Fillable BHD Temp Seasonal Fillable Food Serv Estab License App Jan 2020 Template for Review of Engr plans memo

Fill Online, Printable, Fillable, Blank BHD Temp Seasonal Fillable Food Serv Estab License App Jan 2020 Template for Review of Engr plans memo Form

Use Fill to complete blank online TOWN OF BETHEL, CT (CT) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

BHD Temp Seasonal Fillable Food Serv Estab License App Jan 2020 Template for Review of Engr plans memo

On average this form takes 48 minutes to complete

The BHD Temp Seasonal Fillable Food Serv Estab License App Jan 2020 Template for Review of Engr plans memo form is 9 pages long and contains:

  • 1 signature
  • 53 check-boxes
  • 162 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Town Of Bethel, CT

BROWSE TOWN OF BETHEL, CT (CT) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Last revised 2020 F:\Dept_Docs\FOOD\TEMPORARY FOOD LICENSE\BHD Temp Food Serv Estab License Application 2020.doc
BETHEL HEALTH DEPARTMENT
Clifford J. Hurgin Municipal Center
1 School Street
Bethel, Connecticut 06801
(203) 794-8539
Application for Temporary/Seasonal Food Service License
Instructions for Completion of Form
Please follow these instructions carefully:
1. Read Food Safety Standard Operation Guidelines for Food Service Operators
(attached). Keep Guidelines and the Food Event Self-Inspection Checklist for
reference.
2. Complete the Application for a Food Service License.
All information requested must be completed and all questions answered.
If not applicable, write N/A.
A menu must be submitted on Menu Sheet. Attachment 1
A Food Event Sketch must be submitted. Attachment 2
An Employee/Volunteer list and sign in sheet must be submitted after the
licensed event on Attachment 3.
3. Return completed signed application to the Bethel Health Department no later
then 10 business days BEFORE the event.
4. Out-of-town Food Service Establishments are required to submit a current food
service license issued by another health department or district.
5. Class II, Class III and Class IV Food Service Operations Must Attach A Copy of
the Qualified Food Operator (QFO) Certificate. You can also attach your QFO
Certificate if you have one.
6. Submit Menu Page and Diagram Page with completed application. Submit
completed Employee/Volunteer list to Bethel Health Department after the
licensed event.
BETHEL HEALTH DEPARTMENT
Clifford J. Hurgin Municipal Center,
1 School Street
Bethel, Connecticut 06801
(203) 794-8539
Application For Temporary/Seasonal Food License
Please Check Type of License:
Temporary: 1 to 14 consecutive days Seasonal: 15 days or longer
Name of Applicant:
Address:
State: Zip: Home Phone:
Business Phone: Cell Phone:
Name Event//Organization/ Business:
Mailing Address: Town:
State: Zip: Home Phone:
Business Phone: Cell Phone:
Location of Event:
Date(s) of Event:
Hours of Food Service Operation:
Person in Charge: Home Phone:
Business Phone: Cell Phone:
Please check Type of Water Supply:
Self-contained / Home At Event Site Other (please describe):
Public Water Public Water
Private well * Private well *
* Water analysis results performed within 3 months of the date of the event must be submitted
with application
Please Check Type of Toilet Facilities and Location:
Rest Rooms Portable toilets
Please answer the following questions:
Note: All questions must be answered. Food Service License will not be issued for incomplete applications.
1. Using Menu Sheet (Attachment 1) list all foods and beverages that will be served. Indicate where food
will be made or purchased. (Note: Ice is considered a food)
2. Submit a diagram showing the layout of the food event (Attachment 2). Show work tables/counters;
cooking and hot holding equipment; coolers/refrigeration; hand washing stations; sinks; customer service
table/counter, beverage station, dessert station, etc.
3. Will all foods be prepared at this food service event site? Yes No
If answered “No”, the facility used must be a licensed commercially inspected kitchen and the appropriate
Health Department License must be attached. Also, describe how food will be protected during
transportation and how product temperatures will be maintained (exempt status for CT Farmers).
4. Will any foods be prepared ahead of time? List food item(s) and details of preparation - when; where;
how cooled; how reheated, etc. Please note that preparing food ahead of time may not be allowed.
5. Describe how temperatures of both hot and cold foods will be maintained and monitored during the event
(include equipment, etc.).
6. Describe how food will be stored at the event (minimum of 12 inches off the ground.
7. Describe where and how cleaning and sanitizing of utensils, cutting boards, and other food contact
surfaces will take place. Also, describe provisions for backup utensils (sanitized test strips must be
available/used based on type of sanitizer used).
8. Describe how food items will be protected from public exposure (sneezing, coughing, touching, etc.) and
outdoor elements (flies, dust, etc.)
9. Employee/Volunteer list (Attachment 3) is to be completed at the end of the event and returned to Bethel
Health Department. This List is useful if a problem occurs.
By my signature below, I hereby agree to use standard food safety practices and guidelines when serving food
and/or drink to the public. Failure to comply with the CT food/drink protection general statutes, regulations
including CT Public Health Code Sections 19-13-B40, 19-13-B42, and any other regulations that may apply,
and Town Ordinances, may result in revocation of the Bethel Health Department food service license.
_______________________
Signature of Applicant Date
Fee Schedule:
Check One: Amt. Due Amount Pd Cash/Ck# Date
214 *Temporary Food License $ 65.00 ________ _______ ________
214.1 *Seasonal Food License $130.00 ________ _______ ________
224.5 *Non Profit Temporary Food License $ 25.00 ________ _______ ________
214.2 *Non Profit Seasonal Food License $ 72.22 ________ _______ ________
(Excluding Religious Organizations)
*Temporary Food License: valid 1 through 14 consecutive days, Seasonal license valid 15 days or longer
All fees are non-refundable
FOR BHD OFFICE USE ONLY
Application reviewed by:
Comments:
APPROVED BY:
DATE:
ATTACHMENT 1
MENU SHEET
Menu Item
Include beverages, desserts,
snack items, etc.
Source
(Check Appropriate Box)
Where Made?
Where Purchased
Example: Tossed Salad
Made by organization
Commercially made
Pre-cut lettuce from Bethel Food Market
Salad made at event
Example: Meatballs & Sauce
Made by organization
Commercially made
Sauce made at event
Meatballs from Costco, Brookfield
Example: Baked Ziti
Made by organization
Commercially made
Tonelli’s, Bethel
Made by organization
Commercially made
Made by organization
Commercially made
Made by organization
Commercially made
Made by organization
Commercially made
Made by organization
Commercially made
Made by organization
Commercially made
Made by organization
Commercially made
Made by organization
Commercially made
Made by organization
Commercially made
Made by organization
Commercially made
Made by organization
Commercially made
Made by organization
Commercially made
Made by organization
Commercially made
Made by organization
Commercially made
Made by organization
Commercially made
Made by organization
Commercially made
Made by organization
Commercially made
Made by organization
Commercially made
Made by organization
Commercially made
ATTACHMENT 2
FOOD EVENT SKETCH
Draw the location and identify all equipment including handwashing facilities, dishwashing or utensil
washing facilities, ranges, refrigerator, hot and cold holding equipment worktables, food/single
service storage, grills, etc.
Describe food booth, including walls, flooring, screening, counter materials, and lighting.
BETHEL HEALTH DEPARTMENT
Clifford J. Hurgin Municipal Center, 1 School Street,
Bethel, Connecticut 06801
(203) 794-8539
PAYSHEET FOR SERVICES RENDERED REGARDING FOOD SERVICE ESTABLISHMENTS
ESTABLISHMENT NAME: ___________________________________ PHONE:_____________________
ESTABLISHMENT ADDRESS: ____________________________________________________________
OWNER/OPERATOR NAME: _________________________________ PHONE: ____________________
OWNER/OPERATOR ADDRESS: __________________________________________________________
SIGNATURE OF OWNER/OPERATOR: _________________________ DATE: ______________________
PLEASE
CHECK
OFFICE USE ONLY
No. 212.1
________
NEW OR CHANGE OF OWNER – Class 1 License
$175.00
No. 212.2
________
NEW OR CHANGE OF OWNER – Class 2 License
$350.00
No. 212.3
________
NEW OR CHANGE OF OWNER – Class 3 License
$350.00
No. 212.4
________
NEW OR CHANGE OF OWNER – Class 4 License
$375.00
No. 213.1
________
YEARLY LICENSE RENEWAL – Class 1
$175.00
No. 213.2
________
YEARLY LICENSE RENEWAL – Class 2
$350.00
No. 213.3
________
YEARLY LICENSE RENEWAL – Class 3
$350.00
No. 213.4
________
YEARLY LICENSE RENEWAL – Class 4
$375.00
No. 214
________
TEMPORARY LICENSE
$65.00
No. 214.1
________
SEASONAL LICENSE
$130.00
No. 214.2
________
NON-PROFIT SEASONAL LICENSE
$72.22
No. 215
________
REINSPECTION
$75.00
No. 223.1
________
PLAN REVIEW – Class 1
$150.00
No. 223.2
________
PLAN REVIEW – Class 2
$200.00
No. 223.3
________
PLAN REVIEW – Class 3
$300.00
No. 223.4
________
PLAN REVIEW – Class 4
300.00
No. 224
________
REVISED PLAN REVIEW
$100.00
No. 224.1
________
LICENSE APPLICATION/RENEWAL LATE
$75.00
No. 224.2
________
TEMPORARY FOOD APPLICATION LATE FEE
$25.00
No. 224.3
________
QFO DEMONSTRATION KNOWLEDGE COURSE/TEST
$220.00
No. 224.4
________
FEE FOR TRANSLATION QFO COURSE/TEST
$50.00
No. 224.5
________
NON-PROFIT TEMP FOOD SERVICE APPLICATION
(Excluding Religious Organizations)
$25.00
NOTE: FEE MUST BE PAID AT TIME OF APPLICATION
AMOUNT PAID: $___________CASH OR CHECK NUMBER:_________DATE REC’D: __________
click to sign
signature
click to edit
ATTACHMENT 3 Food Event – Employee/Volunteer List and Sign-in Sheet
Event Name:
Date of Event:
Person in Charge: Phone (home): (cell):
Date
Name (Please Print)
Phone Number
Time In
Time Out
* The applicant is responsible for maintaining a complete and current list, including addresses and phone numbers, of employees and
volunteers working for this event. Failure to comply with this regulation may result in revocation of the food license.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

BHD Temp Seasonal Fillable Food Serv Estab License App Jan 2020 Template for Review of Engr plans memo

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 11 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document