HomeMy WebLinkAbout2017-4-20 - 138 Ayers Road - Food Permit Application 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
Restaurant Establishment Jlfi`ormacion New Permit❑ Permit Renewal
***(Please Print Clearly)***
Name of Establishment: a��r�,,�, „�,�h1/��£�`
Manager's Name:
Street Address:
City, State, Zip Code:
Phone#: Cell Phone#:
Fax#:
E-Mail Address: o, e.,,e. ,�&-t Seating Capacity:
Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office.
Qualified Food Operator: YES Ef NO ❑ (Required for Certificate#:
Class 3&4)
Name: f�v� � x Date:
Testing Organization: r/ � Phone#:
E-Mail Address: Alternate Phone#:
Designated Alternate 1: Designated Alternate2
Restaurant nwnPr cnntact Information
Owner's Name: oCeTStreet Address: /3 F �y-f� d/�_/4
City, State, Zip Code: ,,,y,v*I (2—dOo`— 06 q�fC
Phone#: &'.4a �c4 . Q6 /-�;& Fax #:
E-Mail Address: �n�gsclrr�,�,�dGJ t; � Cell Phone#: 1�k4e Sra3 �5_W?4-
Renovations
Were there any renovations made last year? YES❑ No !7 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:
Address:
City, State, Zip Code: DECEIVED
Phone#:
APR 2 0 2017
SOUTH WINDSOR
HEALTH DEPT.
Town of South Windsor — Health Department
v 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
KeS-Eaurafft Menu/LIsIC of All Items bevved/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.
Additional Information
Please check one only:
State Licenses: ❑ Bakery ❑ Liquor Permit None
Water Supply: _ Public Private Well
Wastewater Disposal: 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):
Applicant Signature: Date: /�►
Office Use Only
Inspector Name (Print): �,4r1�� 6-t,4.-L_
Inspector Signat Date:
Food Class: 1 ❑ 3 a 4 ❑ Expiration Date:
Date Received: 7 Ak 2e;-7— Date Approved: 'w