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Home My WebLink About625 Chapel Road (2) <°"'" "44� 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 s ` Phone Number: (860) 337-6173 Fax: (860) 644-1930 SOR.GU,c+v Restaurant Establishment Information New Permit❑ Permit Renewal ❑ ***(Please Print Clearly)*** Name of Establishment: Manager's Name: Street Address: City, State, Zip Code: Phone#: Cell Phone#: Fax#: E-Mail Address: Seating Capacity: Please submit latest copy of the Oualified Food Operator/ServSafe certificates to the office. Qualified Food Operator: YES(] NO ❑ (Required for Certificate#: _ C!ass 3 4 4) _ -Name: Date: Testing Organization: Phone#: E-Mail Address: Alternate Phone#: Designated Alternate 1: Designated Alternate2 Restaurant Owner Contact Information Owner's Name: Street Address: City, State, Zip Code: Phone#: Fax #: E-Mail Address: Cell Phone#: Renovations Were there any renovations made last year? YES❑ NO ❑ 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: Attention: Address: City, State, Zip Code: Phone#: 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. Additional Information Please check one only: State Licenses; ❑ Bakery ❑ Liquor Permit ❑ None Water Supply: — Public — Private Well Wastewater Disposal: Public 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: INTERNATIONAL MAGNET SCHOOL Pre-K Breakfast December 2017 MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY Warm Mini Bagel with This institution is an equal Cinnamon Creamy Cheese opportunity provider I Fresh Fruit Choice Milk Choice 1 Assorted Cereal Breakfast Pizza Warm Mini Waffles BREAKFAST SANDWICH Warm Mini Bagel with Fruit Choice Fresh Fruit Choice Maple Madness Egg&Cheese Strawberry Creamy Cheese Milk Choice Milk Choice I Fresh Fruit Choice Sandwich Fresh Fruit Choice Milk Choice Fresh Fruit Choice Milk Choice Milk Choice 4 51 Early Dismissal 6 Early Dismissal I Early Dismissal 8 Assorted Cereal Breakfast Pizza Warm Mini French Toast BREAKFAST SANDWICH Warm Mini Bagel with Fruit Choice Fresh Fruit Choice Cinnamon Rush Egg&Cheese Cinnamon Creamy Cheese Milk Choice Milk Choice I Fresh Fruit Choice Sandwich Fresh Fruit Choice Milk Choice Fresh Fruit Choice Milk Choice Milk Choice Assorted Cereal Breakfast Pizza Warm Mini Pancake BREAKFAST SANDWICH Warm Mini Bagel with Fruit Choice Fresh Fruit Choice Maple Burstin Egg&Cheese Strawberry Creamy Cheese Milk Choice Milk Choice I Fresh Fruit Choice Sandwich Fresh Fruit Choice Milk Choice Fresh Fruit Choice Milk Choice Milk Choice Early Dismissal 22 No School Winter Break Daily Milk Choice—1%White Milk OR Skim Milk Menu Subject To Change INTERNATIONAL MAGNET SCHOOL Pre-K Lunch December 2017 MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY PIZZA DAY Personal Cheese Pizza Chicken Noodle Soup Mixed Garden Salad Fruit Cup Choice Milk Choice Crispy Chicken Tenders Beef Chili Pizza Dipper Brunch Da v PIZZA DAY Mac And Cheese Tortilla Chip Scoops Pizza Dipping Sauce Pancakes&Syrup Stuffed Crust Cheese Pizza Steamed Broccoli Florets Steamed Kernel Corn Cucumber Salad Sausage Links Minestrone Soup Fruit Cup Choice Fruit Cup Choice Fruit Cup Choice Hash Brown Patty Mixed Garden Salad Milk Choice Milk Choice Milk Choice Fruit Cup Choice Fruit Cup Choice Milk Choice Milk Choice Early Dismissal 6 Early Dismissal 7 Early Dismissal 8 Crispy Chicken Patty Chicken Quesadilla Crispy Chicken Nuggets Burger Day PIZZA DAY on Bun Sour Cream&Salsa Baked Oven Fries Beef Patty with Cheese Real Cheese Pizza Slice Roasted Sweet Potatoes Tomato Salad Steamed Kernel Corn on Bun Vegetable Soup Fruit Cup Choice Fruit Cup Choice Fruit Cup Choice Potato Rounds Mixed Garden Salad Milk Choice Milk Choice Milk Choice Fruit Cup Choice Fruit Cup Choice Milk Choice Milk Choice Crispy Chicken Tenders Beef Chili Mozzarella Sticks Brunch Dav PIZZA DAY Mac And Cheese Tortilla Chip Scoops Marinara Sauce Cup French Toast&Syrup Personal Cheese Pizza Steamed Broccoli Florets Steamed Kernel Corn Cucumber Salad Sausage Links Chicken With Rice Soup Fruit Cup Choice Fruit Cup Choice Fruit Cup Choice Hash Brown Patty Mixed Garden Salad Milk Choice Milk Choice Milk Choice Fruit Cup Choice Fruit Cup Choice Milk Choice Milk Choice Early Dismissal 22 This institution is an No School equal opportunity provider Winter Break I� Daily Milk Choice—1%White Milk OR Skim Milk Menu Subject to Change INTERNATIONAL MAGNET SCHOOL December 2017 MONDAY TUESDAY WEDNESDAY THURSDAY I FRIDAY Warm Mini Bagel with Cinnamon Creamy Cheese Fresh Fruit Choice 100%Fruit Juice Milk Choice 1 Assorted Cereal Breakfast Pizza Warm Mini Waffles BREAKFAST SANDWICH Warm Mini Bagel with String Cheese Stick Fresh Fruit Choice Maple Madness Egg&Cheese Strawberry Creamy Cheese Fresh Fruit Choice 100% Fruit Juice Fresh Fruit Choice Sandwich Fresh Fruit Choice 100%Fruit Juice Milk Choice 100%Fruit Juice Fresh Fruit Choice 100%Fruit Juice Milk Choice Milk Choice 100% Fruit Juice Milk Choice Milk Choice 4 5 Early Dismissal 6 Early Dismissal 71 Early Dismissal 8 Assorted Cereal Breakfast Pizza Warm Mini French Toast BREAKFAST SANDWICH Warm Mini Bagel with String Cheese Stick Fresh Fruit Choice Cinnamon Rush Egg&Cheese Cinnamon Creamy Cheese Fresh Fruit Choice 100% Fruit Juice Fresh Fruit Choice Sandwich Fresh Fruit Choice 100%Fruit Juice Milk Choice 100%Fruit Juice Fresh Fruit Choice 100%Fruit Juice Milk Choice Milk Choice 100% Fruit Juice Milk Choice Milk Choice 11 12 13 141 15 Assorted Cereal Breakfast Pizza Warm Mini Pancake BREAKFAST SANDWICH Warm Mini Bagel with String Cheese Stick Fresh Fruit Choice Maple Burstin Egg&Cheese Strawberry Creamy Cheese Fresh Fruit Choice 100% Fruit Juice Fresh Fruit Choice Sandwich Fresh Fruit Choice 100%Fruit Juice Milk Choice 100%Fruit Juice Fresh Fruit Choice 100%Fruit Juice Milk Choice Milk Choice 100% Fruit Juice Milk Choice Milk Choice 18 19 20 21 Early Dismissal 22 NO SCHOOL WINTER RECESS 25 26 27 28 29 Daily Asst. Cereal and Fresh Fruit Menu Subject To Change INTERNATIONAL MAGNET SCHOOL December 2017 MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY PIZZA DAY Personal Cheese Pizza Chicken Noodle Soup Mixed Garden Salad Fruit Cup Choice Milk Choice I Crispy Chicken Tenders Beef Chili Pizza Dipper Brunch Da v PIZZA DAY Mac And Cheese Tortilla Chip Scoops Pizza Dipping Sauce Pancakes&Syrup Stuffed Crust Cheese Pizza Steamed Broccoli Florets Steamed Kernel Corn Cucumber Salad Sausage Links Minestrone Soup Vi Fruit Cup Choice Fruit Cup Choice 100%Fruit Juice Hash Brown Patty Mixed Garden Salad Milk Choice Milk Choice Milk Choice 100%Fruit Juice Fruit Cup Choice Milk Choice Milk Choice 4 5 Early Dismissal 6 Early Dismissal 7 Early Dismissal 8 Crispy Chicken Patty Chicken Quesadilla Crispy Chicken Nuggets Dog Da X PIZZA DAY on Bun Sour Cream&Salsa Baked Oven Fries Chili Hot Dog Real Cheese Pizza Slice Roasted Sweet Potatoes Tomato Salad Steamed Kernel Corn on Bun Vegetable Soup Fruit Cup Choice 100%Fruit Juice Fruit Cup Choice Tomatoes Vinaigrette Mixed Garden Salad Milk Choice Milk Choice Milk Choice 100%Fruit Juice Fruit Cup Choice Milk Choice Milk Choice 11 12 13 14 15 Chicken Tenders Beef Chili Mozzarella Sticks Brunch Da v PIZZA DAY Mac And Cheese Tortilla Chip Scoops Marinara Sauce Cup French Toast&Syrup Personal Cheese Pizza Steamed Broccoli Florets Steamed Kernel Corn Cucumber Salad Sausage Links Chicken With Rice Soup Fruit Cup Choice Fruit Cup Choice Hash Brown Patty Mixed Garden Salad Milk Choice Milk Choice 100%Fruit Juice 100%Fruit Juice Fruit Cup Choice Milk Choice Milk Choice Milk Choice 18 19 20 21 Early Dismissal 22 This institution is an NO SCHOOL equal opportunity provider WINTER RECESS 25 26 271 281 29 Daily Milk Choice--1%White Milk--F.F.Chocolate--F.F.Strawberry--Lactaid Grab&Go--Asst.Sandwiches--Chef Salad--Bagel Plate Daily Vegetable Cup--Cucumber--Broccoli--Carrot--Bean Salad Menu Subject To Change '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