HomeMy WebLinkAbout2018-1-8 - 20 Baker Lane - Food Permit Application °"'" Sf 4l� 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
Restaurant Establishment Information New Permit❑ Permit Renewal I. J
***(Please Print Clearly)***
Name of Establishment: P U 6e Jh Jj j L�_ 1
Manager's Name:
Street Address: ]
City, State, Zip Code: Cj c,,o T
Phone#: FW_ j Cell Phone#:
Fax#:
E-Mail Address: Ad m r1G?T60s-k11 t,( Seating Capacity: /
Please submit latest copy of the Qualified Food fe certificates to the office.
Qualified Food Operator: YES❑ NO ❑ (Required Certificate#:
Class 3& )
Name: Date:
Testing Organization: Phone#:
E-Mail Address: Alternate Phone#.
Designated Alternate 1: Designated Alternate2
Restaurant Owner Conta)Informs ' n
Owner's Name: 1 U►�n j km 0`
Street Address: U
City, State, Zip Code: CT
Phone#: Fax #: IAA o�(i
E-Mail AddressAdrojnPlbh3w
Cell Phone#:
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Renovations
Were there any renovations made last year? YES❑ NO Li Will there be any renovations? YES❑ NO
If Yes, please list all renovations
that were done/to be done:
RECEIVE®
AN 0 8 2018
SOUTH WINDSOR
Mailing Address to send Food License Renewal Permit to:
HEALTH DEPT.
Name of Restaurant/Company:
Attention:
. lerr�pfe Beth HMO
Address: 20 Baker Lane
City, State, Zip Code: South Windsor, CT 06074
Phone#:
Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES❑ 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.
N1A
Additional Information
Please check one only:
State Licenses: ❑ Bakery ❑ Liquor Permit P-'None
Water Supply: Public Private Well
Wastewater Disposal: 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.
I
Applicant Name (Print): 0r1 WC'X.) D iNC4,
Applicant Signature: Date:
Office Use Only
Inspector Name (Print): �S
Inspector Signature: Date:
Food Class: 1 ff 2 ❑ 3 ❑ 4 ❑ Expiration Date: 1
Date Received: Date Approved: