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SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
PERMIT
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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
suPFOLKCanvfv
oavnarxaNroa nan~rn seances PROVISIONS OF ARTICLE 73 OF THE SUFFOLK COUNTY SANITARY CODE AND ALL APPLICABLE STATE, i
LOCAL AND MUNICIPAL LAWS, ORDINANCES, CODES, RULES AND REGULATIONS.
IF THE FACILITY IS SERVED BY ANON-SITE WELL THE DISINFECTION REQUIREMENTS OF THE
STATE SANITARY CODE ARE WAIVED PENDING CONTINUED SATISFACTORY COMPLIANCE
WITH. THE PROVISIONS OF PART 5.
I , D, * 91:238
APPROVALS
ESTABLISHMENT NAME: SOUTHOLD HUMAN RES. CTR.
ESTABLISHMENT ADDRESS: 750 PACIFIC STREET
MATTITUCK
OPERATOR'S NAME: SCOTT A. RUSSELL, SUPERVISOR
ISSUE DATE: 11/26/13
EXPIRATION DATE: 12/31/14 RESTRICTIONS PERMIT ISSUING OFFICIAL
MECHANICAL DISHWASHER REQUIRED TOWN OF SOUTHOLD
APPROVED FOR HOT AND COLD DELIVERY E. NEVILLE, TOWN CLERK
PO BOX 1179
SOUTHOLD f
NY 11471
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IF NO-
SUFF ! +'l II~l i I, I~UVIL-I'V~I'I!v'r- rIC:ML'I rl Or-MV(CES, FOOD CONTROL
360 YAPHANK AVENUE, STE. 2A - -
YAPHANK, NEW YORK 11980-9744 +
FIRST CLASS MAIL
FOOD ESTABLISHMENT PERMIT ENCLOSED
STEVEN BE ONE S JAMF6 L. TOMARKEN
SIIFFOI.K C.OIINTY EXECUTIVE . MD, MPH, Mm'M6w
COMMISRIONER RECEIVED
SUFFOLK COIJ T W 230
DEPARTMENT OF HEALTH SERVICES
aoulhold Town Clem
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TOWN OF SOUTHOLD
E. NEVILLE, TOWN CLERK
PO BOX 1179
SOUTHOLD
NY 11971
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SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
PERMIT
„~~aRTM.,x,. TO OPERATE A FOOD ESTABLISHMENT
caMN'~1aHVx 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
1 k'±.. SUFFOLK fA
crx saavIcss PROVISIONS OF ARTICLE 13 OF THE SUFFOLK COUNTY SANITARY CODE AND ALL APPLICABLE STATE,
oeenxrM6errot xenM
I / - LOCAL AND MUNICIPAL LAWS, ORDINANCES, CODES, RULES AND REGULATIONS.
IF THE FACILITY IS SERVED .BYAN ON-SITE WELL THE DISINFECTION REQUIREMENTS OF THE
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STATE SANITARY CODE ARE WAIVED PENDING CONTINUED SATISFACTORY COMPLIANCE
WITH THE PROVISIONS OF PART 5.
I.D. # 30926
APPROVALS
ESTABLISHMENT NAME: TOUN OF SOUTHOLD,S'ENIOR DIN
ESTABLISHMENT ADDRESS: 970 PECONIC LANE
PECONIC
` OPERATOR'S NAME: KAREN A. MCLAUGHLIN, DIRECTOR
ISSUE DATE: 10/16/13
EXPIRATION DATE: 09/30/14
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RESTRICTIONS PERMIT ISSUING OFFICIAL
SINGLE-SERVICE TABLEWARE REQUIRED TOUR OF SOVTHOLD-RUMAN SERVICE
SPECIALLY RFSTRICTED: SEE MASTER FILE SE111OR DINING PROGRAM SATE-LLLT
MANNED VENDING LOCATIONS ONLY P.O. BOX 85
KA'TT I TUCK
NY 11952
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TO USE ENVELOPE
1. FOLD AND TEAR OFF BACK FLAP ONLY AT PERFORATION.
2. INSERT REMITTANCE STUB WITH PAYMENT
3. MOISTEN BACK OF THIS FLAP AND FOLD OVER.
PLACE STAMF
OFFICE OF THE TOWN CLERK HERE
t~~R The Post Office
TOWN OF SOUTHO will not deliver
ELIZABETH A. NEVILLE, TOWN CLERK mail without
P.O. BOX 1179 Postage
SOUTHOLD, NEW YORK 1197 '
ADDRESS CHANGE REQUESTED
' SUFFOLK COUNTY
DEPARTMENT OF HEALTH SERVICES
FOOD CONTROL, SUITE 2A
360 YAPHANK AVENUE
YAPHANK NY 11980-9645
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TOWN OF SOUTHOLD #
E. NEVILLE, TOWN CLERK fit"
PO BOX 2174
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