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Home My WebLink About1530 Sullivan Avenue (6) Town of South Windsor — Health Department , 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address Phone Number: (860) 337-6173 Fax: (860) 6"-1930 °sve•c�� Establishment Information New Permit❑ Permit Renewal ❑ Type: Mobile/Itinerant Vendor Temporary Event❑ Permanent Food Service Establishment❑ ***(Please Print Clearly)*** CLASS:3 FEEtfUM.101111 Name of Establishment: The Whey Station Name of Person in Charge: �C �x� iY\Cy31LaS +�'lc ,i�ev1Z►er;i5h. Establishment Street Address: City, State, Zip Code: South Windsor, CT 06074 Phone#: Q)tac>- Cell Phone#: Fax#: tv E-Mail Address: ,(_ Seating Capacity: n(,* Please submit latest copy of the Certified Food Protection Manaaer/ServSafe certificates to the office. Certified Food Protection Manager YES 91 NO ❑ Certificate#: �47,1wz-*j (CFPM)(Required for ALL Class 2,3&4) Name: �,�-y Expiration Date: Testing Organization: Phone#: � 3y2-g 7�z E-Mail Address \:�t'`XX-Qt�raSM Itemate Phone#: �(ac� Alternate Person In Charge .Q �� C fn_ Phone#: � -2 G? � Restaurant Owner Contact Information Owner's Name* YY> .eS Please check one of the following for ownership status: Mailing Address: ki p ho ,�r- Individual] Association❑ Corporation❑ Partnership❑ City, State, Zip Code: ��c (� �,�i CT (4,5 Other Legal Entity❑ Phone#: 'Et)00- OLJ--$7 "�?, Fax #: r\ E-Mail Address: ri3ck�� w�a�-c5a�tio•� Co Cell Phone#: Renovations Were there any renovations made last year? YES❑ NO EL Will there be any renovations? YES❑ NO)[] If Yes, please list all renovations that were done/to be done: RECEIVED J M I ry Z019 SOUTH WINDSOR HEALTH DEPARTMENT Monger$7 Our signature 5 cheese blend Caprese $8 Tomato and basil pesto The Mutt$9 Bacon, Bechamel Cheese Sauce and Potato Sticks AvoMeft $9 Guacamole, Bacon and Creamy Chipotle Nola $9 Spicy Andouille Sausage, Jalapeno and Creamy Chipotle Big Sal $9 Prosciutto, Roasted Red Peppers and Garlic Aioli Barlow$8 Whole Roasted Garlic Cloves, Garlic Aioli and Scallions Channing Tater$9 Tater Tots, Bacon, Sour Cream and Scallions Cardinal $8 Guacamole, Tomato and Creamy Chipotle Josh It Up $9 Ham, Tomato and Whole Grain Mustard Tater Tots $5 Cheesy Bacon Tots $7 Bacon, Bechamel Cheese Sauce and Monger Mix Cali Tots $8 Guacamole, Bacon, Jalapeno and Creamy Chipotle Channing Tater Tots $7 Monger Mix, Bacon Sour Cream and Scallions ADDITIONS: Tomato, Jalapeno, Roasted Red Peppers $.50 Bacon, Ham, Prosciutto, Guacamole $1 Spicy Andouille Sausage$1.50 Sauces .50 Creamy Chipotle, Basil Pesto, Garlic Aioli, Whole Grain Mustard, Sour Cream 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 ,WCooking/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 Ig1 None Water Supply(check only one): "�C_ 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): Ywc- (y�(� Date of Birth: Applicant Address: ua ,� Phone#: &00 - 15 Applicant Signature: V Date: Office Use Only Inspector Name (Print): Inspector Signature: Date: Food Class: Expiration Date: Date Received: Date Approved: � M .'...."rvSaf T�atli• • • f ery e CERTIFICATION MACKENZIE PARRISH 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). 942810 5243 UMBER EXAM FORM NUMBER - 4/412 4/4/2022 DATE OF E DATE OF EXPIRATION Local laws apply.Ch my for recertification requirements. s She e� N0655 In aaordonce wilh NtariMne �201 i Notional logo arc hadamarks of tke NRAEF Contact us vAh questions at 175 W Jackson Blvd,Ste 1500,Chicago,IL.60604 or ServSo(wGreskrurant org. ServSafe National Restaurant ciation servs .... fe CERTIFICATION JOSHUA MOSKITES for successfully completing the standards set forth for the ServSafeo Food Protection Manager Cerfilication Examination, which is accredited by the American National Standards Institute(ANSI)-Conference for Food Protection (CFP). 796023 5237 UMBER EXAM FORM NUMBER 3/1/2 311/2022 DATE OF E DATE OF EXPIRATION Local laws apply.C cy for recertification requirements. She p O r #0655 In accurdoncewith Morifiem ®9'I!?l R9 01 S Noto wl logo are iradw"6 of the NRAEF NcM Cw4ocr w with quetirns al 175 W kxkwn fltid.516 1500.Chicago.k 60604 w Serv$*60restaurow aim.