HomeMy WebLinkAbout2018-12-19 - 1750 Ellington Road - Food Permit Application ►s°*" SF"<Q Town of South Windsor — Health Department
1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
1530 Sullivan Avenue, South Windsor, CT 06074—Office Address
ti Phone Number: (860) 337-6173 Fax: (860) 644-1930
�ibsoa•co
Establishment Information New Permit❑ Permit Renewal Od
Type: Mobile/Itinerant Vendor❑ Temporary Event❑ Permanent Food Service Establishment❑
***(Please Print Clearly)*** CLASS: 3 FEE DUE: 200
Name of Establishment: Danny's Little Taste of Texas
Name of Person in Charge: 4&'1I V_I /Fri
Establishment Street Address: 1750 Ellington Road, #2
City, State, Zip Code: South Windsor, CT 06074
Phone#: jam Y Q�_�C��S Cell Phone#: - gQr�
Fax#:
��e�TpT e��,% Seating Capacity:E-Mail Address: (- �oc
Please submit latest copy of the Certified Food Protection ManagerNervSafe certificates to the office.
Certified Food Protection Manager YESX NO ❑ Certificate#: /9AO;Wy
(CFPM) (Required for ALL Class 2,3&4)
Name: Q! /�G 64F6L Expiration Date: ..
Testing Organization: (' � X Phone#:
E-Mail Address: L T,e,q � ��.ta*lternate Phone#:
Alternate Person In Charge I/A YL C6 L OW Phone#:
Restaurant Owner Contact Information
Owner's Name: i��9�l � � '� Please check one of the following for ownership
status:
Mailing Address: a-;W 5caovb l /4 , Individual El Association ❑
City, State, Zip Code: � � Corporation ❑ Partnership❑
A,0 41,4 j�,,, C f- 6600 Other Legal Entity® G(
Phone#: pp - 'Y32 ?y0S Fax #:
E-Mail Address: 17-0 V,,6 `rpl;IV"k ��CO/IQ 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:
RECEIVE®
�l 1, Q ��� j
SOUTH WINDSOR
HEALTH DEPARTMENT
Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YESIg 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 [gAdvanced 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): �O 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.
Applicant Name (Print): 6 /n Date of Birth:
Applicant Address: Phone#:
Applicant Signature: Date:
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: Expiration Date:
Date Received: Date Approved:
R
� x �
^� srr
Rr� Y ��%
ServSa e CERTIFICATION
DANIEL BELL
6r wocassW ac vWng fie slrn 1, 1,set(ordl(or*w SwsaV Food Proleson Manager cwskaim Erovaudim,
Which is=.e&ed 6y&Ameriaon NdwW I Wk&(ANSIKCa for Food Prated.tCFP).
1408 m 10494
NUMBER EXAM FORM NUMBER
9/6/2021
DATE OF E „, DATE OF EXPIRATION
toad lo+n apply. l` (a reoeeiadion mwi merb-
'#t
Illum
I
6 its x NIBM
is � x
x
01013 Maid Ie�a.rad..s6dYi.WAM
milli ,
.r - C - -w.dkyod'eea173Wladem�5l159Q�oggLAOEW> .ap
Serv- Saiv
National Restaurant Association
ery Safe
CERTIFICATION
DARYL LEBLANC
for successfully owr6fing the stm 6ds set forth for the SwvSafe®Food Promdm Morrager Certificafim b=ni xtion,
which is accredited 6y the Amwmn National Standards h,d*We)ANSI-C�for Food Pmfedion KFP).
197528 10429
UMBER EXAM FORM NUMBER
04/1 04/10/2020
DATE OF E DATE OF EXPIRATION
Loom laws apply.C for mcatifiaslion rewimmenis.
She
t0855 ■
r
�olsr6 ewa..■a.��d6rNRAff.
Ca■■d w.i6 gw■iens at 17i W fodwn BW.Se ISM,Ckkwo,L 60604 a Sm$di Qre■m d a%