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HomeMy WebLinkAbout301 Evergreen Way (3) �­°"'" SE4� Town of South Windsor — Health Department 1640 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 saR.c� Establishment Information New Permit❑ Permit Renewal I Type: Mobile/Itinerant Vendor❑ Temporary Event❑ Permanent Food Service Establishment L'1 ***(Please Print Clearly)*** CLASS: I Name of Establishment: Ben &Jerry's - CT Scoop Shops LLC Name of Person in Charge: filadQ.1 e4q a, M 0 s'r'C tj C Establishment Street Address: 301 Evergreen Way Suite 301 City, State, Zip Code: South Windsor, CT 06074 Phone#: eI�C)"2-- 02-44, Cell Phone#: Fax#: �00) 4113 -2259 Mail_Address: rrr tau i i►'10 BY�O,�` Seating Capacity: Please submit latest copy of the Certified Fvlt�rdl c c i�4lah,01,SmSafe certificates to the office. Certified Food Protection Manager YES W NO ❑ Certificate#: (CFPM) (Required for ALL Class 2,3&4) 7�V Z3 Name: ( Qcje jtvlu, metron-C, Expiration Date: W 412U2 3 Testing Organization: c�{ArV�C �i Phone#: 432 —02 4} 0 E-Mail Address: udtc a' �'Or��^� Altemate Phone#: "' bw►- V-r,ii�r r.cor,, 1H3'22 � Alternate Person In Charge Co�t�� �es���se Phone#: Restaurant Owner Contact Information Owner's Name: S',+i vc L ftMP0+A Please check one of the following for ownership status: Mailing Address: " Individual cation ',Z � J( Ur. 5��, � corporation[!I Par tnership City, State, Zip Code: (tLt)f ai (---r ouc`q Other Legal Entity❑ Phone#: cuo 41,3-2-2',j Fax #: cft0j 4N3- 2252- E-Mail Address: 5t-lyt, @ bt, -W9&r. c,m Cell Phone#: &X00 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 ,�� 8 (1h,C- qv- Z� SOUTH WINDSOF2 HEALTH DEp �TMENT fps°�" sE4<� Town of South Windsor — Health Department 1540 Sullivan Ave., South Windsor, CT 06074- Mailing Address 1530 Sullivan Avenue, South Windsor, CT 06074-Office Address k. Phone Number: (860) 337-6173 Fax: (860) 644-1930 so R.c Establishment Information New Permit❑ Permit Renewal Ev/ Type: Mobile/Itinerant Vendor❑ Temporary Event❑ Permanent Food Service Establishment ***(Please Print Clearly)*** CLASS: 1 FEE DUE:75 Name of Establishment: Ben &Jerry's - CT Scoop Shops LLC Name of Person in Charge: rladc"Ieno Establishment Street Address: 301 Evergreen Way Suite 301 City, State, Zip Code: South Windsor, CT 06074 Phone#: C �'�>�} L L Cell Phone#: _ Fax#: �C4J 413 ---2 5 Z- E-Mail Address: SeatingCa pa Please submit latest copy of the Certified "ServSalle certificates to the office. Certified Food Protection Manager YES W NO ❑ Certificate#: -- (CFPM) (Required for ALL Class 2,3&4) Name: M((cl ctl&lit, fi10ri'(,v7r, Expiration Date: /4/261Z 3 Testing Organization: �,trvsoe, Phone#: 'j "2 —62.`r-o E-Mail Address: Alternate Phone#: C)'H:�--2261 Alternate Person In Charge Coltin j'z.1.;p6rre,0 Phone#: Restaurant Owner Contact Information Owner's Name: �� Please check one of the following for ownership i.tJL'1'1rJC�l status: Mailing Address: Pr. IndividualAssociation❑ City, State, Zip Code: Corporation Partnership❑ _ �C11�j c T_r✓is Other Legal Entity❑ Phone# � G� 4V 3 Z2 ►_ _ Fax #: r(No Cj q4'.3- 22 5:- _ E-Mail Address' :-, C @:" bevii Q ir9 Clt• CC`I ► Cell Phone#: O)443 22-1t 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: ZI SOUTH H�TH06 Restaurant Menu/List of All Items Served/Sold Latest Menu Attached? YES 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 O�cooking/cooling/reheating/thawing reezing hot o cold holding ❑ Prepares food to serve at another site ❑ Prepares food for Highly Susceptible Population(prase re 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 ❑ ,L' uor Permit VNone Water Supply (check only one): V Pub%Pu _ Private Well Wastewater Disposal (check only one): blic 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): C' ( Date of Birth: I ZJ Z-ii Applicant Address: j ��er-(, j r, �� !< ,`r67&'67l`j Phone# 06-7t)) ZH3 -Z2-j� i Applicant Signature: Z,�- Date: 1Z&W J,�$ Office Use Only Inspector Name (Print): Inspector Signature: Date: Food Class: Expiration Date: Date Received: Date Approved: A 4 A& ea • S s r • rvSea fe* ER C TI FICATIC) N MADALENA MORRONtMo for successfully completing the standards set forth for the Se f�o' Manager Cerfifiaation Examination, which is accredited by the American National Standards rence for Food Protection:(CFP). ; IiIM � � t ER EXA' FORM M r 6/4/2018 6/4/2023 DATE OF EX DATE OF EXPIRATION4)1 . Local laws apply.Ch for recertification requirements. #0655 Sher ciatian Solutions- In accordance v4 s ServSafe bgo are trademarks of the NRAEF.National Restaurant Associafion®and the arc design Contact us with questions at 233 S.Wacker Drive,Suite 3600,Chi-go,IL 60606-6383 or SavSofe@restaurant org ServSafe National 'S • • tM ery afe CERTIFICATION COLTIN JESPERS,rN,1�1. for successfully completing the standards set forth for the Se x from; n Manager Certification Examination, which is accredited 6y the American National Standards N� rence for Food Protection(CFP). ER EXA iII' FORM NUAB'Ei 6/4/2018 6/4/2023 DATE OF EX DATE OF EXPIRATION Local laws apply.Ch cy for recertification requirements. is ACCREDITED PROGRAM ® Sher #0655 iation Solutions ©- 0 of k In accordance wi ServSafe ksgo are tindwarla of tie NRAEF.National Restaurant Associations and the arc design Contact us with questions at 233 S,Wacker Drive,Suite 3600,Chicago,IL 60606-6383 or Swv$afe®restaurantorg. 5 ServSafe National01 rvsafe ERTIFI ATI C C 4N STEVE WAMPOLD'"", for successfully completing the standards set forth for the Se °IF n Manager Certification Examination, which is accredited by the American National Stanclarcisr rence for Food Protection(CFP). is rr ER EXA'ittA, (?RM 1tM3 ;R 6/4/2018 6/4/2023 r DATE OF EX DATE OF EXPIRATION Local laws apply.Ch cy for recertification requirements. ACCREDITED PROGRAM aW the Conference for Food Protwbon ® Sher. #0655 ciation Solutions • In accordance vn e ServSafe logo are trademarks of the NRAER National Restaurant Association®and the arc design Contact us wilh questions at 233 S.Wac6r Drive,Suite 3600,Chicago,IL 60606.6383 or ServSaWrestourantorg, • Butter Pecan 250.75C- ,AmerKone Dream i Cheap Wrtia' 200-b06Mocha Fudge Brewak 148.420 " Chocolate 21M30 t, ChorolateChipCeokle 0*10 230490 OIN-DAIRY 1 �A .. '� Chocolate Ftt/ge Brook 220^660 Caramel Almond 8thtle(It)210.630 Clom4k leaaal BMterp SW 250I50 Corona Almd kdge Clip M 230-693 Chocolate iburany. 230{90 Cowwt Se"s Layer Bar 2%750 S i2OU Coffee.Coffee BruBuaBmt 220-660 Berry Berry Extraordinary M-24=' 44LE. i ChwYp Mtxtltep 240.720 Lemonade Milk i Cookies 240-770 Mint Chocolate Chunk M460 .006 a;ie v .Iverus' PbM Food' 230690 Strawberry Cheesecake 200-90 Sii tr?. Sweet Cream&Cookies 210.63il The Tonight Dough+:elr. 25D-15f. =•r^!n�es�ti,Cljnt. _. Triple Caramel Chunk a, :5 Vanilla 6 i Banana Split 8.4.9 MEN �0 U D L y Q � Large S 6.7 9 COFFEE ►�, PrCw_Ganaritrdy t Afteted to Cnomiate la caramel MattMata Cackle Cookre Addicted W, Brc,wrlie tax Half Baked - ar - `'"' FRESH BREWED COFFEE SM LG MiM Cook* `? ,.. - Regular or Decaf 11.00 S2.00 'jr Coffee of The Day Mot Nola Sundae �6'r9 ESPRESSO Brarme SoelSal S T a 9 g+, ... -, '3.75 14.75 taokie Cookie Sundae -ll% '3.00 14.00 7 A 9 S,'1y'e/Double) 12.00 3.00 waMMe B"I Son4ae t; 719 R.. `�'i � r � �t 53.75 `4.75 "5 Waffle Bowl Cookie Cookie ,i,iia uttl_- `4-25 'S 25 Banana Sorlt 3andae Soadae s4.25 'S.25 4.25 5.25 Large ' _ ! '' _ - ICED DRINKS 5 Large _' ,� - •Co'feP '1-00 '2.00 '3.75 '4,75� � Va olio� Ito c C-. M(d La'.te `4,25 '5.25 3t:-awberry Mira rriMocl; Matte 2 Vermonster `4, 5 s^: ;.amona3e -.2 S 5 _