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HomeMy WebLinkAbout2017-1-6 - 245 Chapel Road - Base of Operations w� �� TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address 1530 Sullivan Ave., South Windsor, CT 06074—Office Address Phone Number: (860) 337-6173, Fax Number: (860) 644-1930 DECLARATION OF BASE OF OPERATION This form must be submitted with your application for permit. l Mobile Vendor Business Name: i Cl e G c,<-k-( r, �- Mobile Vendor Owner/Operator Name: (c,t_!CI LS UV l 1) )'t It -s Business Name of Base Of Op.: CP I Address of Base Of Op.: J'I T Lj I K 0S C,e , C I- 060 7 Y Owner of Business for Base Of Op.: 31 rL(0-C ptn E e ew Telephone Number of Base Of Op.: EGO 5 oZg 66� I THE FOLLOWING PORTION TO BE FILLED OUT BY THE OWNER OF THE FOOD ESTABLISHMENT USED AS THE BASE OF OPERATION. I, attest that my licensed food establishment Owner of Food Establishmen t ed as base known as Mdl /-/ is available as the Na of Food Establish ent base of operations for �OA(A5vA �?(2 yOuy-m( owned by 1 /Name of Mobile Vendor Business Owner of Mobile Vendor Business signs wrier of Food ent RECEIVED JAN 0 6 2017 SOUTH WINDSOR HEALTH DEPT. CA, TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT a 1540 Sullivan Ave., South Windsor, CT 06074 x �+ Phone Number: (860) 644-2511 x250, Fax Number: (860)644-7280 DECLARATION OF BASE OF OPERATION This form must be submitted with your application for permit. Mobile Vendor Business Name: 2oR� Mobile Vendor Owner/Operator Name: CU�A�5 yV ► t S Business Name of Base Of Op.: M A v-\c-e (-e-y s Address of Base Of Op.: C7 5 Zy4-1-1 5 � 50C,� to 'V-� i��at� �� 060�2{- Owner of Business for Base Of Op.: ;3,2Lke e 014.gr�ee-j r i Telephone Number of Base Of Op.: THE FOLLOWING PORTION TO BE FILLED OUT Bl , 1 ESTABLISHMENT USED AS THE BASE , D� 1 I, >k P (Ylc�,: 1�Y attest that my lice D Owner of Food Establishment used as base known as Name of Food Establishment II base of operations for `y" `� Name of Mobile Vendor Business Owner of Mobile Vendor Business Signa a of Owner of Food Rtablishment "Please include a copy of the Base of Operation food permit issued by the local health department" i3av FILENUMBEf�---- FILE NAME: ADDRESS: TOWN: DATE TIME ACTION INITIALS DATE TO :DAXTIM I� AMP FRO X�� �' �/ PM H _ PHONE( O O CELL( N FAx E M E 'f� OF - O O M s s E A MG O E E-MAILADDRESS SIGNED PHONED❑ CALL BACK RN ❑ ANTgTp❑ WILL CALL WAS IN ❑ URGENT❑YYOODU AGAIN ❑ OBlueline•REDIFORM• 02012 A• i 2Zh - �.