HomeMy WebLinkAbout465 Buckland Road (10) s°W" Sf4< Town of South Windsor — Health Department
1540 Sullivan Ave., South Windsor, CT 06074-Mailing Address
1530 Sullivan Avenue, South Windsor, CT 06074-Office Address
r_ 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: ,k C95d
Name of Establishment:
Name of Person in Charge: ,C,,v ��,c,
Establishment Street Address:
City, State, Zip Code: Sv L.� ce. C' ( CC 6c' i
Phone#: Cell Phone#: L)6��
Fax#. NA4
E-Mail Address: Seating Capacity: -�
Please submit latest copy of the Certified Food Protection Manager/ServSafe certificates to the office.
Certified Food Protection Manager YESEY'NO ❑ Certificate#:
(CFPM)jRequired for ALL Class 2,3&4)
Name: Expiration Date:
Testing Organization: Phone#:
E-Mail Address: Alternate Phone#:
Alternate Person In Charge q;'tj ✓/� U(qj j�; Phone#:
Restaurant Owner Contact Information
Owner's Name: ��` v,v C ,� �' Please check one of the following for ownership
status:
Mailing Address: cc�111); u ^r i �c v.��� y(Cc{.�, (�^ Individual❑ Association ❑
City, State, Zip Code: L � 1���� Corporation ❑ Partnership❑
v b �+� 7u/ }(°t f Other Legal Entity❑
Phone#: '_ ( ` -'C t Fax #:
C `� cn Cell Phone#: v w— �( , �c;�7
E-Mail Address: C
Renovations
Were there any renovations made last year? YES❑ NO Will there be any renovations? YES ❑
If Yes, please list all renovations 1 �"� c' e-� t �a F-(e.,
that were done/to be done:
Supplemental Questionnaires
For Itinerant and Temporary Event applications, please complete the supplemental questionnaire form
RECF'',._.)
'H'�"INL'SGk
HL-..•,LfH DEPARTMENT
Restaurant Menu/List of :7NO
ems Served/Sold
Latest Menu Attached? YES ❑ 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.
R Ztarant 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 a
State Licenses: Bakery ❑ Li Permit ❑ None
Water Supply(check only one): _Public _Private Well
Wastewater Disposal (check only one): 1/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): "e; n lc �` Date of Birth: 23—
Applicant Address: So tr�zt" ,,(�;�� �. S(,. G( 06C} ` Phone#: ,ti 6 U
Applicant Signature: `— �----__ "` - Date: 0
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: Expiration Date:
Date Received: Date Approved: