HomeMy WebLinkAbout1530 Sullivan Avenue (8) �.1:°W" Se4` Town of South Windsor — Health Department
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
US0 CO.
Establishment Information New Permit❑ Permit Renewal [it
Type: Mobile/Itinerant Vendor[ ] Temporary Event❑ Permanent Food Service Establishment❑
***(Please Print Clearly)*** CLASS: 3 FEE DUE: 100
Name of Establishment: Pizza Pixie
Name of Person in Charge: Rv\y P
Establishment Street Address: �y U1
City, State, Zip Code: South Windsor, CT 06074
Phone#: Cell Phone#: 9Q0 ga_)1-4y(01
Fax#:
E-Mail Address: Ck-M Lk �iZzc.{lX4 •�Cr►� Seating Capacity: �-
Please submit!atest copy of the Ce li ed rood Frotection ManagerlServSafe certificates to the office.
Certified Food Protection Manager YES W NO ❑ Certificate#:
(CFPM) (Required for ALL Class 2,3&4) 1329 15
Name: Rm` p PGA _ Expiration Date: "III 12
Testing Organization: 'v -Safes Phone#: quo- ���.�ly( I
E-Mail Address: � i � 'X'l u„M Alternate Phone#:
Alternate Person In Charge Phone#:
Restaurant Owner Contact Information
Owner's Name: ' `_ — Please check one of the following for ownership
L.i l ?CSCoqr>kas status:
Mailing Address: - 70Cj -SLWIV A,� Individual X Association ❑
City, State, Zip Code: 4 - _ _ Corporation ❑ Partnership❑
4 Other Legal Entity❑
Phone#: (4LA(4 - 41 0 -1 Fax #:
E-Mail Address: 1or� Fj) Cj-\0C11kej jye,i,) C�D^V) Cell Phone#: S��U.. 7.-Ici_y(AD
Renovations
Were there any renovations made last year? YES❑ NO Lk Will there be any renovations? YES❑ NO
If Yes, please list all renovations
that were done/to be done:
i�
1A,N
LSOUTHUHEALTH DEPA,TU't
, EN 1
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)
XCook 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): k 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): Pr%A U f4t Date of Birth: -15
Applicant Address: iLj VC,y- •Z ;-'A Ci Phone#: CLU '�a-A-q q Q
Applicant Signature: Date: (�
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: Expiration Date:
Date Received: Date Approved:
National,ServSafe
•
'S
ervSafe
CERTIFICATION
AMY PORTER
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).
291548 10471
UMBER EXAM FORM NUMBER
3/1/2 3/1/2021
DATE OF E DATE OF EXPIRATION
Local laws apply.Ch ncy for recertification requirements.
ACREDITED PROGRAM
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In=ordrn with Maritim Irbou
VN15 Na iond Ingo are tradarwrks of the NRAff
Coriad us with questions d 175 W Jodmm Blvd.Ste 1500,Chicago,L 6060A ar SmScfa@rwbmant.org.
PIZZA PIXIE MENU
Cheese
Pepperoni
Classic White
Olive Oil, Minced Garlic, Italian Seasoning, Salt, Shredded Mozzarella, Feta, Parmesan
Honey or Maple White
Maple Sweetened Ricotta, Fontina,Shredded Mozzarella, Salt& Pepper, Drizzle Local Maple
Sausage, Feta & Pepperoncini