HomeMy WebLinkAboutApplication 1989 Ellington Road Town of South Windsor — Health Department
J 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address RECEIVED
\ 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address
Phone Number: (860) 337-6173 Fax: (860) 644-1930 DES 2 2- 2016
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Restaurant Establishment Information New Permit ElPerm4 WEND R
***(Please Print Clearly)***
Name of Establishment:
Manager's Name:
City, State, Zip Code: : 4 r�- C T D 71-
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— - -- _- Phone#: 71,?-7 Cell Phone#:
Fax#: 467a - Gf 3(v.. _y 8'-f(0 -
- - -- V E-Mail Address: _ Seating Capacity: 300
Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office.
j Qualified Food Operator: YEsJ NO ❑ (Required for Class 3&4) Certificate#:
Name: �' � ��; o-(-�� Date: I
Testing Organization_ Phone#: C,—
f E-Mail Address: I Alternate Phone#: I
L Designated Alternate 1: Designated Alternate2
Restaurant Owner Contact Information
Owner's Name: _1 ��'ln.Y�
Street Address: q f Rk
City, State, Zip Code: ,��{ w i ,�ef.S ov- G! D&, o r Y
Phone#: Fax #:
E-Mail Address: Cell Phone#: �(�U q'f 73
Renovations
were there any renovations made last year? YES❑ NO,�T_ Will there be any renovations? YES❑ No t,-1
If Yes, please list all renovations
that were done/to be done:
Mailing Address to send Food License Renewal Permit to:
Name of Restaurant/Company: 41
- — - --- Attention: �`(�I � « , e ,f
- ----- - _ Address: '
City, State, Zip Code: o��( L� k ; E 1 ; y-� CT b &,
- Phone#: 8(,D — �2eq - 7` ,?-j
Town of South Windsor — Health Department
u 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address
1530 Sullivan Avenue, South Windsor, CT 06074—Office Address
�A� Phone Number: (860) 337-6173 Fax: (860) 644-1930
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Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YESVNO ❑ 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: ZPublic _ 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):
Applicant Signature: Date:
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
F`bc3d'Mass:_1 r`❑ 2 ❑ 3 ❑ 4 ❑
Expiration Date:
Date Received: Date Approved:
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