HomeMy WebLinkAboutFSE Application 982 Sullivan Avenue Town of South Windsor — Health Department
CO) , � 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
SOR•CID
Restaurant Establishment Information New Permit❑ Permit Renewal I�
***(Please Print Clearly)***
Name of Establishment: � C. 2- C
Manager's Name:
L- - �?/ .-- 7 u s H
Strcct �ddre—,s: ,
ic
City, State, Zip Code: Sp t q t hj A_ j CU(o O 9
Phone#: Cell Phone#: �1)L
Fax#:
E-Mail Address: Seating Capacity: j
Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office.
Qualified Food Operator: YES ( No Clan( s3&4) Certificate": 2 1) 1 �`p ) 6-
Class
- - --- Name: f' Tc�ll'l ]—U f-1 1= Date:
Testing Organization: Phone#:
E-Mail Address: Alternate Phone#:
Designated Alternate 1: ! `� `S,�7) .3 a'� Designated Alternate2
Restaurant Owner Contact Information
Owner's Name:
Street Address: GI 3 ��, �,-C'-S t VC'
City, State, Zip Code:
Phone#: �6 n) 9'� s c, o Fax #:
E-Mail Address: Cell Phone#:
Renovations
Were there any renovations made last year? YES❑ NO [g Will there be any renovations? YES ❑ NO ! '
If Yes, please list all renovations
that were done/to be done:
RECE VED
CAM- 13-2016
Mailing Address to send Food License Renewal Permit to: SOUTH WINDSOR
HEALTH DEPT.
Name of Restaurant/Company:
Attention: I
Address: i. `� g 2- S L l ✓« �% N-
City, State, Zip Code:
Phone#:
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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
So R,`oi
Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES[g 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.
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Additional Information
Please check one only:
State Licenses: Bakery ❑ Liquor Permit ❑ None
Water Supply: ' Public _ Private Well
Wastewater Disposal: LZPublic 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): � 0 (\k C L__ y c t S i-1
Applicant Signature: _j (9 C Date: r 2_
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: 1 ❑ 3 ❑ 4 [D,- Expiration Date:
Date Received: l= , / Date Approved: /S
71
4�0
Y VOC)Ijs
NATIONAL REGISTRY OF
FOOD SAFETY PROFESSIONALS®
CERTIFIES
f
0 o JONEL TUSHE
Y �
HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE
C IED
' FOOD SAFETY MANAGER
UNDER THE
CONFERENCE FOR FOOD PROTECTION STANDARDS
PRESIDENT:
LAWRENCE J. LYNCH,CAE
ISSUE DATE: JULY 16, 2016
.riesF EXPIRATION DATE: JULY 16, 2021
CERTIFICATE NO: 21 25038C
7680 Universal Blvd,Suite 550,Orlando,FL 32819 TEST FORM: EZC 14
P(800)446-0257 F(407)352-3603 www NRFSP.com This certificate is not valid for more
National Registry of Food Safety Professionals® Than five vears from date of issue.
-.r
NATIONAL REGISTRY OF
FOOD SAFETY PROFESSIONALS(&
_f CERTIFIES
Q
ELTON TUSHE
�• HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE
CERTIFIED
R FOOD SAFETY MANAGER
UNDER THE
CONFERENCE FOR FOOD PROTECTION STANDARDS
PRESIDENT:
/,".—
LAWRENCE J. LYNCH,CAE
(` ISSUE DATE: MAY 3, 2016
,oF,a EXPIRATION DATE: MAY 3, 2021
CERTIFICATE NO: 21 225020
76sn Universal Blvd Suite 550,Orlando FL 32819 TEST FORM: EZS29