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HomeMy WebLinkAbout965 Sullivan Avenue (2) Se4` Town of South Windsor — Health Department r 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 SOR•CuV 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: Geissler's Deli/Prepared foods Name of Person in Charge: Establishment Street Address: 965 Sullivan Ave. City, State, Zip Code: South Windsor, CT 06074 Phone#: �t�p_��,� 3Ct>,_1 Cell Phone#: Fax#: '&P0- LpL\q-\AC1'1q E-Mail Address: Cje<<,,�F, Seating Capacity: r� Please submit latest copy of the Certified Food Protection Man g r/ ervSafe certificates to the office. Certified Food Protection Manager YES P"NO ❑ Certificate#: QQ("', (CFPM) (Required for ALL Class 2,3&4) 1 WD2GC"1() Name: V,c t ,� �1 ��► 4 Expiration Date: Testing Organization: Phone#: WO,LA4_3Ct 1 E-Mail Address: �;� u;�f�a �� (S Alternate Phone#: L� � SlLt� -14�3- � Alternate Person In Charge ('*1A(&d1K T2 ec,iul Phone#: G?D. WLA4-3l`7 Restaurant Owner Contact Information Owner's Name: Please check one of the following for ownership -ZAb\L -, status: Mailing Address: �L� � t -1 Individual ❑ Association❑ City, State, Zip Code: Corporation 2' Partnership El Other Legal Entity❑ Phone#: `�l�U 14�3-1��'1lo Fax #: &,10-03-11U15 E-Mail Address: cr`` �r y 6 C2i_-t:A �S .Caryl Cell Phone#: Renovations l Were there any renovations made last year? YES IA NO ❑ Will there be any renovations? YES NO ❑ If Yes, please list all renovations ;��•c�; — u'� ,e ���` ` �{ s u r ��N r S,tac that were done/to be done: i tl a -- ' CE Ve D SOHWAU DSODPNHEALTHE 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): t 'Ic Date of Birth: Applicant Address: 1U � t `04 Phone#: �- .L) Applicant Signature: Date: /,_3k - Office Use Only Inspector Name (Print): Inspector Signature: Date: Food Class: Expiration Date: Date Received: Date Approved: Qc„�, �2 SCE Chi - A Servsa e CERTIFICATION VICKY CHANT fors r m r*" sfr,&eds s*fo,+for 4,e ServSo&s food PmWm M,,,der C,,sf ,o=Em,,mltion, wNch is accreldifed by the Anrrericm National StndcTds kufikft(AMKonerence for,food Proilection,(CFP). 5337 ER EXAM FORM NUMBER 1/25/2018 1/25/2023 DATE Of EX DATE Of EXPIRATION Loral Nwws apoy.C y for rece,of ration requ,4 n7eft. Sher iation Solutions WW In aoaxdance wi SeN/a6 kapn am t adh r6 rd Ilan NPW I Nohc I Raskronmal Aax+caaliond0 and Mar on:<kaipn Cnnho i u� a1Fi cpwshrmu a1)33% W0390 11—Surb 36(K C7aicnpn It 60606 63P3 M Se 5MI aRiesAnnnnl oiFl servSaft" Nationat Restaurant Association 'Se ry fe CERTIFICATION NATASHA TETREAULT for uxKessf Ay completing the ssm"ds set fartft far 4w Ser+Safee Food Prowicxt,Manapr CerAcahan Examination, wfaich is accreJoed by the Arnerican National Standards 4nsl*to IANSli{cxlwferenoe for Food Protection(CFP). 924178 5184 ' UMBER EXAM fOR,M NUMBER 7/26 7/26/2021 DATE OF E DATE OF EXPIRATION tooal laws apply. Cf+ y for recertification requirements. aD-n�-z�ae n.i rheph S #0655 c.«-40w-r with Mvdwns 02015 Nu%o a1 lopn o♦Yadr xnfu of 16 W Af'f 11S W L­tad S�.I'dx), hw.c,e+ M aY✓,f --d x . i-. 1 • t e ry alfeo CERTIFICATION ROBERT RYBICK for successUly corrg6ting die sbndordls set Month for ire ServStAe®food Prolecfion Manager Cent cation Examination, which is occredited by the Am,mxm Notional Skuw6ds Insfitvle!(+4F,Sq-Terence far food)Protettion.('CFP+). P 5337 E:R EXAM FORM NUMBER 1116/2018 1/16/2023 DATE Of EX DATE Of EXPIRATION Local 6w,apply. for recertgiccrlion requireme* She Iotion.Solvlions dw to AI! N.+"'M Aar.-ob z,,v d Ilk m,.bva., ..,•�,yr..-id,pwdiwv,c rn:r a> cvN,rkd i''*,w �,av+nil �0h,.-ny*tll M'kM'1h,*i%i;,,�uknfi4t,w,kw,.,r,+� Servs CERTIFICATION RYAN NILSSON for successfully completing She skmdctrcls sat Earth for (rood Madion Marncx,pr Cersifiodtion Examrination, which,i•s vccredi9ed'by the American Ncohicancil SYmmdwds kto"JANUJ-Cbnference for food Proledion(UP). 5337 ER EXAM FORM NUMBER 1/16/c20 A B 1/16/2023 DATE Of 'EX DATE Of EXPIRATION Local laws apply.C y for recertification requirem Bros. She ration 5<4vtions .r M atx3ieiaree S.w.4d..4y.-;ane r�,w^k..x,+4e,a d,c Ain£+ 'c�n.**,M`Resl�.xnzte+•a, ,,-.,<,n;.e'-0 16 \tinier,f•..F NV �.h,a�•. R �'4wN r.?S�. .,w.�..Met.ss*�r:Mw.,'II Se rvS fe CERTIFICATION FAQ' DAVIS for successfully co mob ing dhe sbndards set Earth for Ifte ServSck-*Foal Pl vbdion Manager Certificdtion'Exo mirusfion, which,is accredited by#*Anwiccm NotiomxA Standards`institute{, Si erence for food Protection{CFP). . 1 5337 it 1i ER EXAM FORA NUMBER 1/25/2018 1/25/2023 HATE Of EX DATE OF EXPIRATION Local laws apply.C for recedification requirements. She iotion So6tions zLr© M ati�.lance $ar..5:1k 4,�,•as�ia•wvi.;d t�rJR.ntl K >^Y.n+.re„si Rav�yu., .ax4..:dbv..R,utl NM my rb.,q� w ,..•.,.r,:po,d.. r !t> ceM An n,.< ti,K WOc i p . s 6 •s P Se ry e 10, CERTIFICATION DAN NILSSON for swocessf l y compfePirag the 0andarrds set fort,for 4e ServSafe®Food Flroiedl9on Manager Certification Emmmartion, w6ch is accredited by The American National Standards infift ie NSO-C= -rence for Food Pm*cfson(Cff'). 5337 ~� ER EXAM FORM NUMBER { 1/25/2018 1/25/2023 DATE OF EX DATE DATE OF EXPIRATION Local 6.,.,mppl .C for recer4cotion requWem os 5 iction So4L4tGom fi. M aararkx�cv .. 5+x4�.icde kge mo hrni.r=....�..,-F�x MPare t+a�tr.�..��fiaahw�a�arr.xxll�*�caME Int rest.55,�,... ..R..+.....d�.�s+M1..ss M i�.'%t l�-piiet(��s �.�.k'Nn'/: �1.....'r .• k A(Vdl+lW .y�c.�`ti�leQwFv�:v�.ry7 i .4 y ServS CERTIFICATION JAMES WILLIAMS far%*ccessufiy co rN**standards set 6+for 6 SenrSafaeo food ftkidw N%arsaWr Cedificotion Exarnineahon, which.is oceredi#ed by+e Arnerican NationcA St ndards InstibAe(ANSI ence for Toad Prrykedfion ICFP). 5337 ER EXAM FORM NUMBER it i'i h 1/25/2018 �1''���°�' 1/25/2023 DATE Of EX , DATE Of EXPIRATION total 6,.,apply. for recert4wartion requmwnents She croon Solutions r,a�rorc4�>tar .`+enScJe 4yr•n,s rM......k,.J d..rK-+l{ —4 doe m..v,•y .��.•,...,d:,x.,+.....M ,�:e..liar t` < `,r.:�t+"A' .)..,�,•4 t-:0..iY•r.. ,.,..,n..ti..�r.4P.wr....,,.,:.i..,y ServS fe CERTIFICATION ERIC NILSSON for swccessUly c"ple&ng#,*standarnls set forth for the ServSdie®Food hubd on Manger CeT*4icafiein:Examincition, w6ia.es,aceredlt d by tine A—nw—ican National Sknntfards Ins` (AM)-CarAwmce for Focd Ptbtectron(cFP). 5337 ER EXAM FORM NUMBER 1/16/2018 1/16/2023 DATE OF EX DATE OF EXPIRATION Local flows'mpp`.C7 y For recertificotion reWiremwts. She Ration Solutions M ucxtl�drnrcx 5Me�5ofv�'N•'a.t hnMr,enk.,J dw NR AFl Nahcvxd Rexkne,mi�.wn.,.iRm.R aril OW WK�a@7✓' i.,,,�kk�i r,a.•,A•,p.nk..,n,,M:.;} \\atl,w Q,•K V„k'.a.A'�lv.rr�• a F(M(L+.a.tF�,�c«�1„F.�,..t.M�,xv,�.rp u. a. tiY ery nfe CERTIFICATION SAMUEL NIEVES for successfully conV6 irrg the stanc6ds set 6th for the ServSaleO Food Pi o,*c iow Manager Cer4cation Examination which is accredited Ivry the American National Standards Institute fANSIKon6ance 6 Food Protection (CFP) 6 610871 507+6 III UMBER EXAM FORM NUMBER 7/21 7/21/2020 DATE OF E tt I pp115 DATE OF EXPIRATION tr��apply C'n. @nC�'6 recwtificotion regUITen'We 7tl, -T-r7% tm 5 NOBSS x4". •t4. t'J.,M«xvnl L .w.s...,iev..,,x A.:•F«h..f1&Q f y • �� ,ter, � (E) fe roCERTIFICATION DANIELLE SAVARIA fof success'ftriffy ccorrWing the oundl ads set forth for 41--ServSafe`'Food Prima MoragwCerlification Excrnrncim w6t,h is accredited 6y t6 American National Stancki cfs'Institute fAN5i)-CMfonH ae 6 food Protection (CFP), U , 610875 5069 UMBER EXAM IFORM NUMBER I 7/2 1 �� � � �'�� 7/2112020 DATE OF E DATE OF EXPIRATION toccol Icr,ws .CIt � I '�'for recertification fequireTtients. 43-TA2786 5 W +tttfi54 �, 4 Q ery CERTIFICATION BETTY GOLDEN for success ui y comp6rg toe ssarw cis set"err t+a ServSc{eo Fc od Pro"on Mot et Cer ,ccrtaon EXacnin,Ihc, w�icb is accre lec(6Y tie Ameficam Nofio I Stanc6ds Institute(A.idSd��rrce fix Food Protection(CFP), 994172 5184, UMBER EXAM FORM NUMBER 7/26 7/26/2021 DATE OF E ' � DATE OF EXPIRATION tonal 6ws apply Cfo Y for rocmlif cation requirements, 4B 79-M6 cr�ar S +U6S5