HomeMy WebLinkAbout869 Sullivan Avenue (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
s Phone Number: (860) 337-6173 Fax: (860) 644-1930
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*Please complete form in its entirety (front and back).
Establishment Information New Permit❑ Permit Renewal
Type: Mobile/Itinerant Vendor❑ Temporary Event❑ Permanent Food Service Establishment
***(Please Print Clearly)*** CLASS: III FEE DUE:250
Name of Establishment: Hong Kong House
Name of Person in Charge: �tG�t� 4ti
Establishment Street Address: C3(n
City, State, Zip Code: _ _S O L 'S,o� 0
_ Phone#: 0 41'4-1 �� , Cell Phone#: _
Fax#: 6_ 64 Cf
E-Mail Address: Seating Capacity:
Please submit latest copy of the Certified Food Protection Manager/ServSafe certificates to the office.
Certified Food Protection Manager YESr NO ❑ Certificate#: 2 I -
r
(CFPM) (Required for ALL Class 2,3&4)
Name: M t G� V vt Expiration Date: gf22�2�
Testing Organization: N c Phone#: c� t�o y-� d 1 S 7
E-Mail Address: F�od S y Pq�S-9a&ate Phone#:
Alternate Person In Charge Phone#:
Restaurant Owner Contact Information
Owner's Name: Y" Please check one of the following for ownership
status:
Mailing Address: �6C1 [ k-3 a A Ve_ Individual ❑ Association❑
City, State, Zip Code: Corporation ❑ Partnership❑
S o w4 wonL4 C c7{p(�� Other Legal Entity L C
Phone#: �� 6 -L+ -/+^l 9 _ Fax #: 6 0
E-Mail Address._ _ Cell Phone#: 1-4 22_6 3 -j
Renovations LL
Were there any renovations made last year? YES❑ NO�C Will there be any renovations? YES❑ NO p�
If Yes, please list all renovations
that were done/to be done:
Supplemental Questionnaires
For Itinerant and Temporary Event applications, please complete the supplemental questionnaire form
RECEIVED
FEB `F 9 7019 !
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)
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 X'l Liquor Permit ❑ None
Water Supply (check only one): 4 Public _Private Well
Wastewater Disposal (check only one): :7 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): C. 0 ti Date of Birth: 2 -
Applicant Address: .-b q SLU Phone#:
Applicant Signature: l r Date:
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: Expiration Date:
Date Received: Date Approved:
401VOODs�' NATIONAL REGISTRY OF
FOOD SAFETY PROFESSIONALS®
CERTIFIES
MING GUANG OU
HAS SUCCESSFULLY SATuww-D THE REQUIREMENTS FOR THE
FOOD SAFETY MANAGER
UNDER THE
CONFERENCE FOR FOOD PROTECTION STANDARDS
. 4 .I° PRESIDENT:
LAWRENCE J.LYNCH,CAE
ISSUE DATE:AUGUST 22,2018
ExpIRATIoN DATE:AuGusT 22,2023
CEIMFICATE NO:21498037
#0656 TEST FORM:EZS41
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