HomeMy WebLinkAbout2019-1-11 - 125 Buckland Hills Drive - Food Permit Application rs ffi
Establishment Information New Permit❑ Permit Renewal
Type: Mobile Itinerant Vendor❑ Temporary Event Permanent Food Servic'eablishment
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***(Please Print Clearly)*** CLASS: FEE,iE U01
Name of Establishment _. . . ...__
Name of Person in Charge
1.. .....
Establishment Street Address:
._. _ _r
City, State, Zip Code: G( Q Z_
Phone#: —�j���(�C Z Cell Phone#:
. . .. _.. _._. _ _ _.
Fax# vJ
E Mail Address: tJction
Seating Capacity:Please submit latest copy of the f anagerlServSafe certificates to the office.
..._.._.. .........
Certified Food Protection Manager YES No p Certificate#:
(CFPM)(Required for ALL Class 2 3&4)
Name: VQ�/f , I Expiration _ ___.. .,. f.
Organization: Date
Testing
Or gti Phone# Z�
E Mail Address. Alternate Phone#
r_ _ _ _ +'� _ _ _ _--------
Alternate
Person In Charge Phone#
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Restaurant Owner Contact Information
Owner's Name {� Please check one of the following for ownership
_�A_ - . -. a.. _ status:
Mailing Address: � c:�s. ,,� £ Individual❑ Association❑
Corporation Partnership❑
City, State, Zip Code: Other L a nt�
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Phone# g'- �.(p^. ._,. __. _ .... Fax #
..... ... .. __.... _......_,.,._....q.. ... ._._,. .......__..._.....,...... ..
E-Mail Address: : Cell Phone#:
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:
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RECEIVED
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�" sip.q� Town of South Windsor — Health Department
. 1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
1530 Sullivan Avenue, South Windsor, CT 06074—Office Address
Phone Number: (860) 337-6173 Fax: (860) 644-1930
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Restaurant Menu/List of All Items Served/Sold
F= mee __�. _ _. -- _ _ � _W _ ..._. W_
Latest Menu Attached? YES❑ NO'� NOTE"*(Must have latest copy on file) I
..................... . ..................................... ..... ...... ...
Please list all menu items in as much detail as possible or a copy of a menu attached is applicable.
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Restaurant Food Prep (check all that apply)
_
❑ Cook to order ONLY ❑ Advanced catering for specific quantities ❑ Uses Time as a Public Health Control
_ _ __.. ___.�. .� ._. . . ..._ . .�. ._ .___. _. _. . ......_,
j1EA 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: ❑ Bakery ❑ Liquor Permit None
Water Supply (check only one): Y Public _ Private Well
Wastewater Disposal (check only bne): Public _Septic _Other(please use space below to explain)
.....
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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): J eie1C�n e Date of Birth:
Applicant Address: 1?S C cA ` _ Z Phone#: -32- -ON
Applicant Signature: Date: F
Once Use O
Inspector Name (Print):
Inspector Signature: Date:
Food Class: Expiration Date:
Date Received: Date Approved:
Gr&r ►'� — t c3"SS 1 Z 3
Notification of Test Result National Registry of Food Safety Professionals
4
CERTIFIED FOOD SAFETY MANAGER
ID#: xxx-xx- r
JEVAANSRADLEY
Scaled Test Score: 76
Candidate Status: Pass
Test Date: February 7, 2018
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Certd'icate44o 2143804t
lssiie Date )e6ruary.7,2018
k Expiration Date:February 7,2023
Congratulations!Attached is your certificate and wallet card.Please notify JEVAAN BRADLEY
the National Registry of name or address changes at the address below. TARGET 3265 BERLIN TURNPIKE
NEWINGTON, CT 06111
Preventing Contamination and Cross Contamination(Needs review)
Ensuring Personal Hygiene and Employee Health(Competent)
Actively Managing Controls in a Food Establishment(Competent)
Monitoring the Flow of Foods(Needs review)
Ensuring Product Time and Temperature(Needs review)
Conducting Cleaning and Sanitizing(Competent)
Managing:Physical Facility Design&Maintenance:Preventing&Controlling Pests(Mastered)
National Registry of Food Safety Professionals® 6751 Forum Drive Ste 220 Orlando,FL 32821 Phone:407.352.3830 Fax:407.352.3603