HomeMy WebLinkAboutApplication 400 Evergreen Way °w" '`.q< 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 i Phone Number: (860) 337-6173 Fax: (860) 644-1930
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Restaurant Establishment Information New Permit❑ Permit Renewal ❑
***(Please Print Clearly)***
Name of Establishment: SToN l; W/-\" 1LITU4EP\I
Manager's Name: I �Q 1� Pl✓ � `
StrnnF Address• _-{�-� Y F—� (�1- -v`-" ` - `�k \; v�JAI l..-I-fll.I lA I.JJ• 1 v
City, State, Zip Code: �0 U VU I ��, T e:q,
Phone#: 1?1&)D (D 4Q) q a4 1 Cell Phone#:
Fax#: Li
j E-Mail Address: LLI K�SvU(1A WJN SSeating Capacl
Please submit latest copy of the�-):jafified Food Operator/ServSafe certificates to the office.
Qualified Food Operator: YESX NO ❑ (nequire'for Certificate#:
Class 3&4)
Name: A Ip/'�l p- �E,Q�IJ1-� ( Date: J-• 1-7
Testing Organization: St�\( Z�Sxrir Phone#: Ste) &4<-
E-Mail Address: Alternate Phone#:
,<< ;-,(- J, w KIT( f�0t 1-< <,, c
Designated Alternate 1: ANN L-(A(�IE � r } 117 , _C-)
Restaurant Owner Contact Information
Owner's Name: ST-6Vj uoA u._ V--1jC,E-YJ
Street Address:
City, State, Zip Code: yowl �(E.
Phone#: 35( ��11 Fax #: I -:�v7 -3S1- ItS
E-Mail Address: Cell Phone#: /Dr
Renovations
Were there any renovations made last year? YES❑ NO Will there be any renovations? YES ❑ NO tx
If Yes, please list all renovations l
that were done/to be done:
I
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Mailing Address to send Food License Renewal Permit to:
Name of Restaurant/Company: STU�E��Ik� ,IT�Ike,
Attention: �:)),k
Address: r C0 I✓Y �C-\_,W Sty lTL-, '+L g
City, State, Zip Code: SOL)TV - W I N�j(�, C k
Phone#: U
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a Town of South Windsor — Health Department
+- 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address
s A 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address
Phone Number: (860) 337-6173 Fax: (860) 644-1930
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Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES❑ NO X 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
Additional Information
Please check one only:
State Licenses: ❑ Bakery ❑ Liquor Permit None
Water Supply: - Public — Private Well
Wastewater Disposal: r� 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.
Applicant Name (Print): Apt,,lV--
Applicant Signature: Lt d Q�L P—�(L� _ Date: 9,- 17
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: 1 ❑ 2 ❑ 3 W 4 ❑ Expiration Date:
Date Received: Date Approved:
Town of South Windsor — Health Department
1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
1530 Sullivan Ave., South Windsor, CT 06074—Office Address
Phone Number: (860) 337-6173, Fax Number: (860) 644-1930
1 understand that the South Windsor Health Department is now conducting routine inspections
electronically. I elect to receive my inspection report by:
Email 0P_ Fax U USPS Mail
S W)(_�QLTF4 VkI L t,�DI�Q 12— & S I U NCWAU—V,L'TCAEN' Co f 4
Email Address (if applicable)
�(40 (�'48 q 10
Fax # (if applicable)
Address
Establishment
Manager/QFO Signature
AC\co f- F i a (f o n ti
Manager/QFO Printed
a- r
Date