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HomeMy WebLinkAbout2018-6-9 - 150 Nevers Road - Temp Food License Application SWRTC 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 SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION ***Must be submitted 2-weeks prior to event'*** ;EVENT INFORMA'1'iCN` Event Name: 5 e & / /i " / Event Date(s):vi/ 4� N, > 2 4) Event Time:,;?. Event Locationce �/_`V'lc PERSON IN CHARGE INFORMATION Last Name: ������ / � First: Street Address: Z_ � �/ D '� Apartment/Unit#: City: �" >`"� G��i.ii Las�,�_ State: zip: Glc C Phone: E-mail Address: ORGANIZATION REPRESENTED (IF ANY) Representing: Street Address: / Z /�Ly �r ��/.� Apartment/Unit#: City: /� , State: �� Zip: ;7 Phone: E-mail Address: f QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) YES NO Name: Certificate#: -5 e-_3Xe-95,,e Date: ADDITIONAL INFORMATION G� Water Supply: YES NO Wastewater Disposal YES ✓ NO Electrical: YES L ENO Base of Operations: i /G�t7 MENU "(.PLEASE _MENU ITEMS IN AS MUCH IDETAILAS 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. ner 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: Jj-.i1:.7. ServSe af National Restaurant Association Certificate of Achievement This certificate is awarded to KATHLEEN DAUGHERTY Ti:P-(�1 1 4n4 Congratulations I You have completed #0655 AffM E2659 ServSafe,& Food Handier Cer6ficale Issuer .-M 10yee Food- Safety Ordine Course ancl Ityl National Restaurant Association Cortificote Number 3303184 Data /13/2018 233 S. Wacker Drive, Suite 3600 Exp1rotlon Date 3/13/2021 Chicago, IL60606-6383 800.765.2122 in Chicago area 312.715.1010 Restaurant,org I ServSafe.com r - CA VIE 41 n D / .c OFFI CE USE ONLY Inspector Name: (Please Print): I nspedor Date: Signature: Food Gass: 1 " 2 'WW. 3 4 m FEE $50, Nonprofits exempt Temporary Food License#: Expiration Date: Notes: Date Received: Town d Sxrth VV ndsor Health Department Temporary Food EAxA UAsti onnai re Form Please co rpletealI questions and return to the Health D�partrnent with your application. 1. What is the source of the food to be served/dispensed? (Please indude 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. �7ur���u�iKJc/>s l5 til�. �/SC�/�r'.Sr.�C'•�ll�itstc'���t�� : !�/�,�/��i l�e� 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. _�?''I�'Acc:"��.�'if� `DYc_.��/�rrl.'�.�Cs u.►��c,C�E-syG�"�-,cam/�"c.; /�c',�,ei�-ir2�i�ftro ��i�.��.�>��.*J'C!'OF',o. �-yh���i�c--/✓l�.�r��f 3. How will the food items be cooked and/or hot held? Asanitized 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. 4. Please describe the type of hand washing facility to be used. 10, ?iL'�� �r ':-�SA� i J'�Tii►c i�r �r�i.`�c�.�e%.�''�/'�',�'t�d"r9'�t' 5. 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? !:�'L%i✓�: �i l.Ll/C.�- /� c�r7i�if/1�/2 e�r/.J �/U /�/�l'��G'�/�i• /��i�L- �l/l/./J 7. Where will excess food (lbtentially hazardous and non-potentially hazardous foods), dry goods, and single service items be stored? X l'l• i �Oc7/� G4J/L � �f����S/S�r`�� .��i����,Dl.4S/�.�.L� 8. Where will ware wash detergents and sanitizers be stored? a 9. How will condiments and single service items(cups, plates, utensils, etc.) be dispensed? 10. What method of garbage disposal will be used? �!� •- .� � �,rJ.L� �/'�l�!!�ic/j+'G�`��E.� /sC/Jr� !��/.�1i©Src"�r