HomeMy WebLinkAbout855 Sullivan Avenue (4) �1%0,0 ``44 Town of South Windsor - Health Department
o J 1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
a 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address
Phone Number: (860) 337-6173 Fax: (860) 644-1930
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Restaurant Establishment Information New Permit❑ Permit Renewal
***(Please Print Cie riy)***
Name of Establishment: h (,v��►- A D���1
Manager's Name: 1-1 11�Y�Q.? -,e ��
Street Address: <q
City, State, Zip Code: S _ W y r��S a
Phone#:-bl00 - b LI 1C� Cell Phone#:
Fax#: c<-b0 `4k"` �l 5 S
E-Mail Address: � .�- U. Seating Capacity:
Please submit latest copy oINO
e Qualified Food Opera r/ServSaf< ertificates to the office.
Qualified Food Operator: YES ❑ (Required for Certificate#:
Class 3&4)
Name:/�,L#, A&!Ja Date:
Testing Organization: Phone#:
E-Mail Address: Alternate Phone#:
Designated Alternate 1: Designated Alternate2
Restaurant Owner Contact Information /
Owner's Name: 1 a rio /(1,0 ergs
Street Address: K`v
City, State, Zip Code:1'9� C O(Q
Phone# aC7
• rho 6w)•a�.� s Fax #: �p �� � � .
E-Mail Address: Cell Phone#: g6o— C
Renovations
Were there any renovations made last year? YES❑ NO �j Will there be any renovations? YES❑ NO ❑
If Yes, please list all renovations
that were done/to be done:
=�EGEIVED
Mailing Address to send Food License Renewal Permit to: ClE .
Name of Restaurant/Company: 1ja(��,,,� 'SOU1H WINI)Sok
Attention: �` , yt��r IO 0 Q r) HER LT I-i of 1'1
Address: 5 �` f�4 yl V_-o
City, State, Zip Code: S . w I n U (J- DI 0,` (�
Phone#: `� J l
Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES❑ NO 2( 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 o y:
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):
Applicant Signature: Date:
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: 1 4 2 ❑ 3 ❑ 4 ❑ Expiration Date:
Date Received: Date Approved: