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HomeMy WebLinkAboutApplication 950 Sullivan Avenue <°W" +`,<� Town of South Windsor - Health Department r 1540 Sullivan Ave., South Windsor, CT OP074—Mailing Address 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address y Phone Number: (860) 337-6173 Fax: (860) 644-1930 SOR•co Restaurant Establishment Information New Permit❑ Permit Renewal �-f ***(Please Print Clearly)*** Name of Establishment: 21 oc,�1Z- Manager's Name: J Ca . , �_arcs: S }� ON �--- City, State, Zip Code: ��,I� o6o7c - Phone#: Jt10 U`+ 6 . $5 t Cell Phone#: tl Fax#: i E-Mail Address: 1 ' Seating Capacity: Please submit latest copy oft ual 0Food Operator/ServSafe certificates to the office. Qualified Food Operator: YES �O ❑ lR'a"l�'�+°r Certificate#: ; q 0 i -_ Class 3&4) ' 1--- 3 1 6_ i Name C Date: Testing Organization: Phone#: E-Mail Address: Alternate Phone#: Designated Alternate 1: /L- , �yv� Designated Alternate2 Restaurant Owner Contact Information Owner's Name: eA_ Street Address: City, State, Zip Code: Phone#: � Fax #: ; E-Mail Address: , Cell Phone#: Renovations ` Were there any renovations made last year?YES❑ NO Will there be any renovations? YES❑ NO �( Tf Vas. please list all renovations /� 1 that were done/to be done: RECEIVED ij JAN 19 2017 -SOUTH-WINDSOR 1 HEALTH DEPT. Mailing Address to send Food License Renewal Permit to: Name of Restaurant/Company: Attention: Address: --- City, State, Zip Code: Phone#: � ,(, Town of South Windsor - Health Department o 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address s 1530 Sullivan Avenue, Sou#h Windsor, CT 06074—Office Address Phone Number: (860) 337-6173 Fax: (860) 644-1930 UJOR 0' Restaurant Menu/List of All Items Se,-ved/Sold Latest Menu Attached? YES�O ❑ 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. i I Additional Information Please check one only: State Licenses: ❑ B kery ❑ Liquor Permit None Water Supply: Public _ Private Well Wastewater Disposal: Public On-Site Other(please,use space below to explain) i 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. I Applicant Name (Print): , L, ( � Applicant Signature: qZAZ7AjL(f — Date: 1 Office Use Only Inspector Name (Print): i �� LeLLL� Inspector gna e: Date: G 7/ Food ss: 1 ❑ 2 3 ❑ 4 ® Expiration Date: Date Received: I b 9 y Date Approved: j EXAM FORM NO. 4895 ServSafe � . . CERTIFICATE N0. 10483906 National Restaurant Association Sery fe , CERTIFICATION To MING FENG CHEN for successfully completing the standards set forth for the ServSafe"Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute(ANSI)-Conference for Food Protection(CFP). 10/30/2013 DATE OF EXAMINATION 10/3 0/2 018 DATE OF EXPIRATION Local laws apply.CL,:ck with your local regulatory agency for recertification requirements. _.00 Paul Hineman ® Executive Vice President,National Restaurnt Association #0655 ©2012 National Restau aqt A>sociplion EtlueaUunal FaunQpliany(N,RAJrf'),AU tli4ht{J?aafvuJ.$a vsafe is a ;,,•v:of the NRAEF,used under license by National Restaurant Association Solutions,LLC. The logo " to5 5 a ti