HomeMy WebLinkAbout2018-2-28 - 1735 Ellington Road - Food Permit Application Sal's Town of South Windsor - Health Department
o r 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 [1
***(Please Print Clearly)***
Name of Establishment: 30 j NCNB 0,(1_ P)zw
Manager's Name: JQ VOJ_bf(f V_A(t1_7L; ti C�kG1,
Street Address: k"7
City, State, Zip Code:
Phone#: ��.(o14 S-—� � Q Cell Phone#:
Fax#:
E-Mail Address: MatiufYcllCA C1 rnCy<& Seating Capacity:
Please submit latest copy of the Qualified Food Operator ervSale certificates to the office.
Qualified Food Operator: YES R/`NO ❑ (Required for Certificate#: a l3 a����
Class 3&4)
Name: Gfy)t Gagner) Date:
Testing Organization: Q F Q CunSLIfin Phone#:
Ptcot-e(,�G
C>°i���
E-Mail Address: f OCDl1SLLthn Alternate Phone#:
Designated Alternate 1: DA L)o r -Oo Designated Alternate2
Restaurant Owner Contact Information
Owner's Name: 5C(i vai-U fe M< u-c(rc l i Ck
Street Address: !3 3 J _P LCO')C;(r0 R CI
City, State, Zip Code: e-TL4)t Eyre CT_ CUy j
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Phone#: 3O j--QS 7-13Lel Fax #:
E-Mail Address: M(tjja(f(jCj CI m�� Y��uU Cell Phone#:
l CDC
Renovations
Were there any renovations made last year? YES❑ NO l j Will there be any renovations? YES❑ NO P
If Yes, please list all renovations
that were done/to be done:
RECEIVED
Mailing Address to send Food License Renewal Permit to:
FEB 2 8
Name of Restaurant/Company: ;C1� S N �� Y y�i PIZ Z SOUTH ND�R
Attention: NCO VC �f� �li(��22Cirel(c� HEaLTH DEPT.
Address: I ? 3 S Ell r1 c
City, State, Zip Code: SOC(, Y� WI���-�; r CT CL E) l
Phone#: ��b3, - &C}�— �) 7
Resta rant 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): �C��VCI�oc� MCl'LZ GZf e �1�
e P.
Applicant Signature: Date: Il �
Office Use Only
Inspector Name (Print): ,S
Inspector Sign% Date:
at
Food Class: 1 0 2 L 3 4 ❑ Expiration Date: 11
Date Received: l l '� I Date Approved: (Z l l 8
�&VDoD s NATION Ai- REGISTRY OF
�f�r, FOOD SAFE'' PROFESSIONALS®
CERTIFIES
►r1
o.
SALVATORE MAZZARELLA
HAS SUCCESSFULLY SATISFIED THE REQumEmEi fs FOR THE
C_ 7TFI FOOD SAFETY MANAGER
R UNDER THE
CONFERENCE FOR FOOD PR®TECT'lOm STA-mvAj;ir5
PRESIDENT:
dr
L,a'n►RENCE J.LYNCH,CAE
l
ACCRFOITFO PROGRAM ISSUE DATE: MARCH 18,2017
ARC r F-I icciwn
,"
niernxe :Rt EXPIRATION DATE: MARCH 18,2022
a�aine co Iw F000�ra
'0656 CERTIFICATE No:213278®7
T mff FORM: EZS36
6751 Forum Drive,Suite 220,Orlando,Fl,32821 This certificate is not valid for more
P(800)446-0257 F(407)352-3603 www.NRFSP.com than rive years from date of issue.
National Registry of Food Safety Professionals'