The URL can be used to link to this page

Home My WebLink About2017-12-17 - 124 Brookfield Street - Permit Application Town of South Windsor - Health Department 1540 Sullivan Ave., South Windsor, CT 06074- Mailing Address 1530 Sullivan Avenue, South Windsor, CT 06074- Office Address x ` Phone Number: (860) 337-6173 Fax: (860) 644-1930 soR.co'`�4t Restaurant Establishment Information New �Per it El Permit Renewal / ***(PI se Print Clearl *** �d� /''1 Name of Establishment: '�� w( roo�5� L L C. , Manager's Name: } Street Address: 0 i e City, State, Zip Code: S 4�� ,► � �� Phone#: N COTO Cell Phone#. `�L Fax#: 1 E-Mail Address: ja pCj 10 sr,4> eating Capacity: �4q Please submit latest copy of t Qualified Food Operator/ServSafe certificates to the office. Qualified Food Operator. YES 71NO ❑ (Reaulred for Certificate#: Cl*ra"s 3 6 4) Name: 1 D , C'-k Date: /�r j��p�� Testing Organization: Q � } Phone#: E-Mail Address: Gr+i• j Alternate Phone#: go ,19,. �[j 0Designated Alternate 1: �ph �CZ �fo Designated Alternate2 : to f �� to A44-.5O t4 Restaurant Owner Contact Information b Owner's Name: Ill�r Q� Street Address: 0 g J City, State, Zip Coder Phone#: Fax #: E-Mail Address: �f'rle5 37kir G) Cell Phone#:(�44% 65 r Renovations i M Were there any renovations made last year? YES❑ NO V/ 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: 0 Attention: Address tal . 4fi 4y City, State, Zip Code: ;nos-drg Phone#: �40 0-46 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: ❑ akery 4Liquor Permit ❑ None Water Supply: Publ' Private Well Wastewater Disposal: 7 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): 40orz� � ;I I C' �. Applicant Signature: Date: rl Office Use Only Inspector Name (Print): Inspector Signature: Date: Food Class: 1 ❑ 2 3 a 4 ❑ Expiration Date: kj, \\tj Date Received: Date Approved: WILLOW BROOK Golf Course Tee It Up Chicken Tenders 895 Chicken Wings 9.95 BBQ,buffalo, honey mustard sauce Buffalo,BBQ or Teriyaki Sesame Chicken Quesadilla 995 Super Nachos 1095 Extra Large flour tortilla filled with grilled chicken, Crisp tortilla chips piled high with chili, melted cheese,tomato and jalapehos jalapenos,tomato,olives&cheese Fried Mozzarella 750 Chips and Salsa 6.25 Lightly golden to perfection w/marinara In the CUP or in the bowl Soup du Jour cap 4.00/bowl 5.00 Homemade Chili cup 5.50/bowl 6.50 On the GREENS Garden Salad 6.95 Caesar Salad 7.95 With grilled chicken breast...9.95 With grilled chicken breast.....10.95 Salad Platter 995 Chef Salad 10.50 Choice of tuna,seafood or chicken salad With egg,ham, cheese,and turkey Served with coleslaw and potato salad Willow Brook Salad 1050 Crispy Chicken Salad 1050 Greens with Apples,walnuts,cranberries, Greens,veggies,mandarin oranges, blue cheese crumbles and raspberry vinaigrette black olives,and dried cranberries Healthy and Tasty Platter 9.25 Cottage Cheese and Grilled Chicken Breast or Veggie Burger with veggies ALL SALADS SERVED WITH YOUR CHOICE OF: Ranch,Low Fat Italian, Oil+Vinegar,Balsamic or Raspberry Vinaigrette,Blue Cheese,Parmesan Peppercorn or Thousand Island The BURGERS* all burgers served with lettuce, tomato,pickle and chips on Michael's Bakery hard roll Substitute French fries for 2.00 Black Bean or Turkey Burger 795 The Steak Burger 750 Healthy choice with all the taste! add cheese OSO...bacon 1.00 Willow Brook Burger 8.95 Served with provolone,bacon,peppers,mushrooms,and onions...a WB Favorite! *Indicates possible raw product.Consuming raw or undercooked product may increase your risk of food borne illness. We Take Pride In Using Local Produce + Bakers Sand-Wedges Sandwiches served wl bag of chips and pickle...substitute fries for 2.00 Grilled Cheese 495 The Big Dog (9 Inch Hummel)4.75 Add ham 2.00 and/or tomato 1.00 Kick it up...wl cheese or kraut 550 w/chili 5.95 The BIX 695 Philly Cheese Steak 9.95 Loaded wl crisp bacon,romaine,tomato w/sauteled mushroom,onion&peppers&cheddar cheese Grilled Chicken 8.25 Chicken Parmigiana 895 Regular,honey mustard,BBQ,or.Buffalo W1 homemade sauce and provolone on a wl lettuce and tomato on bakery hard roll bakery hard roll Corned Beef Reuben 950 Tuna Melt w/ Cheese 850 Xtra lean corned beef on grilled seedless rye Solid white tuna on grilled seedless rye wl sauerkraut and thousand island dressing Turkey Wrap ' 8.95 1brkey and Cranberry Wrap 895 With lettuce,tomatoes,and cucumbers Solid white turkey with lettuce and tomato served with balsamic vinaigrette Sliced Turkey Breast 795 Chicken,Mana,or Seafood Salad 795 Choice of bread and lettuce, tomato,and mayo On a Wrap...........850 Chicken Caesar Wrap 995 Clam Roll 8.95 The classic now in a wrap! Served with coleslaw Willow Brook Club 995 Beer Battered Cod Filet 850 Choice of.-Tuna,turkey, ham,or grilled chicken Served with coleslaw The Hole in One All served with fries and coleslaw Clam Strip Platter 995 Liver & Onions 9.95 Fish and Chips 9.95 Out of Bounds Side of Fries 2.25 Side House Salad 350 Chili Cheese Fries 6.25 Basket of Fries 4.95 Cole Slaw 1.75 Basket of Onion Rings 650 Potato Salad 250 Basket of Sweet Potato Fries 595 The Water Hazard Soft Drinks 2.75 Coffee and Tea 2.00 Root Baer 3.00 Brewed Iced Tea',Lemonade 2.75 (Hot) Chocolate Milk 3.00 Fruit Juice 3.00 ** Gluten Free bread option 1.50** Tw r r _ T• L1 •T��:.Y� t �—" THE NA.ic3�l►1: �EGISTF�� '^ �Ypr�ss!t �' FOOD S*FFf E OFESSIONALS(B) OLCZER ' Co ERTIFI:: (S WE'rYYtYaGij_ ^ AS SUCCESSFULLY SA►! CIE REQUlRE114EM5 i :OR S Sf[c" ��THE FOOD SAFETylANAGER V' ' CERTIFICATION r ATION w PT a� Q �ishe� -,( 6 7 ro 'AfQt) inst;723 S !Regis tn l,f Faarewpr ?— _ ,>L of Cmvontnc lea til 7_- I� c DATE:APP,IL 12 FICATE NO:Z , 2007 CERT T� S20106834 6834 •e� FORM: ZSAC — ��JJJ 71u eet tir"utk is ara Y-ad for more +-•w...�f.�a.te of itaa,r. IN I)t !' ^�- .e(9;Ei .wCw=5 �a4'.•- w�'; ��.ytyL:1�_' ._�.i•'.��, v i� '�.� G� 37 F't :. �'�'•y�(p.p��a —C t -•-� t•v:- -J_•� - f• ?--L�; �,T1H.'yam'i3. � rw.�C [`Ill tme ca - of mood Safety, [nstitUr %gfizcate Of Par icrp at-ion DEBORA�= APOLCZER ' � ems-`` _ _ _ `- -- � � �lf�/� '�=��jl~� -_1-. .... •1`-.•� • Ph!_ �!??S('CSC?T2r�`1 SI, C'T010 04/12/07 � = - ling foul eenitwj _ iea e gall (800) 723 7 3 �» ad,a: � - - ._ _,•.,� --- - _ in[h._Contincn[al l- ►mil.z. - - -R — ".x. 'i •�Mahw:v,cri::_.,,,:-: ..: !, ui!l heIVY gy,uM1•�yw l�fwY:y ip��,i,e:un61.�,L.ii'SI OuL.J:.:_r- •i'te -- - yt�;.V S! •nL�ur•v►.a.i.i.�:�eatc n�oE._� 2� Submitted on Wednesday, December 21, 2016-9:51am Submitted by anonymous user: 70.164.244.45 Submitted values are: Class: 4 Establishment Name: Willow Brook Cafe Street Address (Street,Town, State,Zip): 124 Brookfield Street Mailing Address(Street,Town, State, Zip): South Windsor, CT 06074 Business Phone: 860-648-2061 Website:www.willowbrookgc.com Business Fax: Email:willowbrookpro@cox.net Legal Owner:Jean E. Shepard Mailing Address (Street,Town,State, Zip): 124 Brookfield Street, South Windsor, CT 06074 Home Phone: 860-648-0466 Cell Phone: Email: Emergency Contact Name:Jeffrey Beyer Emergency Contact Phone: 860-655-4520 Emergency Contact Email: jeffbeyer@cox.net Best way to be reached in an emergency: phone QFO/Manager Name (Class 3&4 Establishments): Deborah Apolczer Designated Alternative Name:John Mozicatto Renovations/New Equipment: No Water Supply: Public Wastewater Disposal: Public Other Licenses: Liquor Permit Menu: http://www.southwindsor.org/sites/southwindsorct/files/webform/health files/2016 cafe menu.pdf QFO Certificate: http://www.southwindsor.org/sites/southwindsorct/files/webform/health files/qfo deb apolczer.pdf ==Disclaimer== The results of this submission may be viewed at: http://www.southwindsor.org/node/11601/submission/7313 + r a ew Wllmes �ru,A th""��hoi. sijSeo iA INTE A RATItJN f— { ( R vt I 1 S 1 i l 860.6555896 Fo�D �ym ,��w,��,.��,, sr.�o�o1 S SAFETY CC = � �a�a G 25o South Wacker Drive *sill 1.800.456.oiii - Fax 3I2.7'i�5j. i ............................iiii i�iiiiiilii i►iiiii.......i.ii iiii................... •..iii.......iiii �o��v J n�ozz��ATo . ServSafe• I.D.Number: Certification Date: 1121281 08/29/1998 John R. Farquharson,FMP President h i a5 OPP--- n w, 1 i lip �. . THE NA 0"I REGIS4TAty'lop, ` FOOD Sa' OFESSIONALS(g) 0 1 y OLCZER ERTIFIED 'I E REQUIREMENTS 1 -OF JMM MANAGER HAS SUCCESSFULLY SATISFfC 'MANAGER THE FOOD SAF:TY I VAT10N CERTIFICATION EXACA American 4 of ety lnstitus t00)723-3973 r�Jw.��neMoodsahtyColl! 1 .) � �%"� y President:---- ..ono 1 Ref, of Ea �•t-dy Professionals /.m 9ealth Testing.LLC is a divisio, OWnYironmel ��1� c DATE: : IL 2C "�. ISSFICATE NO Z 620 1 068 CERT TEST/ FORM:ZS. •A�w.rwr Ax•.M 0X V pie , du41 llnl vii ml>`J in aeWUl ill o�Ali `'S f}�:.• 1 American Food Safety Institu ie Certificate of Partici atioit Presented to DEBORAH APOLCZER 't \ has successfully completed a course.of in str ,,li,'i and sanitation for food service manageN' �,,Ilsi,t,' 1�, ; ; V T and the �United States Food&Dru 1)tts,id Ntt.slt,Lseetttire Direct Jr,1'hD•MSI'11• .SI' •�� L'T ��%1. Hu, •,i.r.,•1,, For information r-gal < in 1.101I .tin IuuJ• 'i.�lio ,dr:1.r..illfllktl (� Monday thnn,gih 9'hu g ''.., pm.lion.alywt 1J y.Ift•. Iu111 In .(l 4.J�n..�. e•+" .FIvw.1 n•.e r1.Y+.nl.l J.ux n.w ...•.-..v. .-..... .. v, vJ••"-."'.. r...n x.+.x..ix.�.....v.W r.w.. ....... .1•x.x...i..x.i..�• •..v..x..-.x.... w•' vw,ani-I canfoodsa ,ty.ci►m