HomeMy WebLinkAbout765 Sullivan Avenue (3) /°W" se'` S Town of South Windsor — Health Department
J' f� 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
Restaurant Establishment Information New Permit❑ Permit Renewal ❑
***(Please Print Clearly)***
Name of Establishment:
Manager's Name:
Street Address: 7(-S _S v /r!v M✓
City, State, Zip Code: P,�� y�,s� G j 0607Y
Phone#: v 7y' _ (� �O� Cell Phone#: Xr4_,
Fax#:
E-Mail Address: S Svc e CTV�1� AW- Seating Capacity: j
Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office.
Qualified Food Operator: YES❑ NO ❑ (Required for Certificate#:
Cla.,s3&4)
Name: Date:
Testing Organization: Phone#:
E-Mail Address: Alternate Phone#:
Designated Alternate 1: Designated Alternate2
Restaurant Owner Contact Information
Owner's Name: _-zs-re,) P rAUShj
Street Address: 136 Mlc j
City, State, Zip Code: e,U �DA CT /W CGC-�
Phone#: $(,C) - 77, q• 6 �0? Fax #:
E-Mail Address: C%(/� c�J� , (pq Cell Phone#:
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
JAN 08 ?018
Mailing Address to send Food License Renewal Permit to: SOU TL H THWNDSOR
EPT
Name of Restaurant/Company: Co,j,,,r<.j ci V/ �cc�. �✓'Rr
Attention: >n 0 s A!AS
Address: Aic
City, State, Zip Code: —SouTN U JcQS D , C 060?7
Phone#: S)60 7Rq- 6 �0e
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.
Additional Information
Please check one only:
State Licenses: ❑ Bakery Liquor Permit None
Water Supply: 'a!--'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-
Applicant Signature: Date: .5
Office Use Only
Inspector Name (Print):
Inspector Signature: , I� Date:
Food Class: 1 [2 2 ❑ 3 ❑ 4 ❑ Expiration Date: Z
Date Received: Date Approved: