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HomeMy WebLinkAboutFSE Application 855 Sullivan Avenue ,0*" '`,<� Town of South Windsor — Health Department 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 �QsoR-cor 1 Restaurant Establishment Information New Permit❑ Permit Renewal ***(Please Print Clearly)*** Name of I:._,tablishment: �'�] p.�J,d �� lLj�. Sri¢Co R/L P lanager's Name: . - j cl-�ccl_ adr�.JJ U�• L/'�IAU � j City, State, Zip Code: . Phone#: �Gp - (�y�f.Z 3 Cell Phone#: Fax#: 76-0 Co IVY - ioZ O Z E-Mail Address: /-edo,,;c Ce cur ,.,�+c��� ct; Seating Capacity_ Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office. YES U NO ❑ (Required for Certificate#: Qualified Food Operator: Class 3&4) /7G fs Y S — �- Date: Name: l.��Tf;.rfn/ /�ct5i"/ _ Testing Organization: �j. j,��.h.,�_C i _ -__-____Phone#:_ ����r6 'Xe7?0 �. E-Mail Address: - I _ Alternate Phone#: Designated Alternate 1: Designated Alternate2_ �^ — Restaurant Owner Contact Information Owner's Name: s�f�i ,� �[csii✓ _ - - I Street Address: , ��, <c�,!►�(�_�,,,,,�� /i✓c_ _ yY0 City,State, Zip Code: ��/,�,� (Z7' 0,60 Z Phone#: © / Fax #: E-Mail Address: ���c��� n, i p�Ecr c�xrh«:l.pro�� Cell Phone#: ` Renovations Were there any renovations made last year? YES No !.-j Will there be any renovations? YES I�jl NO ❑ If Yes, please list all renovations ��4� fa �d,�,tf-✓c_�- a ,�cx r e.Ut co x e that were done/to be done: a RECEIVED Mailing Address to send Food License Renewal Permit to: 12 2016 Name of Restaurant/Company: -�f/� %�,5� C�A)110/v SOUTH -- R DE 1 HEALTH DE Attention: Address: g���._.Sc1%/ ✓c�ti _ t4 ve - --- — -- - City, State, Zip Code: C% ..O - - — - - Phone#: 4 Town of South Windsor - Health Department +- 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address r ` 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address y \• Phone Number: (860) 337-6173 Fax: (860) 644-1930 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. I l i I Additional Information Please check one only: State Licenses: ❑ Bakery ❑ Liquor Permit ❑ None Water Supply: )-' Public _Private Well Wastewater Disposal: j( Public On-Site Other (please use space below to explain) 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): Applicant Signature: ! Date: Office Use Only Inspector Name (Print): Inspector Signat �: �/' Date: Food Class: 1 d 2 ❑ 3 ❑ 4 Expiration Date: Date Received: Date Approved: