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Home My WebLink About2018-12-21 - 200 Deming Street - Food Permit Application 0*14 SEA` Town of South Windsor — Health Department 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-EVv Establishment Information New Permit❑ Permit Renewal Type: Mobile/Itinerant Vendor❑ Temporary Event❑ Permanent Food Service Establishment ***(Please Print Clearly)*** CLASS: 4 FEE DUE: 275 Name of Establishment: The Residence at South Windsor Farms Name of Person in Charge: gyp j ra j-,C Establishment Street Address: 200 Deming St. City, State, Zip Code: South Windsor, CT 06074 Phone#: �-60-13z— gel // Cell Phone#: Fax#: 00--q3�L' 227ci E-Mail Address: ( �jw✓y ,� � � ,Se�tinq Capacity: P%ease submit!.-test copy of the Certified Food Protection ManagerlServS�afe certificates to the office. Certified Food Protection Manager YES❑ NO ❑ Certificate#: (CFPM) (Required for ALL Class 2,3&4) Name: Expiration Date: Testing Organization: Phone#: E-Mail Address: Alternate Phone#: Alternate Person In Charge Phone#: Restaurant Owner Contact Information Owner's Name: L.0 B Please check one of the following for ownership status: Mailing Address: (��X'AV6- Individual ❑ Association❑ City, State, Zip Code: Corporation& Partnership El it v- �� 0/,�-(�o � Other Legal Entity❑ Phone#: 7S-1) Oct �j 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: RECEIVED SOUTH WINOSOR r `ti oEPAR_'MENT r:r:. Restaurant Menu/List of All Items Served/Sold Latest Menu Attached? YES[�e 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): I/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 misrep-resentations made on tP-is-applicat-ion may result in immediate shutdown or revocation of my Food Service License for the Town of South Windsor. Applicant Name (Print) Date of Birth: O( -13—IcItt Applicant Address: ! � 1(44 ,5+m+ a4X � Q Phone#: C 3�- 2°i I Applicant Signature: Date: -1 7-Q Office Use Only Inspector Name (Print): Inspector Signature: Date: Food Class: Expiration Date: Date Received. Date Approved: Exam Form No.10368 y* f SevSafe Cart.No. 10799 1 ServSafe' CERTIFICATION ro RYAN the National flestaurant for successfully tdicaoun Examination foundation for the servsale®roc" r- Date of Examination:03111/2 Date of Expiration 03/11/2019 ill If,"ea ants Local laws apply.Check with your local raga �.All r @2014 National Restaurant Association liters.by National reserved ServSafe is a registered tra o S�5afe is a tndPmark of =4 Restaurant Association SoluNo ,mess the National Rasta _ MENU BREAKFAST B-r , A T T SIDES Breakfast choices are available throughout the day. r► Cholesterol-free eggs may be substituted. Choose one to go With your entree: Eggs Your Way Bacon Two eggs cooked your way, served with home fries Sausage and your choice of white, Whole wheat, cinnamon raisin I � or rye toast. r SIDES Home Fries The Omelet Bar Muffin of the day Prepared with 3 eggs and your choice of fillings: Pastry of the day bacon, sausage, onion, green peppers, tomatoes English muffin with cheddar, Swiss, or American cheese. Bagel and cream cheese r Fruit&Cottage Cheese Plate Toast(white,whole wheat, ' Assorted fruit and low fat cottage cheese. cinnamon raisin and rye)IV Fruit Salad pancakes.& French Toast V Fresh Seasonal fruit a Served with your choice of fresh fruit toppings and real maple syrup. r Assorted Cereal&Oatmeal Breakfast Skillet Two poached eggs, Potatoes O'Brien, sausage, lemon- CHICKEN TEND' UCES6 saffron aioli, with choice of toast, served in a cast iron skillet. Buffalo, BBO, Teriyaki c APPETIZERS Boneless Chicken Tenders Served with your choice of blue cheese or ranch dressing. Chicken & Lemongrass Pot Stickers C �'K O M I Served with napa cabbage slaw and teriyaki glaze, [1e:0 BURGER Bomw F Shrimp Cocktail Poached jumbo shrimp served chilled with cocktail sauce and fresh lemon. SANDWICHES All sandwiches are served With a pickle and your choice of potato chips, side salad, or fruit salad. LCB Deli Bar V Heart Healthy items are appropriate Choice of ham, V low sodium turkey, chicken salad, choices for reduced Batt and Low fat diets tuna salad or egg salad, served on your choice of bread, as well as the MIND diet. roll or flour tortilla wrap. Before placing your order, please inform Grilled Chicken Sandwich your server if a person in your party has a Grilled chicken breast served with Vermont cheddar food allergy. cheese, spring mix lettuce, candied bacon,whole grain Consuming raw or undercooked meats, mustard and mayonnaise on a toasted brioche bun. poultry,seafood,shellfish,or eggs, may increase your risk of foodborne Roast Beef Sandwich illness, especially if you have certain House-roasted beef with horseradish mustard, caramelized medical.conditions. onions and Bibb lettuce, served on herb focaccia, yyry� e§' RkESIDENCE 74 ENTREE SALADS Pear and Blue Cheese Salad Fdd Mixed greens with red wine-poached pears, candiedpecans, pomegranate seeds, cucumber and crumbledblue cheese, served with raspberry vinaigrette. these entree: Waldorf Salad icken Belgian endive and mixed greens with toasted rimpwalnuts, apples, shaved celery and sliced red grapes, lmon y tossed with white balsamic vinaigrette. EN-11REES All entrees are served With your choice of sides. Filet Mignon Grilled center-cut filet cooked to your preference, �� DU �� finished with a garlic herb butter. BEEF VEGETABLE'. Shrimp Scampi BARLEYSoup Succulent shrimp sauteed in a garlic butter and V SIDE GARDEN SAIA-1) white wine sauce-with grape tomatoes and basil. Mixed greens, tomato, Butternut Squash Ravioli cucumber, red onion and Served with roasted brussels sprouts, bacon, house vinaigrette. Parmesan cheese and brown butter sauce. SIDE CLASSIC CAESAP SMAD IV Pan-Roasted Statler Chicken Breast Hearts of Romaine lettuce Served with a house-made cranberry sauce. tossed with Parmesan cheese, a crunchy croutons and traditional Pecan-Crusted Salmon Caesar dressing. Pan roasted with choice of sides. Chefs Special of the Day Our specials change daily; please consult your server for today's offerings. SIDES No sugar added dessert and fruit are also available. v Broccoli Florets r► Baby Carrots ' Warm Peach Berry Cobbler v Roasted Butternut Squash Served with vanilla bean ice cream. IV Brussels Sprouts Tiramisu French Fries New York StyLe Cheesecake Sweet Potato Fries With cherry topping and whipped cream. IV Baked Potato Mashed Potato Assorted cookies, pies and a selection of Mashed Sweet Potato premium ice creams Rice Pilaf Signature Hot Fudge Capellini Pasta