HomeMy WebLinkAbout69 John Fitch Blvd. (3) �,°O*" SC44 Town of South Windsor - Health Department
,- 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
t�SnR•CO� ,v
Restaurant Establishment Information New Permit❑ Permit Renewal
***(Please Print Clearly)***
Name of Establishment: �TcLsic r
Manager's Name: L; yr„
Street Address: �.9�k 69 .-L,At-k T i4d 81 VO
City, State, Zip Code: &L 11, lnJ/h�(s,�(r 060.E f
Phone#: 960 _ 2�1`� Cell Phone#: }q — 1fbg
Fax#: AJ/A
E-Mail Address: L Y►� � � �J AQL 1� Seating Capacity: `0
Please submit latest copy of a Dualified ood Operator/ServSafe certificates to the office.
Qualified Food Operator: YES❑ NO ❑ (Required for Certificate#:
Class 3 E,4)
Name: Date:
Testing Organization: Phone#:
E-Mail Address: Alternate Phone#:
Designated Alternate 1: Designated Alternate2
Restaurant Owner Contact Information
Owner's Name: 1(C,r-\ T:a L,r
Street Address: �j Gz� ( L/U
City, State, Zip Code: SUlr4A (ir.r dx- T
Phone#: (¢ 660-��2 -29e.'A Fax #: �tJ�
E-Mail Address: 130fi ca) ?hi�(C/J'I Cell Phone#: &60
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:
Mailing Address to send Food License Renewal Permit to:
Name of Restaurant/Company: Ea'VVf \_ d)i1-6C 1r5-(VTVSin4 RECEIVED
Attention:
Address: 6q J V\ V,�C� Nvt) FEB 14 7018
City, State, Zip Code: { (�Ur►,o15c:r j C-%C'v
- clq SOUTH WIND OR
Phone#:
S(�, �Z — Z 1 HEALTH DE T.
Res urant 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.
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): GV .o, lA
Applicant Signature: Date: 4-/_
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: 1 ❑ 2 ❑ 3 ❑ 4 ❑ Expiration Date:
Date Received: Date Approved:
Department of Revenue Services _
State of Connecticut Sales and Use
25 Sigoumey St Ste 2 -• = ' '' '
Hartford CT06106-5032 Tax Permit
R603(Rev.07/09) Y
Use only at this location: Lic Nbr: 1029868 i
The person named below is licensed under the Salesand Use Tax Act. r
This permit is good only for the named permittee and at the location shown. CHANG JIANG JI TUAN LLC
If there is any change in ownership,the permit is null and void`
Date Expiration Business Connedicut EASTERN
Issued Date Start Date . Tax Registration Number 69 JOHN FITCH BLVD
05/31/201 04/30/2018 05/13/2013 *,�.9503508-001 SOUTH W INDSOR CT 06074-4006
4
i
IIIIIIIIIIIIIIII�IIIIIIIIIIIIIII7111IIIIII�IIIIIIIIIIIIIIIIII�
CHANG JIANG JI TUAN LLC _
EASTERN
69 JOHN FITCH BLVD
SOUTH WINDSOR CT 06074-4006
.Kevin B. St"''an
Commissic of Revenue Services
'his license may not be transferred or assigned. �.