HomeMy WebLinkAboutApplication 1735 Ellington Road (2) Town of South Windsor - Health Department
1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address
• 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address
s Phone Number: (860) 337-6173 Fax: (860) 644-1930
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Restaurant Establishment Information New Permit❑ Permit Renewal ❑
4 ***(Please Print Clearly)***
Name of Establishment:
Manager's Name: i Yue Jim C(X (
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City, State, Zip Code: T U' c' f
Phone#: Cell Phone#: 0) - f! --3
Fax#: I
j E-Mail Address: t/ p� oZ1p�.it,c,,rh Seating Capacity: j
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Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office.
r
ualified Food operator: YES No p (Rogulrod fey Certificate#: �
p I Class 3&4) i
_ - -- --- Name: I LI t1 Date:
Testing Organization: Phone#:
E-Mail Address: Alternate Phone#:
Designated Alternate 1: Designated Altemate2
Restaurant Owner Contact Information
Owner's Name: Li
Street Address: t L ,�
City, State, Zip Code: 7rh�iy�,r- j 0602
Phone#: Fax #:
E-Mail Address: _ Lrti i( r��b��'�' C �� Cell Phone#: �86 -,S1`1
Renovations
Were there any renovations made last year? YES❑ NO [ - Will there be any renovations? YES ❑ NO jj
If Yes, please list all renovations
that were done/to be done:
RECEIVED
JAN_.0 6 2D17
Mailing Address to send Food License Renewal Permit to: SOUTH WINDSOR
HEALTH DEPT.
Name of Restaurant/Company: I r :U 5�� �S e (des
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Attention:
—— - Address:
City, State Zip Code: C c
-- Phone#: 6L�q — / -' �
Town of South Windsor - Health Department
c 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address
s 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address
Al Phone Number: (860) 337-6173 Fax: (860) 644-1930
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Restaurant Menu/List of All Items Served/Sold
Lates �enu ttached? YES ElNO ❑ NOTE''(Must have latest copy on file)
Please list a 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: � Pulplic Private Well
Wastewater Disposal: J Public On-Site Other(please use space below to explain)
Agreement and Signature
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.
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Applicant Name (Print): c'��� Z—
Applicant Signature: Date: O ( D L L
Office Use Only
Inspector Name (Print): �/��i��/ L L l— &--U
Inspector Signature: Date:
Food Class: 1 ❑ 3 ❑ 4 Expiration Date:
Date Received: m Date Approved: / —
ertified rofessi(, nal (79Tood anaer
designation has 6een conferred upon
TONY SHAO MING LIU
who has met aCCthe professionaCrequirements for certification.
Exam 1403 Recognized By Conference For Food Protection
Certificate No: 1275825
Exam Date: 02/24/04
Doq as F. Campbell. CFSP Test Code: 62033014.03
Certificate expires no later than: 02/24/09