HomeMy WebLinkAbout2019-1-24 - 19 John Fitch Boulevard - Food Permit Application �°*" s4r, 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: Between Rounds
Name of Person in Charge: 'It6ep " P
Establishment Street Address: 19 John Fitch Blvd.
City, State, Zip Code: South Windsor, CT 06074
Phone#: 360•acl(-3 770 Cell Phone#:
Fax#: $6 'bZ34 a27
E-Mail Address:jL)a)Ji 1PraRCk,�i)4j, eating Capacity:
Piease suhmir iatest copy of the Certified Food Protection Manager/ServSafe certificates to the office.
Certified Food Protection Manager YES/ NO ❑ Certificate#: QO
(CFPM) (Required for ALL Class 2, 3&4)
Name: J0501+ PL)j A Expiration Date: `D!1 /0)-,3
'Testing Organization:se U 5"L_ Phone#:
E-Mail Address: �a��1{)1A ��cy 6j4"L 0,L, Alternate Phone#: 260 -Pqi
Alternate Person In Charge _�,h (if Mpt��M Phone#: -36o -dgl-67-20
Restaurant Owner Contact Information
Owner's Name: acwl+-4eew pot t/Ar Please check one of the following for ownership
status:
Mailing Address: !4 Sc>14 tO 15 L U Individual ❑ Association ❑
City, State, Zip Code: '5 l 5� �� ?� Corporation ® Partnership❑
1 �-� Other Legal Entity❑
Phone#: M-) -ocit._ 3-�� Fax #: 2�0-o2Vl d 73;),
E-Mail Address: Cell Phone#:
Renovations
Were there any renovations made last year? YES❑ NO 121 Will there be any renovations? YES 0 NO
If Yes, please list all renovations
that were done/to be done:
RECEIVED
$gip 'i I VVvINDSOR
HEM- ` )E"ARTMENT
Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES E2' 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)
❑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)
Z Prepackaged non TCS Food Only ❑ Non TCS Food only (food that does not require refrigeration)
Additional Information
Please check all that apply:
State Licenses: 2T Bakery ❑ Liquor Permit ❑ None
Water Supply (check only one): J 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): -05 p UII� Date of Birth:
Applicant Address: c)4 Phone#:
Applicant Signature: Date:
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: Expiration Date:
Date Received: Date Approved:
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CERTIFICATION
JOSEPH PU11A
for successfully completing the standards set forth for the ServSafe®Food Protection Manager Certification Examination,
which is accredited by the American National Standards Institute(ANSI)—Conference for Food Protection (CFP).
5397
ER EXAM FORM NUMBER
10/1/2018 10/1/2023
DATE OF EX DATE OF EXPIRATION
Local laws apply.Che cy for recertification requirements.
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ACCREDITED
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PROGRAM
American National Standards Institute
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#0655 ciation Solutions
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e ServSafe logo are trademarks of the NRAEF.National Restaurant Association®and the arc design
Contact us with questions at 233 S.Wacker Drive,Suite 3600,Chicago,IL.60606-6383 or Serv$aWrestaurant.org.