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HomeMy WebLinkAboutFSE Application 454 Ellington Road �.,0* '`'<q Town of South Windsor - Health Department r 1540 Sullivan Ave., South Windsor, CT 06074-Mailing Address 1530 Sullivan Avenue, South Windsor, CT 06074-Office Addrr;�Phone Number: (860) 337-6173 Fax: (860) 644-1930 SCANN'T �ASOR Cott Restaurant Establishment Information New Permit `t ai ❑ ***(Please Print Clearly)*** Name of Establishment: 1 eleAr-D19 2016 Manager's Name: I - - -- �CYUTH V\ANDSOR c� �} n aAY-,­: :g G t F I I +�'j G n L -�r_�_ HEALTH DEPT, City, State, Zip Code: :S �J n`: �� G �;G c,9 `l Phone#: 4;(pt� Vq- _-SS`7 7 ! Cell Phone#: _..5. _ Fax#: rjCj- `l3 ro-62 �a I E-Mail Address: +. I. ( h Seating Capacity: ! Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office. YES F NO ❑ (Re^u!red for y Qualified Food Operator: I Certificate#: �1 Class 3&4) /D Name: �A t3S k'Jc�,t-4/ ' - - Date: ►!_/!r T est ing Or anization: s I Phone#: E-Mail Address: Alternate Phone#: Designated Alternate 1: �>�44w2,4 CA2 Sew Designated Alternate2 ; L y yL Af 4, Restaurant Owner Contact Information Owner's Name: yy) IC>►�x� 11� Street Address: 9fi{, I c <�� 12,y:) City, State, Zip Code: G_V,hVg5U j C 1 O 6 U -� Phone#: <6GC) - t?qS Fax #: i56 -436, - . �- E-Mail Address: c'rir36 C� C-C, Cell Phone#: ; Renovations Were there any renovations made last year? YES❑ NO n Will there be any renovations? YES❑ NO Q, If Yes, please list all renovations _ I that were done/to be done: Mailing Address to send Food License Renewal Permit to: Name of Restaurant/Company: Attention: - Address: — - City, State, Zip Code: Phone#: 4 Town of South Windsor — Health Department o 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address Phone Number: (860)337-6173 Fax: (860) 644-1930 yaR-Co' Restaurant Menu/List of All Items Served/Sold Latest Menu Attached? YES [I No ❑ NOTE"(Must have latest copy on file) Please list all menu items in as much detail as possible or a copy of a menu attached is applicable. Additional Information Please check one only: State Licenses: ❑ Bakery ❑ Liquor Permit [i�ione Water Supply: c Public _ Private Well Wastewater Disposal: L Public On-Site Other (please use space below to explain) I I 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 Food Service License for the Town of South Windsor. Applicant Name (Print): �O 0 Applicant Signature: Date: t L Office Use Only Inspector Name (Print): Inspector igna�ure: �� Date: Food" lass: 1 ❑ 2 ❑ 3 ❑ 4 [a- Expiration Date: Date Received: i� i y 42e"Z, Date Approved: % i 2� _ 1� 4 t ' f� 4 11 g EXAM FORM NO. 4774 •, ' ,, r -,i•'1 ' `..�,a_ tik� :,y;•' , CERTIFICATE NO. 9637906 Al _; 2 'yy ry afe CERTIFICATION ro TAMARRA C CARSON for successfully completing the standards set forth for the ServSafe'Food Protection Manager Certification Examination, which is accredited by the American National Standards Ins itute(ANSI)-Conference for Food Protection(CFP). 12/1 5/2012 .. �. DATE OF EXAMINA�. ON 12/15/2017 DATE OF EXPIRATI Local laws apply.Check with youzzzr: t regulatory agency for reeertMeation requiremes i 111,411 y i Paul Hineman ® Executive Vice President,Natloifa estaurant Association #0856 ServSafe Se r 5 a datlon t few National Restaurant AsSY "etl°nalRe CHERYL MCDONALD I Student Name Student Name JAMES C MCDONALD Class Number 1311842 Class Number 1311842 Exam Date 11/11/2013 Exam Date 11/11/2013 Expiration Date 11/11/2018 OGERS Expiration Date JAMES RO Instructor Name DAMES Food Safety Instructor Name DAMES ROGERS Sponsor Name Rogers Food Safety Sponsor Name Rogers Food Safety Exam Location CT Exam Location CT Exafn Form Name 4892 Exam Form Name 4892 77 Overall Point Score 74 92 Overall Point Score Overall%Score 96 75 Overall%Score 75 Passing%Score PASSED Passing%Score PASSED Status Status Perfect Your Perfect Your I Point Point Point Point I Score ` Score Score Score { 80 74 80 77 I Domain Names Domain Names 16 Implement Food Safety SOPS 16 15 11 Implement Food Safety SOPS 16 Employee Hygiene and Health 12 13 Hygiene and Health 12 11 Receipt,Storage,Transport 13 Employee 13 13 25 Receipt. Storage,Transport 27 Food prep.Display and Service 181 10 Food Prep,Display and Service �8 10 Compliance with Regulatory Compliance with Regulatory I I ,I To ha-0 a certificate reprinted,complete a Certificate Request Form cn our webs to at servssle.corn and select Purchase a Duplicate Certificate To have a certificate repainted,complete a Certificate Request Form on our under the Students tab. websito at servsafe.com and select Purchase a Duplicate Certificate under the Students tab. ©201:'National Restaurant Association Educational Foundation.All rights reserved. v 1210 ©2012 National Restaurant Association Educational Foundation All rights reserved. v.1210 100702131 10070201 Exam Forrn No.4892 J ServSafe Exam Form No.4892 �— Cert.No. 10511a3B ServSafe Cert.No. 1051;.1 39 Sf$rv$afe* ServSafe• CERTIFICATION IFICATION ALD CERTIFICATION To CHERYL M To DAMES C MCDONALD q n b4 mo Naaonel rv:urnu! for sl,ueeefulN c°"olQ1i^ er:,l,wra^Fxemmetion far suuesslulN rv^7al'" W Inr National Ractrarant 4aa0tik4afde��"o Four.Zion lar ma SorvSale'a Fao Foundation for�.re$m,Sak�Foo PfKetpn FLm WI,a^ Dara of Examination:11l11 Date of Examination:11/11 Del,e of Expiration: 11/11/201 caaaa n qw emenn I Check with your local regu AEF7.All riatds reserved. . Date ofExpiretion: 11/11/201 �— Locsl:laws aPPY' ranrAssodatlon leol reSu flcan°n requirement, r 020 12 Mtlw l Pe�Au a aY Rational Rastavard Local laws aPPIY•Check wdh your �•M rglht reserved I Serv.Safe Is a relcistered vademu4 0l s a trademark of the Z012 National Restaurant Association E by Natlwul pesnurarrt aoees Anse,ciatlon SoWtl°ns.LLC-The ServSafe is a rr;""red tradarn rk of sat, ademark of the Natir anal Rcvuurant As Ioaaaa Association Solutions,LLC The Assoc.at oecdanrd a..