HomeMy WebLinkAboutApplication 125 Buckland Hills Drive Town of South Windsor — Health Department
1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
y 1530 Sullivan Avenue, South Windsor, CT 06074—office Address
Phone Number: (860) 337-6173 Fax: (860) 644-1930
Permit Renewal
Restaurant Establishment Information New Permit®` ❑
***(Please Print Clearly)***
Name of Establishment:
Manager's Name: i(tx
Street Address: � ?
City, State, Zip Code:
Phone#: o-- 3')J-&0 Cell Phone#:
Fax#: (�-C - �,n - (_)JJ
E-Mail Address: "-Ab it 0,_ oo Seating Capacity: i
Please submit latest copy of the Qualified Food Opera tor/ServSafe certificates to the office.
YES 531"NO ❑ (Required for Certificate#: �'1 1
Qualified Food Operator. Class 3&4) .T
Name: C Date: C4
Testing Organization: N�l-s Phone#: )
E-Mail Address: ; z t,I tG V6rf i�z''� Alternate Phone#:
Designated Alternate 1: Designated Alternate?_
Restaurant owner Contact Information
Owner's Name: `.)U ('a !0,C
Street Address: t�
City, State, Zip Code: ��►�t�
Phone#: Fax #: )()�
E-Mail Address: I�`'�� r( (�(��_A (� Cell Phone#: �(J'�-
Renovations
Were there any renovations made last year? YES❑ NO M. Will there be any renovations? YES❑ NO
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:
Attention:
Address: ,� f .{CYl�n f'Y �! �� D( -
City, State, Zip Code: H(11) Y}Y j}e✓ L r,, ("(kA L
Phone#-.
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Town of South Windsor - Health Department
1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
1530 Sullivan Avenue, South Windsor, CT 06074—Office Address
Phone Number: (860) 337-6173 Fax: (860) 644-1930
Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES❑ No [v]'
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 dV'None
Water Supply: `Public _ Private Well
_Other(please use space below to explain)
Wastewater Disposal: U�Public _On-Site
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): SIX Y ll`%� 1 �
Applicant Signature: `� I'`j�t �,�i� = . Date: �_ i ,l �.� Ij ^
Office Use Only -
Inspector Name (Print): 62e, e.,L61Aj -
Inspector Signa �� Date:
Food Class: ❑ 2 El 4 ❑ Expiration Date:
Date Received /L?— Date Approved:
NATIONAL REGISTRY OF
n c FOOD SAFETY PROFESSIONALS(&
CERTIFIES;`.
" SHAKIRA R HALL
HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE
FOOD SAFETY MANAGER
UNDER THE
CONFERENCE FOR FOOD PROTECTION STANDARDS
PRESIDENT:
LAWRENCE J.LYNCH,CAE
.- ISSUE DATE: SEPTEMBER 30,2015
5 W56 EXPIRATION DATE: SEPTEMBER 30,Y 2020
CERTIFICATE NO: 21152646
a�Blvd:;Sure 650�Ofl' 1tbF s 3
7a ,. �<. .�p�• TEST FORM:TZS03
8� t�fl7r 3J •(� f.ag%,. This certificate as not valid for more
�n4P< e bf1�00(�y SaiYFj���Ji.Y_, than live years from daleof issue.
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NATIONAL REGISTRY OF
FOOD SAFETY PROFESSIONALS®
CERTIFIES:'
DYLAN J JOHNSON
HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE
FOOD SAFETY MANAGER
UNDER THE
CONFERENCE FOR FOOD PROTECTION STANDARDS
y
PRESIDENT:
+ _ LAWRENCE J.LYNCH,CAE
ISSUE DATE:SEPTEMBER 28, 2016