HomeMy WebLinkAboutApplication 965 Sullivan Avenue (2) �Ao*" 8`,<� 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
s Phone Number: (860) 337-6173 Fax: (860) 644-1930
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Restaurant Establishment Information New Permit❑ Permit Renewal 171
***(Please Print Clearly)***
Name of Establishment: , � C-o'1CL Ut
Manager's Name: vj
Street Address: Sci f j,t,',`t 0 4WL
City, State, Zip Code: � WI(1C� v , CT O(ZUN
Phone#: UU COLN—�CX)_] Cell Phone#:
Fax#: L - ( -1 _ 4Ct-1C1
E-Mail Address: ,C>��h � j CC cyisS�kfs CcLy1 Seating Capacity: Nj(-
Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office.
Qualified Food Operator: YES U(NO ❑ (Required for Certificate#: G (� lC,
Class 3&4) () L,
Name: �SCrV Date:
Testing Organization: �Qy\/ Phone#: L
E-Mail Address: iS5 EIS (011ternate Phone#:
Designated Alternate 1: �Vc _6 T94feCt_LLk_j Designated Alternate2 : � }�11C�11 .j(C ✓
Restaurant Owner Contact Information
Owner's Name:
Street Address: I I(_ (�• ►C�C,� `fit .
City, State, Zip Code: ECLSfi �'J IIIA (Sof, C1 I CVJUJ ..�)
Phone#: (1C [0 C,I11 Lo Fax #:
E-Mail Address: Y(��JC k(c� � �(� C�t� Cell Phone#:
Renovations
Were there any renovations made last year? YES❑ NO [✓]/ Will there be any renovations? YES ❑ NO ❑
If Yes, please list all renovations RECEIVED
that were done/to be done:
'iOV 3 0 2017
SOUTH WINDSOR
HEALTH DEPT.
Mailing Address to send Food License Renewal Permit to:
Name of Restaurant/Company: ��{�,,��f D,_` k(mCA( Uf
Attention: T,_not fc r -xnard
Address:
City, State, Zip Code: �L�St oj,.C16 , r ci�7 �s
Phone#: L, - u'C')3 -Gt 1Ln
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.
O,Ssc)(A-CXA QCQLPCL -6 <""YV_0J'3' 5, SCkA( I ��lC���iLIr1Q5
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): j-A ej Al Lss�,•� Jft
I
Applicant Signature: Date: -]
Office Use Only
Inspector Name (Print): l5
Inspector Signature:A�n O Date:
Food Class: 10 2 ❑ 3 g 40 Expiration Date:
Date Received: Date Approved:
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EXAM FOR " NO. -:S03
earv � � CERTIFICATE NO. 9867219
ateonal Restaurant Association
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CERTIFICATION
M. VICKY L CHANT
ikw umccessfWty completing the standards set forth for the ServlSabe Food P>rolectrpn iWanag"Cestvfcation Exam(nateon.
worth is aoaedited by the American Natianal Standarvfs ImdbMe(AMSI);m� for Food Pratectwn(CFP).
OAQ1/2013
DATE O 4a AT
03/21/2
DATE OF EX 'ATtuN
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EXAM FORM NO. 4806
ServSafe
CERTIFICATE NO. 9904005
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CERTIFICATION
,0 KATHLEEN M DESROCHER
for successfully cornpie"the sundar&soe.6or"t Sor:toe 5erv5afe°Food Protection Manager Catrfiscatinn Ezan*a6o%
which is accredited by the Awn National Standards YmbtLft(ANSU-Conference for Food Prcte tion(CM.
®ATE O.
04/04/2
a � ®ATE OF EX
IL
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CERTIFICATION
NATASHA TETREAULT
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UMBER EXA
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DATE OF _ DATE OF EXPIRA " MMM
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