HomeMy WebLinkAbout87 Evergreen Way (2) A < Town of South Windsor - Health Department
A Q 1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
o _ 1530 Sullivan Avenue, South Windsor, CT 06074— Office Address
s _4: Phone Number: (860) 337-6173 Fax: (860) 644-1930
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Restaurant Establishment Information New Permit❑ Permit Renewal Ir
***(Please Print Clearly)***
Name of Establishment: •TCLSic 6 S��IIG��ccr��
Manager's Name: XrcS-�,co-
Street Address: � ) F-u4r-pt., 0o_Y
City, State, Zip Code: s '1 UjIO So,- , C�A O M N
Phone#: A D-Gqq- w3 I Cell Phone#: Yl)�
Fax#: IUjA
E-Mail Address: �,A-,6) ',J�l1b"4 4A ci Yn Seating Capacity: I�
Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office.
Qualified Food Operator: YES❑ NO 2"' (Required for Certificate#:
Class 3&4)
Name: Date:
Testing Organization: Phone#:
E-Mail Address: Alternate Phone#:
Designated Alternate 1: Designated Alternate2
Restaurant Owner Contact Information
Owner's Name:
Street Address:
City, State, Zip Code: Cp�y� j s��, La C) I`4
Phone#: SW Fax #:
E-Mail Address: lh 6 C ���it k:���� o�Yi Cell Phone#: �oj A
Renovations
Were there any renovations made last year? YES❑ NO l" Will there be any renovations? YES ❑ NO [�
If Yes, please list all renovations
that were done/to be done:
DECEIVED
DEC 2 12017
Mailing Address to send Food License Renewal Permit to: SOUTH WINDSOR
HEALTH DEPT.
Name of Restaurant/Company:
Attention:
Address: V Cr ei,, Lie,
City, State, Zip Code: SoL•.� W,Kd s,D, C_j 0(v D j y
Phone#: t l o - (09` - 11 R
Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES ld 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: ✓ 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.
Applicant Name (Print): pp
Applicant Signature: �/ Date:
Office Use Only
Inspector Name (Print): U e J-:5
Inspector Signature: Date:
Food Class: 1 2 ❑ 3 ❑ 4 ❑ V Expiration Date: l ZA 3 1V16
Date Received: Date Approved:
`�G��� *
Taste by Spellbound MENU
Desserts:
Cupcakes
Cookies
Truffles
Pastries
Drinks:
Coffee
Tea
Hot Chocolate
Chai
Cold Bottled Drinks