HomeMy WebLinkAboutApplication 289 Oakland Road Town of South Windsor — Health Department
Y 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
SOR-C-O�.
Restaurant Establishment Information New Permit❑ Permit Renewal
***(Please Print Clearly)***
j Name of Establishment: Ted v 'S _P1 ZLa-
�j o� �v r a►t'�
Manager's Name: rl-
Stro � �ddlmss: �8� O QD�I Qr,d
J ll l-.01. A UIt-.JJ•
City, State, Zip Code: I moo I-v_, L.vu�,G(Ao►- C_�T OCo 0-7
Phone#: $(gyp -(o yy - 4-1 9 Cell Phone#:
Fax#:
E-Mail Address: Seating Capacity:
Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office.
Qualified Food Operator: YES NO 0 (Required for Certificate#: 5 8
Class 3&4)
Name: Kons"+�n'�fq 'rllln7"i-0-1 _ Date:
Testing Organization: Phone#:
E-Mail Address: Alternate Phone#:
Designated Alternate 1: Designated Alternate2
Restaurant Owner Contact Information
Owner's Name: ►' hU r S
Street Address: 3Z 1 V--c3 s4--er- S+r j
City, State, Zip Code: i So U�-} �jo W\d,l,cD r, CT O tab`1 �1
Phone#: ; Fax #:
E-Mail Address: Cell Phone#-
Renovations
Were there any renovations made last year? YES ❑ �II '❑ Will there be any renovations? YES ❑ NO ❑
If Yes, please list all renovations RECEIVED
that were done/to be done:
v 113 2017
-SOUTH WWDSOR
- HEALTH DEFT.
Mailing Address to send Food License Renewal Permit to:
Name of Restaurant/Company: �-T ' S J�1zz� ��1-u�r -(-.- �"f�'Pl rr• S
Attention: 2$ O a.+4- PLO CL
Address: I
City, State, Zip Code: 4Gova-, lx_ )\-* aOy- Cal dt", -114
Phone#: I _�- bqq- Lett 9
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
Phone Number: (860) 337-6173 Fax: (860) 644-1930
�GJ'OR•C��~.
Restaurant Menu/List of All Items 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 of a menu attached is applicable.
Additional Information
Please check one only:
State Licenses: Bakery ❑ Liquor Permit ❑ 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
Service License for the Town of South Windsor.
Applicant Name (Print): R-r`t-hv r- KW)
Applicant Signature: , �� Date:
Office Use Only
Inspector Name (Print):
Inspect? ture Date:
Food Cl : 1 ❑ 2 ❑ 3 ❑ 4 a' Expirati6n Date:
Date Received: 30 Date Approved:
•
KARAHALIOS9 ARTHUR
371 .FOSTER STREET
S. .WINDSUR$7 CT;06074 /
Signature
Exam Form No.4674
SerySa�ie] ,��UT1oN e
Cart.No. 85897�1
ServSafe'Certification
T, KONSTANTIA ICARAHALIQS
la suxaui'wh cornpictng the nsndwils ut lath by the Natwral Ftctuuant As s-z latest Educational
resrdstese la the Ser4ale®rood Protectwn Menegor Cartif"Wnfnmannon 6
Date of Examination:11/22/2011
Date of Expiration: 11/22/2016 ( ��1
Local laws apply.CNecr with your local regulatory agency for recertification revuiremettla.
ON10 National Resawitrn Association Educational Foundation.All rights reserved. aoaes
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