HomeMy WebLinkAbout700 Ellington Road (3) Town of South Windsor - Health Department
1540 Sullivan Ave., South Windsor, CT 06074- Mailing Address
-, 1530 Sullivan Avenue, South Windsor, CT 06074- Office Address
y 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: "7 - t- L E V ET
Manager's Name: H )) F) D S �(
Street Address: 701;
City, State, Zip Code: �,L, ,r 1,1 L%' t Id DSc IQ
Phone#: mil,C, . ti3�" - S-3FF 955-1 Cell Phone#:
Fax#:
E-Mail Address: Si DD►t� S iiAoi D k)ihs,v.,em Seating Capacity: G
Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office.
Qualified Food Operator: YES X NO ❑ (Required Certificate#: a; U ,q
Class 3& )
Name: S H I)H i D S i D u f Cd Date: i i i�;_- 22 i L
Testing Organization: N A-Vie ry u r i,1 S.r r�y oF Phone#: 2 Ll -2 ti 7
E-Mail Address: Fr.c DSHFET J Alternate Phone#:
Designated Alternate 1: Am m i-sz P Designated Alternate2 : A�.I,eh H p 2_lM
Restaurant Owner Contact Information
Owner's Name:
Street Address: Be,i-
City, State, Zip Code: Vt RNO N ) CT'v 6�
Phone#: st<n 003 Fax #:
E-Mail Address: Si I�Dj��S }It�1� D� f11 SN icM Cell Phone#: ��D -�►�3 •�I go
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:
RECEIVED
AAN 18 ZO1k
Mailing Address to send Food License Renewal Permit to:
SOUTH WINDSOR
HEALTH DEFT.
Name of Restaurant/Company: 7 C L t- y' L Aj
Attention: A N i D i DAI
Address: 70 o &LL IN 6 T o tV
City, State, Zip Code: GC o-r H �, �;J)�Scp, C77,-) Ko 7 lI
Phone#: 8I n � 3f _ 9SS
Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES❑ NO D4 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.
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Additional Information
Please check one only:
State Licenses: `V,Bakery ❑ Liquor Permit I_i None
Water Supply: _% Public _ Private Well
Wastewater Disposal: X 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): I ��
Applicant Signature: I Date: 6-1_ o 1 g
Office Use Only
Inspector Name (Print): !
Inspector Sign re: Date:
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Food Class: 1 ❑ 2 ❑ 3 [�J' 4 ❑ Expiration Date: 12�1\l�'
Date Received: Date Approved: I 1 l 11
CT\o
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THE NATIONAL,REGISTRY OF
FOOD SAFETY PROFESSIONALS40
9°
CERTIFIES
K:
SHAHID SIDDIQ
HAS SUCCESSFULLY SATISFIEDTFE REQUIREMENTS FOR
GER:1"_�LGD
R THI3 FOOD SAFETY MANAGER
q **pp••��- hh - CERnFiCATION 0"INATION
Yi lY•kL.t U� A11ySI
1-800-723-3373
PRESIDENT.
LAWRENCE J.LYNCH,CAE
LA
® _ ISSUE DATE:.NOVEMBER 15,2012
EXPIRATION DATE:'NOVEMBER 115,2017
ComFIGATE NO:20809098
TEST FORM:EZS IS
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