HomeMy WebLinkAbout765 Sullivan Avenue (12) SOWN
SC'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
C
nt :re forra"a"'li G fl,- New Permit El Permit Renewal
,
Type: Mobile/Itinerant Vendor❑ Temporary Event❑ Permanent F Pod Service Establishment❑
***(Please Print Clearly)*** CLASS: FEE DUE: rJ
Name of Establishment:
Name of Person in Charge: PAIAC'S; "5-�f
Establishment Street Address: 2o-5-
City, State, Zip Code: C7_ 6667'K
Phone#: Cell Phone#: Y60--Vq- 6 q Or
Fax#:
E-Mail Address: 5'iect e C7-b/4 ljcy A,&j ,eating Capacity:
Certified Food Protection Manager YES Ej NC00— 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#:
Vcw'
Owner's Name: 5-7—.f,)C 2/3 V S Please check one of the following for ownership
status:
Mailing Address: 76-S'_ so Individual E] Association[I
Corporation E] Partnership
City, State, Zip Code: 01\)Aol CT- 0607Y Other Legal EntitIC9, �Pec
Phone#: Fax #:
E-Mail Address: S-r,,j c- C CT 5c Ale,) Cell Phone#: oK)-7Rq- 6 Ye,:f3
Were there any renovations made last year? YES F1 NO Will there be any renovations? YES 0 NO
If Yes, please list all renovations
that were done/to be done:
rnenta' Questionn,
For Itinerant and Temporary Event applications, please complete the supplemental questionnaire form
F RECEIVED
FER 201�j,
SOUTH
;�T
OUTH WlNr)�;Oj�j
LT P
HE
ALTH CO)EPARTMEN1
c, A10 items Served/Sold
Latest Menu Attached? YESE] NO tr
Please list all menu items in as much detail as possible �,r a copy of a menu attached is applicable.
her-ran f c t �-ot-' P 'd H that app'y
Ej Cook to order ONLY E]Advanced catering for specific quantities E] Uses Time as a Public Health Control
[I Cooking/cooling/reheating/thawing/freezing/hot or cold holding [-] Prepares food to serve at another site
E] Prepares food for Highly Susceptible Population(preschoolers or the elderly)
El Prepackaged non TCS Food Only []Non TCS Food only(tood that-does not require refrigeration)
Please check all that apply:
State Licenses: R Bakery r
L' Permit F None
V61
Water Supply(check only one): Li
Private Well
Wastewater Disposal (check only one): j!',"'Public Septic Other(please use space below to explain)
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: 5C 7-1)c,�/,-j 11 BAST IJ,�q C7— Phone#: S60- 7.3
Applicant Signature: Date:
Inspector Name(Print):
Inspector Signature: Date:
Food Class: Expiration Date:
Date Received: Date Approved: