The URL can be used to link to this page

Home My WebLink About301 Evergreen Way (2) SOWN SF"< Town of South Windsor — Health Department o r 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 `tI�OSOR•COc� Restaurant Establishment Information New Permit❑ Permit Renewal ***(Please Print Clearly)*** Name of Establishment: - -_ Manager's Name: Street Address: City,State,Zip Code: Phone#: �'(�Uy Cell Phone# i _ - T Fax#: - E-Mail Address: C#ea ceCapacity Please submit latest copy of the Qualified Food Operator/ServSafecertificates to the office. Qualified Food Operator: YES❑ No ❑ (Required for Certificate#: - class 3&4� Name: Date: Testing Organization Phone#: - --- - --- - _--- ----- ---- _— E-Mail Address: i Alternate Phone#: Designated Alternate 1 Designated Altemate2 Restaurant Owner Contact Information Owner's Name: ^ - Street Address: - City, State,Zip- �� d6�� ---_Code: c r Phone#: Fax#: E-Mail Address: ��- _ i�ex-�LN/1 , Cell Phone#_- Renovations Were there any renovations made last year? YES❑ NO j Will there be any renovations? YES❑ NO r'O LN- - If Yes, please list all renovations that were done/to be done: I a Mailing Address to send Food License Renewal Permit to: Name of Restaurant/Company: . Attention: f; �, ' z Address City,State, Zip Code: C Phone#: + — - Restaurant Menu/List of All Items Served/Sold Latest Menu Attached? YES l 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: ❑ Bakery ❑ Liquor Permit None Water Supply: ,Y/ 4 Public _Private Well Wastewater Disposal: ublic 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: ff l l k,r (J►-G I'C S, Date: 11 Office Use Only Inspector Name (Print): Inspector Signature: Date: Food Class: 1 ❑ 2 ❑ 3 ❑ 4 ❑ Expiration Date: Date Received: Date Approved: °WN Sf 4Q 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 ��SOR•C'� PERMIT / PLAN REVIEW FEE SCHEDULE October 17, 2017 Annual Food Service Establishment Permit: Class 1 $75.00 Class 2 $125.00 Class 3 (1 -25 seats) $200.00 Class 3 (26-49 seats) $225.00 Class 3 (50+ seats) $250.00 Class 4 $275.00 *Seasonal Food Service Establishment Permit (open less than 6 months annually) will be 50% of the annual class fee. *Non-profit organizations exempt Catering Permit: $200.00 Temporary Event/Farmer's Market: $50.00 *Non-profit organizations exempt* Itinerant Permit: $100.00 Food Service Plan Review: $150.00 Reinspection Fee: $100.00 .N £N S �° 44 Town of South Windsor — Health Department c 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 REVISED CLASSIFICATION OF CONNECTICUT RETAIL FOOD ESTABLISHMENTS CURRENT CLASSIFICATIONS UNDER 19-13-842 NEW CLASSIFICATIONS UNDER PA17-93 CLASS 1: CLASS 1: • Commercially prepackaged food • Prepackaged food that is not TCS • Hot and cold beverages • Commercially prepackaged,processed • Hot holding of commercially pre-cooked (fully cooked)food that is TCS and either PHFs that are heated and served in the cold-held or heated for hot holding,but original package within 4 hours not cooled * No preparation or cooking • Preparation of non-TCS foods CLASS 2: CLASS 2: • Preparation of cold or RTE commercially • Preparation of limited menu TCS food that processed food that does not require is served immediately,cold-held or hot- heat treatment held for an unspecified length of time • Hot and cold beverages • No cooling of TCS foods allowed • Hot holding of commercially pre-cooked • Does not include facilities that provide PHFs that are heated and served in the foodservice specifically to a highly- original package within 4 hours susceptible population • Reheat and hot holding of commercially CLASS 3: precooked hot dogs,kielbasa,and soup • Preparation of an extensive menu of TCS taken directly from the package and served within 4 hours food involving complex processes including cooking,cooling,reheating for hot-holding, and handling of raw ingredients CLASS 3: Does not include facilities that provide • Preparation,cooking,hot/cold holding of foodservice specifically to a highly- PHF that are consumed within 4 hours of susceptible population preparation CLASS 4: • On-site preparations of foods by special CLASS 4: processes,such as sous vide,acidification, • Preparation,cooking,hot holding greater ROP,etc. than 4 hours after preparation and prior • Preparation of an extensive menu of TCS to consumption,and cooling of PHF food involving complex processes including cooking,cooling,reheating for hot-holding, and handling of raw ingredients that is served in an establishment which serves a highly-susceptible population L ,T. ' tCQ LQ/Ak leneMrtl Ornwla �� Swath tLts d/>JSIa r •4 _ tap.sil•rlSl••y/ ,, r ++�`+•wIrKIM thaw S.M tlrM 1 Caotka Ittl•a��ft :�. twrr avwrl•av rnwr ta.aarr,o.et �� /W a/HM111• ' eyed hrtt W 44 yy .. (�•� ... H•QHN d trdM" s'i UM iu Wit AWa/WN[►0 ..�I'1�II��,.�=7 " - - 1 W W IWM k tr.rn Wn]a rrwL Heala'/p tnec, •� lTa+�� Hen1AW4 GH01b a.• - tlnralaG ri3alal7Wdf ��i � 1v1 �� •SwaH fT.)S :atlS7tl '.�". ': rr lv.. OaMab FRui.Ao+rlr ul]Ek Ft SR;J Y6 '' tloiWar Nr{al(AaQ qMN '•�,,,,,,..�'r��TT C.`}n�(f��Sc tanr 12J1 :r h:%q 1 �l�'(y.✓''.• /• taru{ee hww Haww/SMrI Mrw harts/.]ed 11��1,S�C}..�� Sbar4ercf(nNaadr ` �• ',eH`�� trs,Nab 11dal1 4rr•rrrl YaaBa Gnaw _ �. •,,,w � y Sxn s..rrWwea,dh • �` vww tetra, enlwRm r./r.a.ae t .,»^ e,..Nm aut tartM Srm ladr M .. � �`�. Water t Man � ..rija.3.rra tMltr �" 1`lewranaY CYM G+ ttAr.,w,.r•m7/ctro ewn e.m tao-aww..n \ � ' CONii MASN tiP tw ieq,swt tr.oaaer u..e � J N'lW i.aw s..a.. 4 �" •W 371l7 wl l•F7ao '�"•sa.wra.t W aT.73 :.S:s]^s •u+wwwrarit we. MO L4Ntn ..I $/t iiif rI HD.]f. tLiS ri 111 iri MW N+�Ie Wae/a :, Q Hn.er lad l*.. •�•;, OptwaIR INLL 1L/S ui 1f.311f0 lane aL7f rd 1t1771 �. Gr11r 4rFY LaW = �,' , .4.WY•a tnaa.t /Y s..d hMa that SPitta4 BATik `� pp L]3•u 13/ �',,' _ '�' 7l.lS s.tsestt37 V ,i ....hwWueYn.WalN 4aa•i17S•r/T7• ►at9 Faoa •gOHiltpawDDY ODYrA [LHDAY fir:ccrl. '� 4uu Srw . s.. tMNrk••4Hr1 S+far tear.li7]•�11i fd�nl' l"„e"w....�::_" a` M'! 7LT3 11 Jt33ille � HePP7'Y1 ite,nt- i lNa/n.ramw _ --�,�� Togo Items Include but not limited to: Pre-packaged ice cream items, bottled drinks and watering Assorted • but • limited to the items below. tm- j1 pit l al IL 4