HomeMy WebLinkAbout2018-4-1 - 138 Ayers Road - Food Permit Application Town of South Windsor — Health Department
' 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address
South Windsor
1530 Sullivan Avenue, , CT 06074—Office Address
Phone Number: (860) 337-6173 Fax: (860) 644-1930
�t`'sf)wA° Permit Renewal
New Permit❑
***(Please Print Clearly)***
Name of Establishment: �
Manager's Name: �� 9 X I A A-�a
Street Address: /,5'r` 11.9,1l 17 �'�``�
City, State, Zip Code:
Phone#: C�4,0&c+�� f
Cell Phone#:ee,,�>
Fax#: y/V
E-Mail Address: A)//.,tx I4//0 A��'ox'.�> Seating Capacity:
Qualified Food Operator:
YES❑ NO ❑ ( Certificate#:
Date:
Name:
Phone#:
Testing Organization: Alternate Phone#:
E-Mail Address:
Designated Alternate2
Designated Alternate 1:
;
Owner's Name: //.7 `'z
- (Jr �..
Street Address: /�' � �r`
City, State, Zip Code: �'•wii ate^'`
Fax #:
Phone#: Cell Phone
E-Mail Address: �/ '�/�I Y�'��'`�� '`,
s made last year? YES❑ NO
Will there be any renovations? YES❑ NO
Were there any renovation
If Yes, please list all renovations
that were done/to be done:
Name of Restaurant/Company:
Attention: 1qA ?Voj 1-i
Address: /
City, State, Zip Code: S,1L_)1.--),2�,--elz
Phone#: S _e,
'as❑ NO a copy of a menu attached is applicable.
Please list all menu it ms in as much detail as possible
Please check one only: �j None
ker ❑ Liquor Permit /`'�-
State Licenses: ❑ E3a y private Well lain
Public Other (please use space below to exp )
Water Supply - P����i� On-Site
Wastewater Disposal:
that the facts set forth in it are true and complete.I understand that any false
this application, 1 affirm �a this application may result in immediate shutdown or revocation of my Food
statements
submitting made o
statements or other misrepresentations
Service License for the Town of South Windsor.
I Name (Print): �n %% ,v/�ri , <."t=-
Applicant Date:
Appli
cant Signature: 1 `
Inspector Name
Print): Date:
Inspector Signature: Expiration Date:
Food Class: 1 ❑ 2
g Date Approved:
� ❑ 4 ❑
Date Received: