HomeMy WebLinkAbout291 Oakland Road (5) °*" SE4< 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
Type: Mobile/Itinerant Vendor❑ Temporary Event❑ Permanent Food Service Establishment Ib
***(Please Print Clearly)*** CLASS: 3 FEE DUE: 250
Name of Establishment: Sun Sun Chinese Restaurant
Name of Person in Charge: k36� � � Lee C�e n
Establishment Street Address: 291 Oakland Rd
City, State, Zip Code: South Windsor, CT 06074
Phone#: Cell Phone#: 6 `LL93
Fax#: I.Cora,
E-Mail Address:
�UYI Su.n q Seating Capacity: S J
Please submit latest copy of the Certified Food Protection Manager/ServSafe certificates to the office.
Certified Food Protection Manager YES V NO ❑ Certificate#:
(CFPM) (Required for ALL Class 2, 3&4)
Name: W& Por\o �Pp ('hel) Expiration Date:
Testing Organization: Stag fog � Phone#:
E-Mail Address: Alternate Phone#:
Alternate Person In Charge Phone#:
Restaurant Owner Contact Information
Owner's Name: LNIe j ��� H� Please check one of the following for ownership
j p status:
Mailing Address: Ck` lOkL13OCCA Individual ❑ /lssociation❑
Corporation�( Partnership❑
City, State, Zip Code: 1 ,\1�A�xY c,T- 066�(Other Legal Entity❑
Phone#: Fax #:
E-Mail Address: SN-\�O,C ven3itn to C�'i'Y Cj,C,," Cell Phone#:
Renovations J
Were there any renovations made last year? YES❑ NO p/' Will there be any renovations? YES❑ NO []1*1
If Yes, please list all renovations
that were done/to be done:
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1
J
A
Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES'0/N0 ❑ 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 Ed None
Water Supply (check only one): ✓ Public _ Private Well
Wastewater Disposal (check only one): —1 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): _ .e Date of Birth: I /y
Applicant Address: 0 , e#: ?& — ,/41- — 4
Applicant Signature: Qom_, Date: %:2- �;/
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: Expiration Date:
Date Received: Date Approved:
P6 ',, I2Sc'� dam- Zl 3
State FoodSafety
QC..ertif i rate of Completton
Awarded to
Wai Ang Lee- Chen
For successfully completing the
Food Safety Manager Training
ci13j-i05iid5 / •Certificate Verification Number - Bryan Chapman,tCFS,CP-FS
O � Verity at www.foObandlerveT fkalion.com
CEO,StattelFoodSafety �
This program prepares the learner tale Foo d Safety
Dec 15 2018 for the Food Protection Manager '`'` `� ' r
Issue date(valid for S years) Certification Exam.
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A CAUTION! This training certificate is not the Food Manager Certification.
You have cor?�pleted the Food Safety ivtjn 9(,(Training.If you are required to gcet the Food P1,1ana,ter Certification and
on.-purchased the Food Safety Manager Training,you can purchase the exam and schedule a proctored session at
Srtatefc oCs #f:�ty_cc�mr`fsm.It your area has a Demonstration of Knowledge requirement.ch(rk,a„rk�
for any additional steps you Need to take beyond completing this training.
cLcyr1
Hoer to get the Food Manager Certh ce" (f tC RR cs0
I his;:raining prepares you for the nationally-accredited Food Protection Manac Lit
to study materials in your account called Learning Extras to help prepare for tl' a��
Wl-ac(recited provider in a proctored setting.You ou can purchase the exam an
)Y_ ;
stz tefoodsafety,comffsm.Good luck! T�"Lt
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This training certificate meets"Demonstration of Kne
if your health department has a Demonstration of Knot ledge requirement,its
by the health department at least once.Be sure to keep a copy of this certificatE $potlfy"
that you have roc-eiveed comprehensive food s*.,.y training and arc.prepared to
food handling procedures,