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HomeMy WebLinkAbout2017-11-14 - 1715 Ellington Road - Food Permit Application °W" SEq< 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 OR•Co��6 Restaurant Establishment Information New Permit❑ Permit Renewal Ej ***(Please Print Clearly)*** Name of Establishment: so(,(, ll Manager's Name: Street Address: y` + City, State,Zip Coder CTI Phone#: K(po �p l (J, qcr _ Cell Phone#: Fax#: 0 1 (4 S E-Mail Address: ` 9 Seating Capacity: e- ��13 Please submit latest copy of the Oualifled Food Oper _ office. Qualified Food Operator: YES NO ❑ (Required for Certificate#:_ � Class 3&4) _ Name: __ l� o—' oily m Date: Testing Organization: Phone#: @UO (QN(1 (4 4 E-Mall Address: I", Designated Alternate 1: Designated Altemate2 Restaurant Owner Contact Information Owner's Name: &-vorAll5tul0 WIMW Street Address: S pZ x� City, State, Zip Code: KIP, 5 1(4 Phone#: L4 4 q i! 010(' Fax #: E-Mail Address: -I Cell Phone#: Renovations Were there any renovations made last year? YES❑ NO [L Will 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: f7yzp ) h Svy' Attention: K'1— Address: City, State, Zip Code: m�hw 00 0-: q Phone#: I 91aO (a (,�(,� L '�/ 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. Additional Information Please check one only: State Licenses: ❑ Bakery ❑ Liquor Permit J None Water Supply: ✓ublicc Private Well Wastewater Disposal: V Public _On-Site _ 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. 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): (j (�l C���Ukkk_ �f r Applicant Signature: y Date: Office Use Only Inspector Name (Print): Inspector Signature: Date: Food Class: 1 ❑ 2 ❑ 3 ❑ 4 ❑ Expiration Date: Date Received: Date Approved: Sunday Monday Tuesday November 12. 2017 _ November 13. 2017 November 14, 2017 L "Entree Homemade Breakfast Pie 1 --Buttermilk Pancakes Eggs To Order I t i Entree I Waffles Scrambled Eggs [ Homemade Pancakes I ' j I I *Breakfast Meat Bacon Strips ' Sausage Patty Bacon Strips j � I I Breakfast Meat Sausage Link Bacon Strips Sausage Link 413 ! 'V-) Fresh Diced Pears and *Breakfast Fruit I Mixed Fruit Compote E Apples % Fresh Banana i_...___...._._..—....._..._.....-....._._._..__._.. _t....._ Old Fashioned Chicken Soup Noodle Soup Tomato Bisque Lentil Soup I i "Entree Hot Meatloaf Sandwich f Tavern Battered Cod j Turkey Salad Plate I Entree Stuffed Cabbage Rolls I Chef Salad I Pepperoni Personal Pizza lD [ *Accompaniment I Classic French Fries I I Accompaniment Garlic Mashed Potatoes1539 I I *Vegetable i Glazed Butternut Squash j Classic Coleslaw I Potato Salad ` I i I '�b Steamed Chefs Fresh I Vegetable i i Roasted Corn and Peppers I Italian Style Green Beans Vegetables I I -- -- __._.... _...... I ; ........._......_......_....._....._...__ ...—...—...._ _.__.._ *Dessert Chocolate Chip Cookie j Chocolate Mousse Chocolate Cake �o —_..�....—..... L......._..._...__...__......._......_..._......_......_.._...-._......... _ ...__.....µ_......._.._......_.... .._....._.......11 _........_......_...-...._......_....__... _, Reduced Sugar Tapioca I No Sugar Added Vanilla Ice Guiltless Pleasures 1 Sugar Free Vanilla Cookie I Pudding Cream ti._._. . __...___.—..—...._....._....._....._...._._..... —... �....— —.._—.— *Salad Mixed Greens with Pear and j Tomato and Cucumber i , Pickled Beets Salad PecansSalad I —..._.._......_...._.._......._......._......._....._..—...—...— r,� - Pork Loin with Roasted-- —^� I E` �- Stir Fry Chicken and "Entree I Salisbury Steak Pears Vegetables I �......_._...�.....—.. __..__....j24......_...._....__.._-__...._._.__.._.__-.__...__ Entree I Barbecue Chicken Italian Sausage with Peppers) Chicken Cordon Bleu ? and Onions I Accompaniment zr Pan Roasted Potatoes j18 Steamed White Rice -- '— Mashed , hed Potatoes 1 1 Creamy Baked Mashed Accompaniment Potatoes I Oven Roasted Potatoes lb Baked Potato j ._.._._.—_.._..._..—...—.....__.......—.._.._—.!_....—.---�._ 173 125 -- } — — --..... *Vegetable 1 Roasted Fresh Green Beans i q) Steamed Zucchini j Buttered Carrots Vegetable ! (1-) Fresh Vegetable Blend Buttered Acorn Squash Steamed Cauliflower i I 1 r--.--------------_.._...._.._......._.....__.... _......-_....-- .`.--,-._.1343 *Dessert Ice Cream Sundae Cherry Pie i Tapioca Pudding Guiltless Pleasures j Sugar Free Vanilla Cookie Reduced Sugar Tapioca I� No Sugar Added Vanilla Ice I Pudding Cream I _—..�.......—..._.—...__—... -...._........—.......—......._._......—......,.___......._......._.—...—....._—......—..—...—_—, FRB Assorted Crackers and *Mid Evening Snack Graham Crackers Granola Bar I Cheese I Milk, Breads&Grains and MargarinelFat are served with all meals. ftot or Cald Cereal, Fruit and Juice are served with breakfast. Other Juices may be offered as a substitute for Orange Jule Please consult the Dining Services page on BSLnet for. Brookdale Diet Manual and Condiment, Cereal, &Beverage Charts for serving instructions by diet. Please note that this approved Menu Cycle must be kept on file for a period of no less than two years. k Optimum Life Cuisine is prepared with reduced sodium, fat and cholesterol. Approved By. Date: K;jz�" nisiin `uo-Fw+n fulaz017 I �a�sdv Wednesdav Thursdav Fridav Saturdav November 15. 2017 November 18, 2017 November 17, 2017 November 18. 2017 ,z__._ —� _ _-- i2_.. _ �._ Farmers Scrambled j French Toast Scrambled Eggs Banana Oat Pancakes Breakfast Eggs To Order Buttermilk Pancakes Quiche Lorraine French Toast 42 3 a j Breakfast Foam Bacon Strips Sausage Link Bacon Strips 42 — 3 Bacon Strips Sausage Link Bacon Strips Sausage Link `13 13 i3 ,3 I f Stewed Prunes 14) Fresh Melon Cup '�E� Fresh Fruit Cup Stewed Prunes 1 1 Cream of Spinach Soup Vegetable Soup Cheddar Beer Soup Classic Split Pea Soup Isis 521 �— 45 51. Meat Lasagna Philly Steak Sandwich Chopped Sirloin with Mushroom Gravy Egg Salad Plate 43 514 51G BLT Plate Pollock Nuggets Stuffed Tomato with Tuna Franks and Beans Salad 0 o Zr o Mashed Potatoes Buttered Noodles 2$ 26 25 Sauteed Fresh Green Buttered Chefs Mixed 6 Beans Roasted Root Vegetables Vegetables Sweet Potato Salad �539 Beet Salad '6 Buttered Yellow Squash cam. Tossed Sliced Tomato Buttered Chefs Fresh � Vegetables 34 t35 Cookies and Cream Ice 4 Oatmeal Cookie Fruited Gelatin .a Frosted Yellow Cupcake y— Cream 6s Gr Sa 57 I No Sugar Added Root Beer Reduced Sugar Banana No Sr Added Ale Pie Sugar Free Strawberry Pudding ugapp Gelatin Mixed Green Salad Triple Bean Salad Tossed Green Salad Carrot Raisin Salad I lot so too W Baked Pollock Ham with Pineapple % Oven Baked Fried Roast Sirloin of Beef with Chicken Gravy I18 ,ot 103 24 i Midwestern Beef Stew (b Baked Tilapia Fib Applesauce Pork Chop Baked Chicken Quarters 28 27 27 -- r Rice Blend �b Baked Potato C Baked Potato Boiled Parslied Potatoes l � Pasta with Tomato Basil 1 Boiled Parslied Potatoes Mashed Sweet Potatoes Tater Tots Sauce i j26 26 28 28 Steamed Broccoli Creamed Spinach Buttered Butternut Squash Buttered Carrots i .F226 --- — 25 25 25 Buttered Winter Mix Buttered Chefs Fresh Braised Red Cabbage Roasted Cauliflower Vegetables 58 92 3G 35 Lemon Cake Pecan Pie Apple Cake Spumoni Ice Cream i— �� No Sugar Added Root Beer Reduced Sugar Banana Sa Sugar Free Strawberry 5J I Float Pudding No Sugar Added Apple Pie Gelatin I Assorted Cold Cereal and Animal Crackers 66 Mini Bagel with Cream Graham Crackers I Milk Cheese :e, Milk, Breads&Grains and MargarinelFat are served with all meals. Hot or Cold Cereal, Fruit and Juice are served with breakfast. Other Juices may be offered as a substitute for Orange Please consult the dining Services page on BSLnet for: Brookdale Diet Manual and Condiment,Cereal, &Beverage Charts for serving instructions by diet. Please note that this approved Menu Cycle must be kept on file for a period of no less than two years. 1Z Optimum Life Cuisine is prepared with reduced sodium,fat and cholesterol, Approved By: Date: RIME U&FAND 1111=017 10 7mS ServSafe National Restaurant Association ot '..,djAtervSafe""CERTIFICATION JACQUELINE GORDON for successfully completing the standards set forth for the ServSafee Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute(ANSI)-Conference for Food Protection(CFP). 641328 5238 UMBER EXAM FORM NUMBER 1/24 1/24/2022 DATE OF E DATE OF EXPIRATION Local laws apply.Ch ency for recertification requirements. oz ACCREDITED PROGRAM She #0655 ❑ ❑ In accordance with Maritime Lobou { WO15 National logo are trademarks of the NRAEF. Nati Contact us with questions at 175 W Jackson Blvd Ste 1500,Chicago,IL.6060A or ServSo{e�resiaurant.org. ServSafe A National Restaurant Association e a ry e CERTIFICATION JEAN LUNDY 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). 640758 5238 UMBER EXAM FORM NUMBER 1/24 1/24/2022 DATE OF E DATE OF EXPIRATION Local laws apply.Ch ency for recertification requirements. She #0655t�; In a orclance witli Moritime Labou Q2015 Nat onal logo are hademarks of the NRAEF_ Nati Contact us with questions at 175 W Jackson Blvd.Ste 1500,Chicago,IL.60604 or SmSa6areslouront.or©.