HomeMy WebLinkAboutApplication 1735 Ellington Road Town of South Windsor - Health Department
r 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address
1530 Sullivan Avenue, South Windsor, CT 06074—Office Address
y Phone Number: (860) 337-6173 Fax: (860) 644-1930
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Restaurant Establishment Information New Permit❑ Permit Renewal f_
***(Please Print Clearly)***
Nunn of Establishment: r'
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Manager's Name_ l Z #y r7YeA
StrcctAdurcJJ• I ✓� V /I • / /��
City, State, Zip Code:
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Phone#• ! 0 Z Cell Phone# �(,0 - 6_ 73_.
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Fax#: _� - - y
F-Mail Address_ (Q� SD�,.Ui ��► Seating Capacity:
Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office.
Qualified Food Operator: YES ❑ NO (;ieg6lrcd for Certificate#:
Class 3&4)
Name: Date:
Testing Organization: ' Phone#:
E-Mail Addres,: Alternate Phone#:
Designated Alternate .1: Designated Alternate2
Restaurant Owner Contact Information
Owner's Name: ; J,44es #"zrip)A-
Street Address: g 7 V+!1 Q�J C e ��
City, State, Zip Code: win J s o� C I 0 b O 9.5.
Phone#: N0 -_6e l- M k- Fax #:
E-Mail Address: J (l r IC f 4g �,�,�� r • Lonrl Cell Phone#: ' 0 -f 4 S- f 7�
Renovations
Were there any renovations made last year? YES❑ NO [9_ Will there be any renovations? YES ❑ NO 21�-
If lies, please list all renovations
that were done/to be done:
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Mailing Address to send Food License Renewal Permit to:
Name of Restaurant/Company: ' S 5 � Q ►i X C
Attention: Jtm yvyl.��h
Address: f 1 y3s � � �► __RECEIVr
City, State, Zip Code: I ,Sav- WInJr��, r _ Q60 71
- — - Phone#: j A0 - .6 y8- as YX P.F.^ 3 0 2016 .
SOUTH WINDSOR
HEALTH DEPT.
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A 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
y% t Phone Number: (860) 337-6173 Fax: (860) 644-1930
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Restaurant Menu/List of All Items Served/Sold
Latest Menu Attached? YES❑ 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.
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Additional Information
Please check one only:
State Licenses: ❑ Bakery ❑ Liquor Permit Eg None
Water Supply: P� Public _ Private Well
Wastewater Disposal: _DWublic 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):
AV ri e�
Applicant Signature: Date: /a d0
Office Use Only
Inspector Name (Print
Inspector Signature: Date:
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Food Class: 1 V] 2 ❑ 3 ❑ 4 ❑ Expiratfon Date:V
Date Received: k Date Approved:
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1 of 1 12/14/2016 4:34 PM
ITALIAN ICE � KICK IT UP A NOTCH�
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� s� �cginnins �► ■ LG $3,49
,�S���L 1 aT $5,99
Party and kids sizes available upon request. _ 4 •
ITALIAN ICE FLAVORS NEW! ALL-NATURAL ICE FLAVORS
Banana Pineapple GELATI
Banana
Orange strawberry Our#1 selling treat made FROZEN CUSTARD
Blood Orange
with Italian Ice layered �.
Blueberry Crearr�y,award-winning'
Blue Raspberry �N�w� AL.l-NATUR.�'L IBC i ��� ■ between Frozen C.Istard. and made with premium
Cantaloupe "` '"v. __-`— 1 . REG $3.99 ingredients.
Cherry LG $4.49 REG CONE/CUP $3.69
Chocolate CREAM 1 RE FLAVORS Chocolate Chocolate Chip LG CONE/CUP 4.19
Chocolate Peanut Butter REG SUNDAE 4.99
Banana Split Crc:arci LG SUNDAE 4. 9
Cotton Candy Birthday Cake y WAFFLE CONE $0.89
Dr Pepper-NEW! Black Cherry Cheesecake a
Florida Orange Caramel BLENDINh WAFFLE BOWL $0.89
Georgia Peach Cheesecake ��•� A Custom h1pnd of Frozen CUSTARD FLAVORS:
Grape Chocolate Chip Cheesecake Custard, Itall al] Ice and your
Green Apple Chocolate-Covered Strawberry ` 'M` favorite toppir':[)S. Vanilla Strawberry
Island Fusion Coconut Crc:ram REG $4.49 Chocolate Orange Cream
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JOLLY RANCHER Green Apple--NEW! Cookie Dour h Twist Light Vanilla
�� _ �. -CUSTARD $5.29
JOLLY RANCHER Watermelon—NEW! OREO Cooki.s n'Crean, Coffee
Juicy Pear Fudge Brownie
Key Urne> Gingerbread TOPPINGS
Kiwi-Strawberry Horrhata EE,
Lemon Iced Coffee ¢ I f,I�r;�
ManE]o Marshmallow Peanut t3utter t 'i��+
Mango-Orange Mint Chocolate Chip k MISTO" SNAKE S teavn
Mango-Pineapple Mint OREO r i
r•�lanto-Stravvberr Italian Ice: and i�uS.r]ri� �
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tvlar nrita i � mixed todr��thE;�i for aperfect
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Passion FiuitPumpkins on-the-go f�u�en treat. 1r
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Peanut Buller ,`Jelly Pumpkin Pie b REG $3.919 ,
P i 6 a rnlada Root Beer Float 1_6 $4.49
" Pineapple S'n'iores Sprinkles
r Raphc=rrY Strawberry-Branan a FROZEN DRINK Whipped Cream
Raspberry Lemonade Strawberry C=ieesecake r Hot Fudge -
Root Beer Vanilla Crer-.im Your favnnte fit,,vnr of Hot Caramel
SOUR PATCH KIDS Red NJaterrnelon Chip our Italian Ice':urncd into Peanut Butter Topping
Strawbe ry a a refreshing Frozen Drink. Strawberry Topping
Strawberry Colada
Strawberry Len'umadc. JF -� � REG $3.19 wet Walnuts .-
Strawberry MaiSUGAR-Ff kEE FLAVORS LG $3 69 Chopped Peanuts y
St�wbcrry WarenYielon Sugar-Free Cherry Chocolate Chips
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Mini Gummy Bears
Swedish Fish Sugar-Free Dragonfruit 3 MILKSHAKE
Tropical Punch Sugar-Free lvlango Peach Maraschino Cherries
A Crean"1V tWISC on it Clc7SSli,
Vanilla] Sugar-Free P neapple available Irl a Unlgele 1 al-iety ML7�.�
Watem�elon Sugar-Free Pink Lemonade $ -
Wild Berns Sugar-Free Root Beer of IaVOrS' 8• ttlf•d Wat-
er $1.36
Wild Black Chem/ Sugar-Free Tangerine REG $4.89 A C,wds AF�1lable _.p
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1 of 1 12/14/2016 4:34 PM