HomeMy WebLinkAbout538 Evergreen Way (3) �'°-" Sf4< Town of South Windsor — Health Department
1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
1530 Sullivan Avenue, South Windsor, CT 06074—Office Address
z Phone Number: (860) 337-6173 Fax: (860) 644-1930
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Establishment Information New Permit❑ Permit Renewal ❑
Type: Mobile/Itinerant Vendor❑ Temporary Event❑ Permanent Food Service Establishment❑
***(Please Print Clearly)*** CLASS: 3 FEE DUE: 250
Name of Establishment: Flatbread
Name of Person in Charge: aa_, 5�L"V
Establishment Street Address: 538 Evergreen Way
City, State, Zip Code: South Windsor, CT 06074
- Phone#: Cell Phone#: 6205 14
Fax#:
E-Mail Address: Seating Capacity: ]
Please submit latest copy of the Certified Food Protection. Manage./ServSafe certificates to the office.
Certified Food Protection Manager YES l)l. NO ❑ Certificate#:
(CFPM) (Required for ALL Class 2,3&4)
Name: V1, Expiration Date: ( >'1Z�2-
Testing Organization: �crw� 5,:L c_ Phone#:
E-Mail Address: Alternate Phone#:
Alternate Person In Charge �, �2 -F���- Phone#:
Restaurant Owner Contact Information
Owner's Name: U �� 5 - n Please check one of the following for ownership
status:
Mailing Address: iZ ��e tc7�- c (_ Individual ❑ Association❑
Corporation ❑ Partnership❑
City, State, Zip Code: �D�tj Other Legal Entity❑
Phone#: Fax #:
E-Mail Address: VI Gj��� LIJ-p-2t--C9^JKf -LcY` Cell Phone#:
Renovations
Were there any renovations made last year? YES❑ NO Will there be any renovations? YES❑ N0114—
If Yes, please list all renovations
that were done/to be done:
RECEIVED
FED, '15'2019
SOUTH WWDSOR
HEALTH DEPARTMENT
Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES❑ NO ET' 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): ---liublic _ Private Well
Wastewater Disposal (check only one): ----Pub_lic_- --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: j
Applicant Address: ' 2 Phone#:
Applicant Signature: Date:
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: Expiration Date:
Date Received: Date Approved: