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Home My WebLink AboutApplication 494 Chapel Road .4.0,$N 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 SOR-Co Restaurant Establishment Information New Permit 7 Permit Renewal E] "(Please Print Clearly)*** Name of Establishment: Manager's Name: L 14(q ---------------- ------------ City, State, Zip Code: Cell Phone#: 11 Phone#: Fax C) (C) cc- E-Mail Address: 2A Cti) Seating Capacity: Please submit latest copy of the Qualified Food OperatorlServSafe certificates to the office. YES NO E_❑ (Required for_ ------- Qualified Food Operator: Cla Certificate#: OU ss 3&4) Name: Date: Testing Organization: P[nne#: L4 & E-Mail Address: Alternate Phone#: Designated Alternate 1: �(e, Designated Alternate2 Restaurant Owner Contact Information Owner's Name: Street Address: j City, State, Zip Code: Phone#: Fax#. E-Mail Address: Cell Phone#: Renovations Were there any renovations made last year? YES F1 NO Fill" Will there be any renovations? YES E] 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: rd Attention: ffii' _.Piz lNa_ ---------- Address: , A A City, State,Zip Code: I ........... ------------- Phone#: ---------- Town of South Windsor — Health Department o a 1540 Sullivan Ave., South Windsor, CT 06074-Mailing Address C 1530 Sullivan Avenue, South Windsor, CT 06074-Office Address Phone Number: (860) 337-6173 Fax: (860) 644-1930 soa•co�'� Restaurant Menu/List of All Items Served/Sold Latest Menu Attached? YES VrNO ❑ NOTE`*(gust 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. i f I 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) i 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: I Z- iZ I(I Office Use Only Inspector Name (Print): Inspector Signature: Date: Food Class: 1 ❑ 2 ❑ 3 ❑ 4 ❑ Expiration Date: Date Received: Date Approved: P I.D.Number. 1053806 v ceptinficateC6 , Plevow .. , f DAWN M.IVMAHANEY is recognized for successfully meeting the prescribed requirements by examination of the SetvSafe®Food protection Manager Cerffiication Course. { Presented hY The Educational Foundation of the National Restaurant Association � i Date 219/98 i t—ident - 1 Congratulations! Be proud of your achievement! Now that you have been certified through the ServSafe® We encourage you to prominently display the International course,you qualify to participate in the International Food Safety Council decal in your establishment—to help build Food Safety Council, a coalition committed to food safety customer recognition of your certification and the Council,and education. See the back of this page for more information. to demonstrate the industry's commitment to serving safe food. ,Keep this card with you. Refer to it when you need to update your certification recor4or when you want to contact the Council for food safety information. OIERNATIONAL - 1 INTERNM IONAL FOOD SAFETY COUNCIL C O U N C I L x5o South Wadcer Drive•Suite Lion tYticago,It 6o6o6 t L800.456.om•Fax;u 715.0807 SM W98 DAWN M.MAHANEY senrsafe• I.D.Number. 1053806 Certification Date 219/98 Council 69lration Date `- 219/03 John R Farquharson,FMP President Disclaimer Placement or usage of the international Food Safety council"'decal and/or pal licipatimi in council activities is not an cndm sanenl,nar is any svartzntiy,expressed or implied,made or responsibility assumcd or implied by the International Food Snfcty Council for any act by 111" establishment,including soft Jtad handling Practiccs- GUIDELINE FOR CLASSIFYING FOOD SERVICE ESTABLISHMENTS The Public Health Code (PHC) Section 19-13-11342(s)(3) states that"the director of health, registered sanitarian or authorized agent shall classify each food service establishment by using the criteria outlined in this subdivision..." Similar requirements may be found for itinerant food vending and catering food service operations in PHC sel Lions L La LP-rCP�-"L and L� LO LPY'9�l L` res ectIVCl, IJJI 1 l J Ji N Y• It should be noted that food establishments that do not provide individual portion service of food to the public (e.g., wholesale and retail markets, bakeries, confectionary stores, etc.) are regulated by PHC Section 19-13-11340 and therefore and not subject to classification and qualified food operator(QFO) requirements. The following provides a guide for classifying food service establishments based on the type of food preparation/heating and also provides examples of types of establishments in each classification. CLASS I: ESTABLISHMENTS Description of Food Preparation Permitted • Commercially prepackaged food (e.g., cold commercially packaged sandwiches and sandwich meat and cheeses, pastries, confectioneries, etc.). • Hot and cold beverages(e.g., coffee, tea, soft drinks, etc.). • Hot and cold food preparation limited to non-potentially hazardous foods (e.g., popcorn, pretzels, donuts, etc.) AND potentially hazardous foods heated and served in original package within 4 hrs. (e.g., commercially prepared processed and packaged sandwiches). Examples of Establishment Types • Convenience stores with prepackaged foods and beverages • Snack bars at theaters serving prepackaged foods and popcorn and beverages • Newspaper stands • Coffee shops serving pastries, beverages and prepackaged foods CLASS II: ESTABLISHMENTS Description of Food Handling • Cold or ready-to-eat foods including potentially hazardous foods may be prepared (e.g.,cold deli sandwiches, salads, etc.). • Hot or cold beverages (e.g., coffee, tea,soft drinks, etc.). • Commercially packaged precooked potentially hazardous foods may be heated and served in original package within 4 hours (e.g., commercially prepared processed and packaged sandwiches). • Commercially precooked: hot dogs; kielbasa; and soups (not chili,stew,or other canned products), may be heated if transferred directly out of the original package and served withing 4 hours. (Transferred directly out of the original package means opening a can or package of soup that is in a ready-to-eat form and does not require the addition of water, milk, or other ingredients.). CLASS I1: ESTABLISHMENTS (con't) Examples of Establishment Types • Delicatessens • *Convenience stores • Sandwich shops • Ice cream and yogurt shops • *Donut shop • No hot potentially hazardous foods except hot dogs, kielbasa and commercially processed soups. *It should be noted that some donut shops and convenience stores are heating and serving precooked eggs, bacon & sausage not in individually sealed packages and would therefore be classified as a Class III for IV food service establishment. CLASS III: ESTABLISHMENTS Description of Food Handling • Hot preparation of potentially hazardous foods allowed if served to the public within 4 hours (e.g., hot meat sandwiches, pizza, soups,seafood, etc.) The 4-hour maximum holding time before service includes the cumulative holding, cooling, storage, reheating times, after heat treatment. Examples of Establishment Types • Delicatessens with hot food preparation less than 4 hours holding before service. • Cafeteria (including schools with hot food prepared less than 4 hours before service). • Some restaurants with same day preparation of hot foods (less than 4 hours before service). • Itinerant food vendors • Day Care Centers • Fast food establishments with no preparation for hot potentially hazardous foods more than 4 hours before service. • Cook/serve operations-some diners and short order establishments CLASS IV: ESTABLISHMENTS Description of Food Handling • Hot preparation of potentially hazardous foods (e.g., meats, poultry, eggs,fish, dairy, etc.) served more than a cumulative(include hot holding, cooling, cold storage, reheating, etc.)4 hours after heat treatment. Examples of Establishment Types • Most restaurants • Convalescent homes • Hospitals • Caterers • Institutional food service • Industrial food service • Any food service establishment that serves potentially hazardous foods left over from the day before Food Protection Program 10/02 \\ l 1i\ i`\qN\ •.1 \\\�\\,\\\�\�(��\\\\ 9 �� `� Ili, \\\`V\ \\\ , r \,4 Cereal served with fruit English muffin toasted with Whole-grain French toast Whole-grain bagel with Cereal, served with fruit BREAKFAST and milk sun butter, served with sticks, served with fruit and cream cheese, served with and milk fruit and milk milk fruit and milk MORNING SNACK Yogurt with Cheerios Crackers served with Fruit and low-fat cottage Whole-grain Toasty O's Animal crackers and milk cheese slices cheese cereal and Bananas k Chi d S and Chicken LUNCH Pasta with Rutter Tacos SweetMini Pizza Turkey and Cheese Stackers Rice:Bowl Whole wheat Rotini lightly Tortilla with shredded Diced chicken breast lightly Miniature cheese pizza Sliced Turkey and Cheese tossed in butter with grated cheese served with peas, tossed in sweet and sour served with corn,fruit and on wheat crackers served parmesan cheese served fruit and milk tossed served over rice milk. with Veggie noodle soup, with steamed green beans, pilaf served with carrots, fruit and milk fruit and milk fruit and milk VEGETARIAN OPTION CheaseTac°s ,, ,e"'' Cheese Stockers Sun butter and jelly Whole-grain graham Cinnamon Crackers served Whole-grain crackers with Vanilla wafer and sliced AI;FTERNOON SNACK sandwich on wheat crackers topped with grape with milk hummus bananas crackers jelly curdance with Fetlaral cavil rlghlt.law antl U S Department of Agriculture(USDA)civil righ4 7gul.b.ns and policies.the USDA,its Agencies,offices.and employees,and Insrtutlon¢parlicipednB In or admini¢tarinB USDA programs era prohibited from dlscriminahng based on race,color,notional origin,sex,disability.age,o reprisal or retallellon for prior civil right¢apavlty In any program or activity conducted or lunged by lJSDA.P¢rsons with d;sabllili9a who ragulre elternahva means of communn:ation for proq—lnfo•mabon(a.q.Braille,large print aud.uth,American Slgn LangueBe,eto),should...) tthe Agency(State or local)where they applied for banelta.Indlvlduels who are JeW hard of hearing or have speech dlsabilltiea may contact USDA through the Federal Relay Service at 1800)877-8339.Additional). program;f"'r bp,may be made n,,liable In languages other than English.To file a program complaint of disor—r anon,complete the USDA Program Dc-nn nation Complaint Farm,AD-3027 found onllne al hd llwww ascr usda y nn,•pin,1 loan,call(856)632.9992.Submit p ( ) s govlcomple 1 fl'ng,pu¢t htm and el any USDA ,e or write a letter addressed to USDA and ou.1 opportunity the letter all of the n(ormation requested the form.To request a copy of the your completed loan or Ixllar to USDA by.(i)mail:U.S.Department of Agriculture Office of the A ., ..er:retary/or Civil Rights 14001ndepandenee Avenue.SW Washington.D.C.20250-g410;l2)tax:(2e2)690-]442,or(3)eme I'.progrem.nteke�uede.gov.This nsdlut on's an equal opportunity provltler. Water Is available to children throughout the day and at all meals and snacks.If no beverage is specified the beverage offered will be water. Children(age ill months)are served whole milk.After 24 months,all children are served 1%milk \vvy\vA\vv„a �vvv�\\\yy.,:,vyvyv��yvvy\ \\`\ FFp � i,v \" \p\\e •\\ \\\\�\\...\\\\\\\\\\�\\\ I�M'�� III, ,. + �\�\�`\\\\\\\,�\ • /�� <' �" � (\ v 0\A� VAA- A\\\vA.\,,A ,a VA\ \\\v v`\ v \,A�\•v v A\\\\, �. ,J �', ��' �� \VA\A ,A ,a�mV A VA\V\\��, AA�\V�,;�AA\vU\VA,v vv�Ay�A ,V,,�' ^.V., ,V\,p A\ �A\\�I,•.,: t ,r , :. \ \ \ \ \ \ \ \ � \ \ 1. \ \),r \, \ ,,\,„\,,,1„,,•.•„,�,. ,., \\ ,,,\ .. i1allimil�\ BREAKFAST Cereal, served with fruit Waffles served with fruit English Muffins with Jelly Cereal served with fruit and Cereal, served with fruit and milk and milk with fruit and milk milk and milk MORNING SNACK Crackers with cottage Yogurt and granola Cereal mix, served with Whole-grain graham Wheat crackers and cheese milk Cracker with Sunbutter cheese slices LUNCH Pasta with Butter Chicken and Rice Bowl Mac`n'Cheese Barbeque Chicken Sandwich Sun Butter&Jelly Sandwich Whole wheat Rotini tossed Diced chicken served over Macaroni noodles tossed in Diced chicken tossed in Sun butter and jelly with butter sauce served Rice Pilaf with peas,fruit cheese sauce served with barbeque sauce served on sandwich on whole-grain with steamed carrots,fruit and milk green beans,fruit and milk a bun with corn,fruit and bread,served with tomato and milk. milk soup,fruit and milk Cheese Sandwich VEGETARIAN OPTION Applesauce and whole- Vanilla Wafers, served Whole-grain pita bread and Animal Crackers and Fruit Cereal served with milk grain graham crackers milk hummus AFTERNOON SNACK orlon wlh Fetleral�., dU .Department W Agrcvlture(USDA)c virghtc reg,lat dp ' Age--USDA, Age offces,anem dployeec,and'nHl'Iullpne part'dpaing in edmini a,,USDA programs ere ar .Wedtram diacrlmineling based on reea color-a-1 or9 ,aab'I't n,'a. y ageoreprlHel or relel'al'on for relvll rl hle ecl'viti f,nded by USDA Persons w th d�eab t.,who requ re aXernatve means of cgmmvdcat on(w program'nformaton(e g.Srdlle.large pr nt and otape,Ame^can S Lan r pro g y n any tl80ram or 8339 y conducted. 'fgrmatign ma n made available in Ian u s other than'n 9^ pl,aht etc.),should contact lea Agency(State or local)where they applied far bq cus.Indlrld d It who era A f,hard of Fearing or have speech dlsaniA h may contact USDA through the federal Raley Servlca the f )B7]-5339.Atldilla y y. nrnyran y e g age E gush To(ile aprpgram complaint ofdiscrimination,complete the USDA Program Dlscriminehon Complain)Form(AD-302])found online at http/Iwww.ascr usda ggvlcomplaint fillnq cuathlml.end el any USDA oflce,or wrilealeXer eddressetl to USDA and provide In the letter all of the infwmetion requested in the lain.Terequaslecepy of the complaintform.call(366)632-9992.Submit yourcompleted form or letter tq USDA by(1)mail:U5.Department of Agriculture UK—of the Assistant Secretary for Clvil Rights 1400Independence Avenue,SW Washi^glp DC.20250-9410,(2)<a (202)590-7442',W(3)email',program.i,ak,gu,d,.gpv.This inst,lu eon is en equal opportunity provider. V�VgU APvVAvAVA VvVAVPV@AAAA APv VA A,A AA VVvAv I 1 \ S'mty ,sC;t .Pr."'`f' u;.. .,,jam'"��`; p \�,,� °`•` \� E`Tl"� , \\�\\\\\,`\ \ Lr 9r,"a•?", � •vd✓' A\a\ \��. t, �`c ��\\ \\\\�` \ v vi t ;'y'„W` d. , ' n 1 , \ V V 1 A Cereal, served with fruit Whole-grain bagel topped Whole-grain French Toast Cereal served with fruit and Cereal,served with fruit BREAKFAST and milk with Cream Cheese served Sticks,served with fruit and milk and milk with fruit and milk milk MORNING SNACK Cereal Mix and milk Fruit and low-fat cottage Bananas and Sunbutter Vanilla Wafers and fruit Bananas and milk cheese LUNCH Pasta with Butter Cheese Burger Sliders Chicken and Rice Bowl Turkey and Cheese Roll-Ups Soup and Sandwich Whole wheat Rotini lightly Miniature burgers on a bun Diced chicken breast Sliced Turkey and Cheese Sliced cheese served on tossed in butter with grated topped with cheese served served with rice pilaf with wrapped in a tortilla served whole wheat with veggie parmesan cheese served with corn,fruit and milk baked beans,fruit and milk with peas, fruit and milk noodle soup fruit and milk with carrots,fruit and milk Pit saSa�dvyl�h Rles;Bawl, GharseRail.Ups VEGETARIAN OPTION Animal crackers and milk Vanilla wafers and milk Whole wheat crackers Yogurt and granola Wheat Crackers and sun served with Hummus butter AFTERNOON SNACK nrdfln wt ( 'I':I grc,lture(USDA)c drghls regusM pf ,the USDA.tsAgences.Dittos,and employees andn na parfcpafngn radminislenng USDA programs are proh bitetl from dtsohmmaang based on race color,national orgn.s x.d ab'I ty,a r reprleal or rela at'on for pio,c v lr ht,aclvt gram or ac ycon luntlwrb USDA 'nblte.w, , ns of for pro 9 Yna pro Ivt ducted« Y gram f (.q.Bra Ile,large pr nl and olape,Ame S'q g g t I.should contact the Aqency(State or Iecal)where They appl ed f«benefile.Indlvltluals whg era tleei,hard o/hear nq«haveespeech dsati foes may contact USDA Through the Federal Reley Sary ce at(80010])-8339.Add-1 onelly, progran'n(ormato ,:y boned,avzlabl—anqug th. hn English.To file a-gam complant of d at—complete the USDA Program D'scrm'nefon Complant F.—(AD-302])fwnd-1-at hnp l/www.ascr usdagov/complent flingoust.html.and at any USDA office.or write a letter addressed to USDA and p,ovde nth,Iona,all of the inf,rmatonrequested n the form.Tor,quest a copy of the�omlant 1arm,ca11(b66)6329992.Sub.t your,ornpl.-form or letter to USDA by:(1)maI:U.S.Department of Agrculture Offce of the Assistant Secretary for QW Rights 1—Indepentlence Avenue,SW Washington,D.C.20250.9410',(2)< (202)890.74a2;or(3),mall This institution Is an equal opportunity provide,. �`�AA�V AV y\ v AVA VAA\\VV� %wAvv�A\\V�y��wAv,.,�V�\\��\\VAv\vA,"A�A\VAAA�A AAA\,v I \u\ r a v 1v 1t rvt \ v � yr ry Cereal, served with fruit Bagels topped with cream Whole-grain pancakes, Cereal served with fruit and Cereal,served with fruit BREAKFAST and milk cheese served with fruit served with fruit and milk milk and milk and milk MORNING SNACK Animal crackers and Crackers/Pretzels with Vanilla Wafers and milk Fruit and low-fat cottage Cinnamon crackers and 1%low-fat milk Hummus cheese milk Homemade Baked Cheesy Pasta and Chicken LUNCH Cheese Quesadillas Meatloaf Dinner Cheese Stackers Pasta Casserole Whole-grain rotini with Tortillas toasted with Beef patty topped with a Whole wheat pasta tossed Wheat Crackers with sliced melted mozzarella cheese, cheddar jack cheese tomato glaze served with with diced chicken breast cheese and hummus served with corn,fruit and served with peas,fruit and lightly seasoned Rice Pilaf, in a light cream sauce served with tomato soup, milk milk baked beans,fruit and milk served with carrots,fruit fruit and milk and milk VEGETARIAN OPTION RlceaaIY, Pasta with 8utterSauce AFTERNOON SNACK Yogurt and Granola Wheat crackers and Whole-grain bagel toasted Cereal mix and milk Whole-grain graham cheese slices with cream cheese crackers with sunbutter noManca wi lh Federal civil rights low and U.S Department of Agr�cultura(USDA)civil rights regulations and policies,the USDA,as Agencies.afacas.and employees.and instituaona participating In or edministanng USDA programa era prohibited from dl Ornma ri based on race,odor,national ari Y quire alternative means N communication for program Information(e.g.Braill1.large print a diotape.A--n Sign Lan g gin, a,dlaahlld salt retaliation USD f funrlen M1 USDA Per 5 witM1 disabilities who re se y age,or rapri ra prior civil rights ectivity in any orogram or eclivity canduotetl or infor a be made available in tan a other then En lish To file a r m lain)of tliscrimmaaon,coin late Iha USDA Pr m Disc nation C gage,etc.),shoultl contact the Agency(SIa1e a local)where they epPllad for banoftts.Individuals who era deaf.hard o/hearing or have speech disabilities may contact USDA through Iha Federal Relay Service al(900)877-8339.Additionally. feint Form,Ap-302J found online et htt'.lrwww.e sd I pl t fl t hMl tl t yp USDA aff t I tt dtl essed to USDA and rov da In Iha letter all of the information re uestatl in me fain.Tor oast a co of In vv��V vvv for vh�)vv vv \p\ tv�vA Vv v�v a