HomeMy WebLinkAbout400 Evergreen Way (3) "I'*N 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 Establishment
***(Please Print Clearly)*** CLASS: 3 FEE DUE: 250
Name of Establishment: Red Heat
Name of Person in Charge:
Establishment Street Address: 400 Evergreen Way Suite 466
City, State, Zip Code: South Windsor, CT 06074
Phone#: 6 (f 32 - 'S�6 s Cell Phone#:
Fax#:
E-Mail Address: %owe��1 11-ecl�e a�e.r�?a�tigapacity: a 53
Please submit latest copy of the Certifie7NOEI
Protection Manager/ServSafe certificates to the office.
Certified Food Protection Manager YES Certificate#:
(CFPM) (Required for ALL Class 2,3&4) 1 ep D Lj 76
Name: � � 0 Expiration Date: 0131 oS'I/ 9
Testing Organization: Se co �e_ Phone#: 86c-y37_— 3
E-Mail Address: Alternate Phone#:
CvM
Alternate Person In Charge Chc,S Leif Phone#:
Restaurant Owner Contact Information
Owner's Name: Please check one of the following for ownership
e�i ;•� �C1 f t�rJ status:
Mailing Address: 3LyL 6r,r kSkv.4 S 5,;Gc to3 Individual ❑ Association❑
Corporation ❑ Partnership❑
City, State, Zip Code: � ,u �` �ct p��ii p Other Legal Entity LLL
Phone#: Fax #:
E-Mail Address: ��� f,b J 3����„ r `\ r 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 S ,� i.•�A S �, �} z� v - `
that were done/to be done:
3---RECEIVED
0EC 1 a 2018
SOUTH WINDSOR
HEALTH DEPARTMENT
Restaurant Menu/List of All I ms 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)
5400k to order ONLY ❑Advanced catering for specific quantities ❑ Uses Time as a Public Health Control
li(Cookingicooling/reheatMg/thawingKreezing/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): i/ 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�LrJ Date of Birth: ay
Applicant Address: o� t��CkS1'�.-2- v(A�2 SJ 1�3 Phone#:
Applicant Signature: Date: / /�✓Lp i`�,
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: Expiration Date:
Date Received: Date Approved:
tkk�- � t.%- -4 6�ik�
NP 104921R97
State of Connecticut Workers' Compensation Commission
Notice to Employees
vui t•NE1
/RAXSJUf/TJS
Workers' Compensation Act
Chapter 568 of the Connecticut General Statutes(the Workers' Compensation Act) requires your employer,
Burtons Grill, LLC
to provide benefits to you in case of injury or occupational disease in the course of employment.
Section 31-294b of the Workers' Compensation Act states: "Any employee who has sustained an injury
in the course of his employment shall immediately report the injury to his employer, or some person
representing his employer. If the employee fails to report the injury immediately,the commissioner may
i
reduce the award of compensation proportionately to any prejudice that he finds the employer has
sustained by reason of the failure,provided the burden of proof with respect to such prejudice shall rest
upon the employer." Such an injury report by the employee is NOT an official written notice of claim for
workers'compensation benefits.(The Form 30C is necessary to satisfy this requirement.)
The INSURANCE COMPANY or SELF-INSURANCE ADMINISTRATOR is:
Name Wesco Insurance Company
Address 800 Superior Avenue East, 21st Floor Telephone 877-528-7878
City/Town Cleveland, OH 44114
Approved Medical Care Plan ❑Yes ❑No
The State of Connecticut Workers'Compensation Commission office for this workplace is located at: z
Address Telephone&0-,%(,,-49."�l s
Cityfrown E, f State CT Zip Code ()(al(qFj E
Any questions as to your rights under the law or the obligations of the employer or insurance company
should be addressed to the employer, the insurance company or the Workers' Compensation
Commission(1-800-223-9675).
THIS NOTICE MUST BE IN TYPE OF NOT LESS THAN TEN POINT BOLD-FACE AND POSTED IN A
CONSPICUOUS PLACE IN EACH PLACE OF EMPLOYMENT. FAILURE TO POST THIS NOTICE WILL
SUBJECT THE EMPLOYER TO STATUTORY PENALTY(Section 31-279 C.G.S.).
n
n Date
Posted
i
Rev.8-31-2004
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