HomeMy WebLinkAboutApplication 855 John Fitch Boulevard (2) <°*" Town of South Windsor - Health Department
. Y 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: 5a Le W; X'!E✓�S✓r ��� r;ki_ul� Yc1Yl
Manager's Name: S �� / fJF� j
Street Address: S5-; j "q F i'j:C�_� ��ew,
City, State, Zip Code: 5LraA
Phone#: �C)- -f ®D Cell Phone#: 9;0-SAY- Z/ACV
Fax#:
E-Mail Address: i lOf��FM j ►)jR>d 121),�0,,-1 Seating Capacity: /
Please submit latest copy of the Oualified Food Operator/ServSafe certificates to the office.
Qualified Food Operator: YES'4 NO ❑ (Required for Certificate#: ly 6 J
Class 3&4)
Name: -�5 rri a71-i.Q -A d ern! Date: �// ��.�C l J
Testing Organization: Jegif !j 0 o Phone#:
E-Mail Address: ;�I E�, �(d—fit SA-co,, Alternate Phone#: 6 E L)-J rs- Zt 2;,
Designated Alternate 1: U Designated Alternate2
Restaurant Owner Contact Information
Owner's Name: 1T-.5 rp ct
Street Address:
City, State, Zip Code: S C[/�� � �!�ri ✓SQ , G r �7 rn /
Phone#: F�� `LS9- ��tC� Fax #:
E-Mail Address: i��. F,n� 13� �yl;,�.� y,.) Cell Phone#: eFF>--�( if✓t�
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:
Mailing Address to send Food License Renewal Permit to:
Name of Restaurant/Company: �SCt(�� l,��il�f�,l�'► `�i L�; �'<<?�r/r.l� Cti17�u��7�rr
Attention: A�,It�Y;r/
Address:
City, State, Zip Code: SC" A LUi�l ) a'f'y
Phone#: 8,(- c `ZJ q — (Soc)
Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES K 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: P�Bakery K Liquor Permit l l None
Water Supply: _K 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): /L
Applicant Signature: l !f Date: 12 —03 o17
Office Use Only
Inspector Name (Print): L&&AA o
Inspector Signature: Date:
Food Class: 1 ❑ 2 ❑ 3 []' 4 ❑ Expiration Date:
Date Received: Date Approved: 2 p111
EXAM FORM NO. 4821
CERTIFICATE NO. 9916393
,ServS0
fe
National Restaurant Ass ciati 7
o on
t ry afe
CERTIFICATION
To ISMAIL ADEMI
for successfully completing the standards set forth for the ServSafe Food-Protection Manager Certification Examination,
which is accredited by the American National Standards Institute(ANSk)-Conference for Food Protection(CFP).
04/09/2013
DATE OF EXAMINATION
04/09/2018
DATE OF EXPIRATION
Local laws apply.Check with your local regulatory agency for recertification requirements.
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Paul Hinenlan
Executive Vice President,National Restaurant Associatim,
#0655
02012 National Restaurant Association Educational Foundation(NRAEF).All nlihls reserved.ServSafe Is a registernd trade marl.of the NRAEF,usedunder license by National Restaurant Association Solutions,U.C.
The logo appearing neat to SarvSafe is a trademark of the National Restaurant Association.
This document cannot be reproduced or altered.
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