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Home My WebLink AboutFSE Application 625 Chapel Road -10.$ ``'� 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 oR•cor Restaurant Establishment Information New Permit❑ Permit Renewal ***(Please Print Clearly)*** Name of Establishment: (� ,� ��N�-1i M/�--N� 5cl�alt _.. Manager's Name..; �(/��"✓/1 (�1 /1410- C./W v City, State, Zip Code: SL'(/-/ [✓(/✓�S�YZ. Cj v Phone#: 86G' — Z 9j—641 Cell Phone#: 366--3-0 q-/27s' Fax# U E_MailAddress_;M1./fGGux� G/'6�G -046 Seating Capacity: j Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office. ualified Food Operator: YES NO u e!for Certificate#: Q p cuss 3& 4) - - - /�7i��6 Name.• I - -- - - - --- MIk g IA✓IVG4I Date: Testing Organization-: ANSI - 60 (Ponlltk) Phone#: E-Mail Address: 14 k/Il,e&y @ (i!?C-(, ,C"P-C Alternate Phone#: $bU- 36q_/77p Designated Alternate 1: ,/fnrOS Designated Alternate2 Restaurant Owner Contact Information Owner's Name: i'i X 6—'61 Street Address: City, State, Zip Code: :; 1�11"rtd j 6 lob Phone#: � �- S�lJQ— 377� Fax #: - - -- - E-Mail Address: JSl& WM6A (h> (we, Cj/L Cell Phone#: -3,2e" Renovations Were there any renovations made last year? YES❑ NO Will there be any renovations? YES❑ NO ❑ If Yes, please list all renovations I that were done/to be done: i i Mailing Address to send Food License Renewal Permit to: Name of Restaurant/Company: Attention: Address: 01�-y City, State, Zip Code:I _ _ Phone#: ' �SU rG�% Town of South Windsor - Health Department o 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address ; • 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address A,Co �� Phone Number: (860) 337-6173 Fax: (860) 644-1930 tios� � Restaurant Menu/List of All Items Served/Sold Latest Menu Attached? YES 5�/NO ❑ NOTE••(Must 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. Additional Information Please check one only: State Licenses: ❑ Bakery ❑ Liquor Permit None Water Supply: Public _ Private Well Wastewater Disposal:__1XPublic _ 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): Applicant Signature: Date: Z / Office Use Only Inspector Name (Print): Inspector Signature: Date: Food Class: 1 ❑ 2 ❑ 3❑ 4 Expiration Date: Date Received: Date Approved: GUIDELINE FOR CLASSIFYING FOOD SERVICE ESTABLISHMENTS The Public Health Code (PHC) Section 19-13-642(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 scuiviis 1 -J.J-LJ-TNUJk GJ and 17-J.J-C7-f'`LJGJ, ICJ�1CClIVC1'/. 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. (Transferreddirectiyout of the origina/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.). INTERNATIONAL MAGNET SCHOOL da January Breakfast Everyday y No Breakfast No Beef/Pork MONDAY Vegetarian 2017 TUESDAY WEDNESDAY THURSDAY Daily Milk Choice FRENCH TOAST STICK FRIDAY BREAKFAST PIZZA Aunt lemima Pancakes 1%White Milk MAPLE SYRUP CORN MUFFIN FRESH FRUITS MAPLE SYRUP F.F.Chocolate FRESH FRUITS ASST. 100%JUICE FRESH FRUITS FRESH FRUITS ASST. 100%JUICE Skim Milk ASST. 100%JUICE MILK CHOICE MILK CHOICE ASST. 100%JUICE MILK CHOICE I MILK CHOICE 3 4 5 ASST.CEREAL Belgian Waffle Sticks BREAKFAST SANDWICH 6 STRING CHEESE MAPLE W•W. FRENCH TOAST STICK CINNAMON SWIRL ROLL I SYRUP EGG and CHEESE FREH FRUIT FREH FRUIT FREH FRUIT MAPLE SYRUP STRING CHEESE ASST. 100%JUICE ASST. 100%JUICE ° FREH FRUIT FREH FRUIT ASST. 100%JUICE ASST. 100%JUICE ASST. 100%JUICE MILK CHOICE MILK CHOICE MILK CHOICE MILK CHOICE MILK CHOICE ' M.L.K. 9 FRENCH TOAST STICK 10 BREAKFAST PIZZA it 12 Aunt Jemima Pancakes BREAKFAST SANDWICH 13 MAPLE SYRUP FRESH FRUITS MAPLE SYRUP No School FRESH FRUITS EGG,CHEESE AND SAUSAGE ASST. 100%JUICE FRESH FRUITS FREH FRUIT ASST. 100%JUICE MILK CHOICE ASST. 100%JUICE ° MILK CHOICE ASST. 100%JUICE MILK CHOICE MILK CHOICE 16 17 18 ASST.CEREAL Aunt lemima Pancakes 19 20 BREAKFAST SANDWICH Belgian Waffle Sticks STRING CHEESE MAPLE SYRUP EGG,CHEESE AND SAUSAGE No School FREH FRUIT MAPLE SYRUP FRESH FRUITS FREH FRUIT ASST. 100%JUICE ASST. 100%JUICE FREH FRUIT Professional ASST. 100%JUICE ASST. 100%JUICE MILK CHOICE MILK CHOICE Development MILK CHOICE MILK CHOICE Day 23 24 Daily Fresh 25 W.G. BAGEL HW FRENCH TOAST STICK Fruit 26 27 CREAM CHEESE MAPLE SYRUP Menu FRESH FRUITS FRESH FRUITS Subject ASST. 100%JUICE ASST. 100%JUICE To MILK CHOICE MILK CHOICE Change i 30 31 INTERNATIONAL MAGNET SCHOOL January Lunch Everyday No Lunch No Beef/Pork MONDAY Vegetarian 2017 TUESDAY WEDNESDAY THURSDAY FRIDAY Daily Milk Choice o Dom Crispy Chicken Nuggets Bur erDay 1/o White Milk Chili Hot Do On a �— P1ZZA DAY g Baked Oven Fries Beef Patty with Personal 5"Pizza F.F.Chocolate W.W.Dog Bun Steamed Kernel Corn Cheese on a W.W.Bun Skim Milk Tomato Vinaigrette Mixed Garden Salad g Canned of Fruit Cup Potato Round Fruit Cup Choice 100%Fruit juice Milk Choice 100%Fruit i uce j Milk Choice Milk Choice Milk Choice 3 4 5 Chicken Tenders Mac and Beef Beef Chili 6 Chicken Dipper Teriyaki PIZZA DAY Mac And Cheese Romaine Salad Rice&Beans Veggie Spanish Rice Steamed Broccoli Warm Bread Stick Steamed Kernel Corn Saute'Green Beans Stuffed Crust Canned of Fruit Cup 100%Fruit juice Cheese Pizza 1 Canned of Fruit Cup Warm Bread Stick Mixed Garden Salad Milk Choice Milk Choice Milk Choice o 100/o Fruit Juice Fruit Cup Choice 9 10 11 Milk Choice Milk Choice 12 No School Dog DR v Crispy Chicken Nuggets Bur er Dav 13 Chili Hot Do On a � P1ZZA DAv g Baked Oven Fries Beef Patty with Real Sliced W.W.Dog Bun Steamed Kernel Corn Cheese on a W.W.Bun M.L.K. Tomato Vinaigrette Cheese Pizza g Canned of Fruit Cup Potato Round 100%Fruit Juice Mixed Garden Salad Milk Choice 100%Fruit juice Milk Choice j Fruit Cup Choice 16 17 18 Milk Choice Milk Choice Chicken Tenders Mac and Beef 19Beef Chili 20 Chicken Dipper Teriyaki No School Mac And Cheese Romaine Salad Rice&Beans veggie Spanish Rice Steamed Broccoli Warm Bread Stick gg p Steamed Kernel Corn Saut6'Green Beans Canned of Fruit Cup 100%Fruit Juice Canned of Fruit Cu Professional Milk Choice Milk Choice Milk Choice Warm Bread Stick Development ice 100%Fruit Juice Chicken Patty On 23 Milk Choice 26 27 W.W.Bun Doi D Grab and 24 25 o Daily Vegetable ups Menu Chili Hot Doogg On a Asst.Sandwiches Cucumber Sweet Potato Bite W.W.Dog Bun Chef Salad Subject Canned of Fruit Cu Broccoli To P Tomato Vinaigrette Bagel or Muffin Plates Carrot Milk Choice 100%Fruit juice Change Bean Salad Milk Choice 301 31 'L'311"i"(��ll,,-t''erss ,*oi,-C;,qI Food Alla lie7ger d' nat si( ' n fins been con rred 1111oll 3 10 MARY ELLA WILCOX -evients ftwce lot? 10 tas wet affthe hl SWIlt(111011- Exam 8401 Recognized By Conference For Food Protection C Certificate No: 1620306 Exam Date: 08/16/10 'lleptik:I-ILI Ei it ell i, N i k De\viopIlIL-11, Test Code: 6203038401 Certificate expires no later than: 08/16/15