HomeMy WebLinkAboutMiscellaneous - 158 MAIN STREET 4/30/2018 (2) r
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Jun 191212:52p Dudley Services Inc. 781-270-2652 p.2 r
* C
Commonwealth of Massachusetts
i 1100150380
I
Asbestos Notification Form ANF-001 Decal Number
Important: A. Asbestos Abatement Description
uvnen Elting put on p .
forms on the
computer,use 1. a.Is this facility fee exempt- city,town,district,municipal housing authority, owner-occupied
Only the tab key residence of four units or less?❑Yes ❑J No
to move your
cursor-do not b. Provide blanket decal number if applicable:
use the return `Blanket Decal Number
key' 2. Facility Location:
IST.GREGORY ARMENIAN CHURCH 158 MAIN STREET
a.Name of Facility b.Street Address
!North Andover IMA 101845
a City/Town d.State e.Zip Code f.Telephone Number
INSTRUCTIONS 3. Worksite Location:
1.All sections of this
BASEMENTIPRIESTOFFlCE;
form must be a.Building Name/Building Location b.Building# c.Wing d.Floor e.Room
completed in order
to comply with 4. Is the facility occupied? ✓I Yes L No
DEP notification
requirements of 310
CMR 7.15 5_ Asbestos Contractor:
and the Division
of Occupational (DUDLEY SERVICES INC 143 DUDLEY STREET PO BOX 132 I
Safety(DOS) a.Name b.Address
notrequirements
ARLINGTON i 02-1766
requirements of 453 ! j 178IW4328
WR 6.12 c.Cityrrown d.Zip Code e.Telephone Number
JAC000112 i
f.DOS License Number g.Contract Type: C Written Verbal
h.Facility Contact Person I.Contact Person's Title
ti FSAMUEL J NIGRO III jAS032802
a.Name of . -Site Supervisor/Foreman b.Su ervisorlForeman DOS Certification Number
r– —
7 ENVIRQSAFE ENGINEERING ; AM060297
a.Name of Project Monitor b.Project Monitor DOS Certification Number
8 t
iENVIRO-SAFE ENGINEERING IAA000131 ~�
a.Name of Asbestos Analytical Lab b.Asbestos Analytical Lab DOS Certification Number
--
9' X07/05/2012 107 10512012
��C) a.Project Start Date mmldd
,X) b.End Date(mmlddlyyyy)
-o 8AM-5PM
N c.Work hours Mon-Fri. d.Work hours Sat-Sun.
_o 10. a.What type of project is this?
=a ❑ Demolition Z Renovation '
❑Repair [I Other,please specify: b.Describe
—_r 11. a.Check abatement procedures:
C E/1 Glove bag
01 Encapsulation
o Enclosure ❑Disposal only
LL R Cleanup ❑Other,specify:
-- �✓
---z Full containment b.Describe
�Q 12. Is the job being conducted: E/ Indoors? ❑Outdoors?
anf001 ap.doc•10102 Asbestos Notification Form•Page 1 of 3
Jun 191212:52p Dudley Services Inc. 781-270-2652 p.3
P,
Commonwealth of Massachusetts t
100150380
Asbestos Notification Form ANF-001 Decal Number
A. Asbestos Abatement Description (cant.)
13_ Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed,or
encs sulated:
160 i
a.Total pipes or ducts(linear ft}I b-Totaai other surfaces 7uare �
c.Boiler,breaching,dud,tank I _�
surface coatings Lin.f• d.Insulating cement Lin.ft Sq'fi—�
e.Corrugated or layered paper 160 L f.Trowel/Sprayer coatings
pipe insulation Lin.$. Sq.ft.
Lin.ft. � Sq.ft.
g.Spray-on fireproofing Lin Sq ft. r h,Transite board,wall board Un. = Lsq
i.Cloths,woven fabrics ! }- j.Other,please specify: L�
Lin_R Sp._R. Lin,ft.
k.Thermal,solid core pipe
insulation Lin.IL Sq.ft. I.Specify
14. Describe the decontamination system(s)to be used:
CONTAINMENT BARRIER WITH CLEAN ROOM USING NEGATIVE AIR SYSTEM AND HEPA
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (g):
WET ASBESTOS PROPERLY SEALED IN SIX MIL POLY BAGS PLACARDED FOR ASBESTOS I
16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency:
a.Name of DEP Official b.Title
c.Date(mmlddlyyyy)of Authorization d.DEP Waiver#
e.Name of DOS Official f.WS Official Title
�N g.Date(mmlddlyyyy)of Authorization h.DOS Waiver#
17. Do prevailing wage rates as per M.G.L. c. 149, §26,27 or 27A—F apply to this project?❑Yes No
B. Facility Description
N
=c 1. Current or prior use of facility: CHURCH
—0
2. Is the facility owner-occupied residential with 4 units or less? ❑Yes Z No
T
iSAME
3- a.Facility Owner Name b.Adtlress
o � I
�o c.Ci /Town d.Zip Code e.Telephone Number(area code and extension)
4. a.Name of Facili!X Owner's On-Site Manager b. Mana er Address
—^-R c.City/Town d.Zip Code e.Telephone Number(area code and extension)
ant001ap.doc 10102 Asbestos Notification Form•Pa e 2 of 3
Jun 191212:53p Dudley Services Inc. 781-270-2652 p,4
w
v"
Commonwealth of Massachusetts
100150380_
Asbestos Notification Form ANF—OOT —Decal Number
!L
B. Facility Description (coat.)
5. a.Name of General Contractor b.Address
I ! I
c.City/Town d.7jp Code e.Telephone Number area code and extension
I
f.Contractor's Worker's Comp.Insurer g.Policy Number h_E� mmlddl
6. What is the size of this facility?
a.Square Feet b.Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site(if necessary):
{ 1
Note:Transfer a.Name of Transporter b.Address
Stations must I
comply with the c.CityfFown d.Zip Code e.Telephone Number
Solid Waste
Division 2. Transporter of asbestos-containing waste material from removalftemporary site to final disposal site:
Regulations 310
CMR 19.000 W.O.B.ROLLOFF
a_Name of Transporter b.Address
c.City/Town d.Zi Cop de e.Telephone Number
3.
a.Refuse Transfer Station and Owner j b.Address
c.Ci /Town d.Zip Code e.Telephone Number
4. IWASTE SYSTEMS INCORPORATED l
a.Final Disposal Site Location Name b.Final Disposal Site Location Owner's Name
190 ROCHESTER NECK ROCHESTER
c.Final Disposal Site Address d.Cit!Town
INN {
e.State f.Zip Code g.Telephone Number
M
O
D. Certification
_C14
�...� The undersigned hereby states,under the ISAM NIGRO I
penalties of perjury,that helshe has read the a.Name b.Authorized signature
Commonwealth of Massachusetts regulations 16/12!2012
forthe Removal,Containment or c.Position/Title d. Date fmm;ddr I
Encapsulation of Asbestos,453 CMR 6.00 and
310 CMR 7.15,and that the information i , IDUDLEY SERVICES INC.
contained in this notification is true and Correct e.Telephone Number f.Representing
to the best of his/her knowledge and belief. I
o a_Address
�LL 1
h.City/Town i.Zip Code
Z
anf Clap.doc•10102 Asbestos Notificat on Form•Page 3 of 3
Air Quality Experts, Inc. "i
(603) 894-6465 Asbestos Removal
(800) 621-1189 23 Hall Farm Road Residential-Commercial-Industrial
(603) 894-7044 FAX Atkinson, NH 03811 AirQualityExperts@AQENH.com
August 10, 2007
RECENLU
North Andover Health Department
146 Main Street AUG 2 7 2007
North Andover, MA 01845
TOWN OF NOR-1,-A,.
HEALTH DEP R T N',iEN f
Dear Sir:
i
Enclosed please find a copy of notification sent to the state for an Asbestos j
Abatement Project.
The job will take place on 08/15/07-08/17/07.
Project: St. Gregory Church
158 Main Street -
Any questions concerning this matter should be directed to my attention.
Sincerely,
Christopher Thompson
President
Commonwealth of Massachusetts
100059355
Ll Asbestos Notification Form ANF-001 Decal Number
Important:
When filling out A. Asbestos Abatement Description
forms on the
computer,use 1. a. Is this facility fee exempt-city, town,district, municipal housing authority, owner-occupied
only the tab key residence of four units or less? . Yes ✓ No
to move your
cursor-do not b.Provide blanket decal number if applicable: - - - -
use the return Blanket Decal Number
key. 2. Facility Location:
,7 i,
.. ......_._..............
_...,.. ._._ ._... - .._ ...... ... ._._. _,.... «>. ..............._.
ST.GREGORY CHURCH .158 MAIN STREET
_......
a,.Name of,1 P"cify_ „ b.Street Address
North Andover MA 01845 _
} "- .-•..-:� c.City/Town d.State e.Zip Code f.Telephone Number
INSTRUCTIONS 3. Worksite Location:
1.All sections of this CHURCH
_........ _. .... _.. _..._ ..
form must be a.Building Name/Building Location b.Building# c.Wing d.Floor e.Room
completed in order
to comply with 4. Is the facility occupied? `✓:Yes .._''No
DEP notification
requirements of 310
CMR 7.15 5. Asbestos Contractor:
andthe Division .-------,._.._ __ _.._._...__..__._.. ---.._.._.._..__._ ._ ......__.__ ,__...__._.. _..,
of Occupational ;AIR QUALITY EXPERTS INC 40 LOWELL RD UNIT 1
Safe DOS a.Name b;,Address
--_ .._....___.... . __..__._--_........._.
._
notification ! ,
requirements of 453 SALEM :03079 6038946465
CMR 6.12 C.City/Town d Zip Code e.Telephone Number
`AC000167
g Contract Type: ✓;Written ;_,...'Verbal
f.DOS License Number
I
h.Facility Contact Person J.
Contact Person's Title
ABEL J SANTILLANA SR 'AS032998
6,
a.Name of On_Site Supervisor/Foreman b.Supervisor/Foreman DOS Certification Number
_. _. .
ED MORGAN AM051114
7 _... ..........
a.Name of Project Monitor b.Protect Monitor DOS Certification Number
8. N/A
a.Name of Asbestos Analytical Lab b.Asbestos Analytical Lab DOS Certification Number
08/15/2007 08/17/2007
0 9• _ - _
a.Project Stant Date mm/d _ ....___.___.__-..
_..( __d/YYYY).. b.End Date mm/dd! _ _. ....... _ ...
_. _ _. �._ _ YYYY)_
o
JAM-3PM
N c.Work hours Mon Fri. d.Work hours Sat-Sun.
�0 10. a. What type of project is this?
=o Demolition ✓ Renovation
Repair Other, please specify: b.Describe
11. a. Check abatement procedures:
Glove bag _ Encapsulation
0 1__: Enclosure ; Disposal only
t_.;Cleanup ;-7 Other, specify:
ILL�— ✓; Full containment b.Describe
- z
Q 12. Is the job being conducted: ,✓ indoors? `�,-.�Outdoors?
anf001ap.doc•10102 Asbestos Notification Form•Page 1 of 3
Commonwealth of Massachusetts
Ll 100059355
. ...... .......... ......:
Asbestos Notification Form ANF-001 becalNumber
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed, or
encapsulated;...___._.... __.. ................. ..... .
0 2000
a.Total pipes or ducts(linear ft) b.Totaf other surfaces(square ft)
c.Boiler,breaching,duct,tank d:Insulating cement
---.... .....
surface coatings Lin.ft. Sq.ft_ Lin.ft.
e.Corrugated or layered paper
. . _ f.Trowel/Sprayer coatings i. .-._... .
pipe insulation Lin.ft. Sq.ft. Lin.ft. Sq._._ft.
g.Spray-on fireproofing - ----- - - h.Transite board,wall board -- ..-__._.:
Lin.ft. Sq.ft. Lin.ft. Sq.ft.
i.Cloths,woven fabrics -.- -- j.Other,please specify.
2000
__.... Lin.ft: Sq ft•.__....
k.Thermal,solid core pipe VAT
insulation Lin.ft. Sq.ft. I.Specify
14. Describe the decontamination system(s)to be used:
_....__,................._,_____._.._...r_......_...._.._._.__.__.._..r._.,____. -_.._.._.................
...__,___.__-... _... _.._,__.,_,,._.....__.._._.
3 CHAMBER DECON
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2)(g):
'WET 2 PLY POLY
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
_. _.. __ ._....._.... ...._.._...._ .._..._....._....------.._i
a.Name of DEP Ofriciat _.._. _. _. _.. b.Title
)_._.....___.._____�._._...__. ..._.._.._.. __.._.. d.DEP Waiver#
c.Date(mm/dd! of Authorization
_.-_._.-._.. ai
f
e.Name of DOS Official f.DOS Official Title
N g.Date(mmldd/yyyy)of Authorization h.DOS Waiver#
�
o 17. Do prevailing wage rates as per M.G.L. c. 149, §26, 27 or 27A-F apply to this project? Yes ✓-' No
B. Facility Description
�0 1. Current or prior use of facility: CHURCH
�o
2. Is the facility owner-occupied residential with 4 units or less? Yes ✓i No
ST. GREGORY CHURCH :158 MAIN STREET
3 -_ ____ — _ ....------ - - --- -
a.Faal1 Owner Name -.-_..--_-----_.._._______._.__.-_---...__......__._ ._._._.._. .._._..__. ._._-
h!___..__-_-__-____ b_Address
o 'NORTH ANDOVER MA f � m_-.._.__._..._.._.._._�.�__._.,....._._.__..._._�._.____._..�
01845
o c.City/Town Telephone NumbeIA rea code and extension) _
a.Name of Fagli Owners On-Site Manager _ b.On-Site Manager Address
�Q -------------
c.Ci !Town d.Zi Code e.Telephone Number(area code and extension)
anf001ap.doc•10!02 Asbestos Notification Form•Page 2 of 3
f
Commonwealth of Massachusetts
• 100059355
Asbestos Notification Form ANF-001 Decal Number
Ll
B. Facility Description (cont.)
5
a.Name of General Contractor
........_.... ..-..._. . _. - -.. ...,. b.Address
C.C.4!T wn d.Zip Code- e.Telephone Number(area code and extension
f.Contractor's Worker's Comp.Insurer g.Policy-Number h.Exp Date(mm/dd/yyyy)
6. What is the size of this facility?
a.Square Feet b.Number of Floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site (if necessary):
AIR QUALITY EXPERTS, INC.
a.Name of Trans rter b _ ......_. .... ........ ... _ -__....._._.:
Note:Transfer --..._ .. -._..,_._._..po _.___._._,..._,_..... ,Address.
Stations must
comply with the c.City/Town d.Zip Code e.Telephone Number
Solid Waste
Division 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
Regulations 310
CMR 19.000 'SERVICE TRANSPORT GROUP, INC. PO SOX 2132
............ -.._._......--- -...._._.._.._ _ -.
._, ._.. -_.---- __.... .... -. _._. .... .-. -..... _.. _ . . -_-._
a.Name of Transporter__ b.Address
BRISTOL, PA ,19007 '(877)999-9559
_._d.. p Code e.Telephone Number
3.
a.Refuse Transfer Station and Owner b.Address
C.City/Town d.Zip Code e.Telephone Number
4. 'A$L SALVAGE INC ^~
_ .... _..........
a.Final Disposal Site Location Name T b.Final Disposal Site Location Owner's Name
•11225 STATE ROUTE 45 LISBON
c.,FinaI Disposal Site Address_._. d.CityRown
OH . , _ ' 44432
. - -
e.State f.Zip Code g.Telephone Number
M
�O
D. Certification
9-N
The undersigned hereby states,under the CHRISTOPHER THOMPO'
i�_0 penalties of perjury,that he/she has read the a.Name b.Authorized Signature_
�O Commonwealth of Massachusetts regulations PRESIDENT08/02/2007
for the Removal, Containment or __._._......._-----.._.__._.._...._-
c Position/Title d.
Encapsulation of Asbestos,453 CMR 6.00 and - - - ,
310 CMR 7.15,and that the information (603)894-6465 'AIR QUALITY EXPERTS
contained in this notification is true and correct e..Telephone Number-._.__._ _f_Representing
to the best of his/her knowledge and belief. '40 LOWELL ROAD, UNIT ONE
o g.Address-
LL SALEM;NH --
h.City/Town i.Zip Code
�z
anf001 ap.doc•10/02 Asbestos Notification Form•Page 3 of 3
i
0 6
I�-
V-1-
COMMONWEALTH OF MASSACHUSETTS NUMBER
`� ��r • BHP-2016-0075
North Andover
• BOARD OF HEALTH FEE
$0.00
St. Gregory Armenian Apostolic Church DATE ISSUED
NAME April 15,2016
I
158-MAIN STREET
- ------ ---------------------------------------------------------------
----------------------- -
ADDRESS
IS HEREBY GRANTED A Food Est. - Temporary- TAX EXEMPT
Food Est.-Temporary-Tax Exempt Permit
This permit is granted in conformity with the Statutes and ordinances relating thereto,and
expires April 16,2016 unless sooner suspended or revoked.
RESTRICTIONS: Spaghetti,meatballs,sauce,salad,desserts
BOARD OF
- - ------------ ------------ -- -------------------------- HEALTH
NOTES: Contact: Sossy Jeknavorian 978.853.8130
- - ----------
--- - --- ------------ --
HOURS ACTIVE: Family Night Spaghetti Dinner 6pm-8pm s
------------- ---------------------------------
BOARD OF HEALTH CHAIRMAN
I'
COMMONWEALTH OF MASSACHUSETTS NUMBER
NBHP-2016-0075
North Andover
BOARD OF HEALTH FEE
$0.00
St. Gregoa Armenian Apostolic Church DATE ISSUED
NAME April 15,2016
158 MAIN STREET
--------------------------------------------- - ____
-- MAIN
IS HEREBY GRANTED A Food Est. - Temporary- TAX EXEMPT
Food Est.-Temporary-Tax Exempt Permit
This permit is granted in conformity with the Statutes and ordinances relating thereto,and
expires----------------April 16,2016 ---- unless sooner suspended or revoked.
RESTRICTIONS: Spaghetti,meatballs,sauce,salad,desserts
-----------------------------------------------
BOARD OF
- -------- ----- ----- - ----- ------- ------ - ----- -- HEALTH
NOTES: Contact: Sossy Jeknavorian 978.853.8130 ---------- ----_-------------- -------------- -------------
HOURS ACTIVE:Family Night Spaghetti Dinner 6pm-8pm ---_--------_-----------------------------------_____-_-__
BOARD OF HEALTH CHAIRMAN
L991 '0N NVLE :OI 9102 '11 'ady ;lull Paniaaa�
RECEIVED
APR 11 2016
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
NORTH ANDOVER HEALTH DEPARTMENT
Community Development Division
�p�,y' '.� 3 •nAo y, 1 1pl' 3 .Pm nr i) =4° r.'.'..alliuiur. 'c,pmlvrlt{ti�aacannn' :il'livwss-....�,••i. ,
. i II
In
' � A( ai [i fiff
I,� yi<� n 'y ••II::'.i Mrd
A,ko IW V Iloilo 400d"MU&W
Date: -ft,2D 0 Name of Operator/Manager:
Name of Food Establishment(if applicable) f
1
Address: �7�`
Town: State:)m (� LK
' „Zip:
Contact Phone#'s;9 d �S3 (3 (cell) c� r (other)
1~ederal Tax ID Number: 6-1 q 4 S,7 Tax Exempt?
t
Include a copy of your State Hawker/Peddler License if applicable:
r,l ww a•�;•.�ili�-isbZc +r'Q Irn ++.13th""f�ill'+i.i}•-. rn•.en wuwye
I'�%i<`:;rtnn��ry,e'au r•" �FNrr"ly_' �� � �• , � � y j�
nrinnlonlr. ..
Person in Charge:. AD Contact Phone#: -79IS3
Name of Event:
Date(s)of Event: �' Ij "Ir
Time(s)of Event:
Location of Event: U
1." YOU READY?"Checld"St-(Guideline for plan review and pre-opening inspection). Have you read these materials
--,, 'Y'ES NO
2.MENU:Attach or list below all items.Any changes must be submitted and approved by the North Andover Health Department at
least 5 days prior to the event.
3.FOOD PREPARATION: Will all foods be prepared at the temporary food establishment booth?
YES Com lete SECTIONA below if Youapswered YES stion 3.
North Andover Health Department,
1600 Osgood Street, Suite 2035, North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web http://www.tOwnofnorthandover.com
' I
L991 'ON MLE :fl 91N 'll 'ads ;nail paniaOa�
NO Attach a copy of the permit where the food will be prepared.If food is prepared at a licensed establishment in North
Andover,list name only:
Page 1 of 2
4.List each food item prepared,and for each item cheek which preparation procedure will occur. Please attach a copy of the menu
if applicable..,
SECTION A; At the Booth
Food ><haw Cur/ Portion
Assemble Caok Cool ColdHoldin Reheat Hot&! tng Paeka
SECTION B:At the licensed food establishment.
Food Thaw Cat/Assemble Cook Cool Cold Holding Reheat Hot Holding Parka,ionng
Source and Storage of water/ice; V1
Storage and disposal of wastewater:
Please outline voulr complete Sanitation Process from start to finish for this evert—for example:
methods)o sanitation such as:using ang a 10 gallon igloo of bleach & water for sanitation;yoUr procedures
for the care and cleaning of utensils; tables;equipments etc.
➢ Q
➢ �� Sn VX
➢
I certify that I am familiar with 105 CMR 590.00 Minimum Sanitation Standards for leood Establushm
above described establishment wiff be operated encs-Article X,and the
P and maintained in accordance with the re lotions.
Applicants Signature:
ate-
Page 2 of 2
North Andover Health Department,
1600 Osgood Street, Suite 2035, North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978:688.8476 Web http://www.townofnorthandover.com
I
EXAM FORM NO. 4967
C-ER.TIFICATE N4. 115274370
a..f
1" v S,
CERTIFICATION
SOSSY JEKNA V-
z-.
for sucoessfully completing the standards se X• - _ Vie'Food Protection Manager Certif[cation Examination,
which is accredited by the American.Natio, y �(ANSI)-Confetemce for Food Protection(CFP).IIT 4
Fr
ATE - - -
O�
0917 _ : ="
0
- =7
DATE OF EX
Local laws apply..Ch r recertification requirements. Y
•® tions -—
@20UNhHanalRep alk6tiheNRAFF,usedunderIio wbyNaUanalReetwrantAsso®IianSolutions,LLC- CIO!:
The laga
_ _ _ __-_ _ __ __ _ _ _ _ _
CERTIFI . E F _
ALLERGEN AwAREN-E S RAI N.
5- -,`fir• �'-� - . . .
Name of Recpessr Meavorian
Date of Com '66bn:*. :6- ,14/2-oi
. = I 7
Date of E ira#!6: .t .1-=-!20 �
- ' ca r•
0
d
Issued By:
The above—canted person is hereby issued this certificate
for completing an allergen awareness training programa
Berkshire
recognized by-the Massachusetts Department of Public Health AHF.l. N
in accordance with 105 CMP 590.009(G)(3)(a).
Area Health Education Center
P3titfletd,Massachusetts
This certificate will be valid for five-(5)years froma date ofcompletion.
www.mafoodaUefgytraining.org
d