HomeMy WebLinkAboutApplication 301 Evergreen Way Jan 02 17 02:35p Ben&Jerry's CT 8604132252 p.1
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From: •
To: Town of South Windsor Attn: Health Department
Fax: (860) 644-1930 Pages: 4 including cover page
Phone: (860) 337-6173 Date: Tuesday, December 20, 2016
Re: Ben& Jerry's Permit Renewal CC:
aUrgent F—Xj For Review ❑ Please Comment n Please Reply n Please Recycle
Regarding: Permit Renewal
Good Afternoon,
Transmitted herewith please find the following:
1. Permit renewal application.
2. Restaurant Menu.
Please let us know if you have any questions or concerns. RECEIVED
Thank You, JAN 0 3 2017
Brandi Killoran
SOUTH WINDSOR
CT Scoop Shop South Windsor, LLC dba Ben & Jerry's HEALTH DEPT.
Confidentiality Notice: The information contained in this facsimile may be confidential and legally privileged.
It is intended only for use of the individual named. If you are not the intended recipient, you are hereby notified
that the disclosure, copying, distribution,or taking of any action in regards to the contents of this fax—except
its direct delivery to the intended recipient—is strictly prohibited. If you have received this fax in error,please
notify the sender immediately and destroy this cover sheet along with its contents, and delete from your system,
if applicable.
12 Cheryl Drive, Suite 4,Canton,CT 06019
ToII Free: (855)372-5063 -Phone: (860)413-2281 -Fax: (860)413-2252
Jan 02 17 02:35p Ben &Jerry's CT 8604132252 p.2
Town of South Windsor -- Health Department
1540 Sullivan Ave., South Windsor, CT 06074-Mailing Andress
1530 Sullivan Avenue, South Windsor, CT 06074-Office Address
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 Establishmem: !
Manager's Nam
9 _' _e:_ Z _ �l1���, .•n asp l .._ __?_ . _.. _._ . _ . _ .
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i City, State, Zip Code: :_0 , i� tom.-, Obv �_-• •-..._. ._ _ _
Phone#: r6U 14 33A- -- 60
Cell Phone#•lr
- --- ...--Fax#:
-E-Mail Address: n city: i
Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office.
I YES❑ NO ❑ (Requlred for Certificate#:
Qualified Food Operator: - gass a&a) k
- -.. - Name: .. 1 -- .Date:
Testing Organization: Phone#: ' i
E-Mail Address: Alternate Phone#:
Designated Alternate 1 ` Designated Alternate2; �_-
Restaurant Owner Contact(Information
-Owner's Name. .:11
- -- Street Address: --
k
City, State, Zip Code: �,� L Q�jQ�GJ
Phone#: k6U '1 13 - �)4,0 Fax#: 4.f ��-
_ .. .E-Mail Address_ pb..t-r,:� �jG,J,ers�G'f=tri>>Ce11 Phone#: ._
Renovations .1
Were there any renovations made last year? YES_❑ No Will there be any renovations? YES❑ NO/Qj
If Yes, please list all renovations
j that were done/to be done:
I
i
4f! 1
Mailing Address to send Food License Renewal Permit to:
Name of Restaurant/Company: ;G7�fit� s SON �� �
Attention: ;
Address: 01,
City,State, Zip Code:
' Phone#:
Jan 02 17 02:35p Ben&Jerry's CT 8604132252 p.3
Town of South Windsor - Health Department
1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address
i • 1530 Sullivan Avenue,South Windsor, CT 06074—Office Address
OR•c Phone Number. (860 337-6173 Fax: (860)644-1930
Phone
Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES❑ NO ❑ MOTE"(Must have latest copy on file
Please I;st 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: ❑ kery ElLiquor Permit None
Water Supply: — Publi _ Private Well
Wastewater Disposal: Public On-Site _Other(please use space below to explain)
1 {
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): poh,r1
Applicant Signature:
Date: f a, �1 j1S
Office Use Only
Inspector Name (print):
Inspector Signature: ff
ate:
Food Class: 1 ❑ 2 ❑ 3 ❑ 4 ❑ x Date:
Date Received: Date Approved:
Jan 02 17 02:35p Ben&Jerry's CT 8604132252 p.4
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