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HomeMy WebLinkAbout2019-1-15 - 150 Nevers Road - Food Permit Renewal °*" Sf"< Town of South Windsor — Health Department 1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address 1530 Sullivan Avenue, South Windsor, CT 06074—Office Address yy Phone Number: (860) 337-6173 Fax: (860) 644-1930 bsoR•cv� Establishment Information New Permit❑ Permit Renewal (r Type: Mobile/Itinerant Vendor❑ Temporary Event❑ Permanent Food Service Establishment L`'J ***(Please Print Clearly)*** CLASS: 4 FEE DUE: EXEMPT Name of Establishment: Community Center Kitchen Name of Person in Charge: Establishment Street Address: 150 Nevers Rd. City, State, Zip Code: South Windsor, CT 06074 Phone#: S(ov -10q� _;b ( Cell Phone#: Fax#: IRV- b A — 39S t E-Mail Address: ar cure -Ciity.eS`"Cu Seating Capacity: 5�j 60�(4-h UJI n fir,(en Please submit latest copy of the Certified Food Protection Manager/ServSafe certificates to the office. Certified Food Protection Manager YES R(NO ❑ Certificate#: 0 (CFPM) (Required for ALL Class 2,3&4) 1 C� Name: 0 ndr�u 5',( {,rQr�� (� Expiration Date: Testing Organization: <._eyVsC(T_e_ ,,,� Phone#: E-Mail Address: o nva o� 'Alternate Pne#: U a nGrrQ(1 Alternate Person In Charge Phone#: Restaurant Owner Contact Information Owner's Name: Please check one of the following for ownership status: Mailing Address: Individual ❑ Association❑ Corporation ❑ Partnership❑ City, State, Zip Code: Other Legal Entity❑ Phone#: 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 WWL?SOk u I' _1E,aL1h1EPAr2TMEW Restaurant Menu/List of All Items Served/Sold Latest Menu Attached? YES E3ZNO ❑ 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. YlM rYLQ YLt,( bo JA em C a—I / yam. a ria/ -P/U , Y-114 M-ea& fz; ML Restaurant Food Prep (check all that apply) ❑ Cook to order ONLY ❑Advanced catering for specific quantities ❑ Uses Time as a Public Health Control oking/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) peI 1 ad i Ca t f ❑ 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 ❑ Liguor Permit one 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: J6 7d Applicant Address: n Lk f �' /-(,�� CT Phone#: 1�60 SV-e1q,3 Applicant Signature: 16 U, ie�� Date: j Office Use Only Inspector Name (Print): Inspector Signature: Date: Food Class: Expiration Date: Date Received: Date Approved: CaCommunity Renewal Team Changing 11vw...Crating oppwtunityl SENIORCOMMUNITY CAFE MENU CALENDAR JANUARY 2019 NOMAY '1 WDAY WMNMDAV frHUMAY MDAY 1 CRT CLOSED 2 3 4 Happy New Year? Happy New Year! Cream of Broccoli Soup Macaroni&Cheese !l��a Stuffed Green Pepper Baked Ham w/Raisin Spinach Salad w/Cherry r1 J" 1 9 w/Marmara Sauce Sauce Tomatoes .Lr Shelf Pasta w/Mariners Sauce Baked Potato Italian Dressing Green &Yellow Wax Beans Butternut Squash Club Roll 1 Wheat Dinner Roll Saltine Crackers Pineapples&Mandarins Mix Fruit Cocktail Peaches ago 7 8 9 10 11 Swedish Meatballs Cranberry Juice Mediterranean Soup Grape Juice Orange Juice Bowties Oven Fried Chicken Roast Pork A La Orange Beef Chill w/Beans/ Breaded Fish Filet/Tartar See Peas&Diced Carrots Mashed Potatoes Sweet Potatoes&Apples Shredded Cheese Potato Puffs Wheat Bread Corn Caribbean Blend Vegetables Elbow Macaroni California Blend Vegetables Peaches&Pears Oatnut Bread Corn Muffin Italian Green Beans 12 Grain Bread Mandarin Oranges Cherry-Apple Crisp 100%Whole Wheat Bread Fruit Cocktail Fresh Banana 14 CRT Celebrates National 15 16 17 18 Strawberry Ice Cream Dayl Mini-Beef Meatballs In Sauce French Onion Soup Roast Turkey w/Gravy Orange Juice Orange Juice Shell Pasta w/Sauce Beef Liver w/Sauteed Onions Sweet Potatoes&Apples Tuna fish Salad Hot Dog/Hot Dog Roll Italian Mixed Vegetables Mashed Potatoes Capri Blend Vegetables On Multi-Grain Roll Vegetarian Baked Beans Garden Salad w/Cherry Toms Garden Blend Vegetables Cranberry Sauce Potato Wedges/Ketchup Mustard, Ketchup,Relish &Cucumbers/ Ranch Dressing 12 Grain Bread Corn Muffin Sliced Tomato&Shredded Red,Green, Purple Cabbage Wheat Dinner Roll Pineapple Tidbits Fresh Orange Lettuce Coleslaw Applesauce Peaches Strawberry Ice Cream 21 CRT CLOSED 22 23 24 26 Cranberry Juice Beef Vegetable Soup Macaroni&Cheese Pot Roast w/Vegetable Gravy Martin Chicken Cacciatore Hamburger w/Broth Garden Salad w/Cherry Parslied Potatoes Rotini w/Tomato Sauce Potato Salad Toms,Cucs,Onions Sliced Carrots ,iut ler Brussels Sprouts Sliced Tomato&Leaf Lettuce Ranch Dressing/Stewed Wheat Dinner Roll 100%Whole Wheat Bread Multi-Grain Bun Tomatoes Fresh Grapes Tapioca Pudding w/Whipped Ketchup,Mustard,Relish Wheat Dinner Roll Day Topping Pears Mandarin Oranges 28 Orange Juice 29 Grape Juice 30 CRT Celebrates 31 Turkey Stew w/Potatoes Grande Cheese Ravioll w/ Beef Chili w/Beans JANUARY'S Birthdays Garden Salad w/Toms& " V' Italian Sauce/Mixed Greens Over Baked Potato/Shredded Cucumbers w/Raspberry Vinaigrette Cheese Hearty Vegetable Soup Ranch Dressing/Croutons Dressing/Caribbean Blend Italian Green Beans Roast Pork Hawaiian Style Buttermilk Biscuit Vegetables/Italian Bread Wheat Dinner Roll Brown&White Rice.Medley Peas-&Diced Carrots Tropical Fruit Peaches Broccoli Florets Applesauce Saltine Crackers 1 EXAM FORM NO. 4911 CERTIFICATE NO. 10917942 ry f CERTIFICATION To ANDREA S COFRANCESCO 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). l d'- DATE O 04/08/2 DATE OF EX Local laws apply.Ch or recertification requirements. �f. j ACCREDITEDPROGRAM Annerican National Standards Institute and the Conference for Food Protection ® tions #0655 ©2014 National Resta i'mark of the NRAEF,used under license by National Restaurant Association Solutions,I.I.C. 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