HomeMy WebLinkAboutApplication 1006 Sullivan Avenue 44 Town of South Windsor - Health Department
_ 1540 Sullivan Ave., South Windsor, Cr 06074—Mailing Address
1530 Sullivan Avenue, South Windsor, CT 06074—Office Address
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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:�^ a
Manager's Name: `fin i r n . .__
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City, State, Zip Code,
Phone#: gip _ip4(4 -q 3 i Cell Phone#_Ig4p_�`77S�(pSCo
r_ Fax#:
E-Mail Address: eating Capacity:
Please submit latest copy of the Qualified Food Operator/servsafe certificates to the office. i
I Qualified Food Operator: YES No El (Required for Certificate#•
- — Name:,]
Testing Organization: Phone#:� -
_-^ E-Mail Address: n tJk'rSC 4UQ S}. _ Alternate Phone#:
Designated Alternate 1: S tQh f Designated AlternateZ
Restaurant Owner Contact Information
owner's Name: `1 L-k, SQi-11
Street Address::g ( 1S'(Oyh_ Q-.0 ___... __ _ _-- -•-- -----�I
City, State,Zip Code: � ,bfQ1!�
__ Phone#_ (p� . $'_ g�03. ._.. Fax#: -5 -1�03 '
E-MaiI Address: gnn r(Q( sC Cv �f12. Cell Phone#:
Renovations
Were there any renovations made last year? YES❑- NOX Will there be any renovations? YES❑ NOJ
If Yes., please list all renovations
that were done/to be done:
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Mailing Address to send Food License Renewal Permit to:
_ Name of Restaurant/Company: ,
Attention: i _ --�
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Address:
._._City, state, Zip Code: C
Phone#: �— L — $0 -3 _
SOUTH WINDSOR
HEALTH DEPT.
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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
v Phone Number: (860) 337-6173 Fax: (860) 644-1930
Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES❑ NO)s� 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
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Additional Information
Please check one only:
State Licenses: Bakery ❑ Liquor Permit I ! None
Water Supply: 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
Semite License for the Town of South Windsor.
Applicant Name(Print): ern �-��r .S4 rl �O
Applicant Signature: Date: I {
Office Use Only
Inspector Name(Print): Z— de, e- -'
Inspector Signature:-
_ Date:
Food Class: 1 ❑ 2 ❑ 3 ❑ 4 ❑ Expiration Date:
Date Received: , Date Approved: i//a
Jennifer Santochristo
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