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Miscellaneous - 1600 OSGOOD STREET 4/30/2018 (24)
PLAN REVIEW.•J?CVD � �Au01 U �' 160 W Corporate Chefs,Inc. M t ax o4g ft-ra r..turOWh iuw\"Im. Like Us facebook.com/CorporateChefs _ y is _„t �Oa � I'� E Corporate Chefs,Inc. !1 �i yz rxaati.G3�i "•� G -p I r 0 ra te C h efs mC op �s facebook. co / i �keld—J ' � r � II Kimberly Beal i District Manager I kbeal a@corporatechefs.com cew 978.339.3761 office:978.372.7400 x124 TQ U'11 7 D Ci111 A Coq.,teC6e Ona `p U'll?7ti ' Ji f i � Il�c,u - U .' zd cln 'seEc� 4Cr� y�u ,i��n ou `11� �A%-I�,uucc� Plum i i G 1 i I Grant, Michele From: Kimberly Beal [kbeal@corporatechefs.com] Sent: Tuesday, January 21, 2014 7:20 AM To: Grant, Michele Subject: FW: Plumbing Connections for BOH Attachments: img-120121017-0001.pdf Good Morning Michele, Please see attached Document from Management company. Let me know if you have any questions. Also when would you like to do a walkthrough the cafe this week? As I said I have a meeting tomorrow afternoon but I'm open Thursday or Friday. . Thanks. Kimberly Kimberly Beal District Manager Corporate Chefs, Inc 22 Parkridge Road Haverhill, MA 01835 978.372.7400 www.corporatechefs.com https://www.facebook.com/corporatechefs From: William Medeiros [WMedeiros@ozzyproperties.com] Sent: Monday, January 20, 2014 12:16 PM To: Kimberly Beal Cc: Norman Denault; Robert Bartley Subject: RE: Plumbing Connections for BOH Kimberly, Attached is the completed BOH plumbing connection form. The dishwasher will be installed this week. Thanks, Bill William P. Medeiros Controller Osgood Landing 1600 Osgood Street North Andover, MA 01845 Phone: 978.681.5004 Ext. 116 Fax: 978.681.5109 www.ozzyproperties.com Click here to follow Ozzy Properties on Twitter I ' -----Original Message----- ; From: Kimberly Beal [mailto:kbeal@corporatechefs.com] Sent: Thursday, January 16, 2014 11:43 AM 1 BUNN® Restaurant Equip. CrO.I W- 1 Executive Park Drive rrErJ North Billerica, MA 01862 PROJECT - - Airpot Coffee Brewer DATE - Airpot po Coffee Brewer - Brews 3.8 to 7.5 gallons(14.4 to 28.4 litres) of perfect coffee per hour. - Brews directly into 1.9 to 3 litre airpots, - Convenient airpots keep coffee hot and fresh for hours. - Airpots are easily transported to remote meeting rooms, breakfast bars,. etc. - Pourover model available (CW15-APS). • Pourover feature included on automatic models. f r, X" - Faucet available on CWTF models only. 1 I - Gourmet funnel model availablef r o use with heavier throw weights of coffee, • Digital timer enables users to make brew cycle adjustments from the front panel. - International electrical configurations available. - Model CW15-APS Model CWTF APS with Airpot with Airpot (airpot sold separately.) P Dimensions:23.6"H x 9'W x 18.5'D (airpot sold separately) j (59.9cm H x 22,9crn W x 47cm a) Dimensions:23.6"H x 9"W x 18.5"D (59.9cm H x 22.9cm W x 4 7c O) ..,.ter For current specification sheets and other information,go to www.bunn,cpm. Easy Clear"EQ-17-TL 2.2 litre Push-Button Airpot Universal Airpot Racks Product No.:30200.1000 ~~ Product No.:28696.0002 for push-button and lever- Dimensions: ' , Capacity:74 oz.(2.19 L) action airpots. 127/;6"H x 2'12."W x 3" D ,=-. ± I See page A3.9 for more 31.6 cm H x 6.35 cn W x 7.62 cm D 2.5 litre Push-Button Airpot information. Product No.:13041.0001 Easy Clear,"ED-17-TL , Capacity:84 oz.(2.48 L) Gourmet C Funnel Product No.:30201.1001 r �f Product No.: 34559.0000(7.12 inch width} Dimensions:8:!;"H x 25i,,"Dia. # 01 34559.0001 (7.62 inch width) 20.95 cm H x 5.87 c,,,Dia. ` 2.5 litre Lever-Action Airpot Universal design-handle Product No.:32125.0000 ,^ may be moved to appropriate Paper Filter Pack Capacity:84 oz.(2.48 Q side Product No.:20115.0000r•+ ! Allows brewing with heavier Packed per case:1.000 3.0 litre Lever-Action Airpot `) throw weights of coffee. Dimensions:4K1" Base x 23in"Sidewall Product.No.:32130.0000 Paper Filter Pack 10.8 cm Base x 6.98,m Sidewall Capacity:102 oz.(3.0 L) Product No.:20100.0000 Packed per case: 1.000 Model Agency Listing CW APS CWT APS CWTF APS II Dimensions & Specifications Model Product# Volts Amps Tank Heater Total Brewing Cubic Shipping Cord Watts Watts Capacity Ft. Weight Attached GWI-5-APS=- 2340.1-0000---;2�-1::- 432& 4470-------3:8-04hr. --- 0 2-8-lbs.- Yes GWf I-5-A-PG"= 23041 00&2 —a 28--a 1 4 1320- 1370- 3 8 ga4 r--8:0- 264bs- Yes GWT4S-APS- 2=308#-4043-----#-2a-----#-1.4 4324- 4.370----3-8-coal: r-----5.0- 2-94b67 -a'est- CWTF15-APS 23001.0006 120 11 1320 1370 3.8 gal./hr. 5.0 33 lbs. Yes? G JTIF &A 23001.0007 -4 29 15 4 4 800 4858---5-1-gal4„t 5,8- 32 lbs Ne- GWTF35-APS—_--23004-.0408---#20/248348----1.5- 3589- - 3 0 3a lbs 1 GWTP35 APS" 23001-0023r-12W208 240 15 3599- 3550 :7.6 gal lhr- 3.1; 83 be. Ne- GWT-F35-ARS"" -2300-1-0062- 128/288 240 15 3580 3559 ,-L5-ga1-/hf 5-2- 374bs-- No -Pourover model. "Staintess steel funnel. "'Model has gourmet funnel. rPower cord(NEMA 5-15P) 15 Amp 1201/machine only. Brewing capacity:based upon incoming water temp of 60°F/15°C(140°F/60'C rise)per 1,12 gallon brew time of 4 minutes. Models listed as 1201208V or 120,240V must be connected to 208V or240V electrical service respectively.Please refer to the installation manual. Electrical: CW15-APS, CWT15-APS&CWTF15-APS-require 2-wires plus ground service rated 120V, single phase, 60Hz. CWTF20-APS -requires 2-wires plus ground service rated 120V, single phase.60Hz. CWT35-APS and CWTF35-APS- require 3-wires plus ground service rated 120/240V, single phase,60Hz. Plumbing: 20-90 psi (138-621 kPa).Supplied with 114" (6.4 mm) male flare fitting. United (OJStaAEurlur S"ALL, restaurant Equip. Co., Inc. SGFJS'(C)t:1vq FO IUSTAtI.I 1 Executive Park Drive North Billerica, MA 01862 r- - t i I r-. Ivn' :lot, �+—,1.0 f rr;{i{J TUn'E f A5=5 Atttl r.1 00 P00000 r^--. — (iLh uLASriC �l� Gvrrr=l sin r: J. 1 ^gWE(i COIiC f 1'ACH'tlES OiII:�-, I t: I[i4h I'�t,;71(;: I 155 I 13 iGt�:i1A4E� 2? SSI hs.Hs=Ot. It 3 ftfi I I e p I 1 , IB;+ Bunn-O-Matic Corporation- 1400 Stevenson Drive Springfield.Illinois 62703.800-637-8606.217-529-6601 •Fax 217-529-6644•www.bunn.com BUNN practices continuous product research and improvement.We reserve the right to change specifications and product design without notice.Such revisions do not entitle the buyer to corresponding changes.improvements,additions or replacements for previously purchased equipment. All dimensions shown in inches. • F t R.F American Andrew McAllister 17 D Merrimac Ways Heart y T n sborou h, MA 01879 Association® � 978-758-7655 Learn and Lave i Certificate of Completion Awarded to 1 � rl I �t �/C- �•t r Has Succesfully Completed Training According.to The American Heart Assosiation's HeartSaver CPR/AED 2010 Guidelines. Z©I (� Issue Date Expiration Date rew McAllister AHA BLS Instructor 12110068798 Expire Dec 2015 Grant, Michele From: Kimberly Beal [kbeal@corporatechefs.com] Sent: Friday, January 17, 2014 1:03 PM To: Grant, Michele Maker FW: Osgood St. Coffee M Subject: g e a Attachments: Bunn.pdf Hi Michele, Attached is the cut sheet for the coffee brewer we are installing. Let me know if you have any question. Have a great weekend. Thanks. Kimberly Kimberly Beal District Manager Corporate Chefs, Inc 22 Parkridge Road Haverhill, MA 01835 978.372.7400 www.corporatechefs.com https://www.facebook.com/corporatechefs From: George Zaharoolis [george@unitedrestaurant.com] Sent: Friday, January 17, 2014 8:54 AM To: Kimberly Beal Subject: Osgood St. Coffee Maker Hello Kimberly, The attachment contains a specification sheet on the coffee maker for Osgood St. The coffee maker is at the office if you need to see it. [See Paula] Let me know if you need any additional information. Thanks George GEORGE ZAHAROOLIS UNITED RESTAURANT EQUIPMENT CO., INC. 1 EXECUTIVE PARK DRIVE NORTH BILLERICA, MA 01862 PH:978-439-5500 FX:978-262-9999 Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records.For more information please refer to:hftp://www.sec.state.ma.us/pre/preidx.htm. Please consider the environment before printing this email. 1 Tyngsborough Firefighters Assn. Wt PTyngsborough!"i h Pride and Honor We Serve the People of 26 Kendall Rd PO Box 52 DATE: January 15, 2014 TYn9 sboro, Ma 01879 INVOICE# 1 Phone 978-649-7671 FOR: Heartsaver CPR class Bill To: Cynthia Eklund 121 Coburn Rd Tyngsboro, Ma 01879 DESCRIPTION AMOUNT Heartsaver CPR/AED with Chocking Adult, Child, Infant. $30/per person $30.00 1 V✓ TOTAL $30.00`: Make all checks payable to Tyngsborough Firefighters Assn. If you have any questions concerning this invoice,Andrew McAllister @ 978-649-7671 THANK YOU FOR YOUR BUSINESS! Osgood landing Corporate Chefs,Inc. Monday 2/3/14-2/7/14 Breakfast Omelet Bar-build your own omelet choose form sauteed onions,peppers, $4.35 WEEK OF: mushrooms,spinach,sausage,ham,bacon&cheese served with home-fries Exhibition Quesadilla Bar—Chicken,grilled onions,peppers,jalapenos,black olives, $6.50 Cilantro,cheddar cheese,salsa,sour cream served with Spanish rice This Week's Features: Soup Italian chicken rice $2.75/3.00 Panini Cuban—French bread,sliced ham,slow roasted pulled pork,Swiss cheese, $6.25 Monday pickles,garlic mustard served with a roasted corn and black bean salad Quesadillas " Tuesday "Gold Finger Salad" Tuesday Wednesday Breakfast Breakfast Sandwich—Fried egg,melted cheese with choice of sausage,ham, $3.00 "Turkey Dinner" or bacon on a grilled English muffin served with fresh fruit salad Exhibition Gold Finger Salad—Romaine lettuce,croutons,Bermuda onions,crispy $6.50 Thursday chicken strips with a cattleman's gold sauce served with a wrap on the side "Taco Salad Bar" Soup Tomato Spinach $2.75/3.00 Friday Panini Kicked.upTurkey—Pepper jack cheese,baby spinach,sliced tomatoand $6.25 "Stir Fry Day" Cajun mayo in a tomato wrap served with a gourmet side salad Please contact: Wednesday. Cynthia Eklund Cafe Manager at: Breakfast Two Cinnamon French Toast &Two grilled Sausage Links served with maple $2.60 (978) 208-4422 Syrup Exhibition Turkey Dinner,—Roasted turkey,mashed red bliss potatoes,gravy,butter $6.75 nut squash&stuffing with a fresh baked dinner roll and cranberry sauce Consumer Advisory Soup Chicken Rice $5.75 Consuming undercooked meat, poultry,seafood,shellfish or egg may Panini Italian—Ham,Genoa salami, pepperoni with a tomato bruschetta&green $6.25 increase the risk of food borne illness leaf lettuce in a sub roll served with marinated pasta salad Thursday Before placing your order if 1Breakfast Fried Egg&Croissant with your choice of cheese&choice of sausage,ham or $3.90 pleasebacon on a buttery croissant a person in your party has Exhibition Taco salad bar with seasoned ground beef,grilled veggies,jalapenos, $6.50 tomatoes,olives,lettuce,cheddar cheese in a fried tortilla with salsa ,a food allergy. Soup Roasted vegetable $2.75/3.00 For all your catering needs, Panini Fresh Mozzarella cheese,basil&salt&peppered sliced tomatoes on focaccia $6.25 stop by the Cafe & pick-up our bread drizzled with olive oil&balsamic vinegar Catering Guide. Friday Be sure to get a copy of our Breakfast Two flap jacks&Two slices of bacon served with maple syrup $2.60 Healthy Balance newsletter in the Cafe! Exhibition Stir-Fry,sauteed to order with your choice of chicken,shrimp or tofu with a $6.25 variety of fresh vegetables&sauce served over a bed of rice V = Vegetarian Selection Soup Clam Chowder VV = Vegan Selection HW = Heartwise Selection Panini Albacore Tuna melt on oat meal molasses bread with melted Swiss cheese $6.25 CC = Carb Conscious Selection served with a gourmet side salad Food Employee Reporting Agreement Preventing Transmission of Diseases through Food by Infected Food Employees The purpose of this agreement is to ensure that Food Employees and Applicants who have received a conditional offer of employment notify the Person in Charge when they experience any of the conditions listed so that the Person in Charge can take appropriate steps to preclude the transmission of foodborne illness. I AGREE TO REPORT TO THE PERSON IN CHARGE: SYMPTOMS 1. Diarrhea 2. Fever 3. Vomiting 4. Jaundice 5. Sore throat with fever 6. Lesions containing pus on the hand,wrist, or an exposed body part (such as boils and infected wounds, however small) MEDICAL DIAGNOSIS Whenever diagnosed as being ill with Salmonella Typhi (typhoid fever), Shigella spp. (shigellosis), Escherichia coli 0157:H7, hepatitis A virus, Entamoeba histolytica, Campylobacter spp., Vibrio cholera spp., Cryptosporidium parvum, Giardia lamblia, Hemolytic Uremic Syndrome, Salmonella spp. (non-typhi), Yersinia enterocolitica, or Cyclospora cayetanensis. PAST MEDICAL DIAGNOSIS Have you ever been diagnosed as being ill with one of the diseases listed above? If you have, what was the date of the diagnosis? HIGH-RISK CONDITIONS 1. Exposure to or suspicion of causing any confirmed outbreak of typhoid fever, shigellosis, E. coli 0157:H7 infection, or hepatitis A 2. A household member diagnosed with typhoid fever, shigellosis, illness due to E. coli 0157:H7, or hepatitis A 3. A household member attending or working in a setting experiencing a confirmed outbreak of typhoid fever, shigellosis, E. coli 0157:117 infection, or hepatitis A I have read (or had explained to me) and understand the requirements concerning my responsibilities under 105 CMR 590/1999 Food Code and.this agreement to comply with the reporting requirements specified above involving symptoms, diagnoses, and high-risk conditions specified. I also understand that should I experience one of the above symptoms or high-risk conditions, or should I be diagnosed with one of the above illnesses, I may be asked to change my job or to stop working altogether until such symptoms or illnesses have resolved. I understand that failure to comply with the terms of this agreement could lead to action by the food establishment or the food regulatory authority that may jeopardize my employment and may involve legal action against me. Applicant or Food Employee Name(please print) Signature of Applicant or Food Employee Date Signature of Permit Holder or Representative Date This is a model form created by MA Dept.of Public Health which is offered as a tool for industry to use to aid in compliance with 105 CMR 590.003(C)and Food Code 2-201,11 The use of this form is voluntary and is not required by state regulation. Revised:5/8/2001 1 g Cham ion Project p Item No. The Dishwashing Machine Specialists Quantity W 2E STANDARD FEATURES U H o T 009 I j • NEW"Shear Energy"—a reduction in energy Undercounter High Temperature = requirements while maximizing performance! Dishwashing Machine with • NEW"Multi-Power" —includes"Multi-Volt"and Built-in Booster Heater "Multi-Phase".Allows for infield conversion to UH-100 Model without Booster Heater 208-240 volt and/or single to three phase with ease. I • Rinse Sentry—extends the cycle time to ensure 180OF final rinse. • Built-in electric booster for 180°F final rinse water — ro o 1*100, (standard 407 or optional 70O F rise) • Pumped drain • Door safety switch • Low-water tank heat protection • Detergent and rinse aid pumps • Quiet double-wall construction • 15-3/4"door opening to accept larger wares, including trays 111 • Stainless steel top and side panels } • 141 second cycle ' `"`"' • Wash pump, 1 Hp motor • Fill and dump , • Prime switch on control panel • Automatic tank fill • One year parts and labor warranty OPTIONS & ACCESSORIES NSF. � EIV ❑ 1-RDT Dish Table Durable,heavy-gauge stainless steel dish table with sink,stand-pipe drain,removable scrap screen holder,drain- ___ - SPECIFIER STATEMENT board,backsplash and lower storage cabinet. Sprayhose is optional.See 1-RDT catalog sheet. Specified unit will be Champion model UH-100B Specify right hand or left hand sink. ( undercounter high temperature dishwashing machine ❑Additional Dish Racks with built-in booster heater. ❑ Stainless nd j 'i {' Features 141 second total cycle,Rinse Sentry,detergent n `1 i ,y . and rinse aid pump,stainless steel top and side panels. ❑6"Leg Stand Peg �i Constructed of stainless steel. 1 year parts and labor warranty. ❑70°F Rise Booster Flat a=: ❑3 Phase Connection (prewired at factory) ❑ UH100 without Booster ❑ 1" Roller Kit(includes 4 casters) Champion Industries,Inc. 3765 Champion Blvd,Winston-Salem,NC 27105 Tel:336/661-1556 Fax:336/661-1979 www.championindustries.com 0 v (1 M)9/10 Printed in U.S.A. 6POUP J i Undercounter High Temperature Champion° ® Dishwashing Machine with Built-in Booster Heater The Dishwashing Machine Specialists Volume crated: 15 cu.ft. Dimensions shown in inches and[milimeters] ® Shipping weight crated: 215 lbs. d 24"[610] 40-1/2" ® [1029] ® O°O p 2 3 P D 15-3/4" d [400] Clearance 33-3/4" ; 15-3/4"[400] [857] 25"[635] 0- 2"(511 2"[51] 2 3 Front View Side View Plan View 4"[102] Utilities 1 Electrical 208-240/60/1;3 wire plus ground,(See Box). 208-240/60/3;4 wire plus ground,(See Box). SPECIFICATIONS Field convertible to accept 3 phase power,see service manual for details 2 Hot Water Capacity 1/2"supply;140"F/60"C Min.hot water connection for 40'F/22°C rise booster; Racks per hr.(NSF rated) 21 110°F/43°C Min.hot water connection for 70°F/39°C rise booster.Incoming supply Motor horsepower pressure must maintain a Flow pressure 20-22 PSI(Pressure reducing valve,PRV, Wash 1 supplied by customer or may be purchased unmounted from Champion). Machine equipped with 3/4"[19]hose connector. Water consumption =58x Drain US Gal.per hr.(Max.use) 38 I.D.flexible reinforced hose,6 ft.[1829]long. US Gal.per rack 1.8 flow 15 US gpm.[12.5 imp gal]Max.drain height 3 ft,[914] Temperatures°Frc Warning Plumbing and electrical connections should be made by qualified personnel Wash 150/66 who will observe all the applicable plumbing,sanitary and safety Rinse 180/82 codes and the National Electrical Code. UH-100B with 40°F/22"C Rise Booster Heating Minimum Maximum Tank heat,electric(kW) 2.0 Supplyckt Overcurrent 15V Booster,elec.,40°F rise,kW 6 Amps Ampaaty Device Rated Conductor Protective t2oav� nsv qec Specs — Booster,elec.,70°F rise,kW 9 208/60/1 32 40 40 Li L2 N G Time cycle in seconds 240/60/1 36 40 40 Wash 90 208/60/3 22 30 30 *Note:Electrical supply Rinse 26 240/60/3 24 30 30 service must be a 3-wire plus Drain/fill 25 ground for connection as Total cycle 141 UH-100B with 70°F/39°C Rise Booster shown. Minimum Maximum Standard 2V'x 2V'rack complement SupplyCkt Overcurrent UH-100 without booster Rated Conductor Protective 750Watttankheat Dish 1 Elec.Spem Amps Ampacity Device Elec Rated Open 1 208/60/1 45 60 60 Srecs. Amps 240/60/1 50 60 60 115/60/1 12 208/60/3 29 35 35 240/60/3 1 33 1 40 40 Due to an ongoing value analysis program at Champion,specifications contained in this catalog are subject to change without notice. Champion Industries,Inc.,3765 Champion Blvd,NC 27105.336/661-1556•Fax:336/661-1979•www.championindustries.com -- ----------------- r ------------ 8 - -- ---------- 433 --IDINING AREA 139 KEN MATE 13 FA ROLE IN FLOOR 5 0 ERVI A PROVIDE KE4 DRAI i COVERS FOR RELOCATE fLOC R SINKS- AJT TOASTER r---- --------- fio ---------- [7VIDE BAR -- v CUT 55 COUNTER REWVE TRAY Vs.,Mm.-MR, SERVICE COUNTER I"ROLLING CASH REGISTER CART LUCI �S REOLDO S-0- C3 1) 1600 T IIATCUN r ------- 28 PROVIDE I @ FRP ON UALL r LEGEND I SHOW DASH NO. ITEM: ------------ ------------------------ I six E 2 TWO RELOCATE EXSTING I-RE 'E O_" GATE —3 GRID CMIMS IN SALAD BAR 0 TO NES SAM BAR R LEAVE LOCKM L PAS! rilj IN OPEN POSITION 9, LOCATION 5 FRIA1 RELOCATED v, 4 FRIAJ FO COOLER 1 HOOI PROVIDE PlE)MLASSM11PERED I c 8 1 HOO1 GASS MaRE 115SING IN 01 1 HOO] EMTING SMEEZECAARDS yk PA TILE FLOOR IN THESE 10 PANI .,n I G. 11 PIZZ NARKER Z 12 TAB] OCATED ----------T__ RELOCATED 13 WARI DRINK COOLER SAXDXH COOLER 5 11 Souf ------ 12 F 15 TOA KITCHEN AREA IL CON' RELOCATED 11 MEA* 20 3+— VARMER 18 IN-C r (D It---I JT 19 WALI 7 p WALI 21 ONE W 'RELOCATE RELOCATED TASM, 22 0 E TOASTER PAMI nAKER TOASTERS 23 Foul 24 HAL' 25 Tc E F� 24 DRf� IS 21 Juic 28 SAL 21 REF. 30 COF 11, Foul 32 D5 NEW WALLS TO BE CONSTRUCTED - EXISTING WALLS TO REMAIN EXISTING WALLS TO BE DEMOLISHED ROOM NAME AND NUMBER (SEE FINISH SCHEDULE) �� DOOR SYMBOL (SEE DOOR SCHEDULE) WALL TYPE DESIGNATION SYMBOL (SEE WALL TYPE SCHEDULE) DETAIL/SECTION REFERENCE SYMBOL (SEE DRAWING REFERENCED) NEW 2x2 LIGHT FIXTURE TO BE INSTALLED OR EXISTING LIGHT TO BE RELOCATED EXISTING RECESSED DOWN LIGHTING 1 LIGHTED EXIT SIGNS COMBINATION DEVICE: Lo LIGHTED EXIT SIGNS d" WITH EMERGENCY HEADS co ` P S, EMERGENCY LIGHTS 0 J Q N r l�l N -p U-) -� HVAC SUPPLY GRILL ` Cc 000 00 Zco C _0 EXHAUST GRILL ' Qcb oho FIRE EXTINGUISHER Z u Q FIRE ALARM DEVICE HORN STROBE 3 FIRE ALARM DEVICE PULE,, STATION 2 NUMBER INDICATES ZONE DKITCHEN EQUIPMENT (SEE EQUIPMENT LIST LEGEND) C U OE�OA7.,N 6704 . O F?•l.e� ... Gp • Town of North Andover HEALTH DEPARTMENT ,SS4CHU`+tS QnHECK#: DATE: _�qjj _ LOCATION: Q H/O NAME: CONTRACTOR M— .f r) T_yRe of Permit or License:( e*b-o-x)' ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ Food Service-Ty e: $ V+ ❑ Funeral Director ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink- Treasurer S A •r rRECEIVED AN 14 2014 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Food Establishment Plan Review Guide FOOD ESTABLISHMENT PLAN REVIEW APPLICATION IS TO BE COMPLETED BY THE OPERATOR AND SUBMITTED TO THE REGULATORY AUTHORITY—at least 60 days in advance before commencement of any food establishment planned openings. TOWN OF NORTH ANDOVER, MA Regulatory Authority 1600 Osgood Street, Suite 2035,North Andover,MA 01845 Date: ` 1 NEW -New construction,not yet built REMODEL -partial or major renovation of existing establishment _CONVERSION—existing establishment that you are purchasing `` Name of Establishment: S O6 9Ln t � Corporate Name: C-- - `P Category: Restaurant , Institution ,Daycare , Retail Market , Other 4�� Establishment Address: wo o DG SA-C&A- n f G I Y ` Phone: (at location if available) E-mail Contacts: ciWa( tld cw-&�e-1 J"e �s • CC),,,�\ i Name of Owner: S49-e -��_ � cy,-QCP � Mailing Address: Q,a l�n c,Lnc rA �f� 2._� � 1•�� l Telephone: a C6—" © D Applicant's Name(if different than owner): Town of North Andover,Health Department,1600 Osgood Street,Suite 2035, North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 1 of 19 �� I CORPORATE CHEFS OFFICERS 22 Parkridge Road Haverhill, MA 01832 978-372-7400 FEDERAL I:D. 04-2981626 Kenneth Bickford, President 96 Alpine Park Road Moultonboro, NH 03254 Alan Ayres, Treasurer 34 Sable Run Lane Methuen, MA 01844 -David DesRosiers, Vice President 167 Ocean Drive Seabrook, NH 03874 OW ice\ Title (owner, manager, architect, etc.): l 5 C,A Gt '1, Mailing Address: Telephone: q-X --J] a-'-7 4 bb Date Received:BOH office;use only Date Review completed $OH offic&use only: ..,Approved/Denied Date Revisedapphication Received BOH office use on"ly Date Review complet d BOH office use only -FAppfoved/Denied' Technical Assistance with the Permitting Process The Town Planning Department offers the option of attending a Technical Review Committee(TRC)meeting to all applicants. As the applicant, I acknowledge that I have received an explanation and understand that the purpose of the TRC meeting is it to assist me in the various town processes needed to open my establishment. If declined I understand that I have forfeited this opportunity to learn more about the North Andover permitting process. I wish to attend o decline circle one) participation in the TRC process Date of TRC(Bbf onlay) General Information Hours of Operation: Sun Thursl 3� Mon ���� Fri —�^ Tues Sat Wed ➢ Number of Seats for customers: I b 0 ➢ Number of Staff: 3 (Maximum per shift) ➢ Total Square Feet of Facility: ➢ Number of Floors on which operations are conducted ➢ Maximum Daily Meals to be Served: ➢ Breakfast (approximate number) ➢ Lunch aln'o ➢ Dinner-PT ►T Town of North Andover,Health Department,1600 Osgood Street,Suite 2035, North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 2 of 19 Type of Service: Sit Down Meals (check all that apply) Take Out Caterer Mobile Vendor Other Please enclose the following documents: Proposed Menu(including seasonal, off-site and banquet menus) ��"" Manufacturer Specification sheets for each piece of equipment shown on the plan SMA Site plan showing location of business in building; location of building on site including alleys, streets; and location of any outside equipment(dumpsters,well, septic system - if applicable) P#A Plan drawn to scale of food establishment showing location of equipment,plumbing, electrical services and mechanical ventilation Equipment schedule CONTENTS AND FORMAT OF PLANS AND SPECIFICATIONS 1. Provide plans that are a minimum of 11 x 14 inches in size including the layout of the floor plan accurately drawn to a minimum scale of 1/4 inch = 1 foot.This is to allow for ease in reading plans. 2. Include: proposed menu, seating capacity, and projected daily meal volume for food service operations. 3. Show the location of each piece of equipment. Each must be clearly labeled on the plan with its common name. Each unit must be sequentially numbered and the numbers must correspond to the equipment specification sheets and an equipment schedule. All self-service hot and cold holding units must have sneeze guards. 5. Label and locate separate food preparation sinks when the menu dictates to preclude contamination and cross-contamination of raw and ready-to-eat foods. 6. Clearly designate adequate hand washing lavatories for each toilet fixture and in the immediate area of food preparation,cooking and ware washing. (a hand sink should be located within 10 feet of each area for easy access for all food handlers) 7. Provide the room size, aisle space, space between and behind equipment and the placement of the equipment on the floor plan. 8. On the plan, represent auxiliary areas such as storage rooms, garbage rooms,toilets, basements and/or cellars used for storage or food preparation. Show all features of these rooms. 9. Include and provide specifications for: Town of North Andover,Health Department,1600 Osgood Street,Suite 2035, North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 3 of 19 a. Entrances, exits, loading/unloading areas and docks; b. Complete finish schedules for each room including floors, walls, ceilings and coved juncture bases; c. Plumbing schedule including location of floor drains, floor sinks, water supply lines, overhead waste-water lines, hot water generating equipment with capacity and recovery rate, backflow prevention, and wastewater line connections; d. Lighting schedule with protectors; (1)At least 110 lux(10 foot candles)at a distance of 75 cm (30 inches) above the floor, in walk-in refrigeration units and dry food storage areas and in other areas and rooms during periods of cleaning; (2)At least 220 lux(20 foot candles): (a)At a surface where food is provided for consumer self-service such as buffets and salad bars or where fresh produce or packaged foods are sold or offered for consumption; (b) Inside equipment such as reach-in and under-counter refrigerators; (c)At a distance of 75 cm (30 inches) above the floor in areas used for hand washing,ware washing, and equipment and utensil storage, and in toilet rooms; and (3)At least 540 lux(50 foot candles) at a surface where a food employee is working with food or working with utensils or equipment such as knives, slicers, grinders,or saws where employee safety is a factor. e. Food Equipment schedule to include make and model numbers and listing of equipment that is certified or classified for sanitation by an ANSI accredited certification program (when applicable). f. Source of water supply and method of sewage disposal. Provide the location of these facilities and submit evidence that state and local regulations are complied with; ' g.A mop sink or curbed cleaning facility with facilities for hanging wet mops; h. Garbage can washing area/facility; i. Cabinets for storing toxic chemicals; j. Dressing rooms, locker areas, employee rest areas, and/or coat rack as required; k. Site plan (plot plan for new construction) PLEASE CIRCLE/ANSWER THE FOLLOWING QUESTIONS FOOD PREPARATION REVIEW Town of North Andover Health Department,1600 Osgood Street Suite 2035 North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 4 of 19 Check categories of Potentially Hazardous Foods (PHF's)to be handled,prepared and served. CATEGORY* (YES (NO) 1. Thin meats, poultry, fish, eggs(hamburger; sliced meats; fillets) 2. Thick meats,whole poultry(roast beef; whole turkey, chickens, hams) 3. Cold processed foods(salads, sandwiches,vegetables) (✓� ( ) 4. Hot processed foods(soups, stews, rice/noodles, gravy, chowders, casseroles) 5. Bakery goods(pies, custards, cream fillings&toppings) 6. Other FOOD SUPPLIES: 1.Are all food supplies from inspected and approved sources? (9NO 2. What are the projected frequencies (daily, weekly, etc)of deliveries for Frozen foods W zeAc , Refrigerated foods v__A ` , and Dry goods'w,Vg, t� 3. Provide information on the amount of space(in cubic feet)allocated for: Dry storage —1 C, 'J 5 , Refrigerated Storage 1;5 , and Frozen storage 1,91 4. How will dry goods be stored off the floor? w.—C 4-".—C) C0' c:., COLD STORAGE: 1. Is adequate and approved freezer 4ad refrigeration available to store frozen foods frozen, and refrigerated foods at 41°F (5°C)and belowAOIS NO 2. Will raw,poultry and seafood be stored in the same refrigerators and freezers with cooked/ready-to- eat foods YES/NO If yes,how will cross-contamination be prevented? 0 6 S � GO-Aeo : yes 3. Does each refrigerator/freezer have a thermomete ES NO Number of refrigeration units: A_ Number of freezer units: Town of North Andover,Health Department,1600 Osgood Street,Suite 2035, North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 5 of 19 4. Is there a bulk ice machine available YES/NO Is ice packaged and sold for retail?YE /NO THAWING FROZEN POTENTIALLY HAZARDOUS FOOD: Please indicate by checking the appropriate boxes how frozen potentially hazardous foods(PHF's) in each category will be thawed. More than one method may apply. Also, indicate where thawing will take place. Food Thawing Method *Thick or Bulk Frozen *Thin/Portioned Frozen Refrigeration ( �cAAw 1 Running Water Less than ' 70°F(2I-C) Microwave (as part of cooking process) Cooked from Frozen state F Other(describe) ............................ ............................. ................... ........................... ................................................. .............................- ..................... .............- ............... .............. *Frozen foods: approximately one inch or less=thin,and more than an inch=thick. PREPARATION: 1. Please list categories of foods prepared more than 12 hours in advance of service. '�:)C. 1 C'a b C' ✓ - t k } J. 2. Will food employees be trained in good food sanitation practic ? ES/ O Method of training: Ser�s�,�e Number(s) of employees: �r Dates of completion: 5 ta'I 3 3. Will 9djsKsable gloves and/or utensils and/or food grade paper be used to prevent handling of ready-to-eat food . YES NO Town of North Andover,Health Department, 1600 Osgood Street,Suite 2035, North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 6 of 19 4 here a written policy to exclude or restrict food workers who are sick or have infected cuts and lesions? Please describe briefly: Will employees have paid sick leavegNO �� "' 5 u 5.How will cooking equipment, cutting boards, counter tops and other food contact surfaces which cannot be submerged in sinks or put through a dishwasher be sanitized? Chemical Type:""+-'— Concentration: 4'0 Test Kit( EE /NO 6. Will ingredients for cold ready-to-eat foods sucjLaquna, mayonnaise and eggs for salads and sandwiches be pre-chilled before being mixed and/or assembledkYES YNO If not,how will ready-to-eat foods be cooled to 41'F? 7. Will all produce be washed on-site prior to use. YE . /NO Is there a planned location used for washing produce. YES/NO Describe Sv fC Is JQD�Nod,-ag rs �asr}p�jl J If not, describe the procedure for cleaning and sanitizing multiple use sinks between uses. Town of North Andover,Health Department,1600 Osgood Street,Suite 2035, North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 7 of 19 8. Describe the procedure used for minimizing the length of time PHF's will be kept in the temperature danger zone(41T - 140T) Cx during preparation. y .:llMP_ - ` IV USA /S . Y.-C G•V crJ'C 9. Where raw meats, poultry and seafood are prepared in the same work area or using the same equipment as cooled/ready to eat foods, how will cross contamination be prevented? -Ki'7 lwc,", -Po.1_ -cep�e^._-'p2. Cru d2:1 10 ate n 7 10. Please list all PHF's you plan to serve which will/may not be cooked to the previously listed minimum temperatures.A proper"consumer advisory"warning notation must be printed on menu or menu boards. 0"-' a f( 06,Q~LJ 1419 u C95' fi A40 N ti r 11. Provide a HACCP plan for specialized processing methods such as vacuum packaged food items prepared on-site or otherwise required by the regulatory authority. 12. Will the facility be serving food to a highly susceptible population?YES/ If yes, List measures taken to comply with code requirements. COOKING: 1. Will food product thermometers be used to measure final cooking/reheating temperatures of PHF's? YE NO What type of temperature measuring device:eac(c4-r �AgA -,),w-f--P.L, Minimum cooking time and temperatures of product utilizing convection and conduction heating equipment. ➢ beef roasts ➢ 130-F(121 min) ➢ solid seafood pieces ➢ 145°F(15 sec) ➢ other PHF's ➢ l45°F(15 sec) ➢ eggs: ■ Immediate service 145°F(15 sec) pooled* 155°F(15 sec) (*pasteurized eggs must be served to a highly susceptible population) ➢ pork ➢ l45°F(15 sec) ➢ comminuted meats/fish ➢ l55°F(15 sec) ➢ poultry ➢ 165°F(15 sec) ➢ reheated PHF's ➢ 165°F(15 sec) Town of North Andover,Health Department,1600 Osgood Street,Suite 2035, North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 8 of 19 2. List types of cooking equipment. C©ve 1-41— a e.--/ -r,14 r, i 5 a l l ., a. k � / HOT/COLD HOLDING: 1.How will hot PHF's be maintained at 140°F (60°C)or above during holding for service?Indicate type and number of hot/holding units. T-['2 f 1�ooc��'��-d'c�-SQ.s ����.��Q�-�o+t E �1/s o IoW✓19c�+arc! �"i r'Q ,./'. 2. How will cold PHF's be maintained at 41'F (5°C)or below during holding for service?Indicate type and number o/f^cold holding units. (J /'� n p I .+ rr.l� F1®+P� �/ '� rtwcch U'V� �...1' COOLING: Please indicate by checking the appropriate boxes how PHF's will be cooled to 41'F (5°C)within 6 hours (140°F to 70°F in 2 hours and 70°F to 41°F in 4 hours).Also, indicate where the cooling will take place. F............. COOLING THICK THIN MEATS THIN SOUPS/ THICK RICE/ METHODMEATS GRAVY SOUPS/ NOODLES GRAVY r [ V— Shallow Pans ,.�� .................... ._. ............ Ice Baths i Re i Reduce Volume or Size Rapid Chill Other(describe) i Town of North Andover,Health Department,1600 Osgood Street,Suite 2035, North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 9 of 19 REHEATING: 1. How will PHF's that are cooked, cooled, and reheated for hot holding be reheated so that all parts of the food reach a temperature of at least 165°F for 15 seconds. Indicate type and number of units used for reheating foods. 1 2. How will reheating food to 165°F for hot holding be done rapidly and within 2 hours? A.FINISH SCHEDULE Materials selected must be durable and appropriate to the area and its intended use. High moisture and food splash areas must be non-absorbent, smooth and easily cleanable. All openings must be tight fitting, properly sealed and without voids.Applicant must indicate which materials(i.e. quarry tile, stainless steel,4" plastic coved molding, etc.)will be used in the following areas. (please be specific) Kitchen ( FLOOR COVING WALLS CEILING ; Bar^ _.., _�.w�..._..._._. ._ _. __ �......_...._._.........�._._ .,_,__� N+� Nyo NA Food Storage apo x y c��q,,�, T. ►� Ie Other Storage ,) �CvS}�C T; Toilet Rooms Dressing Rooms ? N ,� n�� Town of North Andover,Health Department, 1600 Osgood Street,Suite 2035, North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 10 of 19 i ............._......_..._.... _.�m.. ........., _....._.____............,....._...�...._ Kitchen Cxro,c � ! jjj I , Garbage& 1 Refuse Storage E Mop Service ��.N-�, i Basin Area /¢' 147.�ct f jb C,�`,I , x, 14 S }( } i Ware washing a,-4 wg Area G Walk-in Refrigerators and f-; 'o� �a �� o ^�� �-,•1 Freezers B. INSECT&RODENT CONTROL APPLICANT:PLEASE CHECK APPROPRIATE BOXES. YES NO N/A 1. Will all outside doors be self-closing and rodent proof? 2. Are screen doors provided on all entrances left open to the outside? 3. Do all operable windows have a minimum #16 mesh screening? / 4. Is the placement of electrocution devices identified on the plan? / 5. Will all pipes&electrical conduit chases be sealed; ventilation systems exhaust and intakes protected? 6. Is area around building clear of unnecessary brush, litter,boxes and other / harborage? 7. Will air curtains be used? If yes,where? 8. Do you have a plan to have a contract pest control company? If yes, list / company name, describe frequency of inspection and type of service. v Town of North Andover,Health Department,1600 Osgood Street,Suite 2035, North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 11 of 19 C. GARBAGE AND REFUSE INSIDE YES NO N/A 9. Do all containers have lids? 10. Will refuse be stored inside? If so,where? 11. Is there an area designated for a garbage can or floor mat cleaning? OUTSIDE 12. Will a dumpster be used? Number: / Size of-_E% a. Number: °V b. Size of po c. Frequency of Pick-Up?Indicate days and how often 13. Will a compactor be used? Number: Size: Frequency of Pick-Up 14. Will garbage cans be stored outside? / 15. Describe surface and location where dumpster/compactor/garbage cans are to V be stored. a�r-.�s�--`, ,..� QZ.o�-,.- ►^-�G��/Lao-vim �^- 16. Describe location of grease storage receptacle West side aF Kl ae,,, 17. Is there an area to store recycled containers? 18. Is there any area to store returnable, damaged goods? Town of North Andover,Health Department,1600 Osgood Street,Suite 2035, North Andover,MA 0184S--Phone:978.688.9S40--Fax:978.688.8476 Page 12 of 19 ? D.PLUMBING CONNECTIONS The FDA Food code and plumbing requirements do not replace or supersede the MA State Plumbing Code, which also must be fully met; instead, it highlights potential hazardous circumstances and particular types of equipment common to food service operations that, if through improper design or installation, could result in contamination of food or water supply.Please indicate proposed properly installed equipment. ............__..�.... _�._...._............. Equipment Code Confirmed ; Describe/Comments Requirements by Operator please } initial 1 ' Dish Machine Backflow prevention device lV__Q..v 3 Indirect Waste Steam Jacketed Backflow prevention Kettle device Indirect Waste 1 i...__....._.__...._ ........__.�......__,... ..... _._.,_....�_......_ ...... ... _, ..... 1_.._..._...-_ ..............._.... r-Steamer Backflow prevention �-- device ._...,..__. __...._ /Vp Indirect Waste �__ .-.... _._. �.�. _...._._............ ..... _ Garbage,-Disposals� Backflow prevention or dish-table device ftroughs;J _ Su6mergedjinlets { t FAt Al-hoge-1> Backflow prevention connections device L� LLL i LGarbage can Backflow prevention rwasher device L— �_ i Carbonated Carbonated Backflow { beverage prevention device dispenser Town of North Andover,Health Department,1600 Osgood Street,Suite 2035, North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 13 of 19 gefrigerator ° Indirect Waste Condensate/.drain 1 j Ir7 i I �sstorage.bins Indirect Waste . Amks Air Gap _ ,.�.m.........�.�.�._. Ice Cream dipper Air Gap wells �,,........ f ..................._>-.... ...........«.....,..............«......._.._, ....� ,..........._< �.........,................... .......,..,.,_._. ,..,.ter. ...._....� Other i 19. Are floor drains provided&easily cleanable, if so, indicate location: ' E. WATER SUPPLY 20. Is water supply public Wor private ( )? 21. If private, has source been approved?YES ( )NO (.)PENDING( ) Please attach copy of written approval and/or permit. 22. Is ice made on premises (1)or purchased commercially( )? If made on premise, are specifications for the ice machine provided?YES ( NO ( ) Describe provision for ice scoop storage:poi sid-4.. K,,.4 „V-J &n0��� Provide location of ice maker or bagging operation ju.0 DFsjd o Nal k ir.. bgdL IZoQ.,.� i 23. What is the ca acity of the hot water generator? _ U ro V i 3k to G Pte► 4 l4b -FCvYy-,\vA j6u5 Town of North Andover,Health Department, 1600 Osgood Street,Suite 2035, North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 14 of 19 24. Is the hotat r generator sufficient for the needs of the establishment?Provide calculations for necessary hot water ,9c 25. Is there a water treatment device?YES ( )NO(U// If yes, how will the device be inspected& serviced? .,26'How is backflow prevention devic inspected& serviced? 1 F. SEWAGE DISPOSAL 27. Is building connected to a municipal sewer? YES (/NO( ) 28. If no, is private disposal system approved? YES ( )NO ( )PENDING( ) Please attach copy of written approval and/or permit. 29.Are grease traps provided? YESNO ( ) If so-where? V;1 Ic Note: Grease Traps must have the following sign. The language in bold is specific;please do not change it in any way. If you have one or more interior grease traps please note the plumbing code 248 CMR 10.09(m): 1. A laminated sign shall be stenciled on or in the immediate area of the grease trap or interceptor in letters one-inch high.The sign shall state the following in exact language: IMPORTANT The grease trap/interceptor shall be inspected and thoroughly cleaned on a regular and frequent basis.Failure to do so could result in damage to the piping system,and the municipal or private drainage system(s). G. DRESSING ROOMS 30. Are dressing rooms provided? YES ( )NO 31. Describe storage facilities for employees'personal belongings(i.e.,purse, coats, boots, umbrellas, etc.) Town of North Andover,Health Department,1600 Osgood Street,Suite 2035, North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 15 of 19 & GENERAL 32. Are insecticides/rodenticides stored separately from cleaning& sanitizing agents? YES (�O ( ) Indicate location. le G,,�-e. W`� 33.Are all toxics for use on the premise or for retail sale(this includes personal me ications), stored away from food preparation and storage areas? YES)PI NO ( ) 34. Are all containers of toxics including sanitizing spray bottles clearly labeled? YES V<0( ) Note: Material Safety Data Sheets(MSDS) are required to be kept for all chemicals on the premises. Where will the MSDS information be kept on display for easy access in an emergency? 35. Will linens be laundered on site? YES ( )NO� If yes,what will be laundered and where? If no, how will linens be cleaned? 36. Is a laundry dryer available? YES ( )NO(� 37. Location of clean linen storage: (9 ,tel LQ 38. Location of dirty linen storage: eQ 39.Are containers constructed of safe materials to store bulk food products?YES (-I'NO( ) Indicate type: PISA►c ,,.Ao)1 jod Aq Ll lig el J'�(I deg- 40. Indicate all areas where exhaust hoods are installed: LOCATION FILTERS WOR SQUARE FEET FIRE AIR CAPACITY AIR MAKEUP EXTRACTION [ PROTECTION CFM CFM DEVICES j Town of North Andover,Health Department,1600 Osgood Street,Suite 2035, North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 16 of 19 41.How is each ventilation hood system that is listed cleaned? I. SINKS 42. Is a mop sink present? YES �. O( ) If no,please describe facility for cleaning of mops and other equipment: 43. If the menu dictates, is a food preparation sink present?YES'(�O( ) detail answer 1 J.DISHWASHING FACILITIES C 44. Will sinks or a dishwasher be used for ware washing? Dishwasher�Ir Two compartment sink( ) Three compartment sink ( ) 45. Dishwasher Type of sanitization used: Hot water(temp. provided) �U Booster heater Chemical type Is ventilation provided?YES ( )NO(vY 46. Do all dish machines have templates with operating instructions? YES (,,'NO ( ) n.k v 47. Do dish machines have temperature/pressure gauges as required that are accurate?YES (v)'NO ( ) 48. Does the largest pot and pan fit into each compartment of the pot sink?YES (•�'N0( ) If no, what is the procedure for manual cleaning and sanitizing? 49. Are there drain boards on both ends of the pot sink? Town of North Andover,Health Department,1600 Osgood Street,Suite 2035, North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 17 of 19 1 YES ( NO( ) 50. What type of sanitizer is used? ❑Chlorine ❑Iodine Quaternary ammonium ❑Hot Water ❑Other 51.Are test papers and/or kits available for checking sanitizer concentration?YES (l.)<O ( ) K.HANDWASHING/TOILET FACILITIES 52. Is there a hand washing sink in each food preparation,cooking and ware washing area?YES (.-<N0 ( ) 53.Do a and washing sinks, including those in the restrooms, have a mixing valve or combination faucet? YES ( NO ( ) 54.Do self-closing metering f cets provide a flow of water for at least 15 seconds without the need to reactivate the faucet?YES Z NO ( ) .55. Is hand cleanser available at all hand washing sinks?YES )NO 56.Are hand drying facilities(paper towels, air blowers, etc.) at all hand washing sinks?YES �NO ( ) 57.Are covered waste receptacles available in each restroom?YES (�NO ( ) 58. Is hot and cold running water under pressure available at each hand washing sink?YES*,j'NO ( ) 59.Are all toilet room doors self-closing?YES (v�NO( ) 60.Are all toilet rooms equipped with adequate ventilation?YEN/)'NO( ) 61.Are hand washing signs and instructions posted in each employee restroom?YES (1,�`NO( ) Town of North Andover,Health Department,1600 Osgood Street,Suite 2035, North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 18 of 19 h L. SMALL EQUIPMENT REQUIREMENTS 62. Please specify the number, location, and types of each of the following proposed for on site use: Slicers I Cutting boards D 01,J 00 /e [ Cb d, J Can openers Mixers C Floor mats Other STATEMENT: I hereby certify that the above information is correct,and I fully understand that any deviation from the above without prior permission from this Health Regulatory Office may nullify final approval. Signature (s) Cu�MJD ) Print: ��M b4 n I 4 Rp C' Owner(s)or responsible representative (s) Date: Ila I *4evY�e*9e*xeFnFxx Approval of these plans and specifications by this Regulatory Authority does not indicate compliance with any other code,law or regulation that may be required--federal,state,or local.It further does not constitute endorsement or acceptance of the completed establishment(structure or equipment). A preconstruction inspection with equipment in place and a preopening inspection of the establishment will be necessary to determine if it complies with the local and state laws governing food service establishments. Page Last Updated: 1/29/2013 Town of North Andover,Health Department,1600 Osgood Street,Suite 2035, North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 19 of 19 J i COMMONWEALTH OF MASSACHUSETTS NUMBER 0212 North Andover BOARD OF HEALTH FEE $270.00 Osgood Landing DATE ISSUED NAME March 01,2017 1600 OSGOOD STREET --------------------------------------------------------------------------------------------------------------------------------------------------------------------_ ADDRESS IS HEREBY GRANTED A Food Est. - Cafeteria/Retail/Catering Permit Food Establishment-Cafeteria/Retail/Catering This permit is granted in conformity with the Statutes and ordinances relating thereto,and expires February 28,2018 unless sooner suspended or revoked. RESTRICTIONS:Food Service; 100 Seat Capacity;3 food employees BOARD OF ------ -- -- -- � - - _-- HEALTH NOTES: Contact:Peter Tracy 978.319.3607 ----------------Eo- HOURS ACTIVE:Mon thru Fri 7:30am to 2:00pm ---------- ------------------------------------------------- BOARD OF HEALTH CHAIRMAN i i ..................."...................... ............... ......................................................".......*............................*......... 1600 OSGOOD STREET Reference No: BHF-2014-000002 ................................... Permit No: BHP-2017-0212 Department: ................................... North Andover BOARD OF HEALTH ......................................................................................... Account No: food FeeType: .................................... Food Est. - Cafeteria/Retait/Catering Receipt No: REC-2017-001099 .................................... ......................................................................................... Paid By: Paid in Full On: T , ....hu.... Feb........02........2017............ Corporate Chefs Inc. ......................................................................................... Check No: 222350 .................................... Received By: Toni Wolfenden ......................................................................................... Amount: DEPARTMENT'S COPY $270.00 ........................... L...........................................................................................................................................................................j Commonwealth of Massachusetts mom: -:, . BOARD OF HEALTH y North Andover 120 Main Street NORTH ANDOVER,MA 01845 DATE PRINTED 12/19/2016 ESTABLISHMENT NAME: Osgood Landing Osgood Landing 22 Parkridge Rd. File Number: BHF-2014-000002 HAVERHILL MA 01835 LOCATED AT: 1.600 OSGOOD STREET ,Commonwealth of Massachusetts OWNER: Corporate Chefs Inc. PHONE:(978)372-7400 PERMIT TYPE FEE Food Est.-Cafeteria/Retail/Catering Permit $270.00 VD Hours Active: Mon thru Fri 7:30am to 2:00pm food employees 1� Total Fees: $270.00 \A OD EpP Application MUST be submitted with l fee in order to be proc�d•� Applications can be found at w.northandoverma.gov Ce s TOWN OF NORTH ANDOVER Community and Economic Development HEALTH DEPARTMENT 120 Main St. NORTH ANDOVER,MASSACHUSETTS 01845 Phone:978.688.9540 Fax: 978.688.9542 E-mail:healthdeptQnorthandoverma.gov FOOD ESTABLISHMENT PERMIT APPLICATION (Ifnew establishment,application naist be submitted at lean 30 days before the planned opening date) FEE: Depends on type of food establishment—Refer to your current permit or call the Health Department for fee amount 1. Establishment Name: C.,0,,p0vt,e Ck1e-4S tt 0:L)q©oa Ictn �� Dater_ 17 a 2. Establishment Address Jt_,00() pScJ oo(3 6jy.e.eA- i 3. Establishment Mailing Address(if different) g a ?(fir IGr't!g e d , 14avek h'#t 1 "A- 6163115- 4. 1$354. Establishment Telephone#: q"1 Zv j L4 L4--a-o\- RECEIVED 1 5. Applicant Name&Title: V1�� �^ k-°.- -U C -n S CLctry\ , 6. Applicant Address: a`�� �l�✓Fi('ia5e �a �'re��evhc\\ , M,� (x�'3S F�� G �� ���� 7. Applicant Telephone No.: Et-T ,,.-3'7a-7c-�ptJ 24-Hour Emergency No.: C�'7 ,3'1DVXI(fOUTHANDOVER 8. Owner Name&Title(if different form applicant): 5; � HEALTH DEPARTMENT 9. Owner Address(if different from applicant): �i 10. Establishment Owned By: 11. If a corporation or partnership,give name,title,and ' ❑An Association;"Corporation;❑An individual home address of the officers or partner: ❑A partnership;❑other legal entityName Title Home Address 12. Person Directly Responsible for Daily Operations(Owner,Person to Charge,Supervisor,Manager, c. Name&Title: VA, CLQ e l n - C\e4- M0-001101" Address: astea-✓t!r`, dye tZ- 4�vel.\1 MfF ()15'5-- Telephone 5Telephone No.:UO3—L43-1- U5 9 co Fax No.: G-7 -3-7Z;)-O)6D E-mail: Emergency Telephone No.: Ct-18 -Ro S --I Lfob 13. District or Regional Supervisor(if applicable) Name&Title: K c be V\✓j P).qa�c --'�:>i 3k-r, CA- (VNC r)CqO'—" Address: a a �Gr � vv\A-- at 3S Telephone No.: _�3Q FaxNo.: a� -mail: �.beGL1��Or�pdrG12C1nr°�S-3-A\o< 14. Water Source: 15. Sewage Disposal: ; DEP Public Water Supply No.:(if applicable) 16. Days and Hours of Operation: 17.No.of Food Employees Page 1 of 3 L . NAME OF ESTABLISHMENT: ` r 18. Name of Person in Charge—Certified in Food Protection Management(required as of 10/1/2001/it accordance with 105 CMR 590.003(A)please attach copy of cerd lcate): _i 011CA t, " > 19. Person Trained in Anti-Choking Procedures(if 25 seats or more:❑Yes ❑No) NAME: "t Cy1 Cc e— t1 2ength of Permit: (check one) 20. Location: (check one) Annual ermanent Structure ❑Seasonal/Dates: ❑Mobile ❑Temporary/Dates/Time: 22. Establishment Type(check all that apply): ❑ Retail( square feet) &' Food Service—( 10 Q seats) ❑ Food Service—Takeout ❑ Food Service—Institution( Meals per day) ❑ Caterer ❑ Food Delivery ❑ Residential Kitchen for Retail Sale ❑ Residential Kitchen for Bed and Breakfast Home ❑ Residential Kitchen for Bed and Breakfast Establishments ❑ Frozen Dessert Manufacturer ❑ Other(Describe) E 23. Food Operations(check all that apply)—DEFINITIONS: ➢ PHF—potential hazardous food(timettemperature controls required); i ➢ Non-PHFs—non-potentially hazardous food(no time/temperature controls required); ➢ RTE—ready-to-eat foods(Ex.-sandwiches,salads,muffins,which need no further processing ❑ Sale of Commercially Pre-Packaged Non-PHF's Wim'PHF Cooked to Order ❑ Hot PHF Cooked and Cooled or Hot Held for More than a Single Meal Service ❑ Sale of Commercially Pre-Packaged PHFs C3' Preparation of PHFs for Hot and Cold Holding for Single Meal Service ❑ PHF and RTE Foods Prepared for Highly Susceptible Population Facility ❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to be prepared by Consumer ❑ Vacuum Packaging/Cook Chill ❑ Reheating of Commercially Processed Foods for Service within 4 hours Q,' Customer Self-Service ❑ Use of Process Requiring a Variance And/Or HACCP Plan(including bare hand contact alternative,time as a public health control) ❑ Customer Self-Service of Non PHF and Non-Perishable Foods Only ❑ Ice Manufactured and Packaged for Retail Sale ❑ Offers Raw or Undercooked Food of Animal Origin 91"Preparation of Non-PHFs ❑ Juice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single Meals for Catered Events of Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage,Out-of-Date or Reconditioned Food ❑ Other(Describe): Page 2 of 3 { NAME OF ESTABLISHMENT: Q **IF YOU DO NOT RENEW BY FEBRUARY 28rn THE FEE WILL DOUBLE**, Please include copies of current Serve Safq%A lergenTraining/C/eoke Saver Cert cations I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and Article X of the State Sanitary Code,and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of t 105 CMR 590.000 and the Federal Food Code. 24. Signature of Applicant: Signature 1" P ' Name , I Pursuant to MGL Ch. 62C,sec. 49A,I certify under the penalties ofpeijury that 1, to my best knowledge and belief,have filled all state tax returns and paid state taxes required under the law. 25. Signature of Individual or Corporate Name: Signature + Co r�o A , Print Name i Page 3 of 3 EXAM FORM NO. 10429 a c � CERTIFICATE NO. 12255225 K. •�s�a Z&WpyNe. ry .. t�.-.,y �"�,t �.f. •'�S�. S�a'�'�:r� I��....�L�1��'.Ti'k3"� f.. -',i'a. ........... 191111 A R"I" I " ILATION To MICHAEL PEPIN - 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)—Confereflce for Food Protection (CFP). ' 01 �t��x M " DATE OF EX P�CRT10 �y� r , u�k Local laws apply. Check ry�fhou�locgl+}regulatory agenry for recertification requirements. . +4 :,d+7m } '.)y. #0655„ o �y �� SheYmanBro � vv stS�Pxla s� Rea n Y o taro oyla�ns �,��• �a �. In accordance with Maritime Labour Coffin renfion�2Q0�R'esoriryo ,Y� pt Reg`LI biJo�i3 Sign are trodemarks�o,�kieN{ aho`rdiabResM-�Uro^t�ys�xi¢ho����¢�" - �f©2015 National Resi are trademarks of the NRAEf.National Restaurant Association®ond the orcdyygn Contact us with questions at 175 W bcbson Blvd.Ste 1500.Chirnn^.it /,WA nr.5—S e.0restourant.orc .. I J J - J , , . _ . lr� . ...-'. - I.i:. . � ,.��, il.;,�- . . , .,I.- - I . , ,. .: . , �;�Il� I,. . . . .P.,. . ,%,. .-.1-1 - . , --.. ,.- .-.:,.;.. p,...%: ,,.,. - ,. ., ...:� :,�:;�I,:., -.- . �_;� ,��. . - :,�, : , , , - 4--.3. � .,�.�:-i�,�. . . ,.,71V;. , . , .1� -- . :� , ,F , ; , ,� ' ' '.'" 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"",-�4 ' , ,��;?�,11: 1,,.,,,,,r:,,,',.,..�,,,,�,,�.',.. ,;-. --:-e,��..- ..�, - � - � . , . 1. . .:. %,.,,, :: ,. -.- .�.�,,�.....".:.;.,.�....,,,.�....".;,,�,.:,r.,��.�; I : L��, -, - �:: -%: I.- ' '. - . . , I � ", � I I ,� -, .' '. .. � . � � . . Narrie of"Rec� �e�t. •� .,Michael,, L Pe .In -..,:.. , R� 1. I - .., J xprs � P ,: I 1: 'g, r 1. i, .3a<5 ..14 t x ,` Date_of C2. om letion '2 4x P x I7.:2O� aE 5 ; � 5^ ti , 1. f ` , Date`.of Explrat�or. �� 12/'—/` �� A s ,:. .:�:.r a z `s n � ' ' � ��� '.e l` a t K+ 1 r1 ": I,:: ssued.B 71�e above .named _er on zs:hereb y:• Issued thts cert�cate "; �.; y ,. .. for-coin letan' aaz Aller en awarene3f tranin ro` — / p g g. , gp. gram recognized by'the Massachusetts De�iartment o Public Health Berkshire f to accordance with 105 CMR 590 009(G)(3)(a) . ,. .... .. :. , Area Health.;Education Center This certutte will.be valid or. ve S' ears zom'date.o pttsfiela,:massausens f � )y f f com4letaon ' � www.mafoodallergytraimng org "rd dw :� . .:• '' . . 1 CERTIFICATE OF CHOKESAVER TRAINING Name of Recipient: Michael Pepin �7, f tr `, Date of Completion: 11.15.16 Date of Expiration: 11.15.18 Presented by The Melrose and Wakefield Health.Departments PablicHealth P—ot.. Ruth' ,Health Dire toi 1 The Commonwealth of Massachusetts F Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit:General Businesses} TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Ledbly Bus mess/Organization Name: C 0 r-no nc i-e- Address: a 1 9CJt>rt.c..P;A Z e Qa a j City/State/Zip: �6c[e ;l I MA GIS 3S Phone#: 9`>8-3`>Q -.7,%G p Are yo employer?Check the appropriate box: Business Type(required): 1.al am a employer with employees(full and/ 5. ❑Retail. or part-time).* 6. ❑RestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑Office.and/or,Sales(incl.real estate,auto,etc.) employees working for me in any capacity. g. Non- rofit, [No workers' comp. insurance required] p 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health`Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers'comp. insurance req.] 12.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information, **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required'and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: .:y Cn . rn +v c,,_0 SSU r<A r-c e (fc3 Insurer's Address: �/ % ;re--J 1�v e - PO 3G nc !/Ci`7O City/State/Zip: v t ,,.� ,� J'1') J=} G ) 8 G 3 U 9 7 O Policy#or Self-ins.Lic.# EC C 600- t/600 1>0 9- ac/ >19 Expiration Date: O> I c/ 1 a G/ Attach a copy of the workers'compensation policy declaration page (showing the policy Ru" and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify,under thepainsand penalties ofppeJrjury that the information provided above is true and correct. Signature: Date: /�� /�..,7 Phone#: �r�G- 3`>a- '7% GO Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia 4 ,nc RD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/°°/YriY) 12/23/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require.an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Cross Insurance—Wakefield, Inc. NAME CONTACT Cross Insurance-Wakefield,Inc. 401 Edgewater Place, Suite 220 PHONE 781-914-1000 a/c No): 781-246-2601 Wakefield, MA 01880 E-MAIL ADDRESS: switchboard crossa enc .com INSURER(S)AFFORDING COVERAGE NAIC# www.tgacross.com INSURER A: Citizens Insurance Company of Arnerica 31534 INSURED INSURER B: Ailmerica Financial Alliance Ins Co 10212 Corporate Chefs, Inc. ABD Catering INSURER C: Hanover Insurance Company 22292 Elite Vending INSURERD: New Hampshire Employers Insurance Co 13083 22 Parkridge Road INSURER E: Haverhill MA 01835 INSURER F COVERAGES CERTIFICATE NUMBER: 33427644 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER"DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICYNUMBER MMIDDffYYY MMIDDIYYri LIMITS A V COMMERCIAL GENERAL LIABILITY D081_700-00 10/31/2016 10/31/2017 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE a OCCUR -DAMAGE TO PREMISES-Ea occu RENTED - $ 300,000 i ✓ Liquor Liability Included MED EXP.(Any one Person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 M'OTHER: L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑JEC �✓ LOC PRODUCTS-COMP/OP AGG $ 2,000,000 Employee Benefits $ 1,000,000 B AUTOMOBILE LIABILITY D081702-00 10/31/2016 10/31/2017 EO aB NEDtsINGLE LIMIT $ 1,000 000 ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ ✓ HIRED NON-OWNED PROPERTY DAMAGE ✓ AUTOS ONLY ✓ AUTOS ONLY Per accident $ i C �/ UMBRELLA LIAB �/ OCCUR D081701-00 10/31/2016 10/31/2017 EACH OCCURRENCE $ 10,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 10,000,000 DED RETENTION$ $ D WORKERS COMPENSATION ECC60040007092017 1/1/2017 1/1/2018. ✓. .STATUTE OERH AND EMPLOYERS'LIABILITY YIN ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? 7N NIA -. (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION Evidence of Coverage SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE g THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ,r Jonathan Cross ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 33427644 1 227080 1 16-17 GL, AU, UM, 17.18 WC I Sue Petro 1 12/23/2016 9:18:25 AM (EDT) I Page 1 of 1 CORPORATE CHEFS OFFICERS 22 Parkrid�e Road Haverhill, MA 01832 978-372-74-00 FEDERAL I.D. 04-2981626 Kenneth Bickford, President 96 Alpine Park Road Moulton boro, NH 03254 Alan Ayres, Treasurer 34 Sable Run Lane Methuen, MA. 01844 David Des,'\.osiers, Vice President, 167 Ocean Drive Seabrook, NH 03 874