HomeMy WebLinkAbout2017-1-3 - 1006 Sullivan Avenue - Permit Renewal Town of South Windsor - Health Department
1540 Sullivan Ave., South Windsor, Cr 06074-Mailing Address
1530 Sullivan Avenue, South Windsor, CT 06074-Office Address
Phone Number: (860)337-6173 Fax. (860)644-1930
Restaurant Establishment Information New Permit❑ Permit Renewal
***(Please Print Clearly)***
4 Name of Establishment: r -
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Manager's Name;
^- .City, State, Zip Code
Phone#: �0�.�44(4 �.. .`-�rq� 3.I Cell Phone#:
Fax#: d
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r----- "il ddress: ! .._— --._._..__.,.�._..... .� atln Ca aci
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( � Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office_
YES NO ❑ (Raqu!red for ''
Qualified Food Operator: _ -- Clas 3&4) I --Certificate#:
Name: nrilie Jon% N1 0 _ _ _ Date_ --- A ---_— _�
Testing Organization: S,L V S Phone#: - _-- —
E-Mail AddEres: Alternate Phone#:
Designated Alterna _id-0�17 Shc4r. -� Designated Alternate2 tla(490�
Restaurant Owner Contact Information
1._Owner's Name::t J4.ML- one
Street Address:
— City, State,Zip Code: Rt
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.—_— __ Phone#_ (�� . $ _ g�O3._ ._.. Fax#:j�_YpQ-5 17-L
- --E�Mail Address: en�r(Q(.se �C� l Cell Phone#:�$(� -
Renovations
Were there any renovations made last ear? YES❑ NO Will there be any renovations? YES❑ NO
If Yes, please list all renovationsthat were done/to be done:
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Mailing Address to send Food License Renewal Permit to:
_ Name of Restaurant/Company__ ._ _.�.�
Attention_ Yl_i'_�1 .J +.✓� hd -- ------ --
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City, State, Zip Code; G 2(4 .�
Phone#:
SOUTH WINDSOR
HEALTH DEPT.
A°" y`'� Town of South Windsor — Health Department
o 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
Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES❑ NO)s� 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.
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Additional Information
Please check one only:
State Licenses: Bakery ❑ Liquor Permit I-1 None
Water Supply: Public _ Private Well
Wastewater Disposal: kPublic On-Site Other(please use space below to explain)
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Agreement and Signature
By submitting this application,I affirm that the facts set forth in it are true and complete.I understand that any false
statements or other misrepresentations made on this application may result in immediate shutdown or revocation of my Food
Semite License for the Town of South Windsor.
Applicant Name(Print): S4.0 �0
jertn �
Applicant Signature: Date: I C_ Aci
Office Use Only
Inspector Name
Inspector Signatu , Date:
Food Class: 1 ❑ 2 ❑ 3 7 4 ❑ Expiration Date:
Date Received: Date Approved: i 0 zz
Jennifer Santochristo
From: jen Santo christo(via Googie Photos)[noreply-dfe32c266dfdbaa649a9c8076aa46276
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