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HomeMy WebLinkAbout601 John Fitch Blvd (2) °*%4" Stq Town of South Windsor — Health Department 1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address r 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address Phone Number: (860) 337-6173 Fax: (860) 644-1930 °soe•c�� Establishment Information New Permit❑ Permit Renewal 1 Type: Mobile/Itinerant Vendor El Temporary Event El Permanent Food Service Establishment E ***(Please Print Clearly)*** CLASS: 2 FEE DUE: 125 Name of Establishment: Dunkin Donuts Name of Person in Charge�,aA�1&M Establishment Street Address: 601 John Fitch Blvd City, State, Zip Code: South Windsor, CT 06074 Phone#: � a�- !a?3 ' Cell Phone# Fax#: E-Mail Address: Sp w�ndQVed&j„/T �SS�eppating--Capacity: P!aase su_=;t!_-test copy of the Certified Food Protection Mans�ger/Se�r iafe ce�ates to the office. Certified Food Protection Manager YES�O ❑ Certificate#: (CFPM) (Required for ALL Class 2,3&4) Name: AU4a;T15j4V" Expiration Date. Testing Organization. Phone#. E-Mail Address: klil I/ Alternate Phone#:Alternate Person In ChargeV Phone#: aOOf��t "fd Restaurant Owner Contact Information Owner's Name: Please check one of the following for ownership status: Mailing Address: LL� Individual ❑ ciation ❑ City, State, Zip Code: �/' %/4; Corporation Pr.. YCK)-04 �� Other Legal Entity Phone#: OI�fV — � � �00 Fax #:E-Mail Address: n>✓ d CellPhone#: �/ � Renovations Were there any renovations made last year? YES❑ NO Will there be any renovations? YES❑ NO F0 If Yes, please list all renovations that were done/to be done: i i i S�UTN V.'II�D50R E HEALTH DEPARTMENT Restaurant Menu/List of All Items Served/Sold Latest Menu Attached? YES❑ NO ❑ NOTE"(Must have latest copy on file) Please list all menu items in as much detail as possible or a copy f menu attached is applicable. 707L Restaurant Food Prep (check all that apply) El 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 that a y: State Licenses: akery ❑ Liquuo Permit El None Water Supply (check only one): 'Public rivate 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 app cation may result in i mediate shutdown or revocation of my Food Service License for le the Town of South Windsor. Applicant Name (Print); ,s�j- Date of Birth: d Applicant Address: Phone#: Applicant Signature Date: Z Office Use Only Inspector Name (Print): Inspector Signature: Date: Food Class: Expiration Date: Date Received: Date Approved: pW I zS Ct-�,(L - 003 9 y 7 i EXAM FORM NO. 10311 CERTIFICATE NO. 9676817 � e Sery fe • FI C EI�T ATION C TO AMANA ISLAM for successfully completing the standards set forth for the ServSafe"Food Protection Manager Certification Examination, Room which is accredited by the American National Standards Institute(ANSI)-Conference for Food Protection(CFP). DATE O I 01/16J DATE OF EX Local laws apply.Ch or recertification requirements. ACCREDITED PROGRAM American Natio"a[=s Institute ant Association 3Td the Conference Protection #0655 ©2012 National Resta mark of the NRAEF,used under license by National Restaurant Association Solutions,I.I.C. The logo