HomeMy WebLinkAbout2018-12-21 - 180 Sullivan Avenue - Food Permit Application °w" Sf 4`� 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
SOR•CO
Establishment Information New Permit❑ Permit Renewal
Type: Mobile/Itinerant Vendor❑ Temporary Event❑ Permanent Food Service Establishment❑
***(Please Print Clearly)*** CLASS: 1 FEE DUE: 75
Name of Establishment: Quick Stop Exxon
Name of Person in Charge:
Establishment Street Address: 180 Sullivan Ave.
City, State, Zip Code: South Windsor, CT 06074
Phone#: Cell Phone#:
Fax#:
E-Mail Address: Seating Capacity:
Please submit latest copy of the Certified Food Protection'danagar,ServSafe certificates to the office.
Certified Food Protection Manager YES❑ NO ❑ Certificate#:
(CFPM) (Required for ALL Class 2,3&4)
Name: Expiration Date:
Testing Organization: Phone#:
E-Mail Address: Alternate Phone#:
Alternate Person In Charge Phone#:
Restaurant Owner Contact Information
Owner's Name: Please check one of the following for ownership
status:
Mailing Address: Individual K Association ❑
Corporation ❑ Partnership❑
City, State, Zip Code: Other Legal Entity❑
Phone#: Fax #:
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:
RECEIVED
DEC z 17018
SOUTH WINDSOR
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 of a menu attached is applicable.
Restaurant 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 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): Date of Birth:
Applicant Address: Phone#:
Applicant Signature: Date:
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: Expiration Date:
Date Received: Date Approved: