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NUMBER
COMMONWEALTH OF MASSACHUSETTS
BHP -2011-0541
Ilk ,4 North Andover
Board of Health FEE
$0.00
Jaime's Restaurant
DATE ISSUED
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�sS4twu�` NAME March 12, 2011
25 HIGH STREET
-----------------------------------------------------------------------------------------------------------------------------------------------------------
ADDRESS
IS HEREBY GRANTED A Food Est. - Temporary - TAX EXEMPT
Food Service
This permit is granted in conformity with the Statutes and ordinances relating thereto, and
expires March 13, 2011 unless sooner suspended or revoked.
RESTRICTIONS: MENU: CHILI
HOURS ACTIVE: TASTEOFNA-MARCH 12, 2011 @NAYC
FROM 7:00 P.M. - 11:00 P.M.
----------- ----------- -
Irl, 1.= I
Board of Health Chairman
Board of
Health
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FEB I
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
NORTH ANDOVER HEALTH DEPARTMENT
Community Development Division
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APPLICATION FOR TEMPORARY FOOD ESTABLISHMENT PERMIT
Fee: 35.00 - This application is to be received at least ten (10) days before the event with the fee, and a
!Copy of the Food Service License from the Town of which you normally operate out of. if applicable Please
make check payable to. Town of North Andover
of Operator/ Manager:)
Name of Food Establishment (if applicable)
Town: State: °t Zip:
Contact Phone #'s: 9 -1 % - %S S - Ll "7 '71 (cell)
Federal Tax ID Number: " tTi 9�51Tax Exempt?
Include a copy of your State Hawker/Peddler License if applicable:
(other)
*****Attach a current ServSafe Certification with every application, even if you think we have one on file*****
Person in Charge: t
1 1 Contact Phone
Name of Event: � ll S� .
Date(s) of Event: hi a� r Time(s) of Event: �' I �'r(1
Location of Event:
1. "AR OU READY?" Checklist = (Guideline for plan review and pre -opening inspection). Have you read these materials
YES 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 Complete SECTION A below if you answered YES to question 3.
X,/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:1e' s�
Pagel of 2
North Andover Health Department,
1600 Osgood Street, Building 20; Suite 2-36, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web http://www.townofnorthandover.com
A�
4
S
� r y
�4. Ust each food item prepared, and for each item check which preparation procedure will occur. Please attach a copy of the menu
if Ypplicabie.
SECTION A: At the Rooth
�'----�Cut/Assemble
Food
Thaw
'�
Cook Cool Cold Holding
Reheat
Portion
Hot Hol g
Packaging
SECTION B: At the licensed food estnhlichmPnt
Food
Thaw Cut/As ble �Coo
_Cool Cod Hold*
Rehe�Hot
ortion
Ho g Packaging
Source and Storage of water/ice:
Storage and disposal of wastewater:
Please outline your complete sanitation Process from start to finish for this event —for example:
method(s) of sanitation, such as: using a 10 gallon igloo of bleach & water -for sanitation; your procedures
for the care and cleaning of utensils; tables, equipment, etc.
I certify that I am familiar with 105 CMR 590.00 Minimum Sanitation Standards for Food Establishments Article X, and the
above described establishment will be operated and maintained in accordance with the regulations.
Applicant's Signature: Date:z�/
i
Page 2 of 2
North Andover Health Department,
1600 Osgood Street, Building 20; Suite 2-36, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web http://www.townofnorthandover.com
Sanitation Process:
• Take temperature of chili to be at 140 degrees, hold in 6 pan wrapped in aluminum foil
• Have cheese wrapped in pan and held in cooler with ice
• Tortilla chips placed in 5 gallon bucket
• Arrive, put gloves on, put sanitizer in bucket and test with test strips, clean all tables and utensils
• Place D10 sanitizer under both with clean rags and test strips readily available for use
• Change gloves, take temperature of chili before placing in steam table to test 140 degrees
• Using electric steam maintain proper temperature of chili constantly checking throughout with
thermometer
• Place extra gloves under booth, readily available for use along with trash bag/barrel for disposal
of used gloves
• Change gloves, place tongs and ladles in separate container from food products, after
sanitization.
• Have closed lid on 5 gallon bucket of tortilla chips with tongs by the side in separate container to
remove chips
• Keep cheese in wrapped pan in cooler with ice to prevent contamination, have another set of
tongs in a separate container to remove cheese
• Change gloves, check temperature of chili, serve
• Once event is finished change gloves, if any left -over product throw away. Remove water from
steam table, test sanitizer with test strips, clean and sanitize table and utensils.
Equipment:
Food:
Portable steam table
Chili
(2) ladles
Cheese
(2) tongs
Tortilla Chips
Cooler with ice
(4) 6 pans
(2) 8 pans
Container of D10
Test strips
Rags
Gloves
Thermometer
Test strips
5 gallon bucket
Sanitation Process:
• Take temperature of chili to be at 140 degrees, hold in 6 pan wrapped in aluminum foil
• Have cheese wrapped in pan and held in cooler with ice
• Tortilla chips placed in 5 gallon bucket
• Arrive, put gloves on, put sanitizer in bucket and test with test strips, clean all tables and utensils
• Place D10 sanitizer under both with clean rags and test strips readily available for use
• Change gloves, take temperature of chili before placing in steam table to test 140 degrees
• Using electric steam maintain proper temperature of chili constantly checking throughout with
thermometer
• Place extra gloves under booth, readily available for use along with trash bag/barrel for disposal
of used gloves
• Change gloves, place tongs and ladles in separate container from food products, after
sanitization.
• Have closed lid on 5 gallon bucket of tortilla chips with tongs by the side in separate container to
remove chips
• Keep cheese in wrapped pan in cooler with ice to prevent contamination, have another set of
tongs in a separate container to remove cheese
• Change gloves, check temperature of chili, serve
• Once event is finished change gloves, if any left -over product throw away. Remove water from
steam table, test sanitizer with test strips, clean and sanitize table and utensils.
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