HomeMy WebLinkAbout2017-11-17 - 180 Sullivan Avenue - Food Permit Application 0,4" Sr"<Q Town of South Windsor — Health Department
r 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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Restaurant Establishment Information New Permit❑ Permit Renewal
***(Please Print Clearly)***
Name of Establishment: 0. (,) !4<__
Manager's Name: Hyy74_:A
Street Address: /Pa
City, State, Zip Code:
Phone#: ��v �/S Cell Phone#: Cl(lo E/ 6
Fax#:
E-Mail Address: Ac,4 m t(LI n A r./47—Seating Capacity: -�
Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office.
Qualified Food Operator: YES❑ NO ❑ (Required for Certificate#:
Class 3&4)
Name: Date:
Testing Organization: i Phone#:
E-Mail Address: �! I Alternate Phone#:
Designated Alternate 1: Designated Alternate2
Restaurant Owner Contact Information
Owner's Name:
Street Address:
City, State, Zip Code: f-J ./0
Phone#: Fax #:
E-Mail Address: Cell Phone#:
Renovations
Were there any renovations made last year? YES❑ NO VT 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: RECEIVED
Name of Restaurant/Company:
Attention: NOV 12017
Address: SOUTH WINDSOR
City, State, Zip Code: HEALTH DEPT.
Phone#:
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 a copy of a menu attached is applicable.
P/P
Additional Information
Please check one only:
State Licenses: ❑ Bakery ❑ Liquor Permit None
Water Supply: _�L 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): /^ oafQ\C� � y
Applicant Signature: _H /\ Date: -- /f r�
Office Use Only I
Inspector Name (Print): f
Inspector Signatur Date:
Food Class: 1 0'2 ❑ 3 ❑ 4 ❑ Expiration Date:
Date Received: Date Approved:
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