HomeMy WebLinkAboutApplication 769 John Fitch Boulevard ��°w" 8`-14
1-own of South Windsor — Health Department
CIOr '1540 Sullivan Ave., South Windsor, CT 06074-Mailing Address
o 1530 Sullivan Avenue, South Windsor, CT 06074-Office Address
Phone Number: (860) 337-6173 Fax: (860) 644-1930
Restaurant Information New Permit❑ Permit Renewal
***(Please Print Clearly)***
Name of Establishment /�' j��N/1 i� IS 6 A /k 7r�t N C
Manager's Name: IVAAic-y P,40 z- A
Jll l..l.l UU14JJ. '
City, State, Zip Code: : so u 174 W ,ti 0 <0 PJ C' A 7�{
Phone# �&o -71 j- Cell Phone# F6 {, 2 /w 73 �f y
Fax#: 2-
E-Mail Address: �jmail,ccyvl, Seating Capacity: : �l_�
Please submit latest copy of the Qualified Food Operat r/ServSafe certificates to the office.
Qualified Food Operator. YES NO El (Required for Class 3&4) Certificate#. A?`'vm 7�
'
Name: Date. b
Testing Organization: /�iJ5l Phone#:
E-Mail Address: e�a �(,(c1h Alternate Phone#: :glb 0 SZ`( 1,3 (45
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Designated Alternate 1: Designated Alternate2
Restaurant Owner Contact Information
Owner's Name:
Street Address: 7 R c `J
City, State, Zip Code: c_ n & I0
Phone#: c 0 S� Y `�� Fax #: 0 2-Y6 'Fes-6
E-Mail Address J '`'���V�/ �� nc Y �'t: c gym' Cell Phone# �l 0 6-2- Y
Renovations
Were there any renovations made last year? YES❑ NO Will there be any renovations? YES❑ NO
_ .._ ..__._. .... -.
! If Yes, please list all renovations
i that were done/to be done:
1
i
i
i
Mailing Address to send Food License Renewal Permit to:
Name of Restaurant/Company: SON A
Attention: ANcic:A- Ye vn er— I
Address: :S 7
City, State, Zip Code: f -A R-7'F% 0 G.T 6-16/10
Phone#: Rb 2 5-Z 'y> yl
MCDONALD'S MENU
BURGERS
CHICKEN
FISH
FRENCH FRIES
EGG MUFFINS
EGG BISCUITS
PANCAKES
BURRITOS
SALADS
YOGURT PARFAITS
COFFEE
MILK SHAKES
ICE CREAM CONES
SUNDAES
SODAS
°WN `Town of South Windsor — Health Department
c r 1540 Sullivan Ave., South Windsor, CT 06074-Mailing Address
ti 1530 Sullivan Avenue South Windsor CT 06074-Office Address
Phone Number: (860) 337-6173 Fax: (860) 644-1930
soR cod.
Restaurant Menu/List of All ItJems Served/Sold
Latest Menu Attached? YES❑ NO ❑ NOTE**(Must have latest copy on file)
Please list all menu items in as much detail as possible or a copy�f a menu attached is applicable.
SP A IT'TAi H
Please check one only:
State Licenses: ❑ Bakery ❑ Liquor Permit 12T None
Water Supply: -_ Public Private Well
Wastewater Disposal: Public _ On-Site _Other (please use space below to explain)
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: i %,
Inspector Name (Print):
Inspector Signature: Date:
Food Class: 1 ❑ -2 ❑ 3 ❑ 4 ❑ _ Expiration Date:
Date Received: Date Approved:
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CERTIFICATION
NANCY PADILLA
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).
12440078 10430
CERTIFICATE NUMBER EXAM FORM NUMBER
6/10/2015 6/10/2020
DATE OF EXAMINATION DATE OF EXPIRATION
Local laws apply. Chilliti:k with your local regulatory agency for recertification requirements.
Sherman Brown
SVP, National Restaurant Association Solutions
#0655
In accordance with Maritime lal—r i.nmenhon 2i?::•6 Res,Aufion ADD.N 068-201!lRequlnhon 12.Standard A 2j
^�2015 National ResMuurnnt Assxmh�w�Edu�ahonal Faund<rfion(NRAEFj All nghts reserved 5erv5afwk and the!�ei Safe logo are hodemarks of the NRAEF
Nanonal Restaurant Asx crthoreP'and the arr,dasign are trademarks of the Nati,•,nal Restaurant Asscxaahon
Thi,da_ument canna be re1:,r,xau,:ed or altered
141.2901 v 1401 Contact us with questions at 175 W Jackson Blvd.Ste 1500,Chicago,IL 60604 or Serv$ofe0restaurant org.