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HomeMy WebLinkAbout845 Sullivan Avenue (3) �Ao*" '`,< Town of South Windsor — Health Department 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 1aSOR C .o Restaurant Establishment Information New Permit❑ Permit Renewal ❑ ***(Please Print Clearly)*** Name of Establishment: �( 6 V e_ e kN_ Manager's Name: _ � W, LmAi k( J Street Address: y ��L( qv --e— City, State, Zip Code: 511A41 CL YAt , pboq q Phone#: IR60 _ q 31) -a Rk(ll Cell Phone#: :�6o - Fax#: 9(,0 - yv y - yo a�_ E-Mail Address: Seating Capacity: 70 se submit latest copy of the ualified Food Oper•Jor/ServSafa certificates to the office. Qualiiif,d Food Operator: YES NO ❑ (Required for Certificate#: Class 3&4) Name: '?L6c - 4, i_x-,\.�tJ Date: Testing Organization: Phone#: S 60- gsra -Sb i E-Mail Address: ,)//2�-G4Rk BL Alternate Phone#: 9&b_ 413a _aSg-o Designated Alternate 1: k'o/e In, //�,� Designated Alternate2 k�5 ti Restaurant Owner Contact Information Owner's Name: o �— i Street Address: ot) �4 ,� C huu II n City, State, Zip Code: 61y0 A., j 06 00 1 Phone#: �-� � - 1 17�a 'S 7J S— E-Mail Address: Cell Phone#: Renovations Were there any renovations made last year? YES❑ NO U 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: �4 i A t vee Attention: 3, E. t Address: City, State, Zip Code: G_I 0b0 7 Phone#: 7_-95- 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. S�e a 7�4e hW Additional Information Please check one only: State Licenses: ❑ Bakery ❑ Liquor Permit ❑ None Water Supply: ZPublic _ Private Well Wastewater Disposal: Zublic On-Site —Other (please use space below to explain) ir7'd02�l� �tSS�ti? A lee n s—e— /A-�& 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: Z, Date: 01) Office Use Only Inspector Name (Print): s Inspector Signature: Date: Food Class: 1 ❑ 2 ❑ 3 E]1 4 ❑ Expiration Date: Date Received: Date Approved: a S- Z ,.C)o 610590 CTd ;'1; STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION This is your license certificate. This certificate shall be posted in a conspicuous location where business is to be conducted and shown to any properly interested person on request. Do not attempt to make any changes or alter this certificate in any way. This license is not transferable. In an effort to be more efficient and Go Green, the department asks that you keep your email information with our office current. All renewal notifications and certificates will only be emailed to the last reported email on record. Questions regarding this license can be directed to the Food& Standards Division at dcp.foodandsLandardsLct.gov. Mailing address: Email on file to be used for receiving all notices from this office: D Q GRILL& CHILL hhrefrigcol954@aol.com P.O. Box 845 South Windsor,CT 06074 iY i�'1 ;� •S" l Y t i STATE OF CONNECTICI!T ♦ DEPARTMENT OF CONSUMER PROTECTION Be it known that D Q GRILL & CHILL i 845 SULLIVAN AVE i - SOUTH WINDSOR, CT 06074-2047 ti has been certified by the Department of Consumer Protection as a licensed 1 FROZEN DESSERT RETAILER =� License #: FDR.0004097 Effective Date: 01/01/2018 Expiration Date: 12/31/2018 - verify online at wivwxlicense.ct.gov Michelle Seagull,Commissioner • ry fe@ CERTIFICATION ROBERT LARKIN for successfully mffV #inq Ilse skindards set 64 for Ih•ServSo6*Food ProMckm MmwVm Codification Exarnindion, which is occrodited 6y Ow Amwiaan Nafiortol Standards 6stlk0e(ANSI}� for Food Noted on OR 690059 4906 UMBER EXAM FORM NUMBER 01/2 01/20/2019 DATE OF E DATE OF EXPIRATION Loaol lava ap*. C ncy fr r ncw*RaeNm roquhwrenh. 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('anted w wk*gmoon d 175 W 1v" Md bb ISM,chmalk t 6004 w t, �y r , 1� rvsafe CERTIFICATION NICOLE MILLER b./ w1..w'Allrlly.19,141 "tj 00 Arwk.rIll %W I.rllt l.r► 11MA n►m11►"I.rwl Poulos" Cm hilt 111101►I tUl11NKfk111, wllkh 11 tM t LgINaI Iry If is A1►wl•.►n Nt►11•wwl '11.IIwltac6 (nMMll• (ANRII-�io"oIo Iw {cmmI Noilalogin(t 1 P). 82402 10440 MRER I XAM FORM N11M1F R 7/2 7/22/2020 DATE Of DATI Of 1 XPIRA HON Lmw It"s r,qJy r w y flow r«N111i..dlr•n rrr.r.lranwrd., 1 EAU rAN1 ...t NI w111 ,...••»,. .1/1 W r..•�.-,w..l Ib 1100,'I,,.,,,,.,K A01111.• r.1.J.�..awr..d� • w ry af CERTIFICATION RONALD BYLYKBASHI for successfully compWng Ilse standards set Forth for the ServSafee Food Protection Managor Certification Examination, which is accredited by the American National Standards Institute(ANSI)-C on6rence for Food Protection OR 12 810386 5067 CF.RTIFICAII NHMBER EXAM f ( kn� NUMBER 9/23/2015 9/23/20:10 DATE OF f XAMINA1ION DATE OF EXPIRATIbN Local Iaws apply, ( 6w w0a yow i" for recwtiNcatton requirements, Shocasee► SV1', .of tleaWt�nnl. tfny • #0866 M aaad.t..w��soeM»r,lr,,,�...w.,xr.�+i..++..,.r>rt ssor►�ou h++�--i� t+.r.d ..J C�+e�1e�!�bA**a rAwm4.. a�e...�� lnpo�n Mad mw6 of th.NRM wy.:a.JW0ppw" v�e+ Lv`Apeww.>.�rr.r�• Vow—bow..we k 1/ :K CmNuN w wth qualwa d 17S W JP&wi 1W St.I SOp,Chicapa,Il BOdO�r L..Sa{.e,«►.w story