HomeMy WebLinkAbout2017-3-30 - 1739 Ellington Road - Food Permit Application Stop and Shop 08/30/2013 08:28 FAX ant 01 001
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Town of South Windsor _ Health ueparimL
1640 Sullivan Ave., South Windsor, CT 06074— Mailing Address
'y 1630 Sullivan Avenue, South Windsor, CT 06074—Office Address
Phone Number: (860) 337-6173 Fax: (860) 644-1930
Restaurant Establishment Information New Permit❑ Permit Renewal ❑
***(Please Print Clearly)***
Name of Establishment; S -�o() '_-i Sr L�O
Manager's Name: j�'C\J V1e- V-\ `� tom"
Street Address: i 1i1C �Uv) C�
City, State, Zip Code; f 1 W� S()Vr , C U UO Ll
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Phone#: c�(�j L-juZLp Cell Phone#:
Fax#: �E_(pC-7 1p�L, ^ '--J.Lb6
E-Mail Address: 5\_rt �,n, Yj���.1�r Q Ci 1c-,�S Cating Capacity:
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Please submit latest copy of the Qualified Food operator/ServSafe certificates to the office_
YES N� NO ❑ (Required for Certificate#: 'Z-( 1 V(o Z,U t4
Qualified Food Operator; Class 3&4)
Name: ' rn�Sc.h���z cr�hvY- Date: ( -
n � Phone#: Q(p p-
Testing Organization: ��. zc�, �RtQ 5� '�'
E-Mail Address: Apno a.5k � t L !� �v1�� k-Dn Alternate Phone4l: ` 14,0
(cl Designated Alternate 1: c`1n d4,c,cn-mesignated Alternate2 M eAc
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Restaurant Owner Contact Information
Owner's Name:
Street Address:
City, State, Zip Code:
Phone#: Fax #:
E-Mail Address: Cell Phone#:
Renovations
JO
Were there any renovations made last year? YES El NO
Will there be any renovations? YES NO
If Yes, please list all renovations
that were done/to be done: RECEIVED
MAR 3 0 2017
SOUTH WINDSOR
Mailing Address to send Food License Renewal Permit to:
HEALTH DEPT.
Name of Restaurant/Company: jh
Attention:
Address; �''� .�1 `�1`t I�1C' �+-��'1
City, State, Zip Code: J�� t �� �)� •Sum' C� � ���
Phone#; �vUL-
08/30/2013 08:28 FAX Z 002
Town of South Windsor — heaitn ueparu11Cl��
1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
1630 Sullivan Avenue, South Windsor, CT 06074— Office Address
r 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 _�( NOTF"(Must have latest copy on file)
of a menu attached is applicable.
Please li all m u It s in as much detail as possible or a copy
Additional information
Please check one only:
State Licenses: p Bakery ❑ Liquor Permit
i. None
Water Supply: x Public _ Private Well
Wastewater Disposal: ,K.Public On-Site
Other (please use space below to explain)
Agreement and Signature complete, I
By submitting this application, I affirm that the facts set forthiit are
true and
ate shutdown adr that any evocation my Food
statements or other misrepresentations made on this applicationY result in
Service License for the Town of South Windsor. _
Applicant Name(Print): `�`�5�,-- ��,,�ck�
Applicant Signature: ` — Ali Date; 3
Office Use Only - --
Inspector Name (Print):"�/ _ 1r �`"��C L �
1 � I Date:
Inspector Signature. 2 /33 �
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-- Expirat on Date:
Food Class: 1 2 Zr - -
-- Date Approved:�
Date Received:
08/30/2013 08:28 FAX [in003
p4 g00Dsq�, NATIONAL REGISTRY OF
FOOD SAFETY PROFESSIONALS®
� CERTIFIES
Q
DONNA M scHULTZr BOYING'T"ON
HAS SUCCESSFUL I Y SA'TISFIED'rHE REQUIREMENTS FOR THE
CERTIFIED FOOD SAFETY MANAGER
R
UNDER THE
CONFERENCE FOR FOOD PROTECTION STANDARDS
PRZSID9N'ri
LAWRENCE J.LYNCH,CAE
ISSUE DATE:JANUARY 27, 2016
EXPIRATION DATE: JANUARY 27, 2021
�olrsr CERTIFICATE NO: 21 186204
TEST FORM: EZS30
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