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Home My WebLink About2018-9-25 - 150 Nevers Road - Temp Food License Application Good Food Catering d041? TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT y 1540 Sullivan Ave., South Windsor, Cr 06074— Mailing Address 1530 Sullivan Ave., South Windsor, CT 06074—Office Address Phone Number: (860) 337-6173, Fax Number: (860) 644-1930 TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION *Must be submitted 2 weeks prior to event*** EVENT Event Name: �.�f I� �V.tit`_xr AFq�L �'l•.r�S� ICSfU.I Event Date(s): QLkU�cN` y� ` Event Time: i I wn f M Event Location: PERSON IN CHARGE INFORMATION Last Name: First: Vi^ M.l. 1�'l Street Address: `jo �_ ieA 1U b�� Apartment/Unit#: City: State: CT_ Zip: 06 Cl 7y Phone: �c//� l/ E-mail Address:" G. !XX\��t�� ORGANIZATION REPRESENTED (IF ANY) t Representing: G.A �OOA � r C Street Address: M 1 1,1 t�_ ` l ArIVL Apartment/Unit#: City: Bro- 1 State: GT Zip: Phone: (��V _ q66 -oicl E-mail Address* QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) LDS YES NO L Name: Kam: V." Certificate#: ( Date: ADDITIONAL INFORMATION / Water Supply: YES I NO -J Wastewater Disposal YES NO I_ I Electrical. YES 1..._i NQ t Base of Operations: I ��[) �1(�c�l W'nCl Lt 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 DECEIVED (Please Print): Applicant Signature: Date: SEP 2 5 2010 '1 I10 r r SOUTH WINDSOR HEALTH DEPT. bwK d",� Town of South Windsor Health Department nth,NM St, Temporary Food Event Questionnaire Form 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. (M�,g �'� �SS� M•.,. C ck W I sar CI QCOW Qo rau' 'r-fn-r� 1 I S�l M S k S(yt h W•-ASy- f-T OG O 7-(` p rn 1'C�- h r�� r C rcx,, , C'� 001( DfcYul Rf' k R„•G� �� 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. gr� L �1 ti y' 1 .r 1�t. c� � N � 1 FrI.�.� 5 � k�l�.�r � c_'�:I.� ro,,l� w t- C)r, ILL 11�J �It ,h ( •-L /' LX., 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. Y- � I 1 IU4 4lh ' Wrl� ) VZL �� /1✓l ! r/A1Aliri . t, 1 �.tc� � 1, / ( IIIL�e L�II\ ttiCy�i4 .ram }�tlr�� Ins ..l W ) b.. C c �� NCB �CILJ 4. Please describe the type of hand washing facility to be used. I I.. 4 3 1 ' Cy �c�t� good ' CATERING CO . Paper towels Soap Was1� Rinse Sanitize Haxd Washing OE Garbage Waste Water gratin❑ Hot Food Bucket Milk Crate ` Hot Box Cold Food Dry goods 00 OOD Hot Sauce / / II Aienus Cards Napkins Forks Pre-Event Self-Inspection Checklist "Prior to your event take a moment to go through this checklist The checklist should be completed for each temporary food site. FACILITY ❑ Storage of dry goods (shelves and/or crates for off the ground/floor storage) ❑ Cold storage (refrigerators/coolers) at 40 degrees F.or below. ❑ Hand wash station that includes potable water,soap and paper towels ❑ Potable water supply ❑ Food preparation area ❑ Wet and dry garbage disposal ❑ Dishwashing facility(wash, rinse,sanitize) ❑ Area to clean and sanitize utensils ❑ Ice and ice storage(freezers/coolers) ❑ Facility free of pests and rodents ❑ Method of wastewater disposal EQUIPMENT AND SUPPLIES ❑ Calibrated metal-probe thermometer(0-220 F degree range) ❑ Plastic wrap ❑ Extra utensils including tongs, spatula,spoons, etc. ❑ Plastic disposable gloves ❑ Bleach/Quaternary Ammonia for sanitizing ❑ Test strips for testing sanitizing solution ❑ Clean wiping cloths and containers for sanitizing solution/spray bottles ❑ Food-grade storage containers ❑ Hair restraints ❑ Log Book ❑ Garbage containers/plastic bags FOOD SUPPLIES ❑ Shellfish tags must be kept for 90 days after purchase. ❑ No home-prepared or home-canned foods can be used in the preparation of any item. ❑ All meats and poultry must be USDA-inspected and come from an approved source. ❑ All preparation must be done onsite or in a licensed commissary or kitchen. ❑ Check temperatures of foodstuffs when they arrive at the site. ❑ Meat, eggs, poultry,fish,shellfish, and milk should be at 40 degrees F or below. good CATERING CO . Roasted Butternut Squash Bisque Roasted early Autumn Butternut Squash, blended with cream, seasoned with fall spices, garnished with herbed croutons. Cider Braised Pulled Pork Sliders Pork Shoulder Braised in Cider until tender topped with Brussels spout slaw and garlic aioli served on slider buns R� � Taco pecl— Broad Brook Rim* easoned with traditional Mexican spices and pico de gallo served on flour tortillas ServSafe National Restaurant As ciation rvSa e CERTIFICATION KEVIN SPADA for successfully completing the standards set Forth for the ServSafel Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute(ANSIKonference For Food Protection(CFP). 2•, 10590 �E. • ' U•MQER EXAM FORM NUMBER 3/26/2018 3/26/2023 u: low DATE OF EX It-JA"i,iO '.', :�; DATE OF EXPIRATION AM E2AS9 local laws a Ch `vith ..tut lotE k,t� for recertification requirements. c., .�.b... PPIY Y re9� � cY m9 1- ' kS Sher ., Pie ttie«t ^lational P•stnuron' 4 yOuation Solutions p p In aaardaue 4ku,x:�43 2' c'`:nc ServSate bgo are hadenwrks of the NfiAF.F.National Restaurant Association®and the art design evenr.—......aL—...C_....6)09 c \N...L..M1..c.—OLM rL:_....II Af%"-AO99