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HomeMy WebLinkAbout989 Ellington Road (4) °*" 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 s Phone Number: (860) 337-6173 Fax: (860) 644-1930 OR CO Establishment Information New Permit❑ Permit Renewal ❑ Type: Mobile/Itinerant Vendor❑ Temporary Event❑ Permanent Food Service Establishment❑ ***(Please Print Clearly)*** CLASS: 3 FEE DUE: 250 Name of Establishment: Mill on the River Name of Person in Charge: rta.Y Igo v Establishment Street Address: 989 Ellington Rd City, State, Zip Code: South Windsor, CT 06074 Phone#: 9(vb—,19q-71JL7 Cell Phone#: Fax#: 0( 0`' E-Mail Address: Seating Capacity: UGC Please submit latest copy of the Certified Food Protection Manager/ServSafe certificates to the office. Certified Food Protection Manager YES . NO ❑ Certificate#: (CFPM) (Required for ALL Class 2,3&4) 1 tp 3/,5- / a Name: 01xre Z Expiration Date: f ©f Testing Organization: Phone#: glib --a g`q-r7 E-Mail Address: Alternate Phone#: Alternate Person In Charge WtrAk-v- loo l'F Phone#: Restaurant Owner Contact Information Owner's Name: LL��� ' �r �, j Please check one of the following for ownership t� t status: Mailing Address: l Individual Association ❑ Corporation Partnership❑ City, State, Zip Code: a hJ _ T- p(,�o7'f Other Legal ntity El Phone#: 0 - -1-91� '-`�`� Fax #: E-Mail Address: _ Cell Phone#: g ® '11&_ y73 Renovations Were there any renovations made last year? YES❑ NO Will there be any renovations? YES❑ NO)Kr If Yes, please list all renovations that were done/to be done: RECEIVED $QQTH 4^ONQ$OR HFALT-H,DEfARTRAENT 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 ❑ Advanced catering for specific quantities ❑ Uses Time as a Public Health Control 'Cooking/cooling/reheating/thawing/freezing/hot or cold holding ElPrepares 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 )Rr Liquor Permit ❑ None Water Supply (check only one): X. Public _ Private Well Wastewater Disposal (check only one): X 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. �c{S Applicant Name (Print): I L,( M �. -— /� Date of Birth: Applicant Address: ( o r � i Phone#: e1P& Applicant Signature: ` Date: Office Use Only Inspector Name (Print): Inspector Signature: Date: Food Class: Expiration Date: Date Received: Date Approved: y� ServSafe ry a fe* CERTIFICATION JOSE CHAVEZ W, For suaftJ+completing the stonclarcils set Forth For the mcnosw C 11&atic which is occredited by the American Notional Standards a For Food Protect E R E "` 8/20/2018 8/20/2023 LL DATE OF EX DATE OF EXPIRATION Local laws apply. for romr ificotion requirements. � S #0655 'a►ion Solutions b amdoeoe Sw4*6 Ego are katieew 6 of dw NRW tbkad Re0ouraea Amomubm*and im arc Jump Carod w wdh querom or 2M S.Wodm Dam,Sine UM.C6cWa,L 606