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HomeMy WebLinkAbout655 John Fitch Blvd. (3) �4oWN °`,<� Town of South Windsor — Health Department 0 1540 Sullivan Ave., South Windsor, CT 06074- Mailing Address 1530 Sullivan Avenue, South Windsor, CT 06074- Office Address z Phone Number: (860) 337-6173 Fax: (860) 644-1930 'tUSOR•CU.. Restaurant Establishment Information New Permit❑ Permit Renewal ❑ ***(Please Print Clearly)*** Name of Establishment: G �Sv,g �j Manager's Name: s,¢L_ L01VC1,12 U Street Address: &5 r ,z►/Y N t,IC-ry "/,o City, State, Zip Code: A0 U r/-1 W/w n.Sc- 't C✓ 0 6 0 7�f Phone#: AoO S Z3- 'L 36, Cell Phone#: &60 - &235-02 37 Fax#: :&. a- a Zy- `/ 9/-Z_ E-Mail Address:S46 GolV EAC&G <✓X Seating Capacity: /S Z Please submit latest copy of the Qualified Food OperatorlServSafe certificates to the office. vES'� NO El (Pequired for Certificate#: Qualified Food Operator: cia 3&4) Name: (pV�6_ li 6VAU Date: Testing Organization: Phone#: E-Mail Address: Alternate Phone#: Designated Alternate 1: Designated Alternate2 Restaurant Owner Contact Information Owner's Name: S4L. Z OnJ,<n e Street Address: /0 Y h,57,Z /4- Art , City, State, Zip Code: /Z 0 cri, CT 6.960C11 7 Phone#: 360 V 7 Fax #: E-Mail Address: 54 L L.C11Vct 0 9 GCS tip✓ Cell Phone#: Renovations Were there any renovations made last year? YES❑ NO j•J Will there be any renovations? YES❑ NO J,1) 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: S � Address: City, State, Zip Code: Phone#: 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: r� Bakery 1� Liquor Permit ❑ None Water Supply: 4_ Public Private Well Wastewater Disposal: 'A 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): 514 vti Applicant Signature: Date: /L i / 7 Office Use Only Inspector Name (Print): 'f Inspector Signature: Date: 4�a& Food Class: 1 ❑ 2 ❑ 3 R"4 ❑ v Expiration Date: t Zl 3'�l l Date Received: Date Approved: Te_� 4 3fb (ol8ti (00 �(ov'ov. EXAM FORM NO. 5001 CERTIFICATE NO. 11721015 ry af CERTIFICATION TO LENA LONERO 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). DATE O 11/10/20 DATE OF EX Local laws apply.Ch or recertification requirements. 1 22 ® lions #0655 ©2014 National Resta mark of the NRAEF,used under license by National Restaurant Association Solutions,I.I.C. In accordance with Maritime Labour Convention 2006, The logo Resolution ADM N 068-2013(Regulation 3.2,Standard A3.2)of the Maritime Labour Convention,2006. Contact us with questions at 175 W Jackson Blvd.Ste 1500,Chicago,IL.60604 or ServSafe(drestaurant.org n■ , • IN � � • . �. IN 0 r •� 01 — ■ � :■ 1i4� • . ■ r' ■� • • - Y IL at • ■ ■ F - y 1 � ■ ti Fs ■ ti • 4 ■A C. �� ■ 1 , 1 A so 0 lip - 1 . s ' - . _ ■ , r` 1 :lom ' a { ■- I LONER4 5 *'MARK L,- *DCKY H_L,: 6 �,L �/�