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HomeMy WebLinkAboutApplication 935 Sullivan Avenue Town of South Windsor — Health Department 1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address r; 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address m Phone Number: (860) 337-6173 Fax: (860) 644-1930 i.t�sok.cu'~. Restaurant Establishment Information New Permit❑ Permit Renewal ***(Please Print Clearly)*** Name of Establishment: Manager's Name: �c,ht Y • 0, Street Address: City, State, Zip Code: - a ' CT Phone#: w _ 7Z 5 Cell Phone#: 76' 3 q9 Fax#: ��� �3� -FZD,� E-Mail Address: t�t;� OYn tV�e� C ya IIO�a���i�I Seating Capacity: 1 &C Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office. Qualified Food Operator: YES K NO ❑ (Required for Cui Lificate It: pZ 2 c L Class 3&4) ( 33� �(0(0 Name: J�C�"1 I(/l V.i-A Date: 7/0Z Testing Organization: 5P Y V 5,; � Phone#: 9(00 - ti 37-�-o j E-Mail Address: a rgeU1L('�C.h't���p [tJvh Alternate Phone#: e(`U- q �- 3ZHq Designated Alternate 1: 06Fj its V05*0 Designated Alternate2 : "Tuo,\ Ca- v1-1 Restaurant Owner Contact Information Owner's Name: Pobc Y) quef fGA Street Address: Z 2 L 00 ` I c g p 0 Y . City, State, Zip Code: iFy)-Cwo 3, e T- 0(eogz- Phone#: 80 -- 7 Lt q.-© 7z- Fax #: E-Mail Address: gCc4ej[cd f C fl�t ����qo l,(,vim 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: MC 13 2017 SOUTH WINDSOR HEALTH DEPT, Mailing Address to send Food License Renewal Permit to: Name of Restaurant/Company: �yLp ;O✓> �� fjln 0 h Attention: Address: a3 City, State, Zip Code: �C,) -fit w 1 y���� L ' �J b ��--y Phone#: OUG- H3 2 - 7 105 EXAM FORM NO. 4866 CERTIFICATE NO. 10330966 ry af ServSafe 'AA CERTIFICATION TO RUBEN HUERTA for successfully completing the standards set(brth for the :er Food Protection Manager Certification Examination, which is accredited by the American Nations Randards fnstitulm(ANSI)-Conference for Food Protection(CFP). 2'01 .3 DATE O "FX :. M :NAT!0N 09/02/2, 18 7bwits DATE OF EX: www.wheeh►ritMco tsuItantsrom Local laws apply .c><vrltl-yct,r k.c tl•r.�ri,tarjt;tae .c,j. recertification requirements. • Pisa Har Smut ; tomat+:a Y-cc PttCO--nl,1Nw,a-al Rv J-� Association aF 2012 Nat atal N'•t, 3.• a.t r f the NRAEF,used under license by National Restaurant Association Solutions,I.I.C. The lono fy - i:l� t I .v.tLit3 a