HomeMy WebLinkAbout520 Griffin Road (3) 0A SE4<� Town of South Windsor - Health Department
r _ 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
I�SOR CV .
Establishment Information New Permit❑ Permit Renewal
Type: Mobile/Itinerant Vendor❑ Temporary Event❑ Permanent Food Service Establishment Rr
***(Please Print Clearly)*** CLASS: 3 FEE DUE: 250
Name of Establishment: Topstone Restaurant
Name of Person in Charge: 14<<h4P I' &ey,n&?
Establishment Street Address: 520 Griffin Road
City, State, Zip Code: South Windsor, CT 06074
Phone#: (�-�6) Yy-S(j7� Cell Phone#: X0 lily 003
Fax#:
E-Mail Address: {�/,,� Seating Capacity:
Please submit latest copy of the Certified Food Protection Manager/ServSafe certificates to the office.
Certified Food Protection Manager YES N NO ❑ Certificate#: ►S'�o) ��
(CFPM) (Required for ALL Class 2,3&4)
Name: 091c ,e) Ov/_ h/) Expiration Date: S13I/a0J�
Testing Organization: �54 Phone#:
E-Mail Address: Alternate Phone#:
Alternate Person In Charge SST-el jfn SrJq�4 Phone#
Restaurant Owner Contact Information
Owner's Name: ,h� I � � Please check one of the following for ownership
v' status:
Mailing Address: (�� �,n rf� Individual ❑ Association ❑
�I Corporation RJ Partnership❑
City, State, Zip Code: ,� Oxi�- LT 06c 16 Other Legal Entity❑
Phone#: Fax #:
E-Mail Address: Aith pd Ce-toevi Cell Phone#:
Renovations
Were there any renovations made last year? YES❑ NO [5C Will there be any renovations? YES❑ NO ❑
If Yes, please list all renovations
that were done/to be done:
RECEIVED
SOUTH 4VINUSOR' 1�
-EALTH DEPARTMEN
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.
Restaurant Food Prep (check all that apply)
❑ Cook to order ONLY [Z Advanced catering for specific quantities ❑ Uses Time as a Public Health Control
Cooking/cooling/reheating/thawingMreezing/hot or cold holding ❑ Prepares food to serve at another site
❑ Prepares food for Highly Susceptible Population(preschoolers or the elderly)
❑ Prepackaged non TCS Food Only ❑ Non TCS Food only(food that does not require refrigeration)
Additional Information
Please check all that apply:
State Licenses: ❑ Bakery NO -quor Permit ❑ None
Water Supply (check only one): Public _ Private Well
Wastewater Disposal (check only one): _ Public Septic 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 and that I will comply with the
ordinances and regulations of the Town of South Windsor and State of Connecticut. I also affirm to allow the Town of South
Windsor Health Department access to the establishment as required. 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): Date of Birth:M
Applicant Address: 3 (� Phone#: 9-60
Applicant Signature: Date: 3
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: Expiration Date:
Date Received: Date Approved:
I �
e
ry fe
CERTIFICATION
MICHAEL GEYSEN
for successfully completing the star 6ds set forth for the ServSafet Food Protedion Manager Certification Examirwtion,
which is accredited by the American National Standards Institute(ANSI)-Conf+laren x for Food Protection(CFP).
01226 5265
UMBER EXAM FORM NUMBER
5/31 5/31/2022
DATE OF E DATE OF EXPIRATION
Local laws apply.Ch y for recertilicalion requirements.
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