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Home My WebLink AboutApplication 1062 Pleasant Valley Road �'°'"" 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 'hbSOR•Co ,�( Restaurant Establishment Information New Permit Ll Permit Renewal El ***(Please Print Clearly)*** Name of Establishment: 15 Manager's Name: - -. Street Addr-ss: .1 cam\ f :1 . City, State, Zip Code a-Sp�, C..r r S so �a Cell Phone#: ��p Phone# (- Fax#: 1 1 - - E-Mail Address: Seating Capacity: �7+c OU Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office. YES :VO D (Pequlred for ' Certificate#: Qualified Food Operator: Class 3&4) Date: » - Phone#: STestinOization:g S -- - - —- Alternate Phone#: E-Mail Address: Ir/ �05L (�Designated Alternate 1:'' .� US Designated Alternate2 : ! Restaurant Owner Contact Information Owner's Name: .�� G�l U usvC _ 1 cAreet Address: City, `sa C— te, Zip Code: I �j T (�(e S Phone#: Fax # O �l`1''j.- o� 3 3(D E-Mail Address: l Cell Phone#: i SC;,_ Renovations �1y D Were there any renovations made last year? YES❑ NO Q� Will there be b t?bns? YES❑ NO ❑ 1 If Yes, please list all renovations 20�6 l� that were done/to be done: NDSOR Soo-TVA HEAL HI DEPT. Mailing Address to send Food License Renewal Permit to: Name of Restaurant/Company: - I - - C - Attention: Address:. i1G-(� �.\V J( City, State, Zip Code: U ('� ✓ 6�J C C..7 I I --- Phone#: Q Town of South Windsor — Health Department o 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address Lj 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address Phone Number: (860) 337-6173 Fax: (860) 644-1930 '^GSolt-co�� Restaurant Menu/List of All Items Served/Sold Latest Menu Attached? YES D/ 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. i I Additional Information Please check one on y: State Licenses: Bakery ❑ Liquor Permit None Water Supply: ✓Public Private Well Wastewater Disposal: Public n/On-Site _Other (please use space below to explain) /SoCI' S C �Ur� -- — --- 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: c Date: J _ Office Use Only Inspector Name (Print): i GjG/J Ins ignatu Date: Food C s: 10 20 3 740 Expirati n Date: Date Received: Date Approved: EXAM :FORM N4O. 4938 CERTIFICATE NO. 11234284 ry af CERTIFICATION To ELLEN E MAROUSKI for successfully completing the standards set forth for the ServSafe"Food Protection Manager Certification Examina which is accredited by the American National Standards Institute(ANSI)-Conference for Food Protection(CFP). 06/23/2014 DATE OF EXAMINATION 06/23/2019 DATE OF EXPIRATION Local laws apply.Check with your local regulatory agency for recertification requirements. Sherman Brown merlcan National Standards Institute ��cind the Conteronce for Foed Pratectlun SVP,National Restaurant Association Solutions #0655 n2014 National Restaurant Association Educational Foundation(NRAEF).All rights reserved.ServSafe Is a registered trademark of the NRAEF,used under license by National Restaurant Association Solutions,I.I.C. The logo appearing next to ServSafe Is a trademark of the National Restaurant Association. This document cannot be reproduced or altered. 14013002 v.1401 J MS aarda4l-poij Sax SANMA ICHE S ICE CREAM The Kristen Wrap Sundaes Fresh, seasonal veggies with red pepper hummus Kids 3.75 Small 4.75 Regular 5.75 and your choice of cheese Sundae toppings include hot fudge, caramel, The Panini peanut butter sauce, and strawberry sauce Rye bread with red pepper hummus, svviss cheese, caramelized onions, tomato, and spinach Cups & Cones Kids 2.75 Small 3.75 Regular 4.75 The J.P. Melt Counlrto irhito breed. with turkey, spinach, Milkshakes tomato, 0III.MIS, poppers and melted omericon Choose any flavor of ice cream 5.25 cheese Malted Milkshakes The Eggcellent Swid-wich Choose any flavor of ice cream 6.00 Tvvo eggs tr clwc (, ,)n yi)ur choice of bread ivith bacon, spinach, loniatof�,q, onions, and peppers Fusion A blend of frozen fruit and ice cream 6.00 The Mickey One egg, american cheese, green peppers, and Specialty Shake onions on white bread Any special shake listed 6.00 The Popper Country tn,hite bread with red pepper jelly, cream cheese, and pepper jack cheese Vegetarian 5.25 Turkey or Bacon 5.75 Turkey & Bacon 6.25 Drinks on back Check on our Facebook page for daily specials! DRINKS Smoothies 5.25 Choose your fruit -Bananas, strawberries, blueberries, mangos, pineapples Pick your base - Water - Orange juice .50 -Apple juice .50 Lemonade 2.00 Iced Coffee or Tea 2.00 Hot Coffee or Tea 1.50 Bottled Water 1.00 KIDS MENU Grilled Cheese PB&J Egg & Cheese Sandwich Turkey & Cheese Sandwich Comes with fruit and a small chocolate milk, apple, or orange juice 5.00 ABOUT US Contact Info 1062 Pleasant Valley Rd. South Windsor, CT (860) 550-4652 Our hours are seasonal and weather dependent, so don't hesitate to call! facebook.com/jemsgard ens Instogram: @jemsgarden