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IF 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
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FOOD ESTABLISHMENT PERMIT ENCLOSED
STEVEN BELLONE 4 JAMES L.TOMwRKEN
SUFFOLK COUNTY EXECUTIVEMD,MPH,MBA MSW
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SUFFOLK COUNTY
DEPARTMENT OF HEALTH SERVICES
TOWN OF SOUTHOLD
E. NEVILLE, TOWN CLERK
PO BOX 1179
SOUTHOLD
NY 11971
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SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
PERMIT
® e TO OPERATE A FOOD ESTABLISHMENT
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THIS PERMIT WILL EXPIRE UPON THE DATE SPECIFIED OR UPON A CHANGE OF THE OPERATOR.
I> THIS PERMIT IS NOT TRANSFERABLE AND IS GRANTED SUBJECT TO COMPLIANCE WITH THE
SUFFOLK COUNTY
DEPARTMENT OF HEALTH SERVICES 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.
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APPROVALS
ESTABLISHMENT NAME: p_
' SOUTHOLD HUMAN RES. CTR. p
ESTABLISHMENT ADDRESS:
Ip 754 PACIFIC STREET
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OPERATOR'S NAME: SCOTT A. RUSSELL., SUPERVISOR
ISSUE DATE: 12/08/14
08114
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EXPIRATION DATE: 12/31/15
PERMIT ISSUING OFFICIAL
RESTRICTIONS
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MECHANICAL DISHWASHER REQUIRED TOWN OF SOUTHOLD
APPROVED FOR HOT AND COLD DELIVERY E. NEVILLE, TOWN CLERK
PO BOX 1179
' SOUTHOLD ^ 1
4 NY 11971
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