HomeMy WebLinkAbout2017-12-13 - 100 Bidwell Road - Food Permit Application �°'" 8r4 Town of South Windsor — Health Department
1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
1530 Sullivan Avenue, South Windsor, CT 06074—Office Address
s 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: lOtdS jy„-P-.-,7
Manager's Name:
Street Address:
City, State, Zip Code: fh d
C�l O �
Phone#: r��j) q(j %/ 7 Cell Phone#:
Fax#: ` F60 YA - f(,yG,.
E-Mail Address: Seating Capacity:
Please submit latest -opy of the Qualified Food Operator/ServSafe certificates to the office.
Qualified Food Operator: YES No ❑ (Required for Certificate#: �/
Class 3& 4) �. / i f /�/ 7-5-/c//
Name: W04PX,,) Date: i// >�ZGi 7
Testing Organization: 1���s�a �L Phone#: Ac' SO- — 6-Z '79
E-Mail Address: k,� w q tc Alternate Phone#: 1�44 .29Q— �71
Designated Alternate 1: I �h� N Designated Alternate2
Restaurant Owner Contact Information !J
Owner's Name: 6r, ,y
Street Address: (�1v fqa l; S/, ,
City, State, Zip Code: i�7� -%,►�clscrf &7— eM0 _7 -(
Phone#: Fax #:
E-Mail Address: (;x1CA,011 5-:k 16 yti Cell Phone#: —7_Q6
Renovations
Were there any renovations made last year? YES❑ NO Q/ Will there be any renovations? YES ❑ NO [�
If Yes, please list all renovations
that were done/to be done:
Mailing Address to send Food License Renewal Permit to:
Name of Restaurant/Company:
Attention: ��/fa••t'/ �-e�.� �lS DECEIVED
Address: /� � �i.,k/� ��
City, State, Zip Code: 5��.�/j (,�,f /sc� C 7- 56&71 -
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Phone#: �Gc Z�� /�
SOUTH WINDSOR
C.L-)I R.ld o-C�{"i(M^> HEALTH DEPT.
Resta rant Menu/List of All Items Se 'i
Latest Menu Attached? YES ZIINO ❑ st 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: ❑ akery ❑r/Liquor Permit [ ! None
Water Supply: /Pu7Public
Private Well
Wastewater Disposal: 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): /f//C�a.e-�
Applicant Signature: Date: Z o 2v/7
Office Use Only
Inspector Name (Print): -ir
Inspector Signature Date:
Food Class: 1 ❑ 2 ❑ 3 0" 4 ❑ Expiration Date:
Date Received: Date Approved:
ServSafe
N,it i%n,�l P•t tour v,,� .•r,ar r,ii
ServSafea
CERTIFICATION
KYLE WATERS
for successfully completing the standards set forth for the Semsafee Food Protedion Manger Certification Examination,
which is accredited by the American National Standards Institute(ANSO-Confamm for Food Protection(CFP).
_097544 5183
UMBER EXAM FORM NUMBER
8/25/2021
DATE OF DATE OF EXPIRATION
Local laws apply. Ior recertification requiremenh
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