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Town of South Windsor - Health Department
RECEIVED
Y 1540 Sullivan Ave., South Windsor, CT 06074-Mailing Address
• 1530 Sullivan Avenue, South Windsor, CT 06074-Office Address 2016
i Phone Number: (860) 337-6173 Fax: (860) 644-1930
oR.co VL SOUTH WINDSOP,
Restaurant Establishment Information New Permit❑ Permiltik&Aa U,
***(Please Print Clearly)***
Name of Establishment: 6-
Manager's Name: C « 7q T
Strcct Address: eG,S� j C l-L ( Ll/I AJ /fV, p C//4-
City, state, Zip Code: S0uT N t1llU L Sv+2 C_( 7y
Phone#: ,'�66 - 6' 36o7 ! Cell Phone#:
Fax# C!
E-Mail Address_ , ,� ��(����!_S$�S'�Ji.0�1t1 Seating Capacity:
Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office.
YES Y NO ❑ (Required for ' Certificate#:
Qualified Food Operator: I Class 3&4) LWb 7 x J
--- Name: Date: 1 j �1 zC' `/G-
i Testing Organization: Str�� 5 � Phone#: )-L��_� ,07 .I
E-Mail Address: Alternate Phone#:
N A7��1�,� t4.,t AU- Designated Alternate2
Designated Alterno;e 1:
Restallarant�dv &e b niicf Information
Owner's Name: 01 Jy ki /L 5 R'►.�
Street Address: ,LI C hV_ _� eft �fs'7
City, State, Zip Code: 1 M ) _W( O DS OR-/ C (
Phone#: �C ' 3_ ��(7 (� Fax #: F66 --/I
E-Mail Address: /�?1 L 5 5o n; e 5 c,S; C-d N/ Cell Phone#:
Renovations
Were there any renovations made last year? YES❑ NO [/ Will there be any renovations? YES❑ NO ❑
Tf YPc please list all renovations
I that were done/to be done:
I �
I
Mailing Address to send Food License Renewal Permit to:
Name of Restaurant/Company: PL' /Kcz� C
tir I
Attention: �0 13 L.�ti C.N A P—L I- --- - --- - - - ---
Address: f 1 1�` 13 P-1 p(,L- - ST7-
City, State, Zip Code:
Phone#:
Town of South Windsor — Health Department
o r 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
DSOR•(O
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.
FLU �3 (Z r=f Sty 2 A A-=)w (C H
Ho 7- Sc)v �
Additional Information
Please check one only:
State Licenses: ❑ Bakery dL!quor 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):
i
5
Applicant Signature: - Date:
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: 1 ❑ 2 ❑ 3 ❑ 4 ❑ Expiration Date:
Date Received: Date Approved: