HomeMy WebLinkAbout2018-12-20 - 1062 Pleasent Valley 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
s Phone Number: (860) 337-6173 Fax: (860) 644-1930
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Establishment Information New Permit❑ Permit Renewal ❑
Type: Mobile/Itinerant vendor❑ Temporary Event❑ Permanent Food Service Establishment❑
***(Please Print Clearly)*** CLASS: 3 FEE DUE: 200
Name of Establishment: )EM's Garden & Dairy Barn
Name of Person in Charge: c l lo_'o
Establishment Street Address: 1062 Pleasant Valley Road
City, State, Zip Code: South Windsor, CT 06074
Phone#: V6C) S SO -C��r�a Cell Phone#: p - cl"7"? -a33G
Fax#:
E-Mail Address: xyloy,Gc svi e,-_AA.0QT Seating Capacity: c,L
Pleese submit'atest copy of the Certified Food Protection Manager/ServSafe certificates to the office.
Certified Food Protection Manager YES Er NO ❑ Certificate#: \% aS Loa
(CFPM) (Required for ALL Class 2,3&4) dy
Name: Expiration Date: 1
Testing Organization: Phone#:
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E-Mail Address: `t"'�1o�ocuS � Alternate Phone#: "C)_ c7`!'7-a33- P
Alternate Person In Charge rcj �Y�'1a�ou J Phone#: Vda — SSG- �Vo/
Restaurant Owner Contact Information
Owner's Name: \ Please check one of the following for ownership
status:
Mailing Address: C.SC. �a� � I`� Individual W Association ElCity, State, Zip Code: eL / Corporation ❑ Partnership❑
[ J r►C`iSG C?--06c -2 7 Other Legal Entity❑
Phone#: 15t0 - S Sa_ t/6 Jr Fax #:
E-Mail Address: L}-1a 1� - Cell Phone#:
Renovations
Were there any renovations made last year? YES❑ NO LJ' 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 VNO ❑ 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)
Ycook 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: eBakery ❑ Liquor Permit ❑ None �� .� C% u sSx
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): ( (,fir 1gs . �� Date of Birth: �� ,
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Applicant Address: zzly, Phone#: e-,
Applicant Signature: �' _ ,r- Date:
Office Use Only
Inspector Name (Print):
Inspector Signature: Date:
Food Class: Expiration Date:
Date Received: Date Approved:
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EXAM FORM r*O. 4938
CERTIFICATE NO. 11234284
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CERTIFICATION
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The Kristen Wrap Sundaes
Fresh, seasonal veggies with red pepper hummus Kids 3.75 Small 4.75 Regular 5.75
and your choice of cheese
Sundae toppings include hot fudge, caramel,
The Panini peanut butter sauce, and strawberry sauce
Rye bread with red pepper hummus, swiss cheese,
caramelized onions, tomato, and spinach " Cups & Cones
Kids 2.75 Small 3.75 Regular 4.75
The J.P. Melt
Country white bread, with turkey, spinach, Milkshakes
tomato, onions, peppers and melted american Choose any flavor of ice cream 5.25
cheese
Malted Milkshakes
The Eggcellent Sandwich Choose any flavor of ice cream 6.00
Tivo eggs & cheese on your choice of bread with
bacon, spinach, tomatoes, onions, and peppers Fusion
A blend of frozen fruit and ice cream 6.00
The Mickey
One egg, american cheese, green peppers, and Specialty Shake
onions on white bread Any special shake listed 6.00
The Popper
Country white bread with red pepper jelly, cream
cheese, and pepper jack cheese
Vegetarian 5.25
Turkey or Bacon 5.75
Turkev & Bacon 6.25
Drinks on back
Check on our Facebook page for daily specials!
Smoothies 5.25
Choose your fruit
-Bananas, straivberries, blueberries, mangos, pineapples
Pick your base
- Water
- Orange juice .50
-Apple juice .50
Lemonade 2.00
Iced Coffee or Tea 2.00
Hot Coffee or Tea 1.50
Bottled Water 1.00
- D S
N E
Grilled Cheese
PB&J
Egg & Cheese Sandwich
Turkey & Cheese Sandwich
Comes with fruit and a small chocolate milk, apple, or orange juice
5.00
-3 X x-
4 a.
Contact Info
1062 Pleasant Valley Rd.
South Windsor, CT
(860) 550-4652
Our hours are seasonal and weather dependent, so don't hesitate to call!
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