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Home My WebLink AboutApplication 1496John Fitch Boulevard Joh 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 ,f t Phone Number: (860) 337-6173 Fax: (860) 644-1930 bSOR-c Restaurant Establishment Information New Permit❑ Permit Renewal [� ***(Please Print Clearly)*** Name of Establishment: r�tita�S. _A Slap Manager's Name: t Strcc:Addrcss: k V-4' - -- -- City, State, Zip - Phone#: y Cell Phone#: qJ3 Fax#: —- - - - - - E-Mail Address: (� ��-}� K Seating Capacity:_ Please submit latest copy o; uallfied Food OperatorlServSafe certificates to the office. Qualified Food Operator: YE NO .0 (Required for Certificate#: Class 3&4) Name: ��h � �` cS�Z� �- — --- Date_ _�a� �j- j"> -i Testing Organization: I'Aj Phone#: E-Mail Address: Alternate Phone# Designated Alternate 1: sp U�2f� Designated Alternate2 Restaurant Owner Contact Information Owner's Name: Street Address: 41, �� I City, State, Zip Code. 6v4,e_ Phone#: 4� y7 Fax #: N E-Mail Address lX/ Pik-, oe Cell Phone#: I Renovations Were there any renovations made last year? YES❑ NO [Will there be any renovations? YES ❑ NO If Yes, please list all renovations RECEIVED that were done/to be done: DEC 3 0 SOUTH WINDScR I. HEALTH DEPT. Mailing Address to send Food License Renewal Permit to: Name of P-4--urant/Company: I ..I --- Attention: Ne Address: ,� l, - ,l state, Zip Code: (/ Phone#: s/,S 4 Town of South Windsor — Health Department r • r 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address ie 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address Phone Number: (860) 337-6173 Fax: (860) 644-1930 SOR•CO�� Rests rant 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 — a copy of a menu attached is applicable. I Additional Information Please check one only: State Licenses: ❑7Be"F'jy ❑ Liquor Permit ❑ None Water Supply: blic Private Well Wastewater Disposal: Public On-Site Other (please use space below to explain) bq&,, o'F 6t,(- t_,�Vj MYMP�e&J- t -Se W ne- Cy— 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): LApplicant Signature: I Date: J Office Use Only Inspector Name (Print). Lb Inspec i natur Date: Food Clas 1 ❑ 2 ❑ 3 4 Exrirati'/n Date: Date eceived: Date Approved: O ServSafe e 7t rvs ., fe CERTIFICATION LINDA SOUZA for successfully completing the standards set forth for the SetvSafe®Food Pro6>sclion Manager Certification Examination, which is accredited Icy the American National Standards Institute(ANSI}-Cnn6er tnw for Food Protection ON. 069780 5102 UMBER EXAM FORM NUMBER 12/8 12/8/2020 DATE OF E NAIICIN DATE OF EXPIRATION Local laws apply.Ch with your kiccd ragu{gtotypgency for recertification requirements. 2 s L She Nauranl A so6olion 5<4vinsn: r In acconclunce with Maritime tabour •i2.;Intdr ON ON 15 Ndonol s—sated ad are,odemarks of the NRAEF Noti ,rndr, Contact us with quagions d 175 w Jodaon Bhd Ste 1500,Chicago,IL 6060e or SewSafe®restauront org Lunch Menu Regular Hot Dog $2.00 Add Cheese for $2.50 Hot Dog with Cheese & Bacon $3.00 Hot Dog with Sauerkraut $2.50 Chili Cheese Dog with onions $3.00 Linda's Pit Dog $3.00 (Chipotle mayo, cheese, grilled onions & peppers & j alapenos.) Kielbasa Dog with cheese, grilled onions & peppers $3.50 Add Sauerkraut or Chili $4.00 Hamburg/ Cheeseburger $4.25 Double Cheeseburger $5.50 Add Bacon to any sandwich add $.50 (Mayo, ketchup, pickles, onions, lettuce and tomato.) Grilled Chicken Wrap or Buffalo Chicken $3.00 (Ranch dressing, shredded cheddar cheese, tomato and lettuce) Grilled Chicken or Buffalo Sandwich $4.00 (Ranch dressing, provolone cheese, tomato and lettuce) Lunch Menu Veggie Burger on Kaiser Roll $4.00 (Provolone cheese, mayo, ketchup.) Cup of Chili with cheese $2.50 BLT on Texas Toast $4.00 Grilled Cheese on Texas Toast $3.00 Grilled Bacon & Cheese $4.00 Grilled Ham & Cheese on Texas Toast $4.00 Steak & Cheese with grilled onions & peppers (on a grilled Kaiser roll) $7.00 Baked Potatoes Sour Cream and Chive Potato $3.00 Cheese Potato $3.50 Bacon & Cheese Potato $4.00 Chili & Cheese Potato $4.00 Fully Loaded $5.00 Drinks & Chips Reg & Decafe Coffee, Tea, Hot Chocolate $1.00 Coke, Diet Coke, Sprite and OJ $1.25 Bottle Water or Gatorade $1.25 Lemonade & Iced Tea $1.25 Chips $1.00 Homemade Cookies 2 for $1.00 �o001 0're �`0 sr TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT V-- 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. Mobile Vendor Business Name: �11�Af S Mobile Vendor Owner/Operator Name: I r Business Name of Base Of Op.: h -eP 6 _ /s Mc `l r Address of Base Of Op.: �i� J ��/P Owner of Business for Base Of Op.: Telephone Number of Base Of Op.: ,2o THE FOLLOWING PORTION TO BE FILLED OUT BY THE OWNER OF THE FOOD ESTABLISHMENT USED AS THE BASE OF OPERATION. I, l attest that my licensed food establishment Owner of Food Establishment used a9 b se known as is is available as the Name of Food Esta lis Gent c base of operations for 111(�'/,-� �� > <' , owned by Name of Mobile Vendor Business ECEIVED Owner of Mobile Vendor Business JAN 17 2017 SOUTH WINDSOR HEALTH DEPT, Signature bF lishment **Please include a copy of the Base of Operati food permit issued by the local health department.** t) eve ley