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HomeMy WebLinkAboutFSE Application 432 Buckland Road 8606447360 The Village at Buckland Court 12:14:39 p.m. 12-21-2016 1 /10 Town of South Windsor -- Health Department 1540 Sullivan Ave.,South Windsor,CT 06074—Mailing Address U 1530 Sullivan Avenue, South Windsor, CT 06074--Office Address REC V D Phone Number: (860)337-6173 Fax: (860) 644-1930 ��SOR•C�� _ 212016 Restaurant Establishment Information New Permit❑ Permit Renewal 1'�4 WINDSOR 7 J ***(Please Print Clearly)*** HEALTH DEPT. Name of Establishment: ' Name: Manager's _..-- -----_--- strict Addriz: — City, State,Zip Code: Phone#: Cell Phone#: , ---- __ _Fax#: S/'Y:12 �— E-Mall Address: 1SU.1l�tn R�d�Y/¢JAt +Z eating Capacity:�1 I Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office. N ❑ {Required for -' Qualified Food Operator: YES O —Certificate#: -- �.—.__-------• ------- - Class 3&4).._ Name: Q � _..._. Date:_1,__ -.— -- Testing Organization: _ _ _ Phone#: -'e"Y _ E-Mall Address: _ -_ T - __ -_—_- Alternate Phone#_: r Designated Alternate 1: Designated Altemate2 CvtiT;f��rc�'1aa2�5ao>s Restaurant Owner Contact Information _ Owner's Name: 'Street Address: _-�_--•�--___.�___-__.—._ ___ _ ----City, State, Zip Code: _ _• --- . __. �__--_-___._—_-_-.-- —_ _.__-------- _ Phone#� _ _ _ —1_---Fax#-. _EE-Mail Address: _-�— ,_-_ - Cell Phone#: �- Renovations Were there any renovations made last year? YES El No 0- _Will there be any renovations? YES❑ 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:�r Attention: Address: _q .�Ul�� ►.w� -- -- City,State,Zip Code: -•--_ _.._.—____ __ _.__Phone#_ ,��/c _7 � -- ___�_._.._..-•--•--- --• 8606447360 The Village at Buckland Court 12:14:50 p,m. 12-21-2016 2/10 "~ r` Town of South Windsor — Health Department o a 1540 Sullivan Ave.,South Windsor,CT 06074—Mailing Address 4 • 1530 Sullivan Avenue,South Windsor,CT 06074—Office Address Phone Number: (860)337-6173 Fax: (860)644-1930 �h�SOR•Go it Restaurant Menu/List of All Items Served/Sold Latest Menu Attached? YES K 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:. ❑ B kery ElLiquor Permit None Water Supply:. Public _Private ell Wastewater Disposal: _Public�V 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: Office Use Only Inspector Name (Print): Inspector Signature: Date: Food Class: 1 ❑ 2 ❑ 3❑ 4 ❑ Expiration Date: Date Received: Date Approved: 8606447360 The Village at Buckland Court 12:15:00 p.m. 12-21-2016 3/10 ALTERNATE PERSON IN CHARGE DEMONSTRATED KNOWLEDGE STATEMENT (viii) IDENTIFY AND RECOGNIZE THE FOODS MOST COMMONLY ASSOCIATED WITH FOOD ALLERGIES. (B) DEMONSTRABLE ELEMENTS OF COMPETENCY (i) ASSESS THE POTENTIAL FOR FOODBORNE ILLNESS IN A FOOD SERVICE ESTABLISHMENT- PERFORM OPERATIONAL FOOD SAFETY ASSESSMENT;RECOGNIZE AND DEVELOP STANDARDS,POLICIES AND PROCEDURES,SELECT AND TRAIN EMPLOYEES;IMPLEMENT SELF AUDIT/INSPECTION PROGRAM; REVISE POLICY AND PROCEDURE(FEEDBACK LOOP);IMPLEMENT CRISIS MANAGEMENT PROGRAM. (ii) ASSESS AND MANAGE THE PROCESS FLOW-IDENTIFY APPROVED SOURCE;IMPLEMENT AND MAINTAIN A RECEIVING PROGRAM;IMPLEMENT AND MAINTAIN STORAGE PROCEDURES; IMPLEMENT AND MAINTAIN PREPARATION PROCEDURES;IMPLEMENT AND MAINTAIN HOLDING/SERVICE/DISPLAY PROCEDURES;IMPLEMENT AND MAINTAIN COOLING AND POST PREPARATION STORAGE PROCEDURES;IMPLEMENT AND MAINTAIN RE-SERVICE PROCEDURES; IMPLEMENT AND MAINTAIN TRANSPORTATION PROCEDURES. ------------------------------------------------------------------------------------ - 1_f1 _t,Lg2f4e:2AV attest that J Pt5 0&� Gf,<<GL :v/1Stc�o � (Print Name of Owner or Operator) (Print Name of Alternate Person in Charge)` is employed as the alternate person in charge and has demonstrated to me the elements of knowledge and demonstrable elements of competent iescribed in A and B,as listed above. Signature and Tit �S Date (Signed y Owner/Operator of the Establishment) Signature and Title �1 .� � Date fj - Lo - igned by Alternate Person in Charge) t Name of Establishment Address of Establishmentv � ��% n\food\legal\copy of altemat Rev.9/1/2006 8606447360 The Village at Buckland Court 12:15:09 p.m. 12-21-2016 4/10 00 m 0 V W T O --I 3 N C 9J eD N 9J r+ OO C 77 EXAM FORM NO. 5020 a_ in CERTIFICATE NO. 12225208 ServSafe National Restaurant ciation TM ervSafee CERTIFICATION TO JASON G CHILLINGSWORTH N for successfully completing the standards set forth for the ServSofe"Fcod Protection Manager Certification Examination, N which is accredited by the American Notionol Stondords Institute fANSIKonference for Food Protection (CFP). N 3 t � N 04/09/20l*5 DATE o 04/09/2 DATE OF EXP Local laws apply. for recertification requirements. u, 0 . ,- '4858 .fir . : S, y - - �iCltal.ti;� urart2 Aacfiatt�'n J� ,n ®tt. N.o. 1'041-984�_ - 5 I t F.j T ID, r'' nt a i m TO E ' :�D 0, S PAU:LI N . 4, 1". for.scicctessfully-Go ipl s itfortli-by:the'Navonal Restaurar;. .'��. - h Fou.ndi:tion>fiGVffie Servs ew— . ' t f- er.Gertifi�at�on;Exam�ilat�c�a D'a t;e;ref Examination: 10/,QA'�.r Q ��. , •r�,::�,, .� ��, :Date of 1,Expiration 201,89" r .icatiomme uirernents. . t: acal:laws apply- Check,with,.your IaCai..►-egul ,, e q Q2.012.,i�ationairRestaurant•Association,; , a c I EPI A11 rights.:;reservedi: SerwStif©its,.a,registereditrad,em�i k�.of�s r " by,!National,,Restaurant 1 Asso,Gaton:Solutions,..LLC. T.h.ersarademrk ohdNJ - Natiot aIAestaurantRVU N I N O V O 8606447360 The Village at Buckland Court 12:16:09 p.m. 12-21-2016 8/10 00 0% C. JIBENCHMARK E NPRINNS Llil2OW 112VILV WMWeek 4 L - 445 The Village at Buckland Court MONDAY Y �DNR�.SDA FRIDAY_.Iz.:, SATURDAY December 18,2016 December 19,2016 December 20,2016 December 21,2016 December 22,2016 December 23,2016 December 24,2016 Eggs Benedict Buttermilk Pancakes Breakfast Sandwich Fresh Donuts Waffles with Toasted Bagels-Served Cinnamon French Toast R with Home Fries with Warm Maple Syrup Sausage,Egg&Cheese and Breakfast Pastries Warm Syrup and Butter with a Variety of With Butter and warm Syru A E on English Muffin --i Flavored Cream Cheese Z_ (D K I F RrenkfastOrrerinys: Cemni:Assorted Hat&Cold Whole Grain Cereals Toasted Breads: White,Wholegrain,Rye,Raisin or English Muffin Fm%li from Um Oven:Freshly Baked Muffins and Breakfast Pastries Fresh F:-_1 i A S Seasonal Whole Fruits&Fresh Fruit Cup Yogurt/Cnitnac Clicu;c:Assorted Low Fat Yogurt&Low Fat Cottage Cheese Eggs and Omclet4;:_Pmpared To Order-Scrambled,Fried or Poached.Served with Fruit,Bacon or Sausag w T Omelet Selectinns:Green Peppers,Onion,Tomato, Bacon,Sausage,Swiss or American Cheese. TEgg Beaters©are available upon request Beverages:Juice Selections,Coffee,Tea and Milk Chicken-Ditalini Soup Vegetable Barley Soup Navy Bean Soup Vegetable Noodle Soup Kole Soup Henny Tomato Soup Garden Salad or Fresh Fruit Garden Salad or Fresh Fruit Garden Salad or Fresh Fruit Garden Salad or Fresh Fruit Garden Salad or Fresh Fruit Garden Salad or Fresh Frui Smoked Salmon Plate vNiediterranem Scrod General Tso's Chicken V Oven Baked YTomato& VOrange Dijon Salmon � Toasted Bagel,Tomato,Onion Tomato Broth w/Fried Rice& Chicken Fingers Swiss Omelette Mixed Green Salad L I and Low Fat Cream Cheese Red Potato Wedges Steamed Broccoli Barbecue Sauce Breakfast Potatoes Wheat Breadstick U Green Peas Community Choice Potato Puffs,Cole Slaw Fruit Cup N C H Frosted Chocolate Cake Fresh Pineapple Vanilla Puddina Jell-O Parfait Freshly Baked Cookies Macaroons Lentil Soup Cream Potato Soup Minestrone Soup Split Pea Soup Butternut Squash Bisque Manhattan Clam Chowder Seafood Gumbo Garden Salad or Fresh Fruit Garden Salad or Fresh Fruit Garden Salad or Fresh Fruit Garden Salad or Fresh Fruit Garden Salad or Fresh Fruit Garden Salad or Fresh Fruit Garden Salad or Fresh Fruit VRoasted Turkey Knockwurst&Sauerkraut TShrimp and IfSpinach& or Beef Brisket TTuscan Chicken Breast Chicken Pot Pie E Savory Bread Stuffing Baked Beans Broccoli Sautd Roasted Pepper Potato Latkes with Mushrooms, Peas and Carrots V Mashed Potatoes&Gravy Potatoes O'Brien Rice Pilaf Stuffed Pork Loin Carrots Tomato&Caper-, Green Bean Casserole Baked Potato Roasted Potatoes Beef Pot Roast N YRosemary Chicken Thigh Turkey ala King Zucchini Provencal Baked Ham Spinach Oven Roasted Potatoes I Tortellini Bolognese Steamed Rice Over Puff Pastry Pineapple Sauce Peas&Carrots N Steamed Broccoli Ratatouille Sweet Peas Spaghetti and Meat Balls Baked Sweet Potato Baked Seafood Casserole G Garlic Bread Side Caesar Salad Vegetable Medley Lobster Cream Sauce Ritz-Crumb Topping Wild Rice,Green Beans Peach Berry Pie Carrot Cake Annle Strudel Lemon Cake Pecan Pie Peach Crisn Chocolate RspbLrry Cake N T Indicates Reduced fat,salt and sugar and are appropriate for these diets 2 rn *Before placing your order,please inform your server if person in your party has a food allergy ,Spring 2016 Choice d