HomeMy WebLinkAboutApplication 869 Sullivan Avenue 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
y Phone Number: (860)337-6173 Fax: (860) 644-1930
4- 4
Restaurant Establishment Information New Permit❑ Permit Renewal
***(Please Print Clearly)*** // `
Name of Establishment: �- ov o L1SC
Manager's Name: J `i JCL _ L}U`
JAI 1.,..1
City, State, Zip Code: V` �/�/ lT►
Phone#: 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: 1 YES NO EliRequired Class s&for Certificate,#: 7 3U
Name: ►v i I (:xtV,
Date: j t��1
Testing Organization: N I T - Phone#: G - Z
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' Alternate Phone#:
E-Mail Address:
Designated Alternate 1: l 1 P�h LiA Designated Alternate2
Restaurant Owner Contact Information
- Owner's Name: -q Lk&P
Street Address: q s u il/a.�� .� ✓�_. _ _ __
City, State, Zip Code: i..)���`' r _-
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Phone#. �5v& o 6 7cj Fax #:
E-Mail Address: Cell Phone#-
Renovations
Were there any renovations made last yt:Iu Yes❑ NO. Will there be any renovations? YES❑ NO
If Yes, please list all renovations
that were done/to be done:
RECEIVED
JAN 17 Z017
Mailing Address to send Food License Renewal Permit to: SOUTH WINDSOR
HEALTH DEPT.-
Name of Restaurant/Company:
Attention: --
Address: I �--4-t! -
City, State, Zip Code: , U�,f�t �/ �Y�d!v-z-, 6 Q
Phone#: 1
Q Town of South Windsor - Health Department
o 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address
s 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address
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Phone Number: (860) 337-6173 Fax: (860) 644-1930
Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES [ I 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: Public _ Private Well
Wastewater Disposal: JZPublic 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): ,
Applicant Signature: Y AA
Date: ( -
Office Use Only / - V C;9 L,VVAI)
Inspector Name (Print): �J
Inspector Si Date:
Food Class: 2 ❑ 3 ❑ 4 Expiration Date:
Date Received: Date Approved:
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Congratulationsl You have passed the National Prometric
Cerdfled Professional Food Manager examination. Score Report
Your name has been added to the National database
of Food Managers.
Congratulations! You passed the Certified
Professional Food Manager examination.
Your Score is as follows:
Score Status Exam Date
78 09125=13
PASS
MING GUANG OU
40 BENJAMIN WAY iL
SOUTH WINDSOR,CT 06074 }} `
7941 Corporate Drive
Nottingham.MD 21236 800.624.2736