HomeMy WebLinkAboutMiscellaneous - 50 MAIN STREET 4/30/2018 (5) 16
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ti- 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, Building 20; Suite 2-36,North Andover, MA 01845
Date: '3 a RECEIVl2D
EW -New construction,not yet built JAN 3 2013
REMODEL -partial or major renovation of existing establishment TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
CONVERSION—existing establishment that you are purchasing
t
Name of Establishment: f
i
Corporate Name: c„v h ' r
Category: ur t , Institution , Daycare , Retail Market , Other
Establishment Address: .1;-�n q,;n _ An d 'vttr 1�4 0 1 kyr
Phone: (at location if available) V,
E-mail Contacts: c m m b a y rac/A v -%
Name of Owner: (`;s b Yy\Aoc.r` Af
Mailing Address: / a c j- c;J o n, -d,Q1"' M,4 d av 0
Telephone:
Applicant's Name(if different than owner):
Title(owner, manager, architect, etc.): 0 C,/ti
Mailing Address: --
Telephone:
Town of North Andover,Health Department,1600 Osgood Street,Building 20;Suite 2-36,
North Andover,MA 01845--Phone:978.688.9540---Fax:978.688.8476 Page 1 of 20
ate Received:BOH office use only
i ate Review com leted: BOH office use only: Approved_/Denied
Date Revised application Received: BOH office use only
l ate Review completed:BOH office use only: Approved/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 t atten or decline(circle one)participation in the TRC process.Oate of TRC (BOH only),
General Information
Hours of Operation: Sun �„��pv�Thurs }?�
Mon v\Fri
Tues Sat
Wed
➢ Number of Seats for customers:;tis.,k•e. a,n �� ✓�'p� �eO)
➢ Number of Staff- H
(Maximum per shift)
➢ Total Square Feet of Facility: ( S D
➢ Number of Floors on which `
operations are conducted_
➢ Maximum Daily Meals to be Served: ➢ Breakfast `ASO
(approximate number) ➢ Lunch
➢ Dinners
Type of Service: Sit Down Meals
(check all that apply) Take Out
Caterer
Mobile Vendor
Other
Town of North Andover,Health Department,1600 Osgood Street,Building 20;Suite 2-36,
North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 2 of 20
Please enclose the following documents:
i/ Proposed Menu(including seasonal, off-site and banquet menus)
Manufacturer Specification sheets for each piece of equipment shown on the plan
.V/Site plan showing location of business in building; location of building on site including alleys, streets;
andlocation of any outside equipment(dumpsters,well, septic system- if applicable)
,"/ 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:
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;
Town of North Andover,Health Department,1600 Osgood Street,Building 20;Suite 2-36,
North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 3 of 20
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 handwashing, warewashing, 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
Check categories of Potentially Hazardous Foods(PHF's)to be handled, prepared and served.
CATEGORY* ptc-s l t4 ho'-, a V, � 01 gs
e DO
1. Thin meats, poultry, fish, eggs(hamburger s ice m ts; fillets) ( ) ( )
2. Thick meats,whole poultry(roast beef;whole turkey, chickens, hams)
3. Cold processed foods(salads, sandwiches, vegetables) yu3"`t Cufs
brea r�Nl�-,°1•er
4. Hot processed food soups stews, rice/noodles, gravy, chowders, casseroles)
Town of North Andover,Health Department,1600 Osgood Street,Building 20;Suite 2-36,
North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 4 of 20
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5. Bakery goods (pies, custards, cream fillings&toppings) ( ( )
6. Other S e t n 0
nCJS J i-I r/ s 4/.X J2 CZ/+"_� L1_
r�C- eN e �
FOOD SUPPLIES: �y,e w,;,1 J o.- /a f, m a l e
1. Are all food supplies from inspected and approved sources? D /NO
2. What are the projected frequencies (daily,weekly, etc)of deliveries for Frozen foods eJ 1✓`e,4
Refrigerated foods �- YL-, and Dry goods 1p,1 �A e')
L �kcc4�f w�•'�� Le
3. Provide information
on the amount of feet cubic space in allocated for:
p ( )
Dry storage iso ,
Refrigerated Storage of 10 a- y 3 , and
Frozen storage 10,(9
4. How will dry goods be stored off the floor?
COLD STORAGE:
1. Is adequate and approved fire,ezer,#A refrigeration available to store frozen foods frozen, and refrigerated
foods at 41 T (5°C) and below? /NO
2. Will raw meats, poaky and sea ood be stored in the same refrigerators and freezers with cooked/ready-to-
eat foods?YES/UO
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If yes,how will cross-contamination be prevented?
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3. Does each refrigerator/freezer have a thermometer?(D/NO
Number of refrigeration units:A_
Number of freezer units:
4. Is there a bulk ice machine available?OS/NO Is ice packaged and sold for retail?YES/0
Town of North Andover,Health Department,1600 Osgood Street Building 20•Suite 2-36,
North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 5 of 20
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
Sa�la�e Sia �`
Running Water Less than
70°F(21°C)
Microwave(as part of cooking
process)
Cooked from Frozen state
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.
Vy(' JDnu�f o,,k rei4ryef Pace— 1'ne, j'P ec-e'( i,i
'?2 ill food employees be trained in good food sanitation practices?�/NO S Y!"- (T 4)
Method of training:
M��CPerl ll t' �1 f Ce.4 —,� --
Number(s) of employees: rQ
Dates of completion: k'
3. Will disposable gloves and/or utensils and/or food grade paper be used to prevent handling of ready-to-eat
foods?
�.J /NO
a4.1Is the . written policy to exclude or restrict food workers who are sick or have infected cuts and lesions?S/Please describe briefly:
�
t
f! )c o 4P� .
Town of North Andover,Health Department,1600 Osgood Street,Building 20;Suite 2-36,
North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 6 of 20
Will employees have paid sick leave? YES ILO
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: sa ��� 1 -7
1
Concentration: � �° _ w
Test Kit: YES
6. Will ingredients for cold ready-to-eat foods such as tuna, mayonnaise and eggs for salads and sandwiches be
pre-chilled before being mixed and/or assembled? YES/NO
If not,how will ready-to-eat foods be cooled to 41'F?
7. Will all produce be washed on-site prior to use /NO
Is there a planned location used for washing produce/NO
Describe �;h
If not, describe the procedure for cleaning and sanitizing multiple use sinks between uses.
8. Describe the procedure used for minimizing the length of time PHF's will be kept in the temperature danger
zone (41°F - 140°F)during preparation.
Town of North Andover,Health Department, 1600 Osgood Street,Building 20;Suite 2-36,
North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 7 of 20
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?
i2l C
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.
?n �
11. Provide a HACCP plan for specialized processing methods uch as vacuum packaged food items prepared
on-site or otherwise required by the regulatory authority. q
12. Will the facility be serving food to a highly susceptible population?YES 0
If yes,List measures taken to comply with code requirements.
COOKING:'
-,Will food product thermometers be used to measure final cooking/reheating temperatures of PHF's?
YE What type of temperature measuring device:
Minimum cooking time and temperatures of product utilizing convection and conduction heating equipment:
➢ beef roasts ➢ 130°F(121
min)
➢ solid seafood pieces ➢ 1457(15 sec)
➢ other PHF's- ➢ 145°F(15 sec)
➢ eggs:
■ Immediate service 1457(15 sec) pooled* 155°F(15 sec)
(*pasteurized eggs must be served to a highly susceptible population)
➢ pork ➢ 145°F(15 sec)
➢ comminuted meats/fish ➢ 155°F(15 sec)
➢ poultry ➢ 165°F(15 sec)
➢ reheated PHF's ➢ 165°F(15 sec)
2. List types of cooking equipment.
me L To o.f e� Q� � J=1�Uaw� fr��
Town of North Andover,Health Department,1600 Osgood Street,Building 20;Suite 2-36,
North Andover,MA 01845---Phone:978.688.9540--Fax:978.688.8476 Page 8 of 20
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.
0
2. How will cold PHF's be maintained at 41°F (5°C) or below during holding for service?Indicate type and
number of cold holding units.
in
COOLING: ,11
Please indicate by checking the appropriate boxes how PHF's will be cooled to 41°F (5°C)within 6 hours
(1407 to 70°F in 2 hours and 70°F to 41°F in 4 hours). Also, indicate where the cooling will take place.
g COOLING THICK THIN MEATS THIN SOUPS/ THICK RICE/
METHOD MEATS GRAVY SOUPS/ NOODLES
j GRAVY
a Shallow Pans
Ice Baths
Reduce
Volume or Size
i
Rapid Chill
Other(describe)
1
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.
Town of North Andover,Health Department,1600 Osgood Street,Building 20;Suite 2-36,
North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 9 of 20
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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(ie. quarry tile, stainless steel,4" plastic
coved molding,etc.)will be used in the following areas. (be specific)
Kitchen FLOOR COVING WALLS CEILING
Bir
1
Food Storage 9-P.xj �p or-1 n�/ Fi b eIs/a_c/ A c
A'3ejfou,�� Com'"��3
9�
p0 0je- 4►.fi);n
Othe torage
Toilet Rooms QC-aw\"e ��Q, Ce-re.',_C-
oe � 'r;le C� �I C2( .`3
Tj Lp- as
Dresop9lrooms
I
Kitchen Qr (rsra r1 s P"&
Garba
Ref a Storage
r
Town of North Andover,Health Department,1600 Osgood Street,Building 20;Suite 2-36,
North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 10 of 20
i
Mop Service —0)o LT o)c 7 be j
Basin Area ���� � ^e S°' e144-. ce Cep ^�
A.�
� (�C9 � h'� . I
[Warewashing 0re"e4rr l'i G o u✓ '�°�
A3 �-'Je('Ic horej01 Pei'X Cer
Area FY0 o Nk C l.er c, re p
Walk-in /Yf J'}��,� �J'�- �l �' ls NfF
Refrigerators and &c.lvQ(„
Freezers
�J Mme+ I
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 openable windows have a minimum#16 mesh screening?
4. Is the placement of electrocution devices identitied 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.
Town of North Andover,Health Department,1600 Osgood Street,Building 20;Suite 2-36,
North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 11 of 20
Use, -�01 per_ n.'de 011� 2"
rc��f
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(ie. quarry tile, stainless steel, 4" plastic
coved molding, etc.) ill be,used the followi areas. (be specific)
Salz
a Kitchen FLOOR COVING WALLS CEILING
Food Storage
I
Other Storage
Toilet Rooms
Dressing Rooms
I
i
Kitchen
Garbage&
Refuse Storage
3 '
Town of North Andover,Health Department,1600 Osgood Street,Building 20;Suite 2-36,
North Andover,MA 0184S--Phone:978.688.9540--Fax:978.688.8476 Page 10 of 20
Mop Service
Basin Area
a Warewashing
Area
Walk-in
Refrigerators and
Freezers
B. INSECT &RODENT CONTROL
APPLICANT.-PLEASE CHECKAPPROPRIATE 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 openable windows have a minimum#16 mesh screening? Y
4. Is the placement of electrocution devices identitied on the plan? /
5. Will all pipes& electrical conduit chases be sealed; ventilation systems V
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?
V
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.
Fav-ce -- rno h t�s�`ce
Town of North Andover,Health Department,1600 Osgood Street,Building 20;Suite 2-36,
North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 11 of 20
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,1?
OCG
OUTSIDE
12. Will a dumpster be used? Number: Size of:
a. Number:
b. Size of
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.
14-
616/Describe location of grease storage receptacle
8r,ej t' F M)OONP, twos�ou.Vi o h P j a h
17. Is there an area to store recycled containers? 4
`18Is there any area to store returnable, d ma d goods?
Town of North Andover,Health Department,1600 Osgood Street,Building 20;Suite 2-36,
North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 12 of 20
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
9 Requirements by Operator
please initial
Dish Machine Backflow prevention
device
Indirect Waste
Steam Jacketed Backflow prevention
Kettle device
f� Indirect Waste
a
Steamer Backflow prevention
device
r a �lyl
cne..
Indirect Waste
Garbage Disposals Backflow prevention
or dish table device
troughs; /
Submerged inlets f (�
At all hose Backflow prevention
connections device
Garbage can Backflow prevention
washer device
Carbonated Carbonated Backflow /
beverage yjO%A prevention device C
dispenser
Town of North Andover,Health Department,1600 Osgood Street,Building 20;Suite 2-36,
North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 13 of 20
Refrigerator Indirect waste
condensate/drain
i lines
ICe storage bins Indirect Waste
J
All sinks Air Gap
a G
A
;1
Ice Cream dipper Air Gap
wells
I Other
Are floor drains provided& easily cleanable, if so, indicate location:
E. WATER SUPPLY
20. Is water supply public (/r 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(/r purchased commercially ( )?
If made on premise, are specifications for the ice machine provided?YES (/NO ( )
Describe provision for ice scoop storage: S � �t�c.�.P �p�r ►„r��� y i ( Q�,�-
Is w ,
Provide location of ice maker or bagging operation 3elel P Q V
23. What is the capacity of the hot water generator?
e.cr ). P—ce �r
Town of North Andover,Health Department,1600 Osgood Street,Building 20;Suite 2-36,
North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 14 of 20
24. Is the hot water generator sufficient for the needs of the establishment?Provide calculations for necessary
hot water Q_S
25. Is there a water treatment device?YES ( )NO
If yes, how will the device be inspected& serviced?
26. How are backflow prevention devices inspected& serviced?
F. SEWAGE DISPOSAL
27. Is building connected to a municipal sewer? YES (�NO( )
28. If no, is private disposal system approved? YES ( )NO ( )PENDING O
Please attach copy of written approval and/or permit. /
29.Are grease traps provided? YES (°�)NO ( )
If so-where? b - 144 � f✓ p e�
Note: Grease Traps must have the following-sign.The language in bold is specifics please do not change it in.any
way.lf,you have one or more interior grease tr-aps'please note`the-plumbing code 248 CMR 10:09(m):
1. (A larriinated 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 This 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 O NO (�
31. Describe storage facilities for employees'personal belongings (i.e.,purse, coats, boots, umbrellas,etc.)
C o 0__— (-GG K. w��, fie. pt--vl�d e
Town of North Andover,Health Department,1600 Osgood Street,Building 20;Suite 2-36,
North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 15 of 20
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H. GENERAL
32.Are insecticides/rodenticides stored separately from cleaning& sanitizing agents? YES KNO( )
Indicate location: C A7!'q S1 b r
33.Are all toxics for use on the premise or for retail sale(this include personal me)ications), stored away from
food preparation and storage areas? YES NO( )
3 . Are all containers of toxics including sanitizing spray bottles clearly labeled? YE4NO ( )
to Mater-ial-Safety-Data Slieet1(MSDS) are required to be kept for all chemicals on the premises. Where
will the^MSDS information be kept�o dis lay for easy access in an emergency?
V351Will linens be laundered on site? YES ( )NO 4
If yes, what will be laundered and where? 1 f�
If no, how will linens be cleaned?
36. Is a laundry dryer available? YES ( )NO
V,A88':/-Location
Location of clean linen storage: F — -of dirty linen storage:11
39.Are containers constructed of safe materials to store bulk food products?YES ( )NOX
Indicate type: YN 0 6v� r� --L � 1�'&
40. Indicate all areas where exhaust hoods are installed:
i LOCATION FILTERS WOR SQUARE FEET FIRE AIR CAPACITY AIR MAKEUP
EXTRACTION PROTECTION CFM CFM
DEVICES
Mcerow 1hc� ;)L h0�� '(o 9e Q3
�a e
?__ o L.r„rrnelt �nJ2fk1 }�,-i..Efh,�c-ZG
Town of North Andover,Health Department,1600 Osgood Street,Building 20;Suite 2-36,
North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 16 of 20
41. How is each listed ventilation hood system cleaned?
SA Ceti"12'�b S-�-V'l&
I. SINKS
42. Is a mop sink present? YES (VNO( )
If no, please describe facility for cleaning of mops and other equipment:
43. If the menu dictates, is a food preparation sink present?YES( NO ( ) detail answer
ah
J.DISHWASHING FACILITIES
44. Will sinks or a dishwasher be used for warewashing?
Dishwasher( )
Two compartment sink(
Three compartment sink(�
45. Dishwasher
Type of sanitization used:
Hot water(temp. provided)
Booster heater
Chemical type
Is ventilation provided?YES ( )NO( )
46. Do all dish machines have templates with operating instructions? YES ( )NO O YN
46. Do dish machines have temperature/pressure gauges as required that are accurate?YES ( )NO (
48. Does the largest pot and pan fit into each compartment of the pot sink?YES (4NO ( )
If no, what is the procedure for manual cleaning and sanitizing?
Town of North Andover,Health Department,1600 Osgood Street,Building 20;Suite 2-36,
North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 17 of 20
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49.Are there drain boards on both ends of the pot sink?
YES (J NO ( )
50. What type of sanitizer is used?
❑Chlorine
❑Iodine
(Quaternary
ammonium
✓U
❑Hot Water
❑Other
51.Are test papers and/or kits available for checking sanitizer concentration?YES (Vf NO ( )
K.HANDWASHING/TOILET FACILITIES
52. Is there a handwashing sink in each food preparation, cooking and warewashing area?YES (,NO ( )
53.Do 1 handwashing sinks, including those in the restrooms, have a mixing valve or combination faucet?
YES ( NO ( )
54. Do self-closing metering faucets provide flow of water for at least 15 seconds without the need to
reactivate the faucet?YES ( )NO( ) r 0�
55. Is hand cleanser available at all handwashing sinks?YES (J)NO ( )
56. Are hand drying facilities(paper towels, air blowers, etc.) at all handwashing sinks?YES (-/)NO ( )
57. Are covered waste receptacles available in each restroom?YES (Jf NO ( )
58. Is hot and cold running water under pressure available at each handwashing sink?YES (-4NO ( )
59.Are all toilet room doors self-closing?YES (,NO ( )
60. Are all toilet rooms equipped with adequate ventilation?YES (V�NO( )
61.Are handwashing signs and instructions posted in each employee restroom?YES 4 NO ( )
Town of North Andover,Health Department,1600 Osgood Street,Building 20;Suite 2-36,
North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 18 of 20
i
L. SMALL EQUIPMENT REOUIREMENTS
62. Please specify the number, location, and types of each of the following proposed for on site use:
Slicers
Cutting boards
Can openers
Mixers i c� _ ✓
Floor mats
Other
ic��Y�xdceF�Yx�Y9:�
li
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)
Print: ��L,-S-60S o kh
owner(s) or responsible representative(s)
Date: �6
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: 10/27/2009
I
I
Town of North Andover,Health Department,1600 Osgood Street,Building 20;Suite 2-36,
North Andover,MA 01845--Phone:978.688.9540--Fax:978.688.8476 Page 19 of 20
50 MAIN STREET
Complaint Detail Report
Printed On: Tue Aug OS,2014
Complaint#: CT-2015-000007 Status: Closed GIS#: Violator: Chris Kombouras
�vrsMW Address:, 50 MAIN,STREET Map: Address: 6 Scotland Drive
Date Recvd.: Aug-04'x2014 Time Rec_v,d.: 08;35,4M Block: ANDOVER,MA 01810
Category: Noise Lot: I Type: Commercial
GeoTMS Module: ;Board of Health District: Trade: Food est. —Restaurant
Recorded By:, Lisa Blackburn Zoning: Structure:
Description
Complaint: Anonymous complaint regarding the dumpster at Heavnly Donuts.Northside Carting is emptying the dumpster twice a week at 3:00am.This has been going on for a
while. -
Comments:
Inspector Assigned to Complaint:IMichele Grant
Contacts
Contact Type Date Time Name Phone Best Time To Reach Recorded By Response
Caller Aug-04-2014 8:35 AM Anonymous Lisa Blackburn Forwarded to Health
Inspector
Actions Taken
GeoTMS Module Status Date Time Response Type Action Taken Comments
Board of Health REFERRAL Aug-05-201.4 4:09 PM Follow-Up by Spoke to Jillian at Heavnly
Michele Grant Donuts.Northside Carting
does not start work until
4:00 am so they couldn't
possibly be emptying the
dumpster at 3:00am.If the
complainant calls again,
Susan Sawyer said they can
call the police department if
they see them there before
7:00am.Case closed for now.
GeoTMSO 2014 Des Lauriers Municipal Solutions, Inc. Page 1 of 1
50 MAIN STREET
Complaint Detail Report
Printed On: Thu Jun OS,2014
Complaint#: CT-2014-000055 Status: IClosed GIS#: Violator: Chris Kombouras
Address: 50 MAIN.STREET Map: Address: 6 Scotland Drive
• Date'Recvd.: Jun-04' 0:14' Time Recvd.: 08:15 AM Block: ANDOVER,MA 0 18 10
Category: Noise Lot: Type: Commercial
GeoTMS Module: Board of Health District: Trade: Food est. -Restaurant
Recorded By:; Lisa Blackburn: Zoning:_ Structure:'
Description
Complaint: Complaint regarding trash pickup at the Heavn'ly Donuts:Trash.is.being picked up:at 2:45am.Michele Grant called the owner of Heavn'ly Donuts.He will call his
rep.Lisa at Northside Carting and make sure they pick up after 7:00am.Case closed.
Comments:
Inspector Assigned to-Complaint:
Contacts
Contact Type Date Time Name Phone Best Time To Reach Recorded By Response
Caller Jun-04-2014 8:15 AM Anonymous Lisa Blackburn Follow-Up by Michele
Grant
Actions Taken
GeoTMS Module Status Date Time Response Type Action Taken Comments
Board of Health REFERRAL
GeoTMS®2014 Des Lauriers Municipal Solutions, Inc. Page 1 of l
i
ti
V- Osgood Landing, Town of North Andover, 1600 Osgood Street—Bldg. 20, Suite 2-36,
North Andover, MA 01845
Phone: 978-688-9535 Fax 978-688-9542 ienright(a townofnorthandover.com
Planning Department
Technical Review Committee Meeting (information form).
Please submit this information to the North Andover Planning Department c/o Jean
Enright no later than the Wednesday preceding the scheduled Technical Review
Committee Meeting. Applicant will confirm with Ms Enright the date and time of the
meeting on Wednesday prior to the actual TRC meeting date. It is important that either
the applicantpp
or the applicant's representative attend the TRC meeting.
Please type or print clearly.
1.Applicant: Chris Kombouras - Heav'nly Donuts
2.Applicant's Address: _6 Scotland Drive, Andover, MA 01810
3.Applicant's phone number 617-780-9328 -mobile
4.Address of proposed location: _50 Main Street,North Andover, MA 0l 845_
51oning District of proposed location: _General Business District
6.Square Footage of proposed project: 1,530 sq. ft.
7.Number of employees 2 -4 full time and 8 - 12 part time
3.Hours of operation 5am- 7pm Mon-Fri and 6am- 6pm Sunday
9.Parking requirements _11 on-site stalls available and 18 public stalls available
nearby on Main Street
l Us there food preparation required? _Yes
11.Description of project: We are proposing to open a Heav'nly Donuts location at the
above mentioned site My in-laws started Heav'nly Donuts in 1975 in Methuen and we
have recently opened new locations in the Merrimack Valley. We will serve coffee,
donuts pastries and breakfast/lunch sandwiches Our kitchen equipment for this location
will be light as all the fried donuts will be made off-site in Methuen and delivered each
morning We plan to have a basic convention oven bagel toasters and microwave ovens
at this location The interior build out will be new construction as the prior use (tanning
salon)went out of business and the space was completely demoed. We Dlan to have an
upscale atmosphere with outdoor patio seating and a gas fireplace inside.
I
If you are proposing to open a business in an existing location please submit a copy of a
site plan(you can obtain this from the landlord). It is not the intention of the Planning
Department to have the applicant incur Architectural or Engineering expenses for
submittal of a plan of land for purposes for a TRC meeting.
Town of North Andover TRC Applicant Form 10.24.12
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5 1 DONUT DISPLAY CASE 115 1 10 • W,RE TO WALL SNITCH
6 I WORK TOP REFRIGERATOR 115 1 2.6 i fi • NEMA 5-15P
7 1 SANDWICH UNIT 115 1 2.6 16 • NEMA 5-15P
8 ! MICROWAVE WALL SHELVES
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13 1 .REFRIGERATOR 1 115 1 9 112
11 1 ICE MMONG HEAD .5, 1 5/2 Ll 12.5 1 EIRE HARNESS SUPPLIES IM
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15 I ICE BIN 1 .75'
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16 1 STAINLESS STEEL WORK TABLES
17 1 REICH IN FREEZER 115 1 1 I!
OFFICE 18 2 • FINISH PRODUCT RACK
15 I9 20 CHAIRS
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22 10 TABLE BASES
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35 30 1 VENT HOOD W FAN 115 1 7 • SWITCH BY OTHERS
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x1 37 3 COFFEE GRINDERS 115 f 13a X I NEMA 5-15P
Il Il 38 3 CREAMER 115 I 3 NEMA 5-I5P
e 2 39 ! SPECIAL BREWING UNIT .38' 120 200 I 21 1 VERIFY
39 1 COFFEE GRINDER 1 115 I 1 8 1 VERIFY
10 1 AN POT BREWER .38' 120 206 1 13 2.62 1 VERIFY
II 2 ICED COFFEE BREWERS .38' 120 1 11.1 1.73 NEMA 5-15P
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ORAw1F:c NUA,eER 135 Route 125,Kingston,New Hampshire 03848
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Tel. 603-642-3873 — Fax 603-542-5787
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Osgood Landing, Town of North Andover, 1600 Osgood Street—Bldg. 20, Suite 2-36,
North Andover, MA 01845
Phone: 978-688-9535 Fax 978-688-9542 jenright a townofnorthandover.com
Planning Department
Technical Review Committee Meeting (information form).
n
Please submit this information to the North Andover Planning Department c/o Jean
Enright no later than the Wednesday preceding the scheduled Technical Review
Committee Meeting. Applicant will confirm with Ms Enright the date and time of the
meeting on Wednesday prior to the actual TRC meeting date. It is important that either
the applicant or the applicant's representative attend the TRC meeting.
Please type or print clearly.
1.Applicant: Chris Kombouras - Heav'nly Donuts
2.Applicant's Address: _6 Scotland Drive,Andover, MA 01810
3.Applicant's phone number 617-780-9328 - mobile
4.Address of proposed location: _50 Main Street,North Andover, MA 01845_
5.Zoning District of proposed location: _General Business District
6.Square Footage of proposed project: 1,530 sq. ft.
7.Number of employees 2 -4 full time and 8 - 12 part time
8.Hours of operation 5am - 7pm Mon-Fri and 6am - 6pm Sunday
9.Parking requirements _11 on-site stalls available and 18 public stalls available
nearby on Main Street
l0.Is there food preparation required? _Yes
I I.Description of project: We are proposing-to open a Heav'nly Donuts location at the
above mentioned site My in-laws started Heav'nly Donuts in 1975 in Methuen and we
have recently gpened new locations in the Merrimack Valley. We will serve coffee,
donuts,pastries and breakfast/lunch sandwiches Our kitchen equipment for this location
will be light as all the fried donuts will be made off-site in Methuen and delivered each
morning We plan to have a basic convention oven bagel toasters and microwave ovens
at this location The interior build out will be new construction as the prior use (tanning
salon)went out of business and the space was completely demoed. We plan to have an
upscale atmosphere with outdoor patio seating and a gas fireplace inside.
If you are proposing to open a business in an existing location please submit a copy of a
It is not the intention of the Planning
u can obtain this from the landlord). g
site plan(yo
pP
Department to have the applicant incur Architectural or Engineering expenses for
P
submittal of a plan of land for purposes for a TRC meeting.
Town of North Andover TRC Applicant Form-1 0.24.12
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WATER WASTE GAS ELECTRICAL
DESCRIPTION d 4� REMARKS
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5 1 DONUT DISPLAY CASE 115 1 10 WIRE TO WALL SMTCH
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7 1 SANDWICH UNIT 115 1 2.6 Ifi v NEW 5-15P
8 J MCROWAVL WALL SHELVES
9 I MOLE ICE CHEST I 1
PREL M NARY10 J MICROWAVE OVEN 208 1 16.4 3.2 NEW 6-20P
IT I ROTARY TOASTER 208 1 16.2 3.2 NEW 6-20P
12 LOT SHELVING
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14 1 ICE MAKING HEAD S 1 5/210 1 12.5 v WIRE HARNESS SUPPLIES IM
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14B I WATER FILTER UNIT 5•
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❑ 16 1 STAINLESS PEEL WORK FABLES
17 1 REICH IN FREEZER 115 1 7 1/3 v
OFFICE ❑ 18 2 v FINISH PRODUCT RACK
15 19 20 CHARS
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38 3 CREAMER IIS 1 ] 1 NEW 5-ISP
5 Il Il JB 3 SPEC14 BREWING UNT .38' 120 208 1 27 vFREY
1239 I COFFEE GRINDER 115 1 B VERIFY
7—I 40 1 NR POT BREWER .58' 120 208 1 13 2.62 VERIFY
LI 41 2 ICED COFFEE BREWERS .3B 120 1 14.4 1.73 NEW 5-I5P
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44 1 MOP SNN 5' .5' 1 2'
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DRAvnr:c NUMBER 135 Route 125,Kingston,New Hampshire 03848
Tel.603-642-3873 - Fax 603-542-5787
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INTEROFFICE MEMORANDUM
DATE: October 31,2012
TO: Judy Tymon planning
FROM: Gene Willis
CC:
RE: TRC 10/31/12 44-50 Main St. Heavnly Donuts
DPW/Engineering issues
1. Saunders St. sidewalk
Crosswalk @ corner of Main & Saunders
Sidewalk along parking area on Saunders St.
Isolate lot from Main & Saunders Sidewalks
Guard rail
Landscape/pervious area
Limit vehicular access to lot
i.e.vehicles crossing over sidewalk in one driveway entrance only
No parking on sidewalk on saunders st.
Build up sidewalk?
Curbing?
2. Drainage
Address runoff into Saunders St.
i
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