HomeMy WebLinkAbout655 John Fitch Blvd (2) Town of South Windsor — Health Department
0 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: Lena's Restaurant
Name of Person in Charge: _ _
Establishment Street Address: 655 John Fitch Blvd.
City, State, Zip Code: South Windsor, CT 06074
Phone#: _ Cell Phone#:
Fax#:
E-Mail Address: Seating Capacity:
Please submit latest copy of the Certified rood Protection wanager:ServSafe certificates to the office.
Certified Food Protection Manager YES�6 NO ❑ Certificate#:
(CFPM) (Required for ALL Class 2,3&4) fto�?13 "
Name: Oil/,F_4Z_0 Expiration Date:
Testing Organization: ,S`jzv S,�- .,_ Phone#: 2?CQa--S2�$-!53Co
E-Mail Address: S. 6 G ON P Alternate Phone#: EGG—b'K3-0Z,3,2
Alternate Person In Charge 4, �44 le4p/-IC-12 Q Phone#:
Restaurant Owner Contact Information
Owner's Name: ,$ G 0^1zWZ.0 Please check one of the following for ownership
status:
Mailing Address: %OY l-> Z/,4 DI2. /Z®G V ,yyL( Individual ❑ ,Ssociation❑
Corporation p' Partnership❑
City, State, Zip Code: 06 V 6 7 Other Legal Entity❑
Phone#: Y&0- 8,Y3-02 37 Fax #:
E-Mail Address: 5,4•4Z-olvFa40 C � Cell Phone#;
Renovations
Were there any renovations made last year? YES❑ NO IR Will there be any renovations? YES[] NO [�
If Yes, please list all renovations
that were done/to be done:
RECEIVED
Jar 20i
L____
SOUTH WINDSOR
HEALTH DEPARTMENT
Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES❑ NO ;9 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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..Res urant 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 tha apply:
State Licenses: Bakery Li 'or 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 Depaftmert aeeess any false-staterner its 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): Z elly C-4Z l) Date of Birth: IO 'I
Applicant Address: /Z OGh Phone#:
Applicant Signature: Date: 12122,,IIS
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: Expiration Date:
Date Received: Date Approved:
1ZM CX\tl-- (-ISO(-
6
Servs , feCERTIFICATION
SALVATORE LONEIRO
for successfully completing the standards set forth for the Se, n Manager Certification Examination,
which is accredited by the American National Standards`' j > rence for Food Protection(CFP).
t
E R E � '
x S �
7/15/202
x �
DATE OF EX DATE OF EXPIRATION
Local laws apply.Ch cy,for recertification requirements.
ACCREDITED PROGRAM
Amerkan Nabonal Standards Institute
Sher
#0655 ciation Solutions
In accordance wi
PIMP—
ServSafe logo are trademarks of the NRAEF.National Restaurant Association@i and the arc design
Contact us with questions at 233 S.Wacker Dive.Suite 3600,Chicago,IL 60606-6383 or ServSafeCrestouront.org.