HomeMy WebLinkAbout601 John Fitch Blvd. (2) S£'t� 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
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Restaurant Establishment Information New Permit❑ Permit Renewal
***(Please Print Clearly)***
Name of Establishment: ��►�'`r� ��C, t
Manager's Name: 6TYN 0 Y1 CA, a-- S `(XY-V\
Street Address: (��,` `�� g�U �.
City, State, Zip Code: S wY � r\ou cf'r I C) U�y
Phone#: %�o -ac�0-C�C�3!3- Cell Phone#: �i,0'��0 �
Fax#:
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E-Mail Address: v. W i rSc�c�i;����5 seating Capacity: 1
Please submit latest copy of the Qualified Food OperatoNServSafe certificates to the office.
YES EJ-140 ❑ (Required for 7
Qualified Food Operator: ll � Certificate#: �r -� � �--1
Name: r�rn Gnu �SIQ m Date: �lb �20 13
Testing Organization: S ��f s�b� Phone#: Tj, 0 - aC�0-(- c\-35
E-Mail Address: �, U klvwvt SC"r-ckcrw+3 'Alternate Phone#:
Designated Alternate 1: (,/f-�r irk F�l�C�C,,yip Designated Alternate2 :
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Restaurant Owner Contact Information
Owner's Name: ��Q L N
Street Address: (,ck ck J-v f-CT k 1(
City, State, Zip Code: V 0_ Q�- O�0 U �c L.
Phone#: IRklz�.V _ ,(�,-Q0 a d Fax #: �� ,$"�c) -o o S l
E-Mail Address: Phone#: 2\c, o _ l�L
Renovations
Were there any renovations made last year? YES❑ NO Lj- Will there be any renovations? YES❑ NO [-3�
If Yes, please list all renovations
that were done/to be done:
REDEOVED
LIAN 2 9 2010
Mailing Address to send Food License Renewal Permit to NDSOR
SOUTH W
HEALTH DEPT.
Name of Restaurant/Company: �li ���r1 ���v kS'
Attention: C"(\C S�G Y ,-
Address: b0 � � oar \ � A d, v c —
City, State, Zip Code: Ste. \Q; V-\&-, C\r Q,� c)\,"r) O
Phone#: Ste, 0_ a c!-A 0
Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES dNO ❑ ter?r " !="� r-t—t ropy 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: [3 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): --V C&
Applicant Signature: ni, C",1^ V e" ! e, Date: \
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: 1 ❑ 2 ❑ 3❑ 4 ❑ Expiration Date:
Date Received: Date Approved:
EXAM FORM NO. 10311
CERTIFICATE NO. 9676817
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Sery fe
CERTIFICATION
TO AMANA ISLAM
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).
01/16/2013
DATE OF EXAMINATION
01/16/2018
DATE OF EXP.'IRATION
Local laws apply.C,, k with your local regulatory agency for recertification requirements.
izz
ACCREDITED
Paul Hineman
Executive Vice President,National Restaurant Association
#0655
@2012 National Re;taumW. 'Edtlemll Foundation(NRAEF).All rights re+en d.SwSafe It a registered trn9•.t, of the NRAEF,used under license by National Restaurant Association Solutions,I.I.C.
The logo tppuarrr Ax1 to ServSafe It a trsdnttark of the National Restaurant Aasaciahon.
snoff-Ir ent cannot be reproduced or altenrd.