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HomeMy WebLinkAbout855 John Fitch Blvd (2) °W" SE4� Town of South Windsor — Health Department f 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 4�SOR Cv� 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: South Windsor Pizza & Family Restaurant Name of Person in Charge: m 12N i L Rlt� E m ` Establishment Street Address: 855 John Fitch Boulevard City, State, Zip Code: South Windsor, CT 06074 Phone#: fpo - 28g —J( 0 Cell Phone#: 660—gf)e) i368 Fax#: E-Mail Address: 0Q&m,(09tj.Co.,Seating Capacity: j Q _ Please submit latest copy of the Certified Food Protection VaragerlServSafe certificates to tha office. Certified Food Protection Manager YES V NO ❑ Certificate#: 0 (CFPM) (Required for ALL Class 2,3&4) Name: i S(Y1 RI L ie-(y), Expiration Date: Testing Organization: Phone#: E-Mail Address: �lOE,tmr v Q ,,% Alternate Phone#: Alternate Person In Charge F(��—�j��D d %E-M) Phone#: g60�gQ 'Z Restaurant Owner Contact Information Owner's Name: 1S M A 11... A t�i;M► Please check one of the following for ownership N status: �5 5 ' Mailing Address: d Of t4 F I T l+ PLV4 Individual ❑ Association❑ Corporation [k Partnership❑ City, State, Zip Code: SOU T/4 WIN I05-091 Cr 06okv Other Legal Entity❑ Phone#: 16 - © "`t 3 Ci,6 Fax #: E-Mail Address: LtpQ ,°�r q w�ei/_ Cell Phone#: 96(0d--� OC6--4� Sp Renovations Were there any renovations made last year? YES❑ NO [jr Will there be any renovations? YES❑ NO If Yes, please list all renovations that were done/to be done: RECEIVED JAN 0110N SOUTH WINDSOR HEALTH DEPARTMENT Restaurant Menu/List of All Items Served/Sold Latest Menu Attached? YES VNO ❑ 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 �dvanced catering for specific quantities drUses Time as a Public Health Control [Cooking/cooling/reheating/thawing/freezing/hot or cold holding �repares food to serve at another site ❑Prepares food for Highly Susceptible Population(preschoolers or the elderly) repackaged non TCS Food Only V on TCS Food only (food that does not require refrigeration) Additional Information Please check all that apply: State Licenses: K Bakery [Liquor Permit ❑ None Water Supply (check only one): V Publi _ 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): (S m p 1 — emk Date of Birth: O 2—`Z Applicant Address: W "d ciw ocM W, Phone#: Q'0 -. $olj—L(36g Applicant Signature: P 6 Date: - to -2,0 t Q6 Office Use Only Inspector Name (Print): Inspector Signature: Date: Food Class: Expiration Date: Date Received: Date Approved: ,.:-,ervSafe Jabonal Restaurant Association 'S f rvs .,.. C ERTIFICATION ISMAIL ADEMI for successfully completing the standards set forth for the ServSafe®Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute(ANSIKonference for Food Protection(CFP). 10591 ER EXAM FORM NUMBER 3/10/2018 3/10/2023 DATE OF EX DATE OF EXPIRATION A57M E1159 local laws apply.Ch for reootfification requirements. Sher iation Solutions ,0 a accordance wi ServSde logo are kademor6 d the NRAu.NoWnal Rrotourord Assoda hwS and the arc design ConW us with questions of 233 S.Wadoer Drive,Suile 3600,Chicago,L 60606-6383 or ServSaWrestaurant.ora.