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HomeMy WebLinkAboutApplication 952 Sullivan Avenue �<o,,N Sf•<� 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 /. : December 7, 2016 Dear Food Service Operator, In an effort to update our records on a routine basis and fulfill the statutory requirement to permit any place where food or beverages are served to the public, the South Windsor Health Department is instituting an annual food service registration and permit. There is no fee associated with the permit at this time. To complete your application: 1. Please complete the enclosed application and submit to the Health Department with a copy of your menu and QFO certificate (Class 3 and 4 only). Your registration will be considered incomplete without all three of these items. You can mail, fax, hand deliver, or scan and email (diane.collelonsouthwindsor.ort;) the required documents by 1,—2017. D1k /d nC 2. You can also visit www. outhwindsor.or,/fsre ,,istration to complete your registration by , 2017. You will need an electronic copy of your menu and QFO certificate (Class 3 and 4 only) to upload as part of the registration. Your registration will be considered incomplete without these items. Please contact the Health Department at (960) 337-6173 if you have any questions about this process. Thank you, in advance, for quickly completing your registration for 2017. If you have any management or QFO changes throughout the calendar year, the contact information can be updated using the same registration form or link. Sincerely, 4WUA 0 n Heather Oatis, REHS, HHS Environmental Health Officer °*" sf4< 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 I�jAUR•i��� Restaurant Establishment Information New Permit[,Permit Renewal ❑ ***(Please Print Clearly)*** Name of Establishment: 14/6X II a' j P Z� Manager's Name: �Lbb' /10> „f-f-{ Street Address: 9 A V{ City, State, Zip Code: �� �,� (S,� C'�- 0 60 7 t i Phone#: 6o — 6,i F --/SS3 Cell Phone#: Fax#: E-Mail Address: qt Q 's 6 C aki h c+- Seating Capacity: Ll0 Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office. Qualified Food Operator: YES 0' NO ❑ (Required ss 3 Certificate#: Ga 23 9 Name: �o �6� `yl��},i , Date: q Y/� oo.0 Testing Organization: �'C f�/SF Phone#: 2_193 -- 4.)02 E-Mail Address: � � � �t, (��,�,.� h�( Alternate Phone#: c?4 3 c.J Designated Alternate 1: b Designated Alternate2 Restaurant Owner Contact Information Owner's Name: SC) r `✓l0,J•j-tk 5 Street Address: 4,1 /4"1 1 fy 9� City, State, Zip Code: 00" Phone#: �G� _ �,� $�l)� Fax #: E-Mail Address: Cell Phone#: Renovations Were there any renovations made last year? YES❑ NO pa' 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: RECEIVED Name of Restaurant/Company: A- � r z MAR 0 2 2017 Attention: 6 Address: a �I,' � :�{- SOUTH VVINDSOR City, State, Zip Code: C ,�� w�;� (lvr Ce 06a ].-( HEALTH DEPT. Phone#: 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 Restaurant Menu/List of All Items Served/Sold Latest Menu Attached? YES R'NO ❑ 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: R�Xftkery [Liquor Permit None Water Supply: P/Public Private Well Wastewater Disposal: r--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): O l / � ���0✓�� Applicant Signature: p�J "` Date: Office Use Only Inspector Name (Print): L Inspector Sign at Date: Food Class: 1 ❑ 2 ❑ 3 ❑ 4 bQ Expiration Date: Date Received: 2- �� Date Approved: 3 �E_ / ~1e EXAM FORM NO. 4377 CERTIFICATE NO. 6083396 0 ServSafe tr, BOBBY MOUTTA for successfully completing the standards set forth by the National Restaurant Association Educational Foundation for the ServSafe®Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute (ANSI)—Conference for Food Protection (CFP). 9/8/2008 DATE OF EXAMINATION 9/8/2013 : DATE OF EXPIRATION Local laws apply.Check with your local regulatory agency for recertification requirements. G mencan mna andardte e Confere .. ® ,/ #0655 //41/ NATIONAL RESTAURANT National Restaurant Association A Mary M.Adolf ASSOCIATION 7 President&COO, Products and Services Division EDUCATIONAL FOUNDATION National Restaurant Association Solutions S 0 L U T 1 0 N S TM ©2008 National Restaurant Association Educational Foundation.All rights reserved.ServSafe•and the ServSafe logo are registered trademarks of the National Restaurant Association Educational Foundation, mrsam, _ : ga Fi Tp%7�Tqr; . � r