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HomeMy WebLinkAbout2018-12-28 - 1006 Sullivan Avenue - Food Permit Renewal Town of South Windsor — Health Department 1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address 1530 Sullivan Avenue, South Windsor, CT 06074— Office Address sl _` Phone Number: (860) 337-6173 Fax: (860) 644-1930 �fbsoe•co` Establishment Information New Permit❑ Permit Renewal IR Type: Mobile/Itinerant Vendor❑ Temporary Event❑ Permanent Food Service Establishment❑ ***(Please Print Clearly)*** CLASS: 2 FEE DUE: 125 Name of Establishment: Subway - Store # 2397 Name of Person in Charge: 2Y) I'L f � l - Cy Establishment Street Address: 1006 Sullivan Ave. City, State, Zip Code: South Windsor, CT 06074 Phone#: $�p �L/ - 013`7 � Cell Phone#: Fax#: E-Mail Address: Seating Capacity: a R aase s(Ibmiilt latest copy of t1he Cartiffied Fccd Protection M2,nage!lSe.(Safe certificates to the office. Certified Food Protection Manager YES_' NO ❑ Certificate#: � (CFPM) (Required for ALL Class 2,3&4) Name: n 1 �e., fo•���(J�11 s-(a Expiration Date: Testing Organization: Phone#: E-Mail Address:,Tnn 1-4,r EQ.4°G(40 Alternate Phone#: g�0 7 (�5 !o z/ Alternate Person In Charge e be cc� Su�-�a Cf)S4 a Phone#: S60 &y y_9 37 3 � Restaurant Owner Contact Informa/tion/�! // Owner's Name: n �'o S'f a Please check one of the following for ownership status: Mailing Address: g j S �oC 2� Individual'g Association❑ Corporation ❑ Partnership[j City, State, Zip Code: .6 p p r? C T 2Lf g:> Other Legal Entity] L(-C, Phone#: 9' 0 — 22&'_ Fax #: 03 E-Mail Address: ap—_n n ► P rS 0 C6mcck -j. �-�. Cell Phone#: 81,a Renovations Were there any renovations made last year? YES❑ NO Will there be any renovations? YES❑ NO €Yes,- ease ist all renov tions k0id© s� wthat v* be done -e t '� -e ►r a� ��lr' �GN � 96-o L;fl,mac,n Ave. �'►FJ c,C,_; SOUTH VNIINDSOR p�GALTH�DEPARTMENT tj ctf l 11,:.{r1 4- yam'� / J t onX" -CWo 0)of 4. 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 ❑ Cooking/cooling/reheating/thawing/freezing/hot or cold holding ❑ Prepares 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): _ 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): Date of Birth: Applicant Address: Phone#: Applicant Signature: Date: Office Use Only Inspector Name (Print): Inspector Signature: Date: Food Class: Expiration Date: Date Received: Date Approved: �> s»7 ©r & ��r \ 0 0 EM 0 M - i A 0 Ila M, is la 3 u ZZ 6'j J1, . 'j- V X *,�A M 'FAA Do 0 0 9 it fv, # .mum ;2 ON 0 0 I N Mil Y9 0 -'K Ma 12 NOR, 41 45 1 0as 0 o M A, z A, Q-0 A, 8 0 2% J, o I FA I I I I L A T 0; . E iW 6 �z ZO aoA `a aO v to 2 JIM-/ 1 E < XWE N 0 0,2 Z5 0 co 0 0 4 10� M I.1 1. 1. , '. '. '. 9 I zo U 000 0ODU 0, Figure 6 Items Offered for Sale by Country/Region Chart Rev. 1 October2018 Chapter 9-Items Offered for Sale&Purchasing 9.29 x= U W Q S W 0 U 22.O Waa S QP UP •a S a 63 gg \ p z (i S 555 LL@@ o U 4 o a ° mp s a o U U mom z mt o $ OZ01 a E tsgS z m g ta' LL �T c'3 q A E9 U g ffi co @ii OLLVC1 o qQE 3 C _ y �n S gffiffi mZ m g 3 > E p4 0€J'� $ 8 E a s333 ffif � $ g ¢ ' a �8als m9 5 n � 8$8. 3 � N W s Q U U Mm N y _ p o ius �EEf f SEE g N'L m v a ffi �� v d`amvv� 3 4444 4 44iZ� � jJ aIU 3 E 3 mom°O wEEv& 8 EEBE 7-8 jy X X msS� a�a a¢nx ¢a¢a` rcn¢ rS rS m3�g m`m` m` m mm ¢aaa Figure 6 Items Offered for Sale by Country/Region Chart-Continued 9.30 Chapter 9•Items Offered for Sale&Purchasing Rev. 1 September 2018 01 'tg • IE 0 AS P,1� A RM .-00 C A a Az 01 1 4- z IN E 0 0-6 'a Z;Z A A A A F 52 Z -6 96 -6 2A 2 2o o 12 3 z9, 3 5 5 5 5 5 5 5 E .1 9 9 9 9'i & .—M 0 0 0 0 w wqp¢ g M M 25 Figure 6 Items Offered for Sale by Country/Region Chart-Continued Rev. 1 October2018 Chapter 9-Items Offered for Sale&Purchasing 9.31 co w N Aatlabnsl Tppig 1(liquid OR eofd)(ae/auf=nane) Aaaieonel To 2 liquid OR W W)("anrr lif AaaBbnal Toppkq 3(liquid OR Wkl) Atlaleonsk Toppkc 4(Igiutl OR WWI) Portion Codrol Packets(not inchdirp asked tlreserpa) Qu • - Dresa Ponbn C.22:Packet#t(aeNulf-r.e) Draw Potion Codro Padel e2(MAWRnone) Oresairrp Porten Codrol Pedal a3(aeleulKnone) ,ems '�* �.• MIN C1poM 0-3 from this fat:Fitt Free Choose 0-3 from ihla ist:Fal Free French,Fal Free Thousand ldand, French,Fat Free Thousand IsliM.Fat Fat Free Caesar,Fat Free Milan,Fat Free Caesar,Fat Free Milan,Fat Free Choose 0-3 flavors in 1.5-ZD Choose 0-3 flavors m 1.5-2.0 Choose 0.3 flavors in 1.5-2.0 Noce' Free Ranch,Fu1 Flavor French,Da Ranch,F W Flavor French,F V Flavor ounce packets ounce packets ounce packets Flavor ThouaM island,Fla Flavor Thousand bland,FN Flavor Caesar, Z Ca—Full Flavor seem Full Flavor seem Q> Chi ,r aK a 'tE1 hi Re uired hi Favor#1 ua —m 15 "' - t i sit ut ato chi am R uired Chi Flavor#2 Baked. a%sin 1.125 oz Baked Plain 1.925 oz. \ Miam d U M Doritoe T Cheese Nacho cheese Wtt& Nadro cheesetorblla chi R uired Chi Flavor lK4 Don[ce Ndoho Cheese 1.75 oz Dors.Naelm.Cheese 1.75 oz .. f ,.�;.: --fir -Yr< :' Walker Chiese80mon ."` t. ,'��•,% i, ,,,,, R uired Chi Flavor#4 Su Harveet Ct Nor 1.5 ea BUrYFi aHmv.9 Chide 15aZ : ^\ Baked Van Cna y'( _ 1144 Additlonal Optional Flavors-SOP Choice •• ( pfj i r '4 CD CD CL BULGARIA.M kApple .ya Buddy FruitOr SPC Fruit Cru.h-UP1-- CZEC REP--Whole Apple Reguiredd l4ds Pak®O PRANCE-StravAx Y urt 8. CATEGORIESMATCH Q ( ±ilY Sbavberry SPC Fruit Crush-Up--Strawberry Bear Yo Yo Fruit Buddy Fruq� wMIeA °g ^OTHER COUNTRIES" 'S SOP optionto display as individual (Required far Kids'Meal Onty (Regtated Par Kids'Meal Only (Required for Kid'Meal OMy (Required For Kira Meal Only Required Side Item l Apple Slices dale ifim) FINAND-Strawberry Yogurt POLICIES (n SOP option to dsplay as SOP option to display as individual SOP opd-to display ea SOP option to display S WEDEN-Whole Apple —"u-"--1"N"e�ee use indviduai side item). sideitem) individual side item) indvidual side item)"' P k aiM M dapbled.W timn tie w roPOUND-Wlwle.Apple (n OLd*FrvMsa, ROMA NIA-Whale Apple LAE-Rskare :r $ Apple Slices \v4" Required Side Item Whole Apple. FRANCE-.Plain Yogurt d latest Optional Side Item l Ma, \ T y 00F, \: C/) "m6 .t tip: ��. � ,� .,r�,;• NCookies USA is, Cookie Flavor#1 Chocolate hip unk Chordate CNp hocolate Chi Chacalaq hunk Qp D Cookie Flavor#2 Oatmeal Raisin Chocolate Chip vein M&M's@ Double Chocolate Double Chocolate Double Chocolate COP aCookie Flavor#3 White Chip Macadamia Nut White,Chip Macadamia Nut White Chip Macadam is Nut White Chip Macadamia Nut White Chip Macadamia Nut OP' C©P.Nzate Cookie Flavor#4 ;+. :�.. COP COP 3 Cookie Flavor#5(De/aUR=None) -*_ppkka - ay GflPo[N4Nre -COP Or Nobel, :, - - FI voroptions Chocolate co Flavor options: tm plat Ch p Uj � Flavor opsorw'.Chocolate Chunk Ch p(defautt 1),Oat sal Retain, (default 1),Oatmeal Rai Nu A8 Double Chocolate(default), Flavor optlons:Chocolate Chip, Flavor options:Oatmeal Raisin, Flavor options Oatmeal Raisin' Flavor optloris:Chocolate Chip, White Chip Macadamia White Cnip Macadamia Nut Peanut Butter,Chocolate Chip Double Chordate(default), Chocolate Chunk,Peanut Butter, Chocolate Chunk,Peanut Butter, Oatmeal Raisin,Peanut Butter, Nutnk.Double Chocolate tQ Cookie Flavor Options with M&M'sie,Sugar, Peanut Butter,Oatmeal Raisin, Chocolate Chip Rainbow,Sugar M&M Candy Chip,Sugar or M&M Candy Chip Idefauh), (default 2).Chocolate Chunk, Chunk,Double Chordate, i 0 SnickerCheee or Raspberry Sugar or Raspberry Cheesecake. or Raspberry Cheesecake. Raspberry Cheesecake. 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