HomeMy WebLinkAbout85 Evergreen Way (2) Town of South Windsor — Health Department
1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
1530 Sullivan Avenue, South Windsor, CT 06074—Office Address
s Phone Number: (860) 337-6173 Fax: (860) 644-1930
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Restaurgnt Establishment Information New Permit❑ Permit Renewal f
***(Please Print Clearly)***
Name of Establishment:
Manager's Name: L_-)y u-Ky 1 j ���s � \ `(0-6
Street Address: ��/
City, State, Zip Code:
Phone#: ��, ��-�(�-71 Cell Phone#
Fax#: �Cv� ���%�� � �� �`>A
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E-Mail Address: , ;V\ ( �I,�.�tl ,C;; ;eating Capacity:
Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office.
Qualified Food Operator: YES `No ❑ quired for ass Certificate#:
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Name: t' (��� L`( ,i1� Date: l l �►
Testing Organization: `4^�' Phone#: � _
E-Mail Address: I C 4�� C�I✓E< _� L,L�'��,L Alternate Phone#: �l
Designated Alternate 1: ;y�c;� 4 �, c.L� Designated Alternate2
Re ura�n+. Owner Contact Information
Owner's Name:
Street Address:
City, State, Zip Coder-Z -�`l T
Phone#: �� - YF�,--I ( 3 j Fax #:
E-Mail Address: ,� �1v1� t.��� Cl /�c,1�,� � , Cell Phone#:
Renovations
Were there any renovations made last year? YES❑ No i-a` Will there be any renovations? YES❑ No I" )
If Yes, please list all renovations 7
that were done/to be done: RECEIVED
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SOUTH WINDSOR
Mailing Address to send Food License Renewal Permit to: HEALTH DEPT.
Name of Restaurant/Company: �L� � : LLB
Attention: i I 1 �'L�.�C t�C
Address:
City, State, Zip Coder Z -��(,l C C��• 33e(
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Phone#: (�(i
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.
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Additional Information
Please check one only:
State Licenses: ❑ Bakery ❑ Liquor Permit _j None
Water Supply: j 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):
A L G � ';k
Applicant Signature: _
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: 1 ["2 ❑ 3 ❑ 4 ❑ Expiration Date: l"Z;13 l�lda
Date Received: Date Approved: I-?,�'' d l I-)
ServSafe
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ServSafe
CERTIFICATION
LYDIA LUBYNSKY
for successf*om*,Wing the siarx6ds set 6th for the ServSafee Food Pro"an Mmoger C"hcation Examination,
which is accredited 6y the American National Standards Institute(ANSIP<bnfi wm nor Food Protection(CFP).
1.344895 5263
B,NUMBER EXAM FORM NUMBER
7/10 ,� 7/10/2022
DATE OF ,WNATION DATE OF EXPIRATION
Local lows apply. ::i,v i -41 yaw Ioal a gw1co y for recertification requirernerts.
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CERTIFICATION
CRYSTAL DIANA
for successfully completing the standards set forth for the ServSafe®Food ProkK§cn McwwW Certification Examination,
which is accredited 6y the American National Standards Institute(ANSIKCon6rarm for Food Protection(CFP).
4397707 5280
UMBER EXAM FORM NUMBER
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7/24 7/24/2022
DATE OF E DATE OF EXPIRATION
Local laws apply i_. For recertification requirements.
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FOOD SAFETY PROFESSIONALSO
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HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE
CERTIFIED
FOOD 3AVEtT AIANAC.7iX R FOOD SAFETY MANAGER
UNDER THE
CONFERENCE FOR FOOD PROTECTION STANDARDS
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PRESIDENT:
LAWRENCE J. LYNCH,CAE
ISSUE DATE: MARCH 10, 2015
noh56 EXPIRATION DATE: MARCH 10, 2020
CERTIFICATE NO: 21078101
7680 Universal Blvd.,Suite 550.Orlando,FL 32819 TEST FORM: EXE49
P(800)446-0257 F(407)352-3503 www.NRFSR=n This certiricate is not valid for more
National Registry of Food Safety ProfessionalsO Ihnn rive vears from date of issne.