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Home My WebLink About2016-12-3 - 1062 Pleasent Valley Road - New Permit Application Town of South Windsor — Health Department c j 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 4- 4`• SOR•Co ,�( Restaurant Establishment Information New Permit El' Permit Renewal El ***(Please Print Clearly)*** --.- Name of Establishment: r5 �� Manager's Name: ��A�11- \Q.�C'U. _- - - - -.I - - -- - ---Strcet Add,css: -- - _ City, State, Zip Code: �C.e�ll P--h-o-�n-e-#:# Phone S SO=H Fax ng Capacity: ail Address �ati: _ 1 - - - Please submit latest copy of the Ouatified Food Operator/ServSafe certificates to the office. - -- — YES t6..NO El (Required for ' Certificate#: - Qualified Food Operator: Class 3&4) _ _.___ -- - --_--_— --___Name: -- - - - -- -• ---- -- Date: -"-- . C1_(� - -------- - � �s _ _ - t ' Testing Organization: Phone#: 5S4_- '1�Q E-Mail Address: Alternate Phone#: Designated Alternate 1: Ga(1. US Designated Alternate2 - Restaurant Owner Contact Information Owner's Name: Ie'��,� Street Address: City, State, Zip Code: . : ; r1�SU C -^ Phone#: p Fax #: I E-Mail Address: +,,,, o`g G1�civlA Cell Phone#: i 5C � Renovations l& WYA Were there any renovations made last year? YES❑ NO Will there be - — -- nsD ? YES❑ NO ❑ If Yes, please list all renovations q 0 20�6 that were done/to be done: f I SOUTH\NiNDSOR HEALTH DEPT. j Mailing Address to send Food License Renewal Permit to: Name of Restaurant/Company: Attention: i �cj - ��n `�`'� Address: 1_G j City, State, Zip Code: D. v - Phone#: <°W N b��< 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 ,(1R-'0 Restaurant Menu/List of All Items Served/Sold Latest Menu Attached? YES D/ 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. Additional Information Please check one on y: State Licenses: akery ❑ Liquor Permit ❑ None Water Supply: ✓Public Private Well Wastewater Disposal: _. Public n/On-Site Other (please use space below to explain) /S oCIl —---- Agreement and Signature By submitting this application, I affirm that the facts set forth in it are true and complete. 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): \� , ��•� 1 ! " tC7 N'C)c a —— Applicant Signature: Date: Office Use Only Inspector Name (Print): Insp ignatu Date: / Food C s: 1 ❑ 2 ❑ 3 4 ❑ Expirati n Date: Date Received: Date Approved: z EXAM -FORM N'O. 4938 CERTIFICATE NO. 11234284 S rV fe CERTIFICATION TO ELLEN E MAROUSKI for successfully completing the standards set forth for the ServSafe"Food Protection Manager Certification Examina which is accredited by the American National Standards Institute(ANSI)-Conference for Food Protection(CFP). 06/23/2014 DATE OF EXAMINATION 06/23/2019 DATE OF EXPIRATION Local laws apply.Check with your local regulatory agency for recertification requirements. ACCREDITED PROGRAM Sherman Brown SVP,National Restaurant Association Solutions #0655 n2014 National Restaurant Association Educational Foundation(NRAEF).All rights reserved.ServSafe Is a registered trademark of the NRAEF,used under license by National Restaurant Association Solutions,I.I.C. The logo appearing next to ServSafe Is a trademark of the National Restaurant Association. This document cannot be reproduced or altered. 14013002 v.1401 .J M S aarda4l-poij Sax SANMAq CH E S ICE CREAM 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, svviss cheese, caramelized onions, tomato, and spinach Cups & Cones Kids 2.75 Small 3.75 Regular 4.75 The J.P. Melt Country whiles bread. with turkey, spinach, Milkshakes tomato, onions, peppers and melted omericon Choose any flavor of ice cream 5.25 cheese Malted Milkshakes The Eggcellent Sandwich Choose any flavor of ice cream 6.00 Tivo eggs h- ehvese on your choice of bread with bacon, spinach, lomatof?s, 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 Counlri' ivhite bread with red pepper jelly, cream cheese, and pepper jack cheese Vegetarian 5.25 Turkey or Bacon 5.75 Turkey & Bacon 6.25 Drinks on back Check on our Facebook page for daily specials! DRINKS Smoothies 5.25 Choose your fruit -Bananas, strawberries, 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 KIDS MENU Grilled Cheese PB&J Egg & Cheese Sandwich Turkey & Cheese Sandwich Comes with fruit and a small chocolate milk, apple, or orange juice 5.00 ABOUT US 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! facebook.com/jemsgard ens Instogram: @jemsgarden