HomeMy WebLinkAbout700 Ellington Road (5) 0*" Se4<� Town of South Windsor — Health Department
r 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 V
Type: Mobile/Itinerant Vendor❑ Temporary Event❑ Permanent Food Service Establishment❑
***(Please Print Clearly)*** CLASS: 2 FEE DUE: 125
Name of Establishment: Seven Eleven (7-11)
Name of Person in Charge: 5 H f)H► S) 1)►1/ 0
Establishment Street Address: 700 Ellington Road
City, State, Zip Code: South Windsor, CT 06074
Phone#: Cell Phone#:
Fax#:
E-Mail Address: Si DD)4)SHANiD6)msN.CoMSeating Capacity:
Please submit latest copy of the Certified Food Protection Manager/ServSafe certificates to the office.
Certified Food Protection Manager YES NO ❑ Certificate#: / 5 7a.
(CFPM) (Required for ALL Class 2,3&4)
Name: SH,9hl D_S/DP/6 Expiration Date: o 4 l oaf aaa 3
Testing Organization: S CRY 5hPC Phone#: 860-3a4 -,'2S1V
E-Mail Address: SjDD/61SPA01 DCm.5m.CcM Alternate Phone#: Sk-993--3186
Alternate Person In Charge f)mMARA_ SHAHO Phone#: p6o--yg3-318a
Restaurant Owner Contact Information
Please check one of the following for ownership
Owner's Name: PI M M A R 6 SHAH[' D
status:
Mailing Address: 91 S o LTo N Pe AD Individual ❑ Association❑
State, Zip Code: `` / Corporation 1K Partnership ElCity
'_ p 1f�R1�10/J C-'-O Oo 6 Other Legal Entity❑
Phone#: $�� � 993-3 19" Fax #:
E-Mail Address: Si D1)i,Q S)MH 11) MAJ -CAM Cell Phone#: $66-aq 3-3 Ig d
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:
RECEIVED
JAN 0 401
SOUTH WINDSOR
HEALTH DEPARTMENT
Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES❑ NO 'K 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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1907 N6 S') t T C C
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: V 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-im-mediate shutdown-or revocatiorr of my Food Service License for -
the Town of South Windsor.
Applicant Name (Print): Date of Birth: ) _)a—197 5-
Applicant Address: ,�� &LO TON AmD, 'V eRNON Phone#: g�0-31?'G -o25 ag
Applicant Signature: Date:
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: Expiration Date:
Date Received: Date Approved:
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for 2cessfully completing t)V standards set forth fosbe e fe's Food PIralection Manager Certifi n Examination, Se
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4/2/2018
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DATE OF EX I DATE OF EXPIRATION
AS*kF2659 Loc s apply.Che r recertification requir nts.
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