HomeMy WebLinkAbout845 Sullivan Avenue (4) °w" S f41 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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New Permit❑ Permit Renewal
Type: Mobile/Itinerant Vendor❑ Temporary Event❑ Permanent Food Service Establishment[�
***(Please Print Clearly)*** CLASS: FEE DUE: �lasb w
Name of Establishment: a,�Y emu{c vl
Name of Person in Charge: Z6 br'ilA'
Establishment Street Address: y 57L,1 , VcL Vk aY
City, State, Zip Code:
Phone#: )Fre& Cell Phone#: O , l g4
Fax#: 7ac4 S_
E-Mail Address: �j S�L�hw r,C�? Seating Capacity: f S'
Certified Food Protection Manager YES p(NO ❑ Certificate#: /O 6 4c o-5 y
(CFPM)
Name: ?u �,. ��2k�+v Expiration Date: i�3°%
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Testing Organization: S-e Nv Phone#: P6,o- y°(f a--5` 7A-S-
E-Mail Address: �(,� s, Zy�L, ,�c� f5 m ( Altemate Phone#: S'66 -y3d - 29-�-D
Alternate Person In Charge x1iC rH ,//T Jt Phone#: S� C?
Owners Name: �be�"` l t� - (tea 2� Please check one of the following for ownership
statLs:
Mailing Address: 100 ���e„Z C�c;S e f n`�� ( Individual❑kAgp�aorctinership
ation❑C ration City, State,Zip Code: . a y0 N C✓� O�ad ( °�° ❑
_ Other Legal Entity❑
Phone#: ��Oa q�� ' ��� Fax #: 5'4,0 -0 yob
E-Mail Address: -LE LR�k l N a I-- A C i, , C 6,)g n Cell Phone#: GU
Were there any renovations made last year? YES❑ NO �ill there be an renovations? YES❑ NO �/
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If Yes, please list all renovations
that were done/to be done:
JAN
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G@.PAFtThh4
YES❑ NO ❑
Please/fist all menu items in as much detail as possible a copy of a menu attached is applicable.
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S iZ"m J7 `0'66, 77/
[J ok to order ONLY ❑ Advanced catering for specific quantities ❑Uses Time as a Public Health Control
[7��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)
Please check all that apply: L
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State Licenses: ❑ Bakery ❑ Liquor Permit El None f-he?e
Water Supply(check only one): ✓ Public _Private Well
Wastewater Disposal (check only one): Public _Septic _Other(please use space below to explain)
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): AC" w , LI'1�-r"\/ Date of Birth: e -9p lg S 7
Applicant Address: p e1 e- aya tl eT Phone#: J6 U- y7 -Af 7aS
Applicant Signature: Date: Id 13 /
Inspector Name (Print):
Inspector Signature: Date:
Food Gass: Expiration Date:
Date Received: Date Approved:
666925
CA-03 Rey U6 13,
STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
This is your license certificate. This certificate shall be posted in a conspicuous location where business is to be
conducted and shown to any properly interested person on request. Do not attempt to make any changes or alter this
certificate in any way. This license is not transferable.
In an effort to be more efficient and Go Green, the department asks that you keep your email information with our
office current. All renewal notifications and certificates will only be emailed to the last reported email on record.
You can update your email, mailing address or print a duplicate certificate by logging into your account with your
User Id and Password at www.elicense.ct.gov.
Questions regarding this license can be emailed to the Food& Standards Division at dcp.foodandstandards(uct.gov.
Mailing address: Email on file to be used for receiving all notices from this office:
D Q GRILL& CHILL
P.O. Box 845 hhrefrigco1954@ao1.com
South Windsor,CT 06074
WA
STATE OF CONNECTICUT ♦ DEPARTMENT OF CONSUMER PROTECTION
Be it known that
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D Q GRILL & CHILL J
{ 845 SULLIVAN AVE
SOUTH WINDSOR, CT 06074-2047 j
has been certified by the Department of Consumer Protection as a licensed
FROZEN DESSERT RETAILER
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License #: FDR.0004097
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Effective Date: 01/01/2019
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Expiration Date: 12/31/2019
verify online at www.clicense.ct.gov _�_ Michelle Seagull,Commissioner l
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