HomeMy WebLinkAboutApplication 86 Evergreen Way ,0* '`,< Town of South Windsor - Health Department
A � 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: Iy)0 '15on'S CV10
Manager's Name:
JII CI.I AUUIcJJ. �V EV z-S\�jull � - i •��/L LC�. �� �' �%7
City, State, Zip Code: 9 cz 4t r L Cx dal, Q Ll
Phone#: L_t Ll - 5-)C. Cell Phone#: —
Fax#:
E-Mail Address: - Seating Capacity_ r4
Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office.
Qualified Food Operator: YES El NO '® (Required for Certificate#:
Class 3&4)
Name: -- - Date: j
Testing Organization: Phone#:
E-Mail Address: Alternate Phone#:
Designated Alternate 1: Designated Alternate2
Restaurant Owner Contact Information
Owner's Name: >,)"II S G l-2L-o
Street Address: Li 1,3,y k v Z-r
City, State, Zip Code: b9 ti-)A c_ 9 L�2 1-; 3
Phone#: o hi.t`i-i,l33of Fax #: c,-
E-Mail Address: Cell Phone#:
Renovations
Were there any renovations made last year? YES❑ NO PS Will there be any renovations? YES ❑ NO g]
If Yes, please list all renovations RECEIVED
that were done/to be done:
BAN 0 3 7017
Mailing Address to send Food License Renewal Permit to:
Name of Restaurant/Company: Ul�9N`_� CG 9 t C-a
Attention:
Address:
City, State, Zip Code: (vj� T �,� `i 6 43
-- Phone#: , G LI S L(
Town of South Windsor — Health Department
o {s 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
0R.00
Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES❑ NO L< Nig tZ-TC i 5;,r� 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.
Additional Information
Please check one only:
State Licenses: ❑ Bakery ❑ Liquor Permit ® None
Water Supply: X Public _ Private Well
Wastewater Disposal: xPublic _On-Site Other(please use space below to explain)
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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): 1/
/21
Applicant Signature: 0,.-,!, Date: 6 4 -2 C,
Office Use Only
Inspector Name (Print):
Inspect` a ure: � /�, Date:
Food Clas • 2 ❑ 3 ❑ 4 ❑ Expiration Date:
Date Received: ��G ���— Date Approved: i�—