HomeMy WebLinkAboutApplication 855 Sullivan Avenue Town of South Windsor - Health Department
r 1540 Sullivan Ave., South Windsor, CT 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: � � 0
Manager's Name: V.
City, State, Zip Code:
Phone#: (Q _ ib Lj Cell Phrmc ,�. Q 7 QS
Fax#: ���7 D.9 �S
E-Mail Address: Seating Capadl:y:
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Please submit latest copy of the Gu d Food Op rator/ServSafe certificates to the office.
Qualified Food Operator: ; Yes NO ❑ (Requlredfor i
Certificate#:
I \/Clads 3&4) j
Name: 0 8 T�P l�f�/0{-J Date: h
Testing Organization: l Phone#: p I
E-Mail Address: ,� 4Lle / Alternate Phone#: 0�3
Designated Alternate 1: U1 v/S Designated Alternate2_ �4� �
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Restaurant Owner Contact Information
Owner's Name: ..�6 y- �' �Oo I V'0 S
:Street Address
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City, State, Zip Code:. I / lot vl6 L�
i'Ilc,i)_�ll: v $ ��. -� "l 5 Fax #: IY66) (0 y/
E-Mail Address: lwq Yt D k �t'(i�h d) (�'n Cell Phone#: , C ���
Renovations
Were there any renovations made last year? YES❑ NO Will there be any renovations? YES ❑ NO
if Yes, please list all renovations
that were done/to be done:
RECEIVED
03_-2017
Mailing Address to send Food License Renewal Permit to: SOUTH WINDSOR
HEALTH DEPT.
Name of Restaurant/Company:
Attention: .-
Address:
City, State, Zip Code: f 44 n ���J f� P C
Phone#: fP 6 Y
��°"~ Y`'`Q Town of South Windsor — Health Department
Cm Y 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address
U 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address
s Phone Number: (860) 337-6173 Fax: (860) 644-1930
SOR.C(1 a:`V
Restau nt Menu/List of All Items Served/Sold
Latest Menu Attached? YES FK 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.
Additional Information
Please check one o
State Licenses: Bakery ❑ Liquor Permit ❑ None
Water Supply: JPublic _ Private Well
Wastewater Disposal: ✓ Public On-Site Other (please use space below to explain)
I
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):
Applicant Signature: Date: -
Office Use Only
Inspector Name (Print): 7)�,q
Inspector Si e: Date:
Food Class: 2 ❑ 3 ® 4 ❑ Expiration Date:
Date Received: l > /�x— Date Approved:
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EXAM FORM NO. 10086 0
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CERTIFICATE NO. 5977272 W
. ServSafe�
CD
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ServSafe Certificatiwon
LYNETTE MALOON
for successfully completing tho standards set forth by the National Restaurant Association Educational Foundation
1cr the ServSafee Food Protection Manager Certification Examination,which is accredited by the American National
Standards Institute{ANSI)—Confarence for Food Protection (CFP).
7/3/2008 00
0
DATE OF EXAMINATION
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7/3/2013 00
1 OilIto
DATE OF EXPIRATION
lo:al laws apply.Clrede with your local regulatory agency for recertification requirements.
110655 �IENT'A �IONrA�L�11"
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National Restaurant Association Miry M.Adolf ASSOCIATION
Pr>sidont&COO.Preouets and Services Division
EDUCATIONAL FOUNDATION flaiiumil Restaurant Association Solutions S p L U T I D N S T^t
m,me N,rtnwi q....... ,a,—,wl—cNi,atinn,t k-lotion All ne is resorved.SanSafee and the RmSafe logo are registered trademarks of the National Restaurant Association Educational Foundation.
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Dunkin' Donuts
1527 Pleasant Valley Road, Manchester. CT 06040
Beverages (Hot/Cold)
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Sandwiches
Chicken Salad Sandwich
Ham &Cheese
a tasty nev,, take on a classic; sandwich ham and white cheddar served on our french
bakery roll pair it with a freshly
Texas Toast Grilled Cheese
we've raised the bar on the basic grilled cheese you ate as a kid melted am ric;an and
white cheddar cheese between
Tuna Sandwiches
our tasty tuna sandwich is blended with mayonnaise, celery, herbs and spices all on a
toasted plain bagel or, try our o
Turkey, Cheddar& Bacon
fleshly sliced turkey topped with cherrywood smoked bacon and white cheddar cheese it's
a great v;ay to brighten up your
Food
Bagel Twists
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Bagel
Big N Toasted
Breakfast Sandwiches
([3acon/IIam/Sauaoe/ Limited time only meets)
Cookies
Danishes
Donuts
Hash Browns
Muffins
Munchkins
Other Bakery
Wake-up Wrap