HomeMy WebLinkAbout915 Sullivan Avenue (2) 0*" Srq 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 RenewalX
***(Please Print Clearly)***
Name of Establishment: LOD W,C6"IS
Manager's Name: 0 �jc)
Street Address: +� �qc
City, State, Zip Code: ^ ( ► ( JJ�
Phone#: Ct,GJ 1�1o`5S Cell Phone#:
Fax#:
E-Mail Address: A Seating Capacity:
Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office.
Qualified Food Operator: YES❑ NO� (Required Certificate#:
Class 3& )
Name: Date:
Testing Organization: Phone#:
E-Mail Address: Alternate Phone#:
Designated Alternate 1: Designated Altemate2 :
Restaurant Owner Contact Information
Owner's Name: �U SQI( �
Street Address: ID-`, `A
City, State, Zip Code: ����f ccw
Phone#: g--l(�,,,,��lCal.� Fax #: I /
E-Mail Address: C� �(1t�R�� 1 (WCell Phone#:
Renovations %
Were there any renovations made last year? YES❑ 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:
Attention: 6��_0
Address: LW fukK ed
City, State, Zip Code: W I n� _ � C�� .
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Phone#: _90JOuG06-k
Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES ❑ NO 4) NOTE"(Must have latest copy on file)
Please list all menu items in as much detail as possible -)r a copy of a menu attached is applicable.
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Additional Information
Please check one only:
State Licenses: [] Bakery Q Liquor Permit Nome
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:trace and complete.I understand that any Use
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:
Office Use Only
Inspector Name(Print): CaEj-
Inspector Signature: Date:� Jti_ 1 I Nr ` ` lU
Food Class: 1 2 E] 3 E] 4 E] Expiration Date: l 1
Date Received: Date Approved: I I I I
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