HomeMy WebLinkAbout465 Buckland Road (9) /°W" SE4<� Town of South Windsor — Health Department
1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
1530 Sullivan Avenue, South Windsor, CT 06074—Office Address
Phone Number: (860) 337-6173 Fax: (860) 644-1930
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Establishment Information New Permit❑ Permit Renewal
Type: Mobile/Itinerant Vendor❑ Temporary Event❑ Permanent Food Service Establishmenlo
***(Please Print Clearly)*** CLASS: 3 FEE DUE: 250
Name of Establishment: Sawadee Thai Cuisine
Name of Person in Charge: �u�rVut<,C�,c,4�I L�tfr�4Qryt1
Establishment Street Address: 465 Buckland Road
City, State, Zip Code: South Windsor, CT 06074
Phone#: (go?? 6#4 -04,V7 Cell Phone#: (9/7)535 ag3,G
Fax#: (009-a A-r iom) 90-)
E-Mail Address: -SAW,4D6-�-'CTd'644-I t_C04eating Capacity:
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Certified Food Protection Manager YES NO ❑ Certificate#: r'�/St12f3 S
(CFPM) (Required for ALL Class 2,3&4)
Name: Ail RA MA-W"Lgt Expiration Date:
Testing Organization: �4"/ Phone#:
E-Mail Address: Alternate Phone#:
Alternate Person In Charge Phone#:
Restaurant Owner Contact Information
Owner's Name: T� f GilAN6KH4H OH(1,40" )Al Please check one of the following for ownership
status:
Mailing Address: ij(p5 BV CKLAND WOAD Individual ❑ Association ❑
City, State, Zip Code: �XvM WfAIDSORl eT 06074 Corporation ❑ Partnership
Other Legal Entity❑
Phone#: 06o) vy -06-'l7 Fax #:
E-Mail Address: Saw a.d.W-elf_egY"a cp,C64 Cell Phone#: ?/7-53S--.2V34
Renovations
Were there any renovations made last year? YES❑ NO ❑ Will there be any renovations? YES❑ NO ❑
If Yes, please list all renovations PAi T►NG ;D tivtN6 ROOM ACEA
that were done/to be done:
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Restaurant Menu/Last 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 [:]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 ❑ Non 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): E14R1AfoKA4N 4t&1,+✓;kjy,4 Date of Birth: 6�%7./,o. lg43
Applicant Address: #05 RUCk'1-,+1VD RD, 9oc(T�l WIAI S0,2 E/ Phone#:��j�
Applicant Signature: �lo� Date:
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: Expiration Date:
Date Received: Date Approved:
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Exam 4902 Recognized By Conference For Food Protection
�) Certificate No: 1984350
Exam Date: 12/28/17
Ryan MCMillion,Client Services Manager Test Code: 6203044902
Prometric 17941 Corporate Drive,Nottingham,MD 21236 I 800.624.2736 Expires on: 12/28/22
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