HomeMy WebLinkAbout2017-11-10 - 200 Deming Street - Food Permit Application A
.".0" Town of South Windsor -- Health Department
rA 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address
0 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 ❑
***(Please Print Clearly)***
Name of Establishment: 2Q5�( Y LJverZ -w�
Manager's Name: IOLP� �14V
Street Address: Zc�G �y�yi
City, State, Zip Code: Ej - C1 CXaCyjLj
Phone#: Cell Phone#:
Fax#: `6U.C?— LK U1
E-Mail Address: 6 Capacity:
"lease submit latest copy of the uatifted Food Operator/ServSefe cerfNicates to the office.
Qualified Food Operator: YES[W NO ❑ (Required for Certificate#: /
Class 3&4)
Name: 1;..�c., C � Date: -711 t 7
Testing Organization: < <, Phone#:
E-Mail Address: Alternate Phone#:
Designated Alternate 1: Rt`�j ( Designated Alternate2 : ��a� �aS6r-
Restaurant Owner Contact Information 1 1
Owner's Name: N P V 1 L.CB Soot-h f/i rlkor j kkc
Street Address:
City, State, Zip Code: C i O00-4y
Phone#: w - 4133. - GL9 I I Fax #: &� _ y3a,o3a�o(
E-Mail Address: J�� �,,G�►eS� �enceSrwf�. Cell Phone#:
Lvi�,pr, COS
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: 11,t 4Si difia ci� �� U.A,�.r (,,�,ns
Attention: '�°�
Address:
City, State, Zip Code: Cj : ��y G 2 �T ��G'1 LA
Phone#: &p ..432 -L H t I
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: --)C 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.
I
Applicant Name(Print): -6f
Applicant Signature: / Date: I tD
Office Use Only
Inspector Name(Print):
Inspector Signature: Date:
Food Class: 1 ❑ 2 ❑ 3 ❑ 4 ❑ Expiration Date:
Date Received: Date Approved: