HomeMy WebLinkAbout2018-12-26 - 100 Bidwell Road - Permit Renewal Application �110%" Se"� 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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Establishment Information New Permit❑ Permit Renewal Ld'
Type: Mobile/Itinerant Vendor❑ Temporary Event❑ Permanent Food Service Establishment L�
***(Please Print Clearly)*** CLASS: 3 FEE DUE: 250
Name of Establishment: Nomads/Reds Tavern
Name of Person in Charge: RIC,44., l fly
Establishment Street Address: 100 Bidwell Rd.
City, State, Zip Code: South Windsor, CT 06074
Phone#: &ob - L9v- /f 7 7 Cell Phone#:
Fax#:
E-Mail Address: ^,-keot@/Ic;clic /,IC"I Seating Capacity:
Please submit iatest copy of the Certified F od Protection..^.".anageaServSafe certificates to the office.
Certified Food Protection Manager YES NO ❑ Certificate#:
(CFPM) (Required for ALL Class 2,3&4) /�CY
Name: �� I,�S ��-s Expiration Date: _f-f -�202-/
Testing Organization: ��y✓S� Phone#: Wj_ _02-S-67T
E-Mail Address: �'�(�w���yriA°�c c ca-1 Alternate Phone#: ?5&O Z�61-//77
Alternate Person In Charge &(fk),+- �S Cil 1 tl S Phone#: Y4'O ;? y6--//7-7
Restaurant Owner Contact Information
Owner's Name: Cr�� � N a"I IUY) Please check one of the following for ownership
status:
Mailing Address: G(yo wn 54 Individual ❑ Association ❑
ty, P v, W,r�� C T G.7 y Corporation ❑ Part ryership❑
Ci State Zi Code: 5 Other Legal Entity C3
Phone#: ��b - ` &?- -7.t-W Fax #:
E-Mail Address: en&" 5-�( @,ro/,ccr vl Cell Phone#: &iJ U2 -7-ra)
Renovations
Were there any renovations made last year? YES❑ NO Will there be any renovations? YES❑ NO
If Yes, please list all renovations
that were done/to be done:
i
8SA1TH DEPARTMENT
Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES[f 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 [� Pub
yiquor Permit ❑ None
Water Supply (check only one): li _Private Well
Wastewater Disposal (check only one): v 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): fC, A c Date of Birth: /v L,7 /983
Applicant Address: C F�oc 7�/^ Phone#: k.,o— Z
Applicant Signature: Date: /Z z7 -,I k
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: Expiration Date:
Date Received: Date Approved:
P4`d (�?Scb 3 3--3
OW14 Srq< 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
t�SO R•C V�
November 30, 2018
Dear Food Service Operator,
All food service permits expire in South Windsor on December 31, 2018. To renew your
permit, please:
1. Please complete the enclosed application and submit to the Health Department
with a copy of your menu, CFPM certificate (Class 2-4 only), and permit
payment. Your registration will be considered incomplete without all four of
these items. You can mail, fax, hand deliver, or scan and email
(heather.oatis(a southwindsor.org)the required documents by December 22, 2018.
2. You can also visit www.southwindsor.or /g fsregistration to complete your
registration by December 22, 2018. You will need an electronic copy of your
menu and CFPM certificate (Class 2-4 only) to upload as part of the registration.
Your registration will be considered incomplete without these items. You may
then mail or hand deliver payment to the Health Department (addresses listed
above).
Please note, there are several changes to the process this year.
1. The application has been modified to reflect the requirements of the FDA Food
Code that will be adopted no later than January 1, 2019.
2. The payment amount due can be found on the top of the first page and is based on
your establishment class and seating capacity. The fee schedule has been included
for your reference. Please contact the Health Department at(860) 337-6173 if
you have any questions about this process or what your class is.
3. Effective July 1, 2018, Qualified Food Operators (QFOs) are now known as
Certified Food Protection Managers (CFPMs). CFPM are required to work in the
establishment. Expiration dates on your training certificate will be enforced. If it
has been more than five years since your certification(ex. ServSafe) you will be
required to retake the exam and obtain a new certificate. A current and valid
certificate is required to process your license application.
Thank you, in advance, for quickly completing your registration for 2019. If you have
any management or CFPM changes throughout the calendar year, the contact information
can be updated using the same registration form or link.
Sincerely,
a, � Dn
Heather Oatis, REHS, HHS
Environmental Health Officer
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