HomeMy WebLinkAbout59 John Fitch Boulevard <ow" Sf 44 Town of South Windsor — Health Department
o ,. 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
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Restaurant Establishment Information New Permit❑ Permit Renewal
***(Please Print Clearly)***
Name of Establishment:
Manager's Name: 13ketj4 4- wAIL--5N
Street Address: .59 TDNM F,1 U4 j�jDltLE✓4,4P/6
City, State, Zip Code: 60 1fjIDS04_
Phone#: (740) nq _ Cell Phone#:
Fax#:
E-Mail Address: -rye_�kb5au+��Jra�SoP ouKo��CCo►� Seating Capacity: /Ob
Please submit latest cop;of the Qualified Feed OperatorVSerifSafe certificates to the office.
Qualified Food Operator: YES Q'NO ❑ (Required for Certificate#:
Class 3&4)
Name: &LW6i _ W A,L-s fA Date: S-/it /ez014-
Testing Organization: 5Ew_- lS4G Phone#: 9�6 -q�i 7 399�
E-Mail Address: �/ Cp (gk�}(o/, •4!� Alternate Phone#:
Designated Alternate 1: ,i j 12'�,Q Designated Alternate2
Restaurant Owner Contact Information
Owner's Name: K&6 -r j kLC__
Street Address: J-0 n r✓j~jcul, rg f Vv(
City, State, Zip Code: Sou 4,k lji AdJ61� C/� D(O-7y
Phone#: le4 U a i-114 D Fax #:
E-Mail Address: �,0 j 5IX W i4J6116&1W0A Cell Phone#: 40 3 f?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
r: 1 2017
Mailing Address to send Food License Renewal Permit to: SOUTH WINDSOR
HEALTH UEPT.
Name of Restaurant/Company: - r— P"
Attention: 'br&ndA_ Wab h
Address: 451 John 1— kG, 6/V-,04
City, State, Zip Code: S')Ock4tj toilldJ61�> W OW Y
Phone#: 8�0 C�9� / /41 D
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.
Additional Information
Please check one only:
State Licenses: ❑ Bakery [ Liquor Permit f None
Water Supply: _✓ Public _Privat Well
Wastewater Disposal: _ Public 7On-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: /S /7
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: 1 ❑ 2 ❑ 3 ❑ 4 ❑ Expiration Date:
Date Received: Date Approved:
ServSafe
National Restaurant A,snciation
ery afe
CERTIFICATION
BRENDA WALSH
for successfully completing the standards set forth for the ServSafe®Food Protection Manager Certification Examination,
which is accredited by the American National Standards Institute(ANSI}- onference for Food Protection(CFP).
15071635 10551
CERTIFICATE NUMBER EXAM FORM NUMBER
5/11/2017 5/11/2022
DATE OF EXAMINATION DATE OF EXPIRATION
Local laws apply.Check with your local regulatory agency For recedificalion requirements.
Sherman Brown
SVP, Nalloncl Restaurant Association Solutions
#0856
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