HomeMy WebLinkAbout83 Gerber Road (3) °*" SE 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
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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: Ticketnetwork
Name of Person in Charge: hNi c&y.-/ Zei 73-h-C
Establishment Street Address: 83 Gerber Road
City, State, Zip Code: South Windsor, CT 06074
Phone#: i Cell Phone#: r' / �
Fax#:
E-Mail Address: NllIle, Leoska O LJ,,t,,efw,rk Seating Capacity:
Please submit latest coov of the Certified Food ProteCtio. 'Vanager,ServSaie certificates to the office.
Certified Food Protection Manager YES j-NO ❑ Certificate#: /V6 yYF5/
(CFPM) (Required for ALL Class 2,3&4)
Name: -�� Expiration Date: _
Testing Organization: Phone#: Wy ��
E-Mail Address: � �-;��, ;s � {/ fLAlternate Phone#:
Alternate Person In Charge /r� f T�r � Phone
Restaurant Owner Contact Information
Owner's Name: Please check one of the following for ownership
l f � If le- h� status:
Mailing Address: Individual ❑ Association ❑
City, State, Zip Code: 1 ;; , 7 � Corporation � Partnership❑
6 G l Other Legal Entity❑
Phone#: '�� �yc/ Cwjt�Uli Fax #:
E-Mail Address: ✓, Cell Phone#: �!el1� 0' 16)
Renovations
Were there any renovations made last year? YES❑ NO U4�-" Will there be any renovations? YES❑ NO a'
If Yes, please list all renovations
that were done/to be done:
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Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES 5 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.
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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): �� � f i,;fj�j Date of Birth:
Applicant Address: , ,, -Cc 1 ,f "aT Phone#:
Applicant Signature: , Date: / /ell
Office Use Only '
Inspector Name (Print):
Inspector Signature: Date:
Food Class: Expiration Date:
Date Received: Date Approved:
Thursday
Baked New England Cod
Friday
Philly Steak Grinder
Saturday
Breakfast
Eggs, French Toast Sticks, Bacon
Lunch
Sandwiches,Salad Bar, Burgers, Dogs, Fries
Monday
Fajita Bar
Tuesday
Spaghetti and Meatballs
Wednesday
Sweet and Sour Chicken
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51115/2018 /2023
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DATE OF EX DATE OF EXPIRATION
1i 's@,`r, -ppv recerfi ficanon requir}Qmnts.
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CERTIFICATION
DAVID FOSS
for successfully completing the standards set forth for the ServSafe®Food Protection Manager Certification Examination,
which is accredited by the American National Standards Institute(ANSIKonference For Food Protection(CFP).
fi49954 5240
UMBER EXAM FORM NUMBER
1/23 q�i �J 1/23/2022
DATE OF E DATE OF EXPIRATION
local laws apply.Ch cy for recertification requirements.
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