HomeMy WebLinkAbout465 Buckland Road (7) Ao*m <� 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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Restaurant Establishment Information New Permit❑ Permit Renewal
***(Please Print Clearly)***
Name of Establishment: SAa0tZ)Fc 7yft 1 Cal l5-Il r
Manager's Name: -P ti'
Street Address: L4 5- _Rt(C jc&+PvD R2) ,City, State, Zip Code: SG u7 iwlivDS6 k , 6 T 01,074
Phone#: (9-60 P14 Cell Phone#: (q17) 5-3
Fax#:
E-Mail Address: Seating Capacity: 5N
Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office.
Qualified Food Operator: YES 0 NO ❑ (Required for Certificate#: �JLj�f
Class 3&4)
Name: Date: .2/2 Z/',�-O
Testing Organization: Phone#:
E-Mail Address: Alternate Phone#:
Designated Alternate 1: Designated Alternate2
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Restaurant Owner Contact Inf�oIrrnation
Owner's Name: %A� L't>'vA✓/'R .4 TiK
Street Address: F4�C"
City, State, Zip Code: km/VefcSTtr' 07 06C'-/.;2
Phone#: 4 3$ Fax #:
E-Mail Address: Cell Phone#: ( -7)5 5' „2�3b
Renovations
Were there any renovations made last year? YES NO ❑ Will there be any renovations? YES❑ NO ❑
If Yes, please list all renovations VA-7�2 �E,¢?/��'
that were done/to be done: ----- —
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RECEIVED
DEC 1 ,9
Mailing Address to send Food License Renewal Permit to: SOUTH WINDSOR
HEALTH DEPT
Name of Restaurant/Company: SA t(-JA[)Ft 7N-/I/ (Ta s ikE
Attention: T K EPANG,,e f1,41-1 t-rh/AvieAl.Q
Address: d/(r S 8 Lf Lr/K f/j V1) ;�U
City, State, Zip Code: SoiiV w1mbsaR , C7 Obl'
Phone#: ( eM ) �41-1-6 Z -/7
Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YESAI 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 i Liquor Permit [ J None
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 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): 7-,40 �, �v1k1-114, 77X &h4C,11t-6'/R%),9-
Applicant Signature: Date: // " 17
Office Use Only
Inspector Name (Print): / 4 S
Inspector Signature: ^ , Date:
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Food Class: 1 ❑ 2 ❑ 3 []'4 ❑ Expiration Date: k"C�3)j loll'
Date Received: Date Approved: mm(lam
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