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Home My WebLink About454 Ellington Road (10) 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) 644-1930 't48OR•CV. Establishment of r a n New Permit❑ Permit Renewal Type: Mobile/Itinerant Vendor Temporary Event❑ Permanent Food Service Establishment❑ ***(Please Print Clearly)*** CLASS:3 FEE DUE: 100 Name of Establishment: Bear's Smokehouse Truck 2 Name of Person in Charge: m��-� p4efA,5e Establishment Street Address: EA � W SNJ� W ULblsC-r' City, State,Zip Code: South Windsor, CT 6074 Phone#: O(9®1) r)r Cell Phone#: Fax#: E-Mail Address: Seating Capacity: Please submit latest copy of the Certf€fed Focd Protection Manager/ServSafe certificates to the office. Certified Food Protection Manager YESOQ NO ❑ � � Certificate#: (CFPM)(Required for ALL Class 2,3 4) LA Name: ,,0 pQ,(-)5tQ— Expiration Date: I l qj�.a Testing Organization:` O-\) � Phone#: ILQU)1952 V11 E-Mail Address: Altemate Phone#: Altemate Person In Charge ,( UCIt'( Phone#: 5?Lq()�j'8_j Restaurant Owner Contact Information Owner's Name: jpm�1Qs }- , ry\%m 5 la Please check one of the following for ownership status: Mailing Address: Individual❑ Association❑ City, State, Zip Code: / p Corporation Partnership El�rQ1"1 Other Legal Entity❑ Phone#: 70c)r) $ r)1)Q)L Fax #: E-Mail Address: Cell Phone#: Renovations Were there any renovations made last year? YES❑ NO bg,_ Will there be any renovations? YES❑ No If Yes, please list all renovations that were done/to be done: Restaurant Menu/List of All Items Served/Sold Latest Menu Attached? YES 16A NO ❑ NOTE'"(Must have latest copy on file) Please list all menu it ms 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 6�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 orgy one): -c Public _Private Well Wastewater Disposal(check only one): o4-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#:VnQ0 "? Applicant Signature: Date: I i Office Use Only Inspector Name(Print): Inspector Signature: Date: Food Class: Expiration Date: Date Received: Date Approved: i y \ ServSafe �by CERTIFICATION MATT PEASE for w=md r aomi A ft#w 1ae1Q 1 sd 6A for dw Sa+4aW food RoMtlia.Maur Cmill -9, E,oa Wmcd;m which is aoctedl 6y the Anion National Starm ,WANuip UhNSO-Confirwma for fnod Pkaledion i(W). � Aa 05994 5208 UM>rER EXAM FORM NUMBER 102022 DAiE F)F E �i� , A DATE OF EXPIRATION Lnrd 6m appl.C i or nquinnNeh. +i9Di3 ...d.wWerwwwF CJrw!w.MHgMAM�d F73 W idwnM.fl'aM►8914 Ciwyq i i,r leMowwtwF BBQ STREET MENU FAVORITES: - BEAR ATTACK o CORNBREAD &MAC&CHEESE TOPPED WITH MEAT MAC ATTACK o MAC&CHEESE TOPPED WITH MEAT BBQ BOWL o CORNBREAD& BBQ BEANS TOPPED WITH MEAT TRUCK SPECIALS: (PLEASE NOTE, SPECIALS SUBJECT TO CHANGE) KOREAN BURNT ENDS o BURNT ENDS,TOPPED WITH TRADITIONAL KIMCHI AND OUR TAKE ON A KOREAN STYLE BBQ SAUCE - TEXAS SAUSAGE&PEPPERS o JALAPENO CHEDDAR SAUSAGE TOPPED WITH SMOKED PEPPERS AND ONIONS SANDWICHES OR BEAR NAKED: BURNT ENDS TEXAS SAUSAGE PULLED PORK PULLED CHICKEN SIDES: MAC&CHEESE BBQ BEANS COLESLAW CORNBREAD A,0*% 8F4< Town of South Windsor — Health Department 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address y. 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address �. Phone Number: (860) 337-6173 Fax: (860) 644-1930 .i. �SOR•CV� 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: Bear's Smokehouse Name of Person in Charge: Establishment Street Address: 454 Ellington Road City, State,Zip Code: South Windsor, CT 06074 Phone#: & ,1 �1-�a Cell Phone#: Fax#: E-Mail Address: Seating Capacity: Please submit latest copy of the Certified Food Protection ManagerlServSafe certificates to the office. Certified Food Protection Manager YESg NO ❑ Certificate#: / ' `^� (CFPM) (Required for ALL Class 2,3&4) I CO�`''V`''�1C)40 Name: � visa C�vkx� Expiration Date: Sh 1 a 3 Testing Organization: Phone#: E-Mail Address: Alternate Phone#: Altemate Person In Charge S t >,�(�� 1Y� Phone#: Restaurant Owner Contact Information Owner's Name: Please check one of the following for ownership status: Mailing Address: lll�G11 Individual❑ Association❑ _'_` �Cl �-r Corporation4J Partnership El City, State, Zip Code: �`�111�"' ` mot ® Other Legal Entity❑ Phone#: 81�� 9 r Fax #: E-Mail Address: Cell Phone#: Renovations Were there any renovations made last year? YES❑ NO Q Will there be any renovations? YES❑ NO If Yes, please list all renovations that were done/to be done: Restaurant Menu/List of All Items Served/Sold Latest Menu Attached? nspp ,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): A 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): L 0 ' Date of Birth: 9 1tp Applicant Address: y Phone#: Applicant Signature: L-DL Date: Office Use Only Inspector Name(Print): Inspector Signature: Date: Food Class: Expiration Date: Date Received: Date Approved: Servsa fe* CERTIFICATION SHANNIA COLON for uKCo1nfilllY'I11111111IIIIgI illy kh11"atl: A6,116 It-1 IIll.'.ntv"alla°"Irxxl I'1ohlction Marlayer Certification Examination, Which 14 lNf Ik.Illr=tl i. (lUl AIINIip tell IJtlhulNll�.kuul�nl1%Inehlulr(ANaI) Conference for Food Protection(CFP). 1 XAM I taRM NUMBER 5/7/7.018 OATH c)I I X DAII til! EXPIRATION Local kwA 01111AY /1 ;'ti t lrtt rnliiit rdix1111tp111amnnls. ��.Itdl ..��tlU.tt�...Itllit tllR k w� r w... krh tNw NtrLatxul..d llw t IpN 1.rLAMtttnl RetkturaM Aaocialwe and iw tre deign C0400 at wMh qur km d 2M 5.1Nae or diva,$A 3W,(14mr,M.MIMk1 A'11I1 nr!av wtla�naA Nnod irH. BBQ • APPETIZERS �IlllAWDAV MOINK BALLS WINGS Bacon wrapped meatballs Dry-rubbed and smoked Half Dozen-71 Dozen-12 Half Dz-7(Dz-12 MEAT CHOICES PULLED PORK KIELBASA TEXAS SAUSAGE BRISKET+2 PULLED CHICKEN TURKEY BREAST CHOPPED BURNT ENDS+2 MORKAND BRISKET) (NOTAVAILABLE IN BEAR SIZE) SALADS ® � Topped with your choice of meat GARDEN* 10 MAC Al n d Cheese K Romaine,cucumber,tomato,red onion Mac a SWEET MAMA BEAR' 12 Romaine,Cucumber,Tomato,Red Onion, SUPER SPUD Dried Cranberries,Candied Walnuts Baked potato topped with mac&cheese,sour cream, bacon,red onion,cheese BBQBACON RANCH" 12 Romaine,cucumber,tomato,red onion, BEAR ATTACK- cheese,bacon Cornbread topped with mac&cheese SANDWICHES 9 BEAR BOWL Topped with your choice of meat and served Cornbread topped with BBQ beans on a potato roll 'BEAR SIZED'(double meat)+4 PAW PAWS POUTINE Topped with coleslaw-+0.50 Hand-cut fries smothered in cheese sauce ENTREES 14 Comes with your choice of meat and any two single-serving sides . . . ACK PIBS BY THE POUND PULLED PORK• PULLED CHICKEN 15 comes whh your choice of any two single-serving sides TX SAUSAGE• KIELBASA 18 HALF RACK 18 FULL RACK 26 CHOPPED•TURKEY BREAST 18 FULL RACK(NO SIDES) 23 BRISKET• BURNT ENDS 21 Two MEATS-16•THREE MEATS-19 Comes with your choice of any two single-serving sides. Choose from any two or three meats: Pulled Pork,Pulled Chicken,Turkey Breast,Kielbasa,Brisket,Chopped,TX Sausage,Wings(4),Moinks(4) Limit one:1/4 Rack Ribs,Burnt Ends FAMILY MEAL 50 CUB MEAL 5 FEEDS 4 TO S PEOPLE Pork or chicken slider,choice of:cub size mac Includes full rack of baby back ribs or fries,milk or juice,and a cookie PLUS: One pound of meat (+3 for Brisket or Burnt Ends) Three pints of any sides SIDE DISHES (May sub three pieces of cornbread for Single-3.25 Pint-6 3.25 each one side choice) Smoked BBQ Beans Apple Crisp Mac and Cheese Side Salad' DESSERTS Baked Potato' Hand-Cut French Fries Apple Crisp (May Contain Nuts) 3.25 Mashed Sweet Collard Greens* Potato* Cornbread - 2 Peach Cobbler 3.50 Bourbon Pecan Pie 3.50 Coleslaw' Cookie 1.00 Broccoli Salad* CONSUMING RAW OR UNDERCOOKED MEATS,POULTRY.SEAFOOD,SHELLFISH OR EGGS MAY INCREASE YOUR RISK OF FOOD®ORNE ILLNESS. Pierce, Melissa From: Oatis, Heather Sent: Friday, December 28, 2018 12:34 PM To: Pierce, Melissa Subject: Fwd: Form submission from: Food Service Establishment Registration Form Heather Oatis,RS,HHS Environmental Health Officer Ph: 860-337-6173 Fax: 860-644-1930 www.southwindsor.org Sent from my iPhone Begin forwarded message: From:Ted's Montana Grill via Town of South Windsor CT<crosmailer@civicplus.com> Date: December 27, 2018 at 12:20:55 PM EST To:<diane.collelo@southwindsor.org> Subject: Form submission from: Food Service Establishment Registration Form Reply-To:Ted's Montana Grill <crosmailer@civicplus.com> Submitted on Thursday, December 27, 2018- 12:20pm Submitted by anonymous user: 66.192.20.180 Submitted values are: Class: 3 (50+Seats)-$250.00 Establishment Name:Ted's Montana Grill Street Address(Street,Town, State,Zip): 500 Evergreen Way,South Windsor, CT 06074 Mailing Address(Street,Town, State,Zip): 133 Luckie ST NW,Atlanta, GA 30303 Business Phone: 860-648-1100 Website:www.tedsmontanagrill.com Business Fax: Email:TMG036@tedsmontanagrill.com Legal Owner:TMG of New England, LLC Mailing Address (Street,Town,State, Zip): 133 Luckie ST NW, Atlanta, GA 30303 Home Phone:404-266-1344 Cell Phone: Email: ssevera@tedsmontanagrill.com Emergency Contact Name:John Halpin Emergency Contact Phone: 860-281-9374 Emergency Contact Email:TMG036@tedsmontanagrill.com Best way to be reached in an emergency: Phone CFPM/Manager Name (Class 2-4 Establishments):John Halpin Renovations/New Equipment: No 1 Restaurant Food Prep: Cooking/cooling/reheating/thawing/freezing/hot or cold holding Water Supply: Public Wastewater Disposal: Public Other Licenses: Liquor Permit Menu: https://www.southwindsor.org/system/temporary/webform/health files/036 menu pdf CFPM Certificate: https://www.southwindsor.org/system/files/webform/health files/i halpin servsafe pdf ==Disclaimer== The results of this submission may be viewed at: https://www.southwindsor.org/node/11601/submission/19913 2