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Home My WebLink About535 Evergreen Way (7) V"am SC4( Town of South Windsor — Health Department 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address h .y 1630 Sullivan Avenue, South Windsor, CT 06074—Office Address :ti Phone Number: (860) 337-6173 Fax: (860) 644-1930 8)R-C Establishment Information New Permit❑ Permit Renewal 011' Type: Mobile/Itinerant Vendor❑ Temporary Event❑ Permanent Food Service Establishment ***(Please Print Clearly)*** CLASS: FEE DUE: Name of Establishment Name of Person in Charge: Establishment Street Address � -- 6 City, State, Zip Code 3 Phone#. � r { ,'` '� Cell Phone#. Fax#: E-Mail Addresser J :l� ` �',a ! (,�t,��,S�_Capacity_.. Please submit latest cony of the Certified Food Protection ManagerlServSafe certificates to the office. Certified Food Protection Manager YES Q NO ❑ Certificate# (CFPM) (Required for ALL Class 2,3&4) Name tl f Expiration Date r ,Li t , , /f,�l /,, -� Testing Organization. � �. Phone# } ` �( e4 i E-Mail Address: j/, x t;`l1 r'L2t+ _�, ,�.' rnate Phone# tt F'sP1�� Alternate Person In Charge ]t! 4. �ji/'` Phone# Restaurant rser Cd—fi` act I f9r ation Owner's Name I !�, h Please check one of the following for ownership .�.g status. Mailing Address Individual El Association El Ci State Zi Code ' "� - f f Corporation ❑ Partnership❑ tY, p ' i.t :, • , Other Legal Entity❑ _. Phone#: Fax # ( E-Mail Address < � '�s �ft1 tt"�/D1 Cell Phone#: Renovations Were there any renovations made last year? YES❑ NO 13 r Will there be any renovations? YES❑ NO a` If Yes, please list all renovations that were done/to be done: RECEIVED r G SOUTH F;E.ALTH DEPARTMENT RestaurantMenu/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 car a copy of a menu attached is applicable. Restaurant Food Prep (check all that apply) ❑Cook to order ONLY ❑Advanced catering for specific quantities ❑Uses Time as a Public Health Control �ooking/cooling/reheatin 1.g/th awing/freezing/ho 1.t or cold holding ❑ Prep 11 ares food to serve at another site [:]Prepares food for Highly Susceptible Population(preschoolers or the elderly) ❑Prepackaged non TCS Food Only ❑ Non TCS Food only(food that does not require refrigeration) Additional'Information Please check all that apply: State Licenses: ❑ Bakery ❑ Liquor Permit None Water Supply(check only one): V Public _Private Well Wastewater Disposal (check only one): -�4 Public _Septic _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 and that I will comply with the ordinances and regulations of the Town of South Windsor and State of Connecticut. I also affirm to allow the Town of South Windsor Health Department access to the establishment as required. 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): gate of Birth: Applicant Address: _:'_ �. x;I' . 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Fountain.................................. 0-365 car 0-525 c.,, - Iced Tea.................................. 15-245cr, 15-355 ca, 20+ FRESH INGREDIENTS • • Just for Kids All kids'meals come with a cookie and choice of apple juice or kid-sized drink At Moe's,everything revolves around our `hides letee Cicadas Cround Beet Carnilas Honestly Awesome Food.With 20+fresh, Moo Moo Mr.COW(Burrito) ............... 495-765 r,, 495-765 Seasoned Rice •....• Grilled Veggies •••••• flavorful ingredients,you've got the freedom to Power Wagon(Taco) ..................... 345-705c,,, 345-705c.,, Shredded Cheese Grilled Peppers create whatever you're craving.The only things Mini Masterpiece(cheese Quesadilla)............... 475-705 ca, Sour Cream Grilled Mushrooms you won't find—microwaves and freezers. •......••• Beans ......••• Grilled Onions Black Beans ••••••• Fresh Veggies •••••• ` Pinto Beans Black Olives r Pico ........... Cilantro ., Cucumbers , Pico de Gallo ' Roasted Corn Pico Diced Tomatoes r 4 Diced Onions ° ' • Sauce/Dressings • F — t resh Jalapenos r 1" �rd3 Kids tireWelt approved option:Moa Moo Mr.Cow with choice of all-natural Rock'n'Roll Sauce Romaine Lettuce -rtaturat chicken. LireWen grass-tedsteak or tofu w hpintobeans.rrce.askolblacNbeansandapplejuice. Chipotle Ranch Pickled Jalapeno s The general nutrition advice is 1,200-1,400 calories a day for kids ages 4-8 and B Y . g Southwest Vinaigrette Shredded lettuce 1,400-2000 calories a day for kids ages 9-13.but caloric needs may vary. ..................................................................... a, - The Rids LNeWl logo is a service mart of lha National Restaurant Association. 02018 Mae's Ranchisor SPY LLC k FIND A MOE'S NEAR YOU vtiill'I � � �r� for locations, visit moes.com ME 51 - *WELCOMETOMOES MOES.COM .,,A , IIIIII I1 Ali `illl ICI r r s ry e a e ERT C IFICATION DIANE ORTIZ for successfully completing the standards set forth for the ServSafe6 Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute(ANSI)—Conference for Food Protection(CFP). 1060 ER EXAM FORM N:UMB'ER .; . 11/28/201 11/28/2023 DATE OF EX PI, DATE OF EXPIRATION 'i I'il Local laws apply.Che ry for recertification requirements. 040d%Q) Sher #0655 ciation Solutions 91 0 In accordance wi e ServSafe logo are trademarks of the NRAEF.National Restaurant Association®and the arc design ` Contact us with questions at 233 S.Wacker Drive,Suite 3600,Chicago,IL 60606.6383 or ServSafe@restaumnt.org. Ak ery . e CERTIFICATION JENNALY NUNEZ for successfully completing the standards set forth for the ServSafe'Food Protection Manager Certification Examination, which is accredited by the American National Standards institute(ANSIKonference for Food Protection(CFP). 106617 ER EXAM FORM NUMBER I 11/28/2018 11/28/2023 DATE OF EXI DATE OF EXPIRATION Local laws apply.Che cy for recertification requirements. ACCREDITED PROGRAM Sher 40655 ciation Solutions a In accordance wi Se Sofe bgo are trademarks of the NRAEF.National Restaurant Association&and the arc design • Contact us with questions at 233 S.Wacker Drive,Suite 3600,Chicago,IL.60606-6383 or SemSofe@restaurant.org.