HomeMy WebLinkAbout2018-2-23 - 249 Oakland Road - Food Permit Application 10*N 'f,< Town of South Windsor — Health Department
1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
1530 Sullivan Avenue, South Windsor, CT 06074— Office Address
Phone Number: (860) 337-6173 Fax: (860) 644-1930
Restaurant Establishment Information New Permit❑ Permit Renewal
***(Please Print Clearly)***
Name of Establishment: ���G >
Manager's Name:
Street Address: -Aj
City, State, Zip Code: _�k��%�� CCf l<-t-
Phone#: f 1 LG�.`C�� Cell Phone#:
Fax#:�
E-Mail Address: Seating Capacity:
Please submit latest copy of the Qualified Food OperatorlServSafe certificates to the office.
Qualified Food Operator: YES❑ NO ❑ (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:
Street Address: 11-f
City, State, Zip Code: `( �i //��
Phone#: / �11 ll2 Fax #:
E-Mail Address: Cell Phone#:
Renovations
Were there any renovations made last year? YES❑ NO �f 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: FEB 2 3 2018
SOUTH WINDSpR
Name of Restaurant/Company:
DZ-141VT__> HEALTH DEPT.
Attention:
Address:
City, State, Zip Code: � ���,,_<�!�v
Phone#: \�I��� 0�C �C� '7�l ,
Restaurant 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): 4d
Applicant Signature: Date:
Office Use my
Inspector Name (Print):
Inspector Signature: Date:
Food Class: 1 ❑ 2 ❑ 3 ❑ 4 ❑ Expiration Date:
Date Received: Date Approved:
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