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Home My WebLink About432 Buckland Road (5) °*" SF4<Q 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 '1bSOR-COv Establishment Information New Permit❑ Permit Renewal Type: Mobile/Itinerant Vendor❑ Temporary Event❑ Permanent Food Service Establishment❑ ***(Please Print Clearly)*** CLASS: 4 FEE DUE: 27S Name of Establishment: The Village at Buckland Court Name of Person in Charge: " l C h At I V l'IA Establishment Street Address: 432 Buckland Rd City, State, Zip Code: South Windsor, CT 06074 Phone#: 60 �p W--t,-7j4_k Cell Phone#: 660 7 yg 6& Fax#: .CGS E-Mail Address: pA KOc(C (�gejcilt4o104eating Capacity: )?� Please submit latest copy of the Certified Food Protection Manager/ServSafe certificates to the office. Certified Food Protection Manager YES 2"-NO ❑ Certificate#: (CFPM) (Required for ALL Class 2,3&4) Name: JiA c C4" ( K 0 t K Expiration Date: Testing Organization: 15,e a CA M Ai2 k y Phone#: E-Mail Address: iM it.oC44"r�tMA( ?JAQ4;r`n toe Phone#: Alternate Person In Charge MI&'Ittt-9 6,4 I ey Phone#: 660 el 7 06 yl Restaurant Owner Contact Information Owner's Name: e ej ct,W 14"X` Please check one of the following for ownership status: Mailing Address: 32 vL k(hrJ!> A 0 Individual ❑ sociation ❑ Corporation Partnership❑ City, State, Zip Code: SO L)l (,✓,w f)Sj.) Cr d 6 0 7 Y Other Legal Entity❑ Phone#: &60 (a If y73 6 Fax #: E-Mail Address: /k vh.ph y / ^�� (�vA��y (C,,,LCell Phone#: Renovations Were there any renovations made last year? YES❑ NO Dd Will there be any renovations? YES❑ NO J If Yes, please list all renovations that were done/to be done: 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. Restaurant Food Prep (check all that apply) ❑,, Cook to order ONLY ❑Advanced catering for specific quantities ❑ Uses Time as a Public Health Control Iitiooking/cooling/reheating/thawing/freezing/hot or cold holding ❑ Prepares food to serve at another site repares 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): ✓Public _ Private Well Wastewater Disposal (check only one): 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): tM i { V J?b t l< Date of Birth: /j *\-97 /9 7 Applicant Address: �� 6 / lLoA-L> Phone#: Ap 7Y i (� v Applicant Signature: V, Date: /Z z� �g Office Use Only Inspector Name (Print): Inspector Signature: Date: Food Class: Expiration Date: Date Received: Date Approved: BENCHMARK Breakfast � F, NI () R LI V IN Daily Offerings Weekly Specials Toasted Breads Sunday White, Wheat, Multigrain, Rye, Breakfast Sandwich Raisin Bread or English Muffin with Jelly and Butter Fried Egg, Sausage Patty and American Cheese on an English Muffin Hot & Cold Cereal Selections Oatmeal, Raisin Bran, Corn Flakes, Monday Cheerios, Rice Krispies Waffles Fruit and Yogurt with Warm Syrup and Butter Fresh Fruit Cup —Melon, Pineapple, Grapes Tuesday Yogurt—Plain, Vanilla or Strawberry Toasted Bagels Fresh from the Oven with a Variety of Flavored Cream Cheese A Daily Variety of Freshly Baked Muffins Wednesday From the Griddle Corned Beef Hash and Eggs Pancakes or Cinnamon French Toast Thursday Eggs and Omelets Donuts and Danish Pastries Eggs Prepared To Order- Scrambled, Fried or Poached. Served with Bacon or Sausage. Fresh from our Local Bakery Omelet Selections —Create your Favorite Friday Peppers, Onion, Tomato, Bacon, Sausage, Cheese Blintz Swiss or American Cheese. with Fruit Topping Egg Beaters are available upon request Beverages Saturday Coffee Tea Cranberry Juice Apple Juice Eggs Benedict Orange Juice Soft Drinks with Home Fries Please Inform Your Server If A person In Your Party Has A Food Allergy __....._-__---------- __._,..��....._.._....._.____...... BENCHMARK Lunch and Dinner d S N 10 R L I I N G Grilled Chicken — Boneless, marinated The Chefs Kettle chicken breast with vegetable of the day or on choice of bread with lettuce and tomato. Soup of the Day The chef s daily creation Steamed Salmon — fresh herbs and lemon, served with vegetable of the day rLow Sodium Chicken & Vegetable Soup Hamburger- 1/4 lb. burger with choice of toppings. Served on a toasted roll with chips Salad Selections and pickles. TGarden Salad —Mixed greens with Hot Dog — All-Beef hot dog served on a tomato, cucumber, red onions and olives. toasted bun with chips and pickles. Choice of dressing. Grilled Cheese and Melt Sandwiches IwGrilled Chicken or Steamed Salmon Salad - Our garden salad topped American or Swiss cheese on your choice of with slices of grilled, marinated chicken bread. Add ham, turkey, tuna salad or breast or salmon with tomato, cucumber, tomato to create a delicious melt. Chips and olives and red onion. Choice of dressing pickles. Deli Sandwich Selections Chefs Salad —turkey, ham and provolone cheese served on mixed greens Baked Ham IV Low Sodium Turkey with tomato, cucumber, olives and red Chicken Salad Egg Salad Tuna Salad onion. Choice of dressing. Swiss, American or Provolone Cheese Scoop Salad — a scoop of freshly made tuna salad, chicken salad or egg salad served Lettuce and Tomato on a garden salad. Choice of dressing. Bread Selections: sliced wheat, white, Cottage Cheese and Fruit multi grain or rye bread, hamburger bun or Cottage cheese with fresh fruit salad. hot dog roll. Served with chips and pickles. Dressing selections; creamy Italian, ranch, Omelets & Eggs All Day thousand island, French, fat free Italian, fat free raspberry vinaigrette or oil&vinegar. Omelets —choice of peppers, onions, diced ham, American, Swiss or Provolone cheese. Entree Specials — Our chef s daily lunch Served with toast. and dinner special offerings. See todays' Scrambled Eggs with toast specials on display outside the dining room. Always Available: r Egg Beaters are available upon request. Baked Potato, Steam Carrots, Pasta with Meat sauce T Indicates reduced fat,salt and sugar and are appropriate for theses diets. Please Inform Your Server If A Person In Your Party Has A Food Allergy ServSafe National Restaurant Association ery nfe CERTIFICATION MICHAEL ROCK for successfully completing the standards set forth for the Se,Safe®Food Protedion Manager Certification Examination, which is accredited by the American National Standards Institute(ANSI)-Conference fot Food Protection(CFP). 908566 5237 UMBER EXAM F101,' . NUMBIw,R : 3/23 3/23/20224•1" DATE OF E DATE OF EXPIRATION Local laws apply.Ch ency for recertification requirements. She 40655 In aaorclonce with Maritirne labou NNuh 15 Nanorwl logo are trodemarks of the NRAEF. �•^` Contad us with questions at 175 W Jackson Blvd.Ste 1500,Chicago,k.60604 or ServSaWre ServSafe National • 'Ate ry nfe .gigCERTIFICATION u ROBERT SCHME hR G f For successfully completing the standards set forth For the ServSaf' FOC;0,p`"'ion Manager Certification Examination, which is accredited by the American National Standards Institute;'t N�, Conference for Food Protection(CFP). pia f EXAM" FORM NUMBER.`: 3/14/2018 3/14/2023 #0655 DATE OF EX DATE OF EXPIRATION �o hiE2659 e, Local laws apply.Ch cy for recertification requirements. Sher ciation Solutions 0 I�, 4 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.Chicoao,IL.60606-6383 or ServSafe0restourant.ora.