp Food License Application Gourmet Creations d 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 �4SON TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION ***Must be submitted 2 weeks prior to eVV11L`** Event Name: S�.J lnl S nr,�r �(4,y Event Date(s): v(l i 1►`�G Event Time: p Event Location: C1 PERSON IN CHARGE INFORMATION lnl Last Name: First: S�l(,`l/ J t��4� M.I.: Street Address: V C L� ��� - Apartment/Unit#: City: �'J h1'k�� 1e. ✓lU��n State: S Zip: Phone: / E-mail �q 00 ��-��+�y Address: ([rti�Ac(fic4 cw aft G!)5 ORGANIZATION REPRESENTED (1IF ANY) J Representing: C_G�(Mc� C(QG11�Q[1.5 Street Address: 0 C } , `�I \�• � �1�5\„�C��� � Apartment/Unit#: City: Y��ti �l S�A� � State: Zip' Phone: mall Address: -- QUALIFIED FOOD /OPERATOR (INCLUDE COPY OF CERTIFICATE) ,✓YES 7, NO Name:--- ©L\6\ Certificate#: 9 12 n I �'1 Date: ADDITIONAL INFORMATION 1 l Water Supply: YES NO Wastewater Disposal YES NO 0 Electrical: YES I_. NO Base of Operations: 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 %L;Jftl(-(Please Print): u(,( Applicant Signature: � Date: RECEIVED ?c :�7" 21 �{ MAY 3 12018 8 SOUTH WINDSOR HEALTH DEPT. 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? 7. Where will excess food(Potentially hazardous and non-potentially hazardous foods),dry goods,and single service items be stored? io -e roole<� 8. Where will ware wash detergents and sanitizers be stored? li 1 -, k ` ,OG I `^I 1`�r i7,11 9. How will condiments and single service items(cups,plates,utensils,etc.)be dispensed? 10. What method of garbage disposal will be used? Town of South Windsor Health Department Temporary Food Event Questionnaire Form O 1 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. c�6i?r 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. I i i u I I I i � I I I I I I I I I OFFICE USE ONLY Inspector Name: (Please Print): Inspector Date: Signature: Food Class: 1❑ 2❑3❑4❑ FEE:$50, Nonprofits exempt Temporary Food License#: Expiration Date: Notes: Date Received: - �K,. nc4� •r CEPTIFICATE OF AttERGEN AWARENESS TRAINING : Name of Recipient: PAULA MENZIES Date of • • - •n: January 5, 2017 Date of Expiration: January 5, 2022 � Y �. Jor completing an alleigen awareness train ingprogram recognized by the Massachusetts Department ofPublic Health Berkshire :► �V = in accordance with 105 CMR 590.009(G)(3)(a). Area Health E'ducation Center Pittsfield,Massadjusetts n.; Y Y,C *�:.c .� 1♦♦� mow..9-# ♦ �� _ ♦♦♦� -__--_- ~ r �a ♦ ♦��� t� tit 1, TOWNSHIP OF RARITAN COUNTY OF HUNTERDON 6923 BOARD OF HEALTH `befall food Establishment ficcue tluii4r 'Y�Igll "11111 LICENSE IS HEREBY GRANTED TO Gwl!f Me I COY u-�IUos ►�� ���U T/A _ — LOCATED AT TO OPERATE a Food Handling or Food & Beverage Establishment IN ACCORDANCE �r,Il0 WITH "AN ORDINANCE RELATING TO LICENSING OF RETAIL FOOD ESTABLISHMENTS" filu�l InlUI 1�,l,nll _�rv�-lG�., rIUIII, SECRETARY `�`�•. EXPIRES DECEMBER 31, _ NOT TRANSFERABLE LICENSE MUST BE POSTED IN A CONSPICUOUS PLACE `� •������r�''����!�t`�f��♦���#S'`��I#�=�==-__�#ram=�1i \r=j HUNTERDON COUNTY DIVISION OF PUBLIC HEALTH SERVICES SANITARY INSPECTION REPORT GO 0CMe 7—CC Z�Irl 7/-/:/,-/1 Name of Establishment Address raj ab --� � / SATISFACTORY DETAILED SUPPORTING DATA SHEETS ARE AVAILABLE UPON REQUEST ON THESE PREMISES AND AT THE DEPARTMENT OF HEALTH HUNTERDON COUNTY DEPARTMENT OF PUBLIC SAFETY DIVISION OF PUBLIC HEALTH SERVICES Route 12 County Complex, Bldg. #1, Suite 200 PO Box 2900 Flemington, New Jersey 08822-2900 (908) 788-1351 NAME OF INSPECTING OFFICIAL (Print) DATE CRV e�Lw SIGNATURE OF IN ECTING OFFICIAL PERMANENT REG. NO. J ��� NOTE: In cord with the State Sanitary Code,this Placard shall be posted in a conspicuous p,ce near the public entrance of the establishment. Specific references in the Detail Data Sheets are to N.J.A.C.8:24(Chapter 24)Sanitation in Retail Food Establishments and Food and Beverage Vending Machines.