HomeMy WebLinkAbout535 Evergreen Way (5) Town of South Windsor — Health Department
1540 Sullivan Ave., South Windsor, CT 06074- Mailing Address
1530 Sullivan Avenue, South Windsor, CT 06074 - Office Address
sy Phone Number: (860) 337-6173 Fax: (860) 644-1930
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Restaurant Establishment Information New Permit❑ Permit Renewal
***(Please Print Clearly)***
Name of Establishment: (vl c,L- 'S S t S:-� (; 2i L-L
Manager's Name: L A(Z_e1"i L!}w S MAAAC
Street Address: S3 �,2(4, �f fit;A f 2 £��,,.,� rZ�
City, State, Zip Code: So,7-R1 v-11 L-i 0(,- 714 At-GAA11 N'q
Phone#: kGu j Z -r5'J 3_� Cell Phone#:
Fax#: S'6,c, (/SL 9J-z=2-
E-Mail Address: 5•�e-,Z"1J L_C, , IC,+ Seating Capacity: 66—
Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office.
Qualified Food Operator: YES&I NO ❑ (Required for Certificate#: 0?
Class 3&4) S
Name: Lq,.✓5 Date: k 1 1 F I I7
Testing Organization: Phone#: 2- S rc_y_
E-Mail Address: �����Sc� ,�,��,� ��� i�Ml Alternate Phone#:
Designated Alternate 1: ;z �2, e�� A Designated Alternate2
Restaurant Owner Contact Information
Owner's Name: ;ZJ C S�f- Al S K`/
Street Address: 4 W )a`d`
c
City, State, Zip Code: sr� ►'�k{��f��aJ C CJG��� l
Phone#: �Slo" - S3� - y3 Py Fax #:
E-Mail Address: S k4_v`\ Cell Phone#: Yc/,\D --5.3 f y3/S
Renovations
Were there any renovations made last year? YES❑ NO b4 Will there be any renovations? YES❑ NO n
If Yes, please list all renovations RECEIVED
that were done/to be done:
N"1V 3 0 Z017
SOUTH WINDSOR
HEALTH DEFT.
Mailing Address to send Food License Renewal Permit to:
Name of Restaurant/Company: LMo�-_ S T
Attention:
Address:
City, State, Zip Code: e�L q��l `� L?O X
Phone#: % - (oJ •(
Restaurant Menu/List of All Items Served/Sold
s Latest Menu Attached? YES 0 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): 3�
Applicant Signature: Date: i sr 17
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: 1 ❑ 2 ❑ 3 Eql�4 ❑ Expiration Date: �-
Date Received: Date Approved:
ServSafe
National Restaurant Association
ServS ..... I e
CERTIFICATION
CARRIN LAWS
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).
15745507 10555
CERTIFICATE '`UMBER EXAM FORM NUMBER
11/8i 2017 11/8/2022
DATE OF F XAMINATION DATE OF EXPIRATION
Local laws apply. whh your boat rtrgulotary og._-_y For recertification requirements.
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i , National Rentouront Association Solutions
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FREE CHIPS
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with every order t a side of queso or guac 2.99 }�
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Burritos Quesadillas
_ Served in a 12"flour or whole-gram tortilla or a 10"pumor size) Served in a grilled 10`flour tortilla with beans,shredded cheese,
Served in o,beans and pko flour tortilla with rice,beans,shredded cheese and pico a side of pica and sour cream
Alright,Alright,Alright Homewrecker,W,ih QuaL, John Coctostan
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8.69 9.39 1240-1325 7.69 1115-1165 8.99 895-1015 9.69 905-1015 7.69 775-855 8.49 185 873 9.19 785-875 6.69 655-705
Junior Served In a grilled 10"flour tortilla with shredded cheese,bacon,
................................................................ lettuce.tomato and chrpotle ranch
Tacos guy z save 5u 8.29 555-625 8.99 555-625 6.99 475-535
Buy 3 save 1 00 First Rule of Chicken Club
JoeyBag of Donuts .................................................
Served in a 4a1t flour ofcrispy cam Shell with beans, � urn m 9.49 925
u+ Ynlw cap
shredded che and pico
8.29 8-15-96.5 6.99 845-965 7.69 715-795
Overachiever'W,th guacJ Junior
.............................................. .................... Sides
................................................................
c Was 7.59 515-595 8.29 520-595 6.99 445-495
rrndn Cow, Wile. )
4.49 375.505 4.79 330-505 3.89 255.405 Served in a grilled 10"flour tona►a with beans,shredded cheese,
a side of pico and sour cream
Funkmeister
. .. . . .I............. ... .................................. � � Moe's Famous Queso
Seri e,
4.19 4.49 295-463 3.89 225-375 1; 1.29 f4l 3.69 573 5.99 855
Served m a bowl with rice,beans,shredded cheese,guar and pico
Earmuffs Handcrafted Guac
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Clam".Pal' tak arSalads Glum,F, d WAmItn 1:a+ Vplu Cd Cn, sa•I fl•
8.99 745-875 9.69 755-875 7.69 625-715 1.19 3.69 245 5.99 315
Sfllvei;nith chopped romame lettuce.
r:uis shredded rheese and pico
Close Talker Stacks Add-ons
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,i Glalnl eyl ,�' LY.IIII :✓ YIr(e ':JI Extra eat ............................... 2.00 123-165
8.99 d85•J015 9.6! 485 l015 7.99 355 855 Served with queso,beans,shredded cheese and pica,stacked in two
crunchy corn shells wrapped and grilled in a 12"tortilla Bacon...................................... 1.00255
.................
2.000Catonesadayrs use forgenoralnutationii&w,but calorre needs vary. Wrong Doug Queso...................................... 1.29 140
AddiNonalnutritron infamatron available upon request. .................................................................
chlc►an.TYa Sink or Guac........................................ 1.29 55
rn G.1 BM U Lltaln Cgl Yr!!n L"
Thoroughly cooking meats,poultry seato d,,sheltbsh or eggs reduces the risk 9.99 975-l075 10.69 985-1075 8.99 855 915 Bela,placml,m:allJar ukase rnlonn Your%m lei F I oennl m mug prig het!loaf llVrtY
of bodborne illness
Drinks '
MAKE IT YOURS WITH _
Fountain...... ............... 'Z7tl al r0y- 2.6a
. . 3n:rim: ' 20+ FRESH
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Iced Tea .... .. .. . 2.39 ! 245 2.69 15 ?55
INGREDIENTS
Just for Kids
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All kids'meals come with a cookie
and choice of apple juice or kid-sized drink Seasoned Rice At Moe's,everything revolves around our
Shredded Cheese Black Olives Honestly Awesome Food.With 20+fresh,
Moo Moo Mr. Cowtowndw...............5.69 495-765 5.99 495-765 Sour Cream Hard Rock Roll Sauce Cilantro
Chipotle Ranch Cucumbers flavorful ingredients,you've got the freedom to
Power Wagon i,oi ......................4.49 M5-705 4.79 345-705 Black Southwest Vinaigrette Diced Tomatoes create whatever you're craving.The only things
Beans Mini Masterpiece icheeseouaaadnfof...............4.49 475-705 Diced Onions Pinto Beans 1 - you won't find—microwaves and freezers.
Grille
d Peppers Fresh lalapenos
Grilled Mushrooms Romaine lettuce
Pico de Gallo Grilled Onions Pickled lalapenos
R. asted Corn Pico Shredded lettuce
............ .......
FIND A MOE'S NEAR YOU + "-
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Hamden,CT 06514 Enfield,CT 06082 ti
(203)7454706 (960)741 0502 �' 4
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L6ve Wei 1 C r dm wo~w"emiaw • (860)785-8990 (203)873-0776
the 8r nerul auWwn advke is 1.200-1.400 colones a day for k*alas 4-8 and
1•400.2,OW caWes a day 1a kids ages 9-13.but caloric nwds mayuary. 641 Farmington Ave. 385 W.Main Street
Bristol,CT 06010 Avon,CT 06001
(860)506-4861 (860)269-6106 '
tie Fad,LIMWU�n.uw.u.au.YRWu�l�y,y�upy arulf WellnaNm LLC I (
164 Federal Road 970 N.Colony Road • ' �'
Brookfield,CT 06804 Wallingford,CT D6492
(203)885-0748 (203)678-4250 .10
720 Queen Street 301 East Main Street 4
Southington,CT 06489 Westfield MA 01085
(860)276-9532 (413)579-5713
\ � 1 535 Evergreen Way 601 Memorial Drive
I I l A - South Windsor,CT 06074 Chicopee MA 01020 MENU
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�1 (860)432-9500 (413)331-4983
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