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HomeMy WebLinkAboutApplication 520 Griffin Road Town;of South Windsor — Health Department y 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 Restaurant Establishment Information New Permit❑ Permit Renewal ***(Please Print Clearly)*** Name of Establishment � RE ,s�. J � jf SCCf Manager's Name ._. St '-Addr:.s: 5G�(] Ci�'2.r1 RO QC� Ci State Zip Code SoL, n W;nVSpt' C. 0(.,o -7`f - Phone# $&0 Loq { 50 �7 Cell Phone#: _ - Ali - Fax# �Pq.4. _�3 - - -- E-Mail Address. ; (K L . Seating Capacity: Please submit latest copy of the Qualified ood OperatorlServSafe certificates to the office. i - -_ —Qualified Food Operator: YES NO ❑ (Required lor s a a # 3941 iL , _ Name Date Testing Organization Phon -- e# -- -- --- ---- Ali - _ — -- - - — E-Mail Address: 1 Alternate Phone#: Designated Alternate 1: Designated Alternate2 Restaurant Owner Contact Information Owner's Name S�¢lfa,. �� =r 4 — — -- Street Address ,AJf �Q City, State, Zip Codecpa: Gt-� ©�DeLni Phone# A .B'oS�:oZlolS� _Fax #: -- E-Mail Address: Cell Phone#: Renovations Were there any renovations made last year? YES❑ NO �i Will there be any renovations? YES❑ NO L� - ----- -- __._-- --- - — —....--- f \ - -_- ---- ---_ ...---r�- --! If Yes,_nlease list all renovations that were done/to be done: i I i i i Mailing Address to send Food License Renewal Permit to: --- — —... _... _._ _. Name of Restaurant/—Company ptp �FQ I� ��fc /A Attention Address City, State, Zip code l�. ind5o C� _OCoO _._ _.- 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 s Phone Number: (860) 337-6173 Fax: (860) 644-1930 SOP•Gpri Restaurant Menu/List of All Items Served/Sold Latest Menu Attached? YES, NO M 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. � I Additio nf rmatio Please check one only: State Licenses: ❑ Bakery XLiqU0r Permit ❑ None Water Supply: Public _ Private Well Wastewater Disposal: Public On-Site _Other(please use space below to explain) J 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. / t Applicant Name (Print): _ i Date: Applicant Signature: z Office Use Only Inspector Name (Print): Inspector Signature: Date: Food Class: 1 ❑ 2 ❑ 3 ❑ 4 ❑ Expiration Date: Date Received: Date Approved: t EXAM FORM NO. 5003 CERTIFICATE NO. 11673949 41. ServSaf e M 1 �1, 1' .i "Y t .d Y CERTIFICATION RICHARD III DAWSON >r� for successfully completing the standards set forth for the ServSafe"Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute(ANSI)-Conference for Food Protection(CFP), 10/29/2014 DATE OF EXAMINATION 10/29/2019 DATE OF EXPIRATION Local laws apply.Check with your local regulatory agency for recertification requirements. Sherman Brown SVP,National Restaurant Association Solutions #0655 2014 N urinoul Restaurant Association Edaeational Foundation(NRAFF).All in,hts reserved.ServSafe is a rogistered tradenark of the NRAES used under license by National Restaurant Association Solutions,LLC. In accordance with Maritime Labour Convention 20C the Ingo n,,00 ,nexttoS,vWi,isotrademarko(the Natlonal Resuni Assodutlon. Resolution ADM Mankin13(Regulation nti Stanch Thou document ammo[be.eproduarl nr altered. A3.2)ot the Maritime Labour Convention,20: 14013002 v.1401 Contact us with questions at lJSwJackeon Blvd.-Ste iS00,Chicago, L.Si or ServSafearestxurantorg. Collelo, Diane From: threeseasonscafe <threeseasonscafe@yahoo.com> Sent: Friday, December 30, 2016 2:49 PM To: Collelo, Diane Subject: RE: Food Service Registration Hi Diane, The named designated alternate is Michael Geysen. Please let me know if you need anything else from me. Thank you, Stephen Shonty -------- Original message -------- From: "Collelo, Diane" <Diane.Collelo@southwindsor.org> Date: 12/30/16 1:13 PM (GMT-05:00) To: 'stephen shonty' <threeseasonscafe@yahoo.com> Subject: RE: Food Service Registration Good Afternoon, Thank you for submitting your food service application. We appreciate your cooperation with our department. Please submit the named designated alternate that is missing on your form. This is required for all class 3 and 4 restaurants and will delay the issuance of your permit. Regards, DianeL. Cdldcl REHS/RS Environmental Health Specialist Town of Scurfy Wi ncbcC Health Department 1540 Sul I ivan Avenue—N/b I i ng AdcVess 1530 Scl I Ivan Averw-0(fi ce Adless Sa.h Wi rdco CT 06074 Ph: 860-337-6182 Fax: 860-644-1930 \Am..sakW r ita.crg Fi nd Ls cn Facdmdc https://www.facebook.com/SouthWindsorHealthDepartment From: stephen shonty [mailto:threeseasonscafe@yahoo.com] Sent: Friday, December 30, 2016 12:37 PM To: Collelo, Diane <Diane.Col lelo@southwi ndsor.org> Subject: Re: Food Service Registration Please see forms attached. Thank you. 2 UKINKS BEERS FOR THE COURSE BUD, BUD LIGHT, BUD LIGHT LIME, MILLER LIGHT, YUENGLING, COORS LIG �. HOPSTILLO IPA, MICHELOB ULTRA, GUINNESS, TWISTED TEA, MIKE'S HARD. SAMUEL ADAMS, SPIKED SELTZER, NON-ALCOHOLIC BEVERAGES Powerade or Bottled Water 2.25 Coffee, Tea or Hot Chocolate 1 .5', Bucklers or O'Douls 3.25 Fountain Drinks 2.0C_ Coke,Diet Coke, Ginger Ale, Sprite, Club Soda,Unsweetened Ice-Tea, or Lemonade r BOTTLED BEERS 3.25 Budweiser Bud Light Michelob Ultra Bud Light Lime Coors Light Miller Light PREMIUM BOTTLED BEERS 4.2_5 Twisted Tea - can Heineken -0 Corona / Corona Light Newcastle Sam Adams Boston Lager Amstel Light Sam Adams Light Redbridge - gluten free Stella Artois Ten Penny Ale Guinness - can 5.25 Mike's Hard - can BEERS ON TAP Pints 3.25 Premium Pints Pitcher 10.00 Premium Pitchers WINE BY THE GLASS 6.00 Chardonnay White Zinfandel Cabernet Sauvignon Sauvignon Blanc Pinot Grigio Merlot Pinot Noir ttf ■ ■ ■ • BURGERS ■ Y Served with your choice of Fries. Chips. or Cole Slaw ■ Add Onion Rings or Sweet Potato Fries for S1.00 ■ 3 Seasons Burger Wrap" 8.95 6oz Cheeseburger* 7.95 A flour tortilla filled with a Our Angus burger topped with 6oz cheeseburger, shredded your choice of American.Swiss or ■ romaine,diced onion,diced pickles cheddar jack cheese served or, ■ and thousand island dressing a hard roll with lettuce and tomato ■ ■ 6oz Burger` 7.50 6oz Bacon Cheeseburger 8.95 ■ An Angus fire grilled burger served Our Angus burger topped with t on a hard roll with lettuce and tomato American cheese and thick cut bacon served on a hard roll i with lettuce and tomato Patty Melt' 8.95 f Our 6oz burger patty served on grilled rye bread with caramelized Topstone Burger* 9.95 onions and Swiss cheese 6oz Angus burger topped with t peppers, onion. mushrooms. and ■ { bacon topped with melted cheddar ■ Smokey Barbecue Burger* 9.95 jack cheese with lettuce and tomato A 6oz Angus burger smothered in served on a hard roll sweet barbecue sauce topped with bacon,melted cheddar jack cheese covered with battered onion straws ■ served on a hard roll ■ SUMMER CATCH ■ ■ Lobster Rolle Market Price Fish and Chips' 10.95 ■ Lump lobster claw and lobster tail Battered and fried cod filets served ain warm butter served on a buttered over French fries with a side of New England roll cole slaw and tarter sauce Fish Sandwich* 9.95 A fresh cod filet lightly battered and fried to perfection served on a hard roll with lettuce tomato, ■ tarter sauce on the side ■ JANUMCHES r X Served with your choice of Fries; Chips, or Cole Slaw Add Onion Rings or Sweet Potato Fries for S 1.00 Egg Sandwich 3.00 Grilled Cheese* 5.95 j TI-ac eggs topped with melted cheese _ Choose between American. served on your choice of bread Swiss, or shredded cheddar jack +: Add Bacon or Sausage for 1 .00 cheese on your choice of bread Half Deli Sandwich BLT* 6.95 and Cup of Soup 6.95 Thick cut bacon layered on top Choose from turkey, ham, roast of lettuce, tomatoes, and mayo, beef, chicken salad. or tuna salad, served on your choice of bread served on your choice of bread with lettuce and tomatoes Reuben Sandwich* 9.95 Deli Sandwich* 7.95 Warm Corned beef or turkey Choose between, turkey, ham, served on rye bread with melted chicken salad or tuna salad on your Swiss cheese, sauerkraut, and choice of bread with lettuce and thousand island dressing tomatoes Roast Beef Sandwich* 8.95 Philly Cheesesteak* 9.95 Thinly sliced roast beef served on Shaved steak,peppers,onions,and a hard roll with lettuce tomatoes mushrooms, smothered in melted Swiss cheese and homemade American cheese horseradish cream sauce Hot Dog* 4.50 Club Sandwich 9.95 A Hummel Brothers dog served on Turkey, ham. roast beef. chicken a New England style bun salad or tuna salad triple decker sandwich on your choice of bread Add Kraut 0.50 M1 with thick cut bacon, lettuce, tomato,and mayo Chili Cheese Dog* 5.50 Grilled Chicken Sandwich* 8.95 A Hummel Brothers dog topped with our house made chili and Marinated chicken breast grilled melted cheddar jack cheese. and tossed in your choice of sauce, served on a hard roll with lettuce and tomato = s SALADS ■_ Garden Salad 6.95 ■ Mixed greens, topped with C_a- ■ = cucumbers. grape tomatoes and carrots Caesar dress:-.= s.- Add Chicken 2.95 Parrne z Add Lobster Market Price Add Chicken 2.95 ■ Add Lobster Market Price Buffalo Chicken Salad 9.95 Grilled or crispy buffalo chicken Sesame Chicken Salad 9.95 ■ tossed in a tangy buffalo sauce Crispy or grilled chicken tossed ■ over crisp romaine with grape in an Asian sesame sauce served tomatoes, cucumbers, shredded over mixed greens, mandarin ■ carrots and blue cheese crumbles oranges, grape tomatoes, ■ served with your choice of dressing cucumbers, carrots, scallions and Asian noodles served with a side of ■ Chef Salad 9.95 sesame dressing Sliced turkey, ham, American ■ cheese and Swiss cheese over mixed greens topped with egg, grape ■ tomatoes, cucumbers and carrots served with your choice of dressing WRAPS x Served with your choice of Fries, Chips, or Cole Slaw ■ Add Onion Rings or Sweet Potato Fries for $1.00 ■ Veggie Wrap* 7.95 Barbecue Chicken Wrap* 8.95 i ■ A flour tortilla stuffed with lettuce Crispy or grilled chicken tossed ■ tomatoes, sauteed onions, peppers, in a sweet and smokey barbecue mushrooms and broccoli with a sauce served in a flour tortilla with balsamic drizzle shredded romaine, diced tomatoes and onion straws Buffalo Chicken Wrap* 8.95 Grilled or crispy chicken tossed in Sesame Chicken Wrap 8.95 buffalo sauce served in a flour tortilla Grilled or crispy chicken 1 with shredded romaine and blue tossed in our sesame teriyaki ■ cheese dipping sauce on the side sauce served in a flour tortilla with shredded romaine and Chicken Caesar Wrap* 8.95 diced tomatoes Your choice or grilled or crispy chicken tossed in creamy caesar dressing and Parmesan cheese a, s } _ APPETIZERS Basket of Fries 3.50 JalaYe�.o Caps 5.95 jalapeno slices lighted battezemz Basket of Rings 5.50 and fried fresh to order served vn i a side of ranch Basket of Sweet Potato Fries 5.50 � # 4.50 Boneless Wings 8.95 Seasoned Fries _ Fresh chicken tenderloins battered French fries tossed in our house and fried to perfection tossed in your blend of spices served with a side choice of sauce seined with a side of i of chipotle ranch blue cheese dressing ■ ■ Nachos 8.95 Chicken Quesadilla 9.95 A hefty portion of tortillas piled Flour tortilla filled with seasoned l� ■ ; ■ y high with jalapenos, scallions, chicken breast, diced tomatoes, diced tomatoes layered with diced scallions and cheddar jack cheddar jack cheese served with a cheese ■ ■ side of sour cream and salsa. ■ Add Chicken or Chili 2.00 ■ ■ ■ SOUP Homemade Chili Clam Chowder Cup - 3.95 Bowl - 5.95 Cup - 2.95 Bowl - 4. 95 A sweet and spicy chili topped with New England style ■ t cheddar jack cheese. ■ : Soup of the Day t ■ Cup - 2.95 Bowl - 4. 95 Ask your server for details. ■ ■ • CHICKEN WINGS ■ t 8 - 8.95 16 - 14.95 24 - 19.95 Jumbo chicken wings fried and tossed and your choice of sauce served with blue cheese dressing SAUCES Fire, Hot, Mild,Smokey Barbecue, Honey Mustard, Sesame Teriyaki, Garlic Parmesan, Honey Hot