HomeMy WebLinkAboutApplication 855 John Fitch Boulevard 0*"
Town Town of South Windsor - Health Department
Q, 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address
1530 Sullivan Avenue, South Windsor, CT 06074—Office Address
s Phone Number: (860) 337-6173 Fax: (860) 644-1930
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Restaurant Establishment Information New Permit❑ Permit Renewal
***(Please Print Clearly)***
Name of Establishment: I Y
Manager's Name: j 1�5,Yi �I-LL
A C'4�CC1- � �� g�5 �0 �(
City, State, Zip Code: pLj44"
Phone#: q 2$ Cell Phone#: 63
Fax#:
- E-Mail Address: Seating Capacity: -7 D
Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office.
~ Qualified Food Operator: YES K NO ❑ (Required for Certificate#:
Class 3&4)
i Name; L M ASL /-D t_Xl ' Date:
I Testing Organization: Phone#:
E-Mail Address; Alternate Phone#:
Designated Alternate 1;- j-� Z flj/ Designated Alternate2
Restaurant Owner Contact Information
Owner's Name: ,� 5 I-Y/- 4 t j)
Street Address: 8.56 Tv1-1H F-/1 %C ff �3 4 v
City, State, Zip Code: 5.C)c f
Phone#: A 2_?17 SO Fax #:
E-Mail Address: Cell Phone#:
Renovations
Were there any renovations made last year? YES RL NO ❑ Will there be any renovations? YES ❑ NO ❑
If Yes, please list all renovations
that were done/to be done: Q�-col pv y f/ 0
RECEIVED
DEC 23 2016
SOUTH WINDSOR
Mailing Address to send Food License Renewal Permit-td: HEALTH DEPT.
Name of Restaurant/Company: S C^ r,�/j001-0
Attention: I S M k L L D C=�K
- -
Address: SS ,701-1// �L(C!-I �Qd. `
City, State, Zip Code: S p c e (,vl r1(�,Co r' G.T 0 6 0�4_
Phone#: Y 6a 2_9q— 180f.) - -
�t°.pn "44 Town of South Windsor — Health Department
rA 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address
s • �e 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address
Phone Number: (860) 337-6173 Fax: (860) 644-1930
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Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES K NO ❑ NOTE"`(Must have latest copy on file)
Please list all rnenu items in as much detail as possible or a copy of a menu attached is applicable.
Additional Information
Please check one only:
State Licenses: R, Bakery ❑ Liquor Permit ❑ None
Water Supply: -�L Public _ Private Well
Wastewater Disposal: �(,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.
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Applicant Name (Print): S/ L �- �`�"b t=
Applicant Signature:
Office Use Only
Inspector Name (Print):
Inspector Sig �7 � Date:
Food Clas . 1 ❑ 2 ❑ 3 ❑ 4 L Expiration Date:
Date Received: 1P/,�r Date Approved: ,;Lzo; .
EXAM FORM NO. 4821
CERTIFICATE NO. 9916393
5ervSaffe
Matloral Restaurant Association
ery af
CERTIFICATION
TO ISMAIL ADEMI
for successfully completing the standards set forth for the ServSafe"Food Protection Manager Certification Examination,
which is accredited by the American National Standards Institute(ANSI)-Conference for Food Protection(CFP).
04/09/2013
DATE OF EXAMINATION
04/09/2018
DATE OF EXPIRATION
Local laws apply.Check with your local regulatory agency for recertification requirements.
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Paul Hineman
® Executive Vice President,National Restaurant Association
#0655
l02012 National Restaurant Association Educational Foundation(NRAEF).All rights reserved.ServSafe Is a registered trademark of the NRAEF,used under license by National Restaurant Association Solutions,U.C.
The logo appearing next to ServSale is a trademark of the Natlonal Restnurant Association.
This clocumant uinnot be reproduced or altered.
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