HomeMy WebLinkAboutApplication 86 Evergreen Way (2) �,°"'" '`,<� 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 0
***(Please Print Clearly)***
Name of Establishment: H l,l,I►s oru"s NO Q,J
Manager's Name:
Street Address: lq� Bui ld ' J (0 V U
City, State, Zip Code: 50LtA (�I I- CT 04p074
Phone#: V&o-6qq_ 957� Cell Phone#: --
Fax#: k�c)_(0gq-- 959(O
E-Mail Address: — Seating Capacity: N/A
Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office.
Qualified Food Operator: YES ❑ NO J�J (Required for Certificate#:
Class 3&4)
Name: Date:
Testing Organization: Phone#:
E-Mail Address: Alternate Phone#:
Designated Alternate 1: Designated Alternate2
Restaurant Owner Contact Information
Owner's Name: HLA n-5orl'S Cf iO Qtee6
Street Address: /7f Hop KI VQ, , 1d -
City, State, Zip Code: c3o An j QT' a(opLt3
Phone#: Fax #: 4 p _ b 4 9-gam
E-Mail Address: Cell Phone#:
Renovations
Were there any renovations made last year? YES❑ NO,K Will there be any renovations? YES❑ NO []
If Yes, please list all renovations
that were done/to be done:
RECEIVED
Mailing Address to send Food License Renewal Permit to: NOV 17 2017
SOUTH WINDSOR
Name of Restaurant/Company: M(a strl:S i�we6 HEALTH DEPT,
Attention: Key((a 9 C]
Address: 174P
NO Lcrm -
City, State, Zip Code: J3p 1�{jh CT 04
143
Phone#: 'i?(op _ Ucl _ 433a
Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES❑ NO [ N f H H64 0 Slur,-) 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: ❑ 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): /LI A I
Applicant Signature: I l �V��. Date: 11 /3 17
Office Use Only
Inspector Name (Print):
Inspector Signature: UOT Date:
ICI
Food Class: 1 ED/ 2 ❑ 3 ❑ 4 ❑ Expiration Date:
Date Received: � kl1 Date Approved:
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