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HomeMy WebLinkAboutApplication 496 Rye Street Apr. 04 . 2017 09 : 09 PM Point Leasing 8606447973 PAGE. 1/ 2 Town of South Windsor — Health Department o Y 1540 Sullivan Ave., South Windsor, CT 06074 — Mailing Address �^ 1630 Sullivan Avenue, South Windsor, CT 06074— Office Address Phone Number: (060) 337-6173 Pax. (860)644.1930 ��/1tiuR•CPv Restaurant Establishment Information New Permit p Permit Renewal ❑ ***(Please Print Clearly)*** Name of Establishment: ��' G� �t/ Manager's Name: G� /a�2A4 Street Address: ' City, State,Zip Code; J"W' 61�1 j 7 Phone#: Cell Phone#; Pax#: E-Mail Address: �j',�j�u- '� G� Seating Capacity: Please submit latest copy of the Qualified Food Operator/Servsafe certificates to the office_ Qualified Food Operator: YES❑ NO © (Required for Certificate#: Class 3&4) Name: Date: Testing Organization: Phone#; E-Mall Address: Alternate Phone#; Designated Alternate I: Designated AlternateZ Restaurant Owner Contact Information Owner's Name: /Pr/lt'ole �, -41 Street Address: City, State, Zip Code; Phone#: Fax #: E-Mall Address: Cell Phone#: Renovations Were there any renovations made last year? YES C]�b lJ Will there be any renovations? YES Ito U 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: RECEIVED City, State, Zip Code: Phone#: , 0 - 2017 SWTH VNJOSOR WEALTH CEPT_ Apr. 04 .2017 09 : 09 PM Point Leasing 8606447973 PAGE. 2/ 2 se" Town of South Windsor — Health Department o 1640 Sullivan Ave., South Windsor, CT 06074— Mailing Address 1630 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❑ NO1P 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 1s applicable. Additional Information Please check one only: State Licenses: p Bakery 0 Liquor Permit None Water Supply: Public —Private Well Wastewater Disposal: )a-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): Applicant Signature: Date; Office Use Only Inspector Name(Print): Inspector Signature: Date: Food Class: 1 0 20 3 0 4 ❑ Expiration Date. Date Received: Date Approved: