HomeMy WebLinkAbout2017-3-2 - 180 Sullivan Avenue - Food Permit Application �,°"'" 5`,4 Town of South Windsor — Health Department
' 1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
5% 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address
=" Phone Number: (860) 337-6173 Fax: (860) 644-1930
Restaurant Establishment Information New Permit❑ Permit Renewal ❑
***(Please Print Clearly)***
Name of Establishment: L— �,c��/C�L���
Manager's Name: (� a� Alfi�Irn )
Street Address: j OC) -) ,/f ( i( Alto
City, State, Zip Code: sooty 6-1111,_636Z
�+ Phone#: 9 C) �5b /1 � 4 Cell Phone#: Rt)
Fax#: (�u — 'ej— kjs qI
E-Mail Address: *—f�P- 4! �/ z']—Seating Capacity:
Please submit latgst copy of the Qualified Food Operator/ServSafe certificates to the office.
YES R o Certificate#:
Qualified Food Operator: , S 4)r
Name: __ Date:
Testing Organization: Phone#:
E-Mail Address: Alternate Pl ione?l:
Designated Alternate 1: Designated Alternate2
Restaurant Owner Contact Information �/�
Owner's Name: (�(/ ,�; j 71hIll +
Street Address: (' '%'_ Cf4/1�7_
City, State, Zip Code: v"� / C�J/ti1.7Sb>e\ �� C�&
Phone#: Fax #:
E-Mail Address: Cell Phone#:
Renovations
Were there any renovations made last year? YES❑ NO 'E� Will there be any renovations? YES❑ NO
If Yes, please list all renovations
that were done/to be done:
Mailing Address to send Food License Renewal Permit to:
Name of Restaurant/Company: /
Attention: OU
Address:
City, State, Zip Code: RECEIVED
Phone#:
1 > 2017
SOUTH WINDSOR
HEALTH DEPT.
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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11iSOR•co�
Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES❑ NOAZ::� 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 0-,None
Water Supply: -,,/Public _ Private Well
_Other (please use space below to explain)
Wastewater Disposal: �Public _On-Site
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):
Applicant Signature: __ �.__ _ -� Date: D
Office Use Only
Inspector Name (Print): z_-
Inspector Sign
at Date:
Food Class: 1 2 ❑ 3 ❑ 4 Expiratio Date:
Date Received: �� Date Approved: