HomeMy WebLinkAbout2017-12-15 - 1062 Pleasent Valley Road - Food Permit Renewal 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, t Phone Number: (860) 337-6173 Fax: (860) 644-1930
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Restaurant Establishment Information New Permit❑ Permit Renewal Lg'
***(Please Print Clearly)***
Name of Establishment: �� �,� S U-/` �� ��'� �w✓`F'�
Manager's Name:
Street Address:
City, State, Zip Code: �o C� 4 ��SU✓ CT C) &0`Z N
Phone#: 1_&C) 5 5 O_ (A (D Cell Phone#:
Fax#:
E-Mail Address: may , \ QeMeating Capacity: r c_ GU�.
Please submit latest copy of the Qualified Food Operator/ServSafe certificates to the office,.
Qualified Food Operator: YES M/ NO ❑ (Required for Certificate#: ��
Class 3&4) \\' � o�S
Name: C,1�i r1 `1� )", v, ; Date: (���3� I N +c
Testing Organization: ip%/y Phone#:
E-Mail Address: Alternate Phone#:
Designated Alternate 1: Ja�-`l�,,,r % ���r^v Uv , Designated Alternate2
Restaurant Owner Contact Information
Owner's Name: \"
Street Address:
City, State, Zip Code: C.77- O (s U l
Phone#: � C."t—Z a33 Fax #:
E-Mail Address: ex j44i*+Cell Phone#:
Renovations
Were there any renovations made last year? YES❑ NO [v' Will there be any renovations? YES V 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: -3-F,YN"1 S � -�j �
Attention: L+LQ�/1 ���5
Address:
City, State, Zip Code:----* :
Phone#: 9&0 550 - u G- S o?
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 ❑ None
Water Supply: *!Public Private Well
Wastewater Disposal: _ 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):
a-'r-
Applicant Signature: Date: fVJj
Office Use Only
Inspector Name (Print): f 1
Inspector Signature: Date:
Food Class: 1 ❑ 2 ❑ 3 ❑ 4 ❑ Expiration Date:
Date Received: Date Approved:
CTax `)aky Box
SANDWICHES 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, swiss cheese,
caramelized onions, tomato, and spinach Cups & Cones
The J.P. Melt Kids 2.75 Small 3.75 Regular 4.75
Country white bread, with turkey, spinach, Milkshakes
tomato, onions, peppers and melted arnerican Choose any flavor of ice cream 5.25
cheese
The E cellent Sandwich Malted Milkshakes
gg Choose any flavor of ice cream 6.00
Tivo eggs & cheese on your choice of bread i/vith
bacon, spinach, tomatoes, onions, and peppers Fusion
The Mickey A blend of frozen fruit and ice cream 6.00
One egg, american cheese, green peppers, and Specialty Shake
onions on white bread Any special shake listed 6.00
The Popper
Country white bread t-vith 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
- Oi-ange juice .50
-Apple juice .50
Lemonade 2.00
Iced Coffee or Tea a.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!
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EXAM FORM N*O. 4938
CERTIFICATE NO. 11234284
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