HomeMy WebLinkAbout2018-12-28 - 1735 Ellington Road - Food Permit Application Sal's �t°%*4" Seq<� Town of South Windsor — Healtgi 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
Type: Mobile/Itinerant Vendor❑ Temporary Event❑ Permanent Food Service Establishment
***(Please Print Clearly)*** CLASS: 3 FEE DUE: 250
Name of Establishment: Sal's New York Pizzeria
Name of Person in Charge: ! 6Cav&-4DYe. Moazel-r"e.—
Establishment Street Address: 1735 Ellington Rd, Unit 5
City, State, Zip Code: South Windsor, CT 06074
Phone#: p •(oY ''L2 01> Cell Phone#: 203 606- ro487
Fax#:
E-Mail Address: tit Rt,14raa dm(� ?y�p� eating Capacity: yS
Please submit latest copy of the Certified F od Protection Manager/ServSafe certificates to the office.
Certified Food Protection Manager YES NO ❑ Certificate#: p
(CFPM) (Required for ALL Class 2,3&4) 213 2:7 d -7
Name: Sa\qa+are MaLZarel p Expiration Date: M Arcj-) 1 S j 2O ZZ
Testing Organization: O F C)con_3 ult'l nc3 Phone#: 2C)3-592—'2 4 3
_ E-Mail Address: (po CO»SU(j-j r�5 CQnte(Alternate Phone#:
Alternate Person In Charge 01t4-I00K.CnM Phone#:
one. Rignon
Restaurant Owner Contact Information
Owner's Name: S �Q-f- e M aZZ �Q Please check one of the following for ownership
status:
Mailing Address: 6335- PL41rheLm )Zd Individual [Association ❑
/v Corporation ❑ Partnership❑
City, State, Zip Code: GwIford CT) Up6� Other Legal Entity❑
Phone#: 203- (POE-9-acrl _ Fax #: _
E-Mail Address: M Gl ZZOI relr�C11'Y1�y(�.h •CC�O'1 Cell Phone#:
Renovations
Were there any renovations made last year? YES❑ NO Q� Will there be any renovations? YES❑ NO 2
If Yes, please list all renovations _
that were done/to be done:
RECEIVED
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Restaurant Menu/List of 7NO
ms 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.
Restaurant Food Prep (check all that apply)
Vcook to order ONLY [Advanced catering for specific quantities ❑ Uses Time as a Public Health Control
L_Kcooking/cooling/reheating/thawing/freezih§ttWtor cold holding El Prepares food to serve at another site
❑ Prepares food for Highly Susceptible Population(preschoolers or the elderly) Sovv eh�nvd
❑ Prepackaged non TCS Food Only ❑ Non TCS Food only (food that does not require refrigeration)
Additional Information
Please check all that apply:
State Licenses: [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 immediate shutdown or revocation of my Food Service License for
the Town of South Windsor.
Applicant Name (Print): AVQ' DY-e M 60.WurelLla Date of Birth: �(p� 0 i 5�
Applicant Address: js plat cw» I,CiI�U/d 71)oy3 P : 203-
Applicant Signature: Date: Ja
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: Expiration Date:
Date Received: Date Approved:
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4 o FOOD ,.
NATIONAL REGISTRY OF
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,.� FOOD SAFETY PROFESSIONALSO
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CERTIFIES
�.s SALVATORE MAZZARELLA
" HAS SUCCESSFULLY SATISFIED THE R9QUIREMENTS FOR THE k
FOOD SAFETY MANAGER
x. UNDER THE
CONFERENCE FOR FOOD PROTECTION STANDARDS
a� I
is
PRESIDENT:
is LAWRENCE J,LYNCH,CAE
ISSUE DATE: MARCH 18,2017
ntxse EXPIRATION DATE: MARCH 18, 2022
e CERTIFICATE NO:21327807
, 0 U"*Orsal 8W.,SuiP 5%Orlando,FL 31819 TEST FORM: EZS36
+I���rvq(8U0)446.0257 F(A07}352 3603.wYv1N.IVitF.SFoO[n This certificate is not valid fer more
60681 Regl*.b Food S8f8tY PfOf@$&ibnafedl than five years from date of issue.