HomeMy WebLinkAbout2017-1-3 - 19 John Fitch Boulevard - Food Permit Application s°"'" ``,< 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
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Restaurant Establishment Information New Permit 0 Permit Renewal ❑
***(Please Print Clearly)***
Name of Establishment_
Manager's Name: U l
.Ill l.l.l NV.11\..J.. �•IIrr
City, State, Zip Code: I Sv�1T-14 Wlk).6V_ 1L, L-J . C:(007y.
Phone#: �(9U- g l- 7 Cell Phone#: -3 60 61 It-0 ZSU
- Fax#: 4- a j 3
E-Mail Address: ) I Seating Capacity: Z
Please submit latest copy of the Oualkd 4rhttlF/ServSafe certificates to the office.
Qualified Food Operator: T YES NO ❑ (Class
for ! - Certificate#:
_ la _s_3&_4)
Name: Date: �12qi 9-7
I Testing Organization: A -r () j Phone#:
E-Mail Address: I Alternate Phone#: _
Designated Alternate 1: �Sj�W-/ k)�\(, U Designated Alternate2 :-
Restaurant Owner Contact Information
Owner's Name: i 'Lq- 1i-
Street Address: . ),30
City, State, Zip Code: I �,��- (��U✓s.ail , LT JE�`�7 i -
Phone#: 7,60 - 6,N 14 Fax #:
E-Mail Address: vU 1 , ueppr �r1[�tL �� Cell Phone#:
Renovations
Were there any renovations made last year? YES❑ NO Lj / Will there be any renovations? YES ❑ NO
If Yes, please list all renovations
that were done/to be done: RECEIVED
JAN 0 3 2017
SOUTH WINDSOR
HEALTH DEFT
Mailing Address to send Food License Renewal Permit to:
Name of Restaurant/Company: `' � ' ,i�?FU_t^eOJ -
Attention:
Address: /�y .J DIN_ �=_i tU
City, State, Zip Code:
Phone#: 5160 _a 11 -2�7-3. _.
°wN Y'R"` Town of South Windsor — Health Department
o 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address
y 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address
Phone Number: (860) 337-6173 Fax: (860) 644-1930
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Restaurant Menu/List of All Items Served/Sold
i
Latest Menu Attached? YES X 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.
Additional Information
Please check one only:
State Licenses: akery ❑ Liquor Permit None
Water Supply: Public — Privat Well
Wastewater Disposal: — Public _7On-Site _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. 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): ��S �1L mv� Il�
Applicant Signature: Date: IdIl S
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: 1 ❑ 2 ❑ 3 ❑ 4 ❑ Expiration Date:
Date Received: Date Approved:
I
-now 06/ 24/97
PUIIAq JOSEPH V
19 JOHN FITCH BLVD.
SO. WINDS R9 CT 06074
Signature