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Home My WebLink About2016-12-30 - 1735-1 Ellington Road - Food Permit Application Ritas Town of South Windsor - Health Department Y 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 Restaurant Establishment Information New Permit❑ Permit Renewal ***(Please Print Clearly)*** Name of Establishment: t✓C3 ��1,a h 'lop P Manager's Name_ '- ✓�� Jf�/L Str:,t durc�,.,: 17 3 Y City, State, Zip Code: �- So�-J4 SoA- 1- D t, 0 7 Y Phone#: Cell Phone#: -LZyX60 - y63 -S3?. Fax#: E-Mail Address: Seating Capacity: Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office. —�- ❑YES NO YF (Required for I Certificate#: Qualified Food Operator: --- ----- Class 3&4) -Name: Date: i ' Testing Organization Phone#: E-Mail Address: Alternate Phone#: - -- — Designated Alternate 1: Designated Alternate2 Restaurant Owner Contact Information Owner's Name: J,I94L'_S vll_�en - — - --_ _ Street Address: 7 v�1 Q�J C City, State, Zip Code: win J 3 en C I 0 b O 9.S- Phone#: N 0 -_61S - ��'6 Fax #: 1 E-Mail Address: Jim. R ft;I C 5,�,��I r • r o nrt Cell Phone#: ' 0 -y�(3- f 179 Renovations Were there any renovations made last year? YES❑ NO [9_ Will there be any renovations? YES ❑ NO R�- If lies, please list all renovations that were done/to be done: I i f i I Mailing Address to send Food License Renewal Permit to: Name of Restaurant/Company: ' ff I J� S _'� /#-! �T C r• - - ---.Attention: I _jf flu 147Yh -- -. --- -- - - Address:- ----1735 3;'An1*00 --REAM-1VW-.. City, State, Zip Code: .S_a� �� winJso� Phone#: e6 0 - 6 a- as YX 3 0 201.6.--- SOUTH WINDSOR HEALTH DEPT. 1°Wn ",< 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 L�USOR (ll'q': Restaurant Menu/List of All Items Served/Sold Latest Menu Attached? YES❑ 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. 5ee a YC C-4 Additional Information Please check one only: State Licenses: ❑ Bakery ❑ Liquor Permit Eg None Water Supply: P� Public Private Well Wastewater Disposal: j>-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): GMT �. d✓1 �� Applicant Signature: Date: /a a0 Office Use Only Inspector Name (Print : Inspector Signature: Date: Food Class: 1 V] 2 ❑ 3 ❑ 4 ❑ Expirat on Date: Date Received: 3 Date Approved: �t =� - Rita's eta - s ;cc.Custard-Nappi,,14 1 r • NNW itas } r j l�l Rita's. -- ilita's lZita's_ MAP _All, Rita's of South Windsor 2016 RI A'S FRANCHLSE COMPANY ALL RIGHIS RESENVEU.SWFDISH FISH sid SOUP'rA Ir P KIDS ma n.IsslernJ!lodr•niarks ul MundeMr Inlernnhumrl 9-1,irvd colder IKen.,•THE RLESE'S MIA I- ANDPIF'R IRADFMARKS AND TRADI DRFSSdRs':Srr•UN':JRIIfFNSF,ORF(7.rcrd Nil IA.sr- prvrHlli,,I-aiWnlMnMrlFrhnr•s-Iloimlormm lunlnnderlirvnv /'MKM�S :1735 Ellington Road I HE LE I I ER M MNM 5 MIN15 AND SNICKERS ARE REGISTERED I RAUEMARKS OF MARS INC.AND 115 AIRILIAIES*20 R.'MARS.INCORPORAI ED USED UNDER LICENSE WONKA'one NER'JS am ZHlemd Ir e—,Is of Sooele des Pmddils Wnlb S.A..View Swdurland.PLEASE NOI E:WONKA NERDS'dnl Mrm Gum me Gummy Ise-are nol kosher nu hems.The P lore Is a re9aleled j d!mdk of Pos Foods,LLC.Pebble s,relislered Irz,wk of Hanna•Enlhef Producllorls Inc.ChB JDLY RANCHER Uademark and bevlo dress are wed under license DR PEPPER¢,I South Windsor CT 06074 re9istemd trademuk of Or PeoPer/Semn Up.IrK.•r201fi Or Peopor'Sewn Up,Inr https://www.fi sidaranet.com/p/vO41/vlp41/abtwsacN006_ValueLinkTitleBarView First Data Net PRODUCTION(P41) Product Selection Options Client Selection Search Lo out I of 1 12/14/2016 4:34 PM MIN IC K IT UP A NOTCH! p ojili ICE v esI-gaily with real: . 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