HomeMy WebLinkAbout2016-12-30 - 1750-2 Ellington Road - Food Permit Application Town of South Windsor — Health Department
1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address
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1530 Sullivan Avenue, South Windsor, CT 06074—Office Address
z Phone Number: (860) 337-6173 Fax: (860) 644-1930
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Restaurant Establishment Information New Permit❑ Permit RenewalI
***(Please Print Clearly)***
Name of Establishment: f 00ahyr j f�,�� ��fic, o� ��K,y-f
Manager's Name: II 407 >>r� ZC If - - - -
City, State, Zip Code; 54�� Wjti rfd" 4-4- Oro 0.7 y
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one#: Phe#:
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Fax#: I I
E-Mail Address: .IV,oeSeating Capacity:
Please submit latest copy of the Qualified Food Ope 0F/ServSafe certificates to the office.
YES NO ❑ (Required for Certificate#: T
Qualified Food Operator. Class 3_& ) ; Nod,6 yo zf 4
Date:
Testing Organization_ S V f',o {{ - Phone#: C-(,0 Yf,y'0- gq��
E-Mail Address: i�f'p�a fokM�s�' �h Alt Phone#: a .
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Designated Alternate 1: Designated Alternate2
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Restaurant Owner Contact Information
Owner's Name:
Street Address: 07�2 P,L rc�2�lC
City, State, Zip Code: G(j6h�ra�, c,_� p(pmoo --
Phone#: aG�` e?6- i',170 Fax #: fW- Y-7d .l02
E-Mail Address: Cell Phone#: ko Iq $fft
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Renovations
Were there any renovations made last year? YES❑ NO N Will there be any renovations? YES ❑ NO ®'
If Yes, please list all renovations
i that were done/to be done:
DEC 02016
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SOUTH i11 INDSOR
HEALTH DEPT.
Mailing Address to send Food License Renewal Permit to:
Name of Restaurant/Company: ; /Jrr GZ`r�L� 75�tSre-
Attention:
Address: I 17,Sa
City, State, Zip Code: ! _fp,� j ,0 h � d ft ds 7 y
Phone#: : 40 610- gill
/ Q 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
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Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES K 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: ❑ Bakery ❑ Liquor Permit ® None
Water Supply: _G Public _Private Well
Wastewater Disposal: )0- Public _On-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):
h e _
Applicant Signature: Date: /a
Office Use Only
Inspector Name (Print):
Ins g ure: Date,
Foo lass: 1 ❑ 2 ff 3 ❑ 4 Expiration Date:
Date Received: Date Approved:
ServSafe
ServSafe"
CERTIFICATION
DANIEL BELL
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which m acae&ed by the kawm m Ncft"&mK6&InAiule IA aL -Can(aenoe For Food Rafe m(UP).
14086404 10494
IFICAIF NUMBER EXAM FORM NUMBER
9/6/2016 9/6/2021
DATE OF EXAMINATION DATE OF EXPIRATION
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Certificate# 14086405
S*fv>iNr Issued 9/6/2016
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CERTIFICAMN
Name: RONALD BROOKS
Ic Expires 9/6/2021
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