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HomeMy WebLinkAbout2017-12-15 - 125 Buckland Hills Drive - Food Permit Application s0%4 ,< Town of South Windsor — Health Department r 1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address s . 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address N_ Phone Number: (860) 337-6173 Fax: (860) 644-1930 SOR ``1" Restaurant Establishment Information New Permit❑ Permit Renewal [� ***(Please Print Clearly)*** Name of Establishment: SI lv oui.lC Manager's Name: 5nCjr) j rct, kA C1 ` Street Address: J �_5 I, uc tiC lck. City, State, Zip Code: Phone#: K)-� 7 -LSD-- Cell Phone#: ?)'VI j Fax#: ) -v j�jrj E-Mail Address: C16(Ct.Ejcjl� , r jrTJ (ems Seating Capacity: 30 Please submit latest copy of the 0ua1i i..-c1; c,od O,,erator/ServSafe certificates to the office. Qualified Food Operator: YES[ENO ❑ (Required lass 3&4)r Certif•icate#: j I +," Name: ro KI ra- Date: 9'-30-, )15 Testing Organization: NRiP1S1 Phone#: jlcr)Q) E-Mail Address: 'zfrCkj-Ck W,jjQ—jCke j,A. (� Alternate Phone#: Designated Alternate 1: Designated Alternate2 Restaurant Owner Contact Information Owner's Name: IfiC)n pe-{ - Street Address: City, State, Zip Code: 1 Phone#: tj ..r��r7� J JI y Fax #: E-Mail Address: Cell Phone#: �13.. ' C.Cf Y'\ 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: RECEIVED DEC 15 2017 SOUTH WINDSOR Mailing Address to send Food License Renewal Permit to: HEALTH DEPT. Name of Restaurant/Company: 1 Attention: G� j j ►'C` f-i G �l Address: 1;A1J &C /C.ff J5 L) City, State, Zip Code: lYl CA Yl e 6 f e (�_ I , 6" ' Phone#: &06 -- 33 7- Grw'-,)- g00 r _•: 4.i; Y�'� i-'7... :tom•,.�'.!� ��'� •�s - NATIONAL REGISTRY OF I *T j!� � '� �` �• FOOD SAFETY PROFESSIONALS® +'- CERTIFIES kNi ''i �s Y•. ` Y� . `K" :'s • '''�' SHAKIRA R HALL ��=�{;,��,;!^.;: 4.�:j•{ 4 pit HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOFt THE FOOD SAFETY MANAGER UNDER THE CONFERENCE FOR FOOD PROTECTION STANDARDS n +'�tr •'�! rri,' '.' � '.a .. +t t.-!� . •(��'�' 5� S • 1raL e F PRESIDENT: LAIIVRENCE.1.LYNCH,CAE Qu) ISSUE DATE:SEPTEMBER 30, 2015 "° '-•' EXPIRATION DATE:SEPTEMBER 30,2020 #0656 CERTIFICATE NO: 21 152646 7680:Unlversal Slvd Sujte 556 Orlando FL 32a.9 TEST FORM:TZS03 P(800)44t$0257 F(407)`352=3E.03'.w,ww.NRFSP.n m This certificate is not valid for more Nabohal Re4Istry of FOOd SBfEt/,-P(0fessi0nais&. Than rive years from date or issues