HomeMy WebLinkAboutApplication 1750 Ellington Road Town of South Windsor — Health Department
,. 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address
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. 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address
s Phone Number: (860) 337-6173 Fax: (860) 644-1930
SO R•COS
Restaurant Establishment Information New Permit❑ Permit Renewal )
***(Please Print Clearly)***
Name of Establishment: 00c.hh f �f ! ��rA, p� reX,p-f
Manager's ,Name: Qary it/
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J ll• l/-1 .11�.SS. // 5V �I/I� I _06 -I IP
City, State, Zip Code: S � W�h�, G-e, 0407y-
Phone#: j &p p_ /a,? Cell Phone#:
Fax#:-!---&D - -9-- --� .
E-Mail Address: Seatin Capacity:
Please submit latest copy of the Qualified Food Ope /ServSafe certificates to the office.
Qualified Food Operator: I YES NO ❑ (C�a s'3&fo Certificate't: /yO�6 y0
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Name: ,(�Q/ti ��G� Date:
Testing Organization: S v Xa r, Phonell: -X f-0-
E-Mail Address: Alternate Phone#: Ad .
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Designated Alternate 1: / Designated Alternate2
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Restaurant Owner Contact Information
Owner's Name:
Street Address:
City, State, Zip Code: -
Phone#. aG�` e,�_T(- 1,?,70 Fax #: fW �f�d :l02
E-Mail Address: ,Nfevrlowd, Cell Phone#: ko lqp_$fft
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Renovations
Were there any renovations made last year? YES❑ NO N Will there be any renovations? YES ❑ NO Mr
If Yes, please list all renovations
that were done/to be done: RECEIVED
DEC 0 2016
SOUTH WINDSOR
HEALTH DEPT.
Mailing Address to send Food License Renewal Permit to:
Name of Restaurant/Company: ; ��A&,Yr G T7X0 7;VSrC5 d f
Attention:
Address: 7SD / 'l�//t4
City, State, Zip Code. ! p 4 1n ,a h (�
S Js � 7 y
Phone#: : 40 ` 6/C►d� �9D0
� Q 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
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Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES K 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.
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Additional Information
Please check one only:
State Licenses: ❑ Bakery ❑ Liquor Permit ® None
Water Supply: _G Public _Private Well
Wastewater Disposal: )0- 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):
h e
Applicant Signature: Date: 40
Office Use Only
Inspector Name (Print):
Inspae ure: Date,
11
Foo lass: 1 ❑ 2 [f3 ❑ 4 Expiration Date:
Date Received: Date Approved:
ServSafe
ciatton
's
ervSafe
CERTIFICATION
DANIEL BELL
-ffvwrg#w spa J,I,sr 6Ah 6or i6 Swvsai6•rood PhA"on Manage.Cerr(Iomon E,=viwm iorr,
which a amedied by dre lllrre—Nalioral Slardords InAiule For Food Plate m(UP).
�}U864U4 10494
E NUmBE:R EXAM FORM NUMBER
9/6/2 6 9/6/2021
DATE OF OF EXAMINATION DATE OF EXPIRATION
Local I a�Cl. e&Mdh yaw"rcg.kdory ctu—y E«rKNi c.A1 requeaerdL
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- �Noeiand Res7o�»r Aisocirlion Sokliona
V..d..d►1r.=--td—La zoa,km" .AM H oOM0%%,Wm spa u,'� �
�e01i1 ��• 'r..+.oi�o.C�rtij�I.�rw..�3S..Sddeadl.5...�d,�4,�.:.�..n��.�.�unr: [=J
Certificate# 1408"05
5erv" Issued 9/6/2016
CERTI� �
Name: RONALD BROOKS
Expires 9/6/2to
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