HomeMy WebLinkAboutApplication 180 Sullivan Aveneu 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
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Restaurant Establishment Information New Permit❑ Permit Renewal ❑
***(Please Print Clearly)***
Name of Establishment: 4L— a N
Manager's Name:
Street Address: j OU S (-/GL I(/47,)
City, State, Zip Code: sooty 6-1111,_636Z
�+ Phone#: 9 e) �5b /1 �-4 Cell Phone#:
Fax#: 06L, — jt'1— r js q I
E-Mail Address: Lf-/j/�j 4� q� C > .N 'j—Seating Capacity:
Please submit lat copy of the Qualified Food Operator/ServSafe certificates to the office.
Qualified Food Operator. YES NO El (Required 3 f4o)r Certificate#:
_
Name: Date:
Testing Organization: Phone#:
E-Mail Address: Alternate Ili =i:
Designated Alternate 1: Designated Alternate2
Restaurant Owner Contact Information Owner's Name: W rl� )4pv ��/�
Street Address: J B'%'_ cl-6 00017— L/\-)
City, State, Zip Code: "► / tA_)/`PY)Sb>� �� �a 9
Phone#: Fax #:
E-Mail Address: Cell Phone#:
Renovations
Were there any renovations made last year? YES❑ NO 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: OU
Address:
City, State, Zip Code: RECEIVED
Phone#:
1 > 2017
SOUTH WINDSOR
HEALTH DEPT.
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
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Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES❑ NOAZ::� 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 0-,None
Water Supply: -,,/Public _ Private Well
Wastewater Disposal: _\_Z 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): C , /�
Applicant Signature:
Office Use Only
Inspector Name (Print):
Inspector Sign Date:
Food Class: 1 2 ❑ 3 ❑ 4 Expiratio Date:
Date Received: /. Date Approved: