HomeMy WebLinkAboutApplication 65 Rye Street (5) �,t°"'" <� Town of South Windsor — Health Department
o 1540 Sullivan Ave., South Windsor, CT 06074- Mailing Address
1530 Sullivan Avenue, South Windsor, CT 06074- Office Address
yy _ 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: J�-
City, State, Zip Code: j �� ?r� 'ij�
Phone#: ��e S� 7l, as Cell Phone#:
Fax#: e6Da9/- y36�
E-Mail Address: �j�G / 2�y�� /� 1O� Seating Capacity:
Flcase submit latest copy of the Qualified Food Operator/ServSafe certificates to the office.
Qualified Food Operator: YES Ej�NO ❑ (Required for Certificate#:
Class 3&4)
Name: Date:
Testing Organization: Phone#:
E-Mail Address: Alternate Phone#:
Designated Alternate 1: Designated Alternate2
Restaurant Owner Contact Information
Owner's Name: ZcLoc--e� (rfr,-Xe
Street Address: " Sfte
City, State, Zip Code: s c,,kA �� � - L)i"
Phone#: 1Zw "Sdq "la(aaa Fax #: `alb- a91 9 -;-
E-Mail Address: ('(lAle .S ,� 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
0 2017
Mailing Address to send Food License Renewal Permit to: SOUTH WINDSOR
HEALTH DEPT.
Name of Restaurant/Company: (Y1P1f�yS
Attention: � � ( \ft-Aerl,--y
Address: (S (1-716 S
City, State, Zip Code: S��ti t1 (j,_3►�4-40ik, 0&0r1+
Phone#: C�la; - S n_"}')-
ServSafeo
CERTIFICATION
PABLO VAZQUEZ
For wooessFally aanpleling die smnderds set forth for the ServSafee Food Prokdian Monager CeriiBcation Exarnination,
which is acaediled by the American National Slandards Inslitule(AN�Fenrtae For Food ProWian(CFPI.
N
15448393 5282
:ER11F1CATE NUMBER EXAM FORM NUMBER
8/7/2% 8/7/2022
DATE OF EXAMINATION DATE OF EXPIRATION
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045 -40- 7883 04,f
MANEELEY, BRUCE
26 SC.HWEIR ROAD .
S. WINDSOR, CT 06074
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