HomeMy WebLinkAbout2012IF NOT DELIVERED AFTER 5 DAYS RETURN TO:
SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES, FOOD CONTROL
360 YAPHANK AVENUE, STE. 2A
YAPHANK, NEW YORK 11980-9744
FIRST CLASS MAIL
STEVE LEVY JAMES L TOMAF~KEN MD MPH MBA
SUFFOLK COUNTY EX£CUTIVE COMMISSIONER
SUFFOLK COUNTY
DEPARTMENT OF HEALTH SERVICES
FOOD ESTABLISHMENT PERMIT ENCLOSED
DEC 1 5
TOWN OF $OUTHOLD
E. NEVILLE, TOWN CLERK
PO BOX 1179
$OUTNOLD
NY 11971
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SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
PERMIT
~ _.L~;~ .... TO OPERATE A FOOD ESTABLISHMENT
THIS PERMIT WILL EXPIRE UPON THE DATE SPECIFIED OR UPON A CHANGE OF THE OPERATOR.
THIS PERMIT IS NOT TRANSFERABLE AND IS GRANTED SUBJECT TO COMPLIANCE WITH THE
PROVISIONS OF ARTICLE 13 OF THE SUFFOLK COUNTY SANITARY CODE AND ALL APPLICABLE STATE,
LOCAL AND MUNICIPAL LAWS, ORDINANCES, CODES, RULES AND REGULATIONS.
IF THE FACILITY IS SERVED BY AN ON-SITE WELL THE DISINFECTION REQUIREMENTS OF THE
STATE SANITARY CODE ARE WAIVED PENDING CONTINUED SATISFACTORY COMPLIANCE
WITH THE PROVISIONS OF PART 5,
ESTABLISHMENT NAME:
ESTABLISHMENT ADDRESS:
SOUTHOLD HUMAN RES. CTR.
750 PACIFIC STREET
MATTITUCK
I.D. # 9t238
APPROVALS
OPERATOR'S NAME:
ISSUE DATE:
EXPIRATION DATE:
SCOTT A. RUSSELL,
12/0611!
i2/$t/t2
RESTRICTIONS
~F. CHANICAL DISHWASHER REQUIRED
APPROVED FOR HOT AND COLD DELIVERY
SUPERVISOR
PERMIT ISSUING OFFICIAL
TOVN OF $OUTHOLD
E. NEVILLE, TOWN CLERK
PO BOX 1179
$OUTHOLD
~NY i197i
TOWN OF SOUTHOLD
E. NEVILLE, TOWN CLERK
PO BOX 1179
SOUTHOLD
NY 11~71
SUFFOLK COUNTY DEPARTMENT OF
360YAPHA~ ~
YAPHANK. NY11
THIS IS YOUR BILL FOR RENE
YOU MOST PROVIDE YOUR'TAX
tN ORDER TO RECEIVE YOUR
***~ NOTE **** YOUR P~RMIT
ENTER TAX NUI~BE~DR:
~II .
BILL
'2012
ID ~ ,~1258
SOUTHOLD HUMa~ I~,,~. CTa .... '
I FOLD AND TEAR OFF BACK FLAP ~N~ Y AT PERFORATION
2 INSERT REMITTANCE STUB WITH PAYMENT.
3 MOISTEN BACK OF THIS FLAP AND FOLD OVER
Town of F,o,~thold
E. Neville, Town Clerk
PO Box 1179
Southold, NY 11971
"X" IF CHANGE OF ADDRESS
ADDRESS CHANGE REQUESTED
II II
PLACE STAMP
HERE
The Post Office
will not deliver
mail without
Postage
FOOD CONTROL, SUITE 2A
360 YAPHANK AVENUE
YAPHANK NY 11980-9645