HomeMy WebLinkAbout520 Griffin Road (2) LbSOR-SCO.
Town of South Windsor - Health Department
1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
1530 Sullivan Avenue, South Windsor, CT 06074Office Address
Phone Number: (860) 337-6173 Fax: (860) 644-1930
Restaurant Establishment Information New Permit❑ Permit Renewal ❑
***(Please Print Clearly)***
Name of Establishment: XQ
Manager's Name:
Street Address: -,r, y� /
City, State, Zip Code: �� � W,hC _(vr Lf 6 0 (1L/
Phone#: �-(G 6 q 4 S-D)7 Cell Phone#:
Fax#:
E-Mail Address: I/1/'f'(��1['��,/�c4t� *hu,�/ Seating Capacity:
Please submit latest copy of the Oualified Food Operator/ServSafe certificates to the office.
Qualified Food Operator: YE$F<rNO ❑ (Required for Certificate#:
Class 3&4)
Name: r Ike j ZA Date: /)0/7
Testing Organization: / ,(k � A5.5 Phone#:
E-Mail Address: Alternate Phone#:
Designated Alternate 1: Designated Alternate2
Restaurant Owner Contact Information
Owner's Name: ��6& l C�Loyse
Street Address: 5
City, State, Zip Code: %C;e CT9, 16
Phone#: 60 6X j Fax #:
E-Mail Address: .C�l� '�i6f r/� Cell Phone#:
Renovations
Were there any renovations made last year? YES❑ NO fij�' Will there be any renovations? YES❑ NO ❑
If Yes, please list all renovations RECEIVED
that were done/to be done:
W 15 ?0 17
SOUTH WIN R
HEALTH D
Mailing Address to send Food License Renewal Permit to:
Name of Restaurant/Company: ` I Yee Res *�ewi
Attention: -L 1714e/ �I SC�7
Address:
Cily, Slate, Zip Code: �z�/1 Irl/, sr O6C�7L/
Phone#: �stC 6 qI/ r-O7
vP V0 �l,�ecL � 12J
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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 m ch detail as possible or a copy of a menu attached is applicable.
Additional Information
Please check one only:
State Licenses: ❑ akery Liquor Permit I I None
Water Supply: Public _ Priva 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): PIC/ �A
Applicant Signature: Date:
Office Use On'y
Inspector Name (Print):
Inspector Signature:44� / Date:
Food Class: 1 ❑ 2 ❑ 3 E2/4 ❑ Expiration Date:
Date Received: Date Approved.
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ServSafe
National Restaurant Association
rvSa fe
CERTIFICATION
MICHAEL GEYSEN
For successfully completing the standards set forth for the ServSafe"Food Protection Manager Certification Examination,
which is accredited by the American National Standards Institute(ANSI}-Conference for Food Protection(CFP).
i 5265
UMBER EXAM FORM NUMBER
5/31 2 i 7 5/31/2022
DATE OF : DATE OF EXPIRATION
Locul laws apply. For recertification requirements.
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Corsi us with questions d 175 W Jo&m 116d.Ste 1500,Chicago,IL.6060A or SwSohiioreskwani org.
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