HomeMy WebLinkAboutApplication 97 Commerce Way (2) °`,<� Town of South Windsor - Health Department
o J 1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
_ 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address
y 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: .6 �)L o u_ �t1vr
Manager's Name: I� S' �� zon
Street Address: (�'� C13YY1(WJ _ * ````VV cu
City, State, Zip Code: ,Y `� (r_ ,6 I
Phone#: ' r�� _ C Cell Phone#:
Fax#:
E-Mail Address: %(A e*) �kV)LC-1Ckk-O,(U(flSeating Capacity:
Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office.
Qualified Food Operator: YES❑ NO ❑ (Required .or Class 3&4) Certificate#:
Name: Date:
Testing Organization: Phone#:
E-Mail Address: Alternate Phone#:
Designated Alternate 1: Designated Alternate2
Restaurant Owner Contact Information
Owner's Name: Scow c 3 �tknk f
Street Address: !A` v,V
City, State, Zip Code: ` ' eft C- l6
Phone#: Sic -- 1 - Fax #:
E-Mail Address: S�G�SI�T� ��a Qp` Cell Phone#: - �11f- %43�
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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
DEC 78 2017
SOUTH WINDSOR
Mailing Address to send Food License Renewal Permit to: HEALTH DEPT.
Name of Restaurant/Company:
Attention:
Address: A1 cc `L
City, State, Zip Code: JACSZ UY I LT
Phone#: , -1 S'1 -3
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.
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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.
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Applicant Name (Print): n
Applicant Signature: e ' Date: 3
Office Use Only
Inspector Name (Print): Q�
Inspector Signature: Date:
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Food Class: 1 ❑ 2 ❑ 3 ❑ 4 ❑ Expiration Date: lZl3\�1 1
Date Received: Date Approved: i 0 1