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Home My WebLink About2017-1-17 - 1715 Ellington Road - Food Permit Application Jan, 17. 2017 2: 07PM Brookdale — South Windsor No, 0892 P. 1 13ROOKDAIlk _ Gcron Lisrao coriW+G.. __ _.r�... � .-. •d :' P F 'fl,:by f +%LL tK&d LmctA LIP2 2Ati 6D" Brookdale Senior living 1715 Ellington Road South Windsor, CT 06074 Phone 860.644.4408 Fax 860.644.4485 Wellness Office Fax 860.644.5481 Today's Date: Attention: ( - — Co l,i ej 0 At ( G p Y)name of om an • S Fax Number: Phone Number: Number of Pages being faxed: From. ct.a� ST) S,,m.fK Message: RECEIVED. JAN 1 2 SOUTH WINDSOR HEALTH DEPT. Jan, 17. 2017 2: 07PM Brookdale - South Windsor No- 0892 P. 2 °"'� '`.4{ Town of South Windsor - Health Department 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address 1530 Sullivan Avenue, South Windsor, CT 06074 Office Address y�. Phone Number. (860)337-6173 Fax: (860)644-1930 �1�SOR•GON� Restaurant Establishment Information New Permit❑ Permit Renewal IX ***(Please Print Clearly)*** Name of Establishment: Manager's Name; "Street Ado'ress; - ,;�1 — _ City` State,Zip Code: 6' �� V�JY__. —C - ( 'I` _ _.. .�_�Phone#: Q r,� Y(,!Q.4 _ — Cell Phone#: ---- --�____. Pax#; � _ __•-_____ ..__ _ E=-Mall Address; ne_ _M ^ Seating Capacity: , Please submit latest copy (L r/ ertilicstes to the office. �Qualified Food operator: Yrs i 'No (Required for ( ^~Certificate#: i -_... .__._._. t1 ciass3&ay _ _ _ i --- Name;� jt�Ui/► _- JlI�( �.._. Date: Testing Organization; � !". - Phone#: E-Mail Address: 111 N1 WWII v __ Designated Alternate 1: Designated Alternate2 Restaurant Owner Contact Information owner's Name: Street Address: _ Ilia S1 - � oQ3OD -- City, State, Zip Code: i//7�� Phone#.' I. _ ...."t- ... � Fax#: E-Mail Address: Cell Phone#:V Renovations Were there any renovations made last year? YES❑ NO WIII there be any renovations? YES❑ NO .__... _...._..._. __._,. ,.:,.__............_._., ....,, - - ---- - -- -..._. ... ...._� If Yes, please list all renovations that were done/to be done: Mailing Address to send Food License Renewal Permit to: Name of Restaurant/Company: '/►� � �� !`., _ Attention: Address; City,State, Zip Code: ,� .__Phone#; _ - . an. 17. 2017 2: 08PM Brookdale - South Windsor No. 0892 P. 3 I vvv11 of -';)Uu1.1 I vv„luav, — „ealth Department 1540 Sullivan Ave.,South Windsor, CT 06074—Mal ling Address .� • 1530 Sullivan Avenue,South Windsor, CT 06074--Office Address Phone Number: (860) 337-6173 Fax: (860) 644-1930 l�L�tiRGO�� Restaurant Menu/List of All Items Served/Sold Latest Menu Attached? YES,9_No ❑ NOTI=`(Must have latest copy on file) Please list all menu Iterns in as much detail as possible or a copy of a menu attached is applicable, Additional Information Please check one only: State Licenses: ❑ Bakery ❑ Liquor Permit ,None Water Supply: Public// _Private Well Wastewater Disposal: ✓Publlc On-Site Other(please use space below to explain) Agreement and Signature By submitting this application,I aMrm 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 Immedfate shutdown or revocation of my Food Service License for the Town of South Windsor, m Applicant Name (Print): /� C a I� Applicant Signature: �A, Ll. M Date; Office Use.001V Inspector Name (Print); -- Inspector Signatur Date: low" Food Class; 1 2 ❑ 3❑ 9 kExpiratlon Date: Date Received; �� Date Approved; / /� it J o. o l:J CXD z P e rvS fe CERTIFICATION DOROTNY AGYEMANG DUAH for successfully conTWing the skrrdcrde set fcd For the Serv&63 Food P n' riot did:Ge i(icadinn 5comination, vhich 6 ac=c6J 6y the American N,atiaclol-%ndords Instriute Ga C'` or Fcod Pratec}ion ft:FP7. yr. ..,t,a2V, 882514 51'Q~ ti UMBER EXA14 R'tv�-`N t`. 4ok- ' `+ •� 10/1 10/15/202'C--. 7 A;' °• m Q,�S E OF DATE �F EXF'li: lomi 6'" po Ch enc f_ recerTiRaofan n*gviremenh uj t .4 �' f►" '•+. �` .• ..J�rR � S�� •y 1�, iK.' cp � Ei S i, c .:^l�:�C.,o - a�eruaw:,.coFl�ePgznff. G�lo»cs*dit,gms6mz 117E W!ed 964,1e 1030,d kzM L 6004 4,r r.SdnS vir�. . Jan, 17. 2017 2: 08PM No, 0892 P. 5 5unaav Mondav Tuesuav Jenuary 22, 2017 Janimry 23, 2017 January 24, 2017 *Entr6e Banana Oat Pancakes Scrambled Eggs Waffles Entr6e Denver Omelet Buttermilk Pancakes Eggs To Order 'Breakfast Meat I Sausage I-Ink Bacon Strips Sausage Patty i -- �� Breakfast Meat Bacon Strips Sausage Link Bacon Strips 'Breakfast Fruit Fresh Fall Fruit Cup �b Fresh Banana Fresh Fruit Cup IG 1 A 'Soup Cream of Carrot Soup Split Pea Soup White Bean and Escarole Soup ♦3 E di7 e,! 'Entr6e Chopped Sirloin with Chicken Caesar Salad Spaghetti with Meat Sauce Mushroom Gravy Ou die eN Entr6e Taco Salad Beef Enchilada Casserole Hot Turkey Sandwich *Accompaniment Mashed Potatoes 0 o U Accompaniment "Vegetable a Stewed Tomatoes V Marinated Carrot Salad with 25 tZ Steamed Italian Mix Lemon Dijon Dressing p Vegetable Roasted Corn and Black ___j Bean Salad Roasted Green Beans I Buttered Winter Mix I{. "Dessert Pumpkin Spice Mousse I Gelatin Cake Peppermint Ice Cream ip) 37 Guiltless Pleasures Reduced Sugar Quick Cooking Tapioca Pudding Applesauce Spice Bars Reduced Sugar Custard 7 Mixed Greens with Pear and „ Garden 7 lb Marinated Cucumber, `Salad Pecans Garden Slaw Tomato and Onion Salad � 4� Golden Apple Stuffed *Entr6e Oven Roasted Chicken Beef Goulash Cod Fillet I Entr6e Hunter Style Lamb Stew L. Shrimp Scampi Liver and Onions "Accompaniment Dutch Potatoes Buttered Noodles Stir Fried Barley r Accompaniment Boiled Parslied Potatoes Rice Pilaf Hash Brown Potatoes "Vegetable Sauteed Spinach I Buttered Butternut Squash ib Steamed Green Peas i Vegetable I Braised Green Beans Lemon Butter Broccoli Braised Red Cabbage u "Dessert Coconut Cake Butterscotch Pie Carrot Cake Guiltless Pleasures Reduced Sugar Orange Reduced Sugar Pumpkin Reduced Sugar Nutty Carrot Dreamsicle Cake Spice Chiffon Cheesecake 1 Cake Bars Assorted Cold Cereal and Mini Bagel with Cream ® "Mid Evening Snack Milk Animal Crackers Cheese Milk,Breads A Grains and MargarinelFat are served v.itr, all meals. Hot or Gold Careel, Fq,il and Juice are saved mh breaNleel. other Juices may be offered err,a subseute for orange Jule Please contull the Dining services page on BSLnet for. Brookdale Dial Manual and Condiment, Cereal, &Beverage Charts for eervina Instructions by diet. Please note that this approved Menu Cycle must be kept on file ror a period of no less than two years. %A Opllmurn Life Culelne le prepared with reduced sodium.(pl and choiesteral. rApproved By, Date! l —s—�ierrda�'o CW-. :Me. 117r_)U 17I Jan, 17. 2017 2: 08PM Brookdale - South Windsor No. 0892 P. 6 weanesaav i nursaav Frldav -jaturdev January 25, 2017 _ Januery 26, 2017 January 27. 2017 January 28. 2017 Boiled Egg , Buttermilk Pancakes Fanners ScrambledBreakfast French Toast (� French Toast I Fresh Baked Quiche Homemade Pancakes Scrambled Eggs I Bacon Strips Breakfast Ham Bacon Strips Sausage Link Sausage Link Bacon Strips 9 Sausage Link Bacon Strips f1313 Fresh Diced Pears and I f� Stewed Prunes �b Fresh Banana Tropical Fruit Apples 1 Italian Minestrone Soup Cream of Vegetable Soup Rhode Island Clam Chowder Cream of Broccoli Soup m � i§57 6fB Sliced Breast of Chickens Citrus Tilapia Turkey Salad Plate Chicken Pot Pie Sandwich JJII .6 - --. •—•.••— ..ISt7!t fits E!t { Lemon Baked Salmon `` Sesame Ginger Chicken American Chop Suey Hot Meatloaf Sandwich L Salad ;a a `I I Whole Wheat Couscous lu u Pan Roasted Potatoes Broccoli Raisin Salad `Q) Steamed Brussels »6 Sprouts potato Salad Sauteed zucchini Steamed Chefs H tb Tossed Sliced Tomato y Sauteed Spinach ly Buttered Succotash Vegetables M & M Cookies Fruited Gelatin Double Chocolate Banana Snack Cake I Orange Sherbet No Sugar Added Flg Reduced Sugar Lime Sugar Free Chocolate Chip Reduced Sugar Chocolate Almond Bar Mousse Cookie Mousse layer Cake I" j Beets and Onions Salad Marinated Vegetable Salad I Bacon Ranch pea Salad Mixed Green Salad ! 't Rosemary Pork Loin B13Q Chicken Braised Beef Provencale (b Baked Pollock Chicken Thighs Parmesan Veal Loaf Friday Fish Fry Salisbury Steak q) Baked Sweet Potato Tater Tots Mashed Potatoes Steamed Brown Rice Mashed Potatoes Mashed Potatoes Sweet Potato Fries Mashed Potatoes Roasted Parsnips and Collard Greens and Bacon �— Glazed Butternut Squash Braised Rod Cabbage Carrots l Sauteed Zucchini with Green Beans with Buttered Cauliflower I Buttered Beets Peppers and onions Mushroom and shallots 16 5' M9 ftl i Butter Pecan Ice Cream Cherry Cobbler Rice Pudding I Boston Cream Pie Cake Reduced Sugar Caribbean Reduced Sugar Chocolate Reduced Sugar Basic �� Reduced Sugar Chocolate L Cruise Cake Souffle Pistachio Pudding Banana Layer Cake Assorted Crackers and Assorted Cold Cereal and Graham Crackers 1 Cheese Granola Bar I Milk i .e. MO. Breads a Grahls and MargarinatFal ere served With ell meals. Hot or Cold Cored. Fruit and Juice are sorved vMlh breakfast. other Juices may be offered ea a Subslilute for Omnge Please consul[ the Dining services page on BHLnet for Brookdale 1)(e1 Manuel and Condiment, Cereal, B Beverage Cnerta for serving Instruelfons by diet. Please role 1lrral this approved Menu Cycle must be kept on Me for a parted or no leas Ulan two years. '-A Optimum Lire cuisine Is prepared with reduced sodium. Ial and cholesterol. Approvedey: Dale! F �`�aa eo cad"a rnxo 1/17@0171