HomeMy WebLinkAbout2018-12-28 - 109 Sand Hill Road - Food Permit Renewal °W" Sf4< 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
soR•co �,/
Establishment Information New Permit El Permit Renewal L►�
Type: Mobile/Itinerant Vendor❑ Temporary Event❑ Permanent Food Service Establishment❑
***(Please Print Clearly)*** CLASS: 3 FEE DUE: EXEMPT
Name of Establishment: St Peter
Name of Person in Charge: ./ KKL�;-Altq
Establishment Street Address: 109 Sand Hill Road
City, State, Zip Code: South Windsor, CT 06074
Phone#: '9I6O-4,,44•_854g Cell Phone#: lof5. 3LI7 8630
Fax#:
E-Mail Address: Wo1fd4hccQ W5rv)c.1,to m Seating Capacity: I D o
Please submit latest copy of the Certified Food Protection Manager/ServSafe certificates to the office.
Certified Food Protection Manager YES❑ NO Z Certificate#:
(CFPM) (Required for ALL Class 2,3&4)
Name: Expiration Date:
Testing Organization: Phone#:
E-Mail Address: Alternate Phone#:
Alternate Person In Charge Phone#:
Restaurant Owner Contact Information
Owner's Name: Please check one of the following for ownership
status:
Mailing Address: Individual ❑ Association ❑
Corporation ❑ Partnership❑
City, State, Zip Code: Other Legal Entity❑
Phone#: Fax #:
E-Mail Address Cell Phone#:
Renovations
Were there any renovations made last year? YES❑ No Will there be any renovations? YES❑ NO 2r
If Yes, please list all renovations _
that were done/to be done:
pEcF_NVD
Soul t4
TMENT
H LTH DF 'R
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.
co Kw wr, W'a.c � (cu l4t-e, C.001Cat-;, t"'dcbrLAA4
oc-cas►'onal poh lutlCw�eals
-[G�Anks�i'�;;,� nnea l� S�v�l� W�'ndsor scwiptrS
Restaurant Food Prep (check all that apply)
❑Cook to order ONLY ❑Advanced catering for specific quantities ❑ Uses Time as a Public Health Control
❑Cooking/cooling/reheating/thawing/freezing/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 ZNon TCS Food only(food that does not require refrigeration)
Additional Information
Please check all that apply:
State Licenses: ❑ Bakery ❑ Liquor 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: 5113 ►c{5
Applicant Address: to !!�ar-j It Tzd . S. "'IA40e Phone#: CIS 3c}7. 3�
Applicant Signature: Date: I-;t- ►G1 t g
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: Expiration Date:
Date Received: Date Approved: