HomeMy WebLinkAboutApplication 856. Sullivan Avenue Town of South Windsor — Health Department
1540 Sullivan Ave., South Windsor, CT 06074- Mailing Address
1530 Sullivan Avenue, South Windsor, CT 06074 - Office Address
y, 4� Phone Number: (860) 337-6173 Fax: (860) 644-1930
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Restaurant Establishment Information New Permit❑ Permit Renewal ( 1
***(Please Print Clearly)***
Name of Establishment: FOS I'F'1 CtV � # S 1 (0
Manager's Name: 111�ireoy/enn
Street Address:
City, State, Zip Code: So�i� �ti i h�ISUr J L' V(ov
Phone#: (�6G� 6 iS 3( Cell Phone#:
Fax#:
E-Mail Address: /i uni h� C,; gmihveS+IMer�-f�rvl Seating Capacity:
Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office.
Qualified Food Operator: YES J-1 NO �. Certificate#:
Name: L(-c"5 S ( Date:
Testing Organization: Phone#:
E-Mail Address: Alternate Phone#:
Designated Alternate 1: Designated Alternate2
Restaurant Owner Contact Information
Owner's Name: APAI Il1ve O- E'04> LL C-
Street Address: 5
City, State, Zip Code:
Phone#: (gU J)�3 /j Fax #:
E-Mail Address: //'L'e j,1< /'� �� i,�m l'� Cell Phone#:
Renovations
Were there any renovations made last year? YES❑ NO [] Will there be any renovations? YES❑ NO I-i
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: Li'aill il� Del)
Address: SGS pies" SJO 1/00
City, State, Zip Code: E1*e1,/r,,v,d1 (/A
Phone#: (Icq 330 156 x 11 7 (oo
Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES❑ NO 1-.1 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 j I None (IV 1 1
Water Supply: Public Private Well Y� 9il I �� ✓� 540/t rC✓(f 1� 5>.
Wastewater Disposal: Public On-Site _Other (please use space below to explain)
Agreement and Signature
By submitting this application, I aff-m that the facts set forth in it are true and complete. I understand that any false
statements or other misrepresent ions made on this application may result in immediate shutdown or revocation of my Food
Service License for the Town of S uth Windsor.
Applicant Name (Print): A K e Kol/P rl C 170
Applicant Signature: N Date: 11 2 1)0 0-
Office Use Only
Inspector Name (Print): S
Inspector Signature: Date:
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Food Class: 1 g 2 ❑ 3 ❑ 4 ❑ Expiration Date:
Date Received: Date Approved: k'1