HomeMy WebLinkAboutMiscellaneous - 733 TURNPIKE STREET 4/30/2018 (13)fit"
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THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF NORTH ANDOVER 1600 Osgood Street, Building 20; Suite 2-36
North Andover, Massachusetts 01845
Phone - 978.688.9540 Fax - 978.688.8476
FOOD ESTABLISHMENT INSPECTION REPORT e-mail: healthdeptr&townofnorthandover.com
Name of Establishment �^
'
Dat
Type of Operation(s)
T m e of Inspection
PICS Signature:
Food Service
❑Retail
❑Residential Kitchen
ElMobile
❑ Temporary
Re -inspection
Previous In ectio
Date:
Address `�' T
R' k Level
Telephone ! 7
r
Owner
HACCP:
❑ Pre-operation
Y / N
❑ Caterer
❑ Bed & Breakfast
❑ Suspect Illness
❑ General Complaint
❑ HACCP
❑Other
Person -in -Charge (PIC)
Time
In: "
� "�
`
Inspector
Out:
Year:
Each violation chMked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti -Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009 (F) ❑
corrective action as determined by the Board of Health. Allergen Awareness 590.009 (G) ❑
FOOD PROTECTION MANAGEMENT
❑ 1. PIC Assigned/Knowledgeable/Duties
EMPLOYEE HEALTH
❑ 2. Reporting of Diseases by Food Employee and PIC
❑ 3. Personnel with Infections Restricted/Excluded
FOOD FROM APPROVED SOURCE
❑ 4. Food and Water from Approved Source
❑ 5. Receiving/Condition
❑ 6..Tags/Records/Accuracy of Ingredient Statements
❑ 7. Conformance with Approved Procedures/HACCP Plans
PROTECTION FROM CONTAMINATION
❑ 8. Separation/Segregation/Protection
❑ 9. Food Contact Surfaces Cleaning and Sanitizing
❑ 10. Proper Adequate Handwashing
❑ 11. Good Hygienic Practices
Violations Related to Good Retail Practices (Blue Items)
Critical (C) violations marked must be corrected immediately
or within 10 days as determined by the Board of Health.
Non-critical (N) violations must be corrected immediately or
within 90 days as determined by the Board of Health.
C N.
23. Management and Personnel (FC -2)(590.003)
24. Food and Food Protection (FC -3)(590.004)
25. Equipment and Utensils (FC -4)(590.005)
26. Water, Plumbing and Waste (FC -5)(590.006)
27. Physical Facility (FC -6)(590.007)
28. Poisonous or Toxic Materials (FC -7)(590.008)
29. Special Requirements (590.009)
30. Other
9
❑ 12. Prevention of Contamination from Hands
[:113. Handwashing Facilities
PROTECTION FROM CHEMICALS
❑ 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
TIMEITEMPERATURE CONTROLS (Potentially Hazardous Foods)
❑ 16. Cooking Temperatures
❑ 17. Reheating
❑ 18. Cooling
❑ 19. Hot and Cold Holding
❑ 20. Time as a Public Health Control
REQUIREMENTS FOR HIGHLY -SUSCEPTIBLE -POPULATIONS (HSP)
❑ 21. Food and Food Preparation for HSP
CONSUMER ADVISORY
❑ 22. Posting of Consumer Advisories
Number of Violated Provisions Related To
Foodborne Illnesses Interventions and Risk O
Factors (Red Items 1-22):
Official Order for Correction: Based on an inspection today, the items
checked indicate violations of 105 CMR 590.000/federal Food Code. This
report, when signed below by a Board of Health member or its agent
constitutes an order of the Board of Health. Failure to correct violations
cited in this report may result in suspension or revocation of the food
establishment permit and cessation of food establishment operations. If
aggrieved by this order, you have a right to a hearing. Your request must
be in writing and submitted to the Board of Health at the above. address
within 10 days -of receipt of this order.
DATE OFRE-INSPECTION:
Inspector's Signature:f/�
Print:
wp l
Page )oll`A'�Ages
PICS Signature:
Print:
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REC IVED
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MAR 1 � Z011
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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REC IVED
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MAR 1 � Z011
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
I
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:
NEW - New construction, not yet built
REMODEL - partial or major renovation of existing establishment
CONVERSION — existing establishment that you are purchasing
Name of Establishment:
Corporate Name:
Category: Restaurant , Institution , Daycare , Retail Market , Other.
Establishment Address:
Phone: (at location if available)
E-mail Contacts:
Name of Owner:
Mailing Address:
Telephone:
Applicant's Name (if different than owner):
Title (owner, manager, architect, etc.):
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
v
ate Received: BOH office use only
ate Review completed: BOH office use only_ Approved / Denied
ate Revised application Received: BOH office use only
ate Review com leted: BOH office use only. Approved / Den ei d
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 or decline (circle one) participation in the TRC process.DCate of TRC (BOH only_)
General Information
Hours of Operation: Sun
Mon
\ Tues.
Wed
➢ Number of Seats f customers:
➢ Number of Staff.
(Maximum per shift)
➢ Total Square Feet of\Faci:Number of Floors on
operations are conducted
➢ Maximum Daily Meals to be Serve(
(approximate number)
Type of Service:
(check all that apply)
Sit Do Meals
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:
Proposed Menu (including seasonal, off-site and banquet menus)
Manufacturer Specification sheets for each piece of equipment shown on the plan
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)
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 C/-
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.
proposed menu, seating capacity, and projected daily meal volume for food service operations.
3. S ow the location of each piece of equipment. Each must be clearly labeled on the plan with its common
�afne. 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.
and locate separate food preparation sinks when the menu dictates to preclude contamination and
Ztamination of raw and ready -to -eat foods.
Clearly designate adequate hand washing lavatories for each toilet fixture and in the immediate area of food
p eparation, 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.
On the plan, represent auxiliary areas such as storage rooms, garbage rooms, toilets, basements and/or cellars
ell for storage or food preparation. Show all features of these rooms.
and provide specifications for:
exits, loading/unloading areas and docks;
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. Lig ting schedule with protectors;
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;
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
rsilsn
least 540 lux (50 foot candles) at a surface where a food employee is working with food or working with
orAt
such as knives, slicers, grinders, or saws where employee safety is a factor.
od Equipment schedule to include make and model numbers and listing of equipment that is certified or
ssified for sanitation by an ANSI accredited certification program (when applicable).
of water supply and method of sewage disposal. Provide the location of these facilities and submit
that state and local regulations are complied with;
AXop sink or curbed cleaning facility with facilities for hanging wet mops;
. Garbage can washing area/facility;
for storing toxic chemicals;
ing rooms, locker areas, employee rest areas, and/or coat rack as required;
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*
1. Thin meats, poultry, fish, eg (hamburger; sliced meats; fillets)
2. Thick meats, whole poultry (roa beef; whole turkey, chickens, hams)
3. Cold processed foods (salads, sand
4. Hot processed foods (soups, stews,
vegetables)
gravy, chowders, casseroles)
(YES)
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
5. Bakery goods (pies, custards, crea fillings & toppings)
6. Other
FOOD SUPPLIES:
1. Are all food
2. What are the proj
Refrigerated foods _
from inspected and
frequencies (daily, weekly,
and Dry goods_
3. Provide information on the
Dry storage
Refrigerated Storage
Frozen storage
sources? YES / NO
of deliveries for Frozen foods ,
of space (in cubic feet\allocated for:
and
will drv_ .oWs be stored off the floor?
�5 0- .Z/-
VVj
1. -Is-E a e and approved freezer and refrigeration available to store frozen foods frozen, and refrigerated
foods at 41°F (5°C) and below? YES / NO
2. Will raw meats, 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?
3. Does each refrigerator/freezer have a thermometer? YES / NO
Number of refrigeration units:
Number of freezer units:
4. Is there a bulk ice machine available? YES / NO Is ice packaged and sold for retail? YES/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 5 of 20
Please indicate by checkiMorean
ropriate boxes how frozen potentially hazardous foods (PHF's) in each
category will be thawed. one method may apply. Also, indicate where thawing will take place.
Food Thawing Method
Thick or Bulk Frozen
*Thin/Portioned Frozen
Refrigeration
Running Water Less than
70°F(21°C)
Microwave (as part of cooking
process)
i
Cooked from Frozen state
y
Other (describe)
*Frozen foods: approximately one inch or less = thin, and more than an inch = thick.
PREPARATION:
1. Please list categorks of foods prepared more than 12 hours in advance of service.
ill food employees be trained in good food sanitation practices? YES / NO
iod of training:
s) of employees:
of completion:
disposable gloves and/or utensils and/or food grade paper be used to prevent handling of ready -to -eat
YES / NO
Is there a written policy to exclude or restrict food workers who are sick or have infected cuts and lesions?
?S / NO Please describe briefly:
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
employees have paid sick leave? YES / NO
5. Pow will cooking equipment, cutting boards, counter tops and other food contact surfaces which cannot be
odbmerged in sinks or put through a dishwasher be sanitized?
Chemical Type:
Concentration:
Test Kit: YES / NO
6. Will ingredients r cold ready -to -eat foods Nch as tuna, mayonnaise and eggs for salads and sandwiches be
pre -chilled before beihg mixed and/or assembled. YES/NO
If not, how will ready -to -6#t foods be cooled to 41
7.Will all produce be washed on-site prior to use? YES / NO
there a planned location used for washing produce? YES / NO A V_.'
Describe
If not, describe the procedure for cleaning and sanitizing multiple use sinks between uses.
8. Describe the procedure used for'nimizing the length of time PHF's will be kept in the temperature danger
zone (41°F - 140°F) during preparatio
Town of North Andover, Health Department, 1600 Osgood Stre uil ding 20; Suite 2-36,
North Andover, MA 01845 --Phone: 978.688.9540-- Fax: 978.688.8476 Page 7 of 20
ere raw meats, poultry an' eafood are prepared in e same work area or using the same equipment as
c led /ready to eat foods, how wi cross contamination be revented?
10. Please list all PHF's you to serve which wil may not be cooked to the previously listed minimum
temperatures. A proper "consum r advisory" warning otation must be printed on menu or menu boards.
X1�1. Provide a HACCP plan for�special�d processing method?; such as vacuum packaged food items prepare
on`sLe or otherwise required by the regulatory authority. v
`- 2. Will the facility be serving food to a highly susceptible population? YES / NO
If yes, List measures taken to comply with code requirements.
COOKING:
1 Will ft
YES / NO
thermometers be used to measure final cooking/reheating temperatures of PHF's?
of temperature measuring device:
➢eef roasts
➢ soli afood pieces
➢ other PH '
➢ eggs:
➢ 130-F(121
min)
➢ 145°F (15 sec)
➢ 145°F (15 sec)
■ Immediate seXPHF's
c) pooled* 155°F (15 sec)
(*pasteurized eggo a highly susceptible population)
➢ pork➢ 145°F (15 sec)
➢ comh ➢ 155°F (15 sec)
➢ pou➢ 165°F (15 sec)
➢ rehe➢ 165°F (15 sec)
\List types of cooking equipment.
Town ofNorth 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.
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.
COOLING:
Please indicate by checking the appropriate boxes how PHF'swill e cooled to 417 (5°C) within 6 hours
(140°F to 70°F in 2�h rs and 70°F to 417 in 4 hours). Also, Indic e where the cooling will take place.
COOLING
METHOD
THI
MEAT
THIN MEATS
THIN SOUP /
GRAVY
THICK
SOUPS/
GRAVY
RICE/
NOODLES
Shallow Pans
Ice Baths
Reduce
Volume or Size
Rapid Chill
Other (describe)
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
It
2. How will reheating food t 165°F for hot holding be2 apidly and within 2 hours?
FA.INISIHH 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)
FLOOR
COVING
WALLS
CEILING
I Bar
i
i
1
LFW@d ko- Qge
OtheStorage
9
Toilet Rooms
i
i
Dressing Rooms
1
Kitchen
Garbage &
Refuse Storage
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 10 of 20
Mop Service
YES
NO
N/A
1. Will all outside doo be self-closing and rodent p of?
Basin Area
1
2. Are screen doors provide n all entrances left open to e outside?
9
1
3. Do all openable windows have a inimum #16 mesh screem �
Warewashing
4. Is the placement of electrocution devic identitied on the plan?
Area
6. Is area around building clear of unnecessary brush, litter, b es and other
harborage?
Walk-in
7. Will air curtains be used? If yes, where?
Refrigerators and
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.
Freezers
INSECT & RODENT CONTROL
APPLICANT. PLEASE CHECKAPPROPRL4TE BOXES.
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
YES
NO
N/A
1. Will all outside doo be self-closing and rodent p of?
2. Are screen doors provide n all entrances left open to e outside?
3. Do all openable windows have a inimum #16 mesh screem �
4. Is the placement of electrocution devic identitied on the plan?
5. Will all pipes &electrical conduit chases be sea d; ventilation systems
exhaust and intakes protected?
6. Is area around building clear of unnecessary brush, litter, b es 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.
C. GARBAGE AND REFUSE
INSIDE
YES
NO
N/A
9. Do all containers have lids?
10. Will refuse b stored inside? If so, where.
11. Is there an area esignated for a garbage c n or floor mat cleaning?
OUTSIDE
12. Will a dumpster beuTNumber: Size of:
a. Number:
b. Size of:
c. Frequency of Pick -Up? Indicate ays 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 a to
be stored.
16. Describe location of grease storage receptacle
17. Is there an area to store recycled containers?
1.8. Is there any area to store returnable, damaged 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
Requirements
by Operator
please ' itial
Dish MachiBackflow
prevention
device
Indirect Waste
I Steam Jacketed
ackflow prevention
Kettle
de 'ce
Indirect aste
f
1 Steamer
Backflow prevetion
l
i
device
Indirect Waste
Garbage Disposals
Backflow prevention
I or dish table
device
troughs;
Submerged inlets
At all hose
Backflow prevention
connections
:
i
s
device
Garbage can
Backflow prevention
washer
device
Carbonated
Carbonated Backflow
beverage
prevention device
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/ drai
lines
Ice storage bins
direct Waste
All sinks
Air Gap
Ice Cream dipper
Air Gap
wells
Other
i
. Are floor drains �ovided & easily cleanable, if so-,"tqdicat\10 ion:
20.s water suppl%ub)or private ( ) ?
21. If private, hasen approved? YES ( ) NO O PENDING ( )
Please attach copy of written apMval and/or permit.
22. Is ice made on premises ( ) or purcfilmed commercially ( )?
If made on premise, are specifications for the ice maM%ine provided? YES ( ) NO ( )
Describe provision for ice scoop storage:
Provide location of ice maker or bagging operation
23. What is the capacity of the hot water generator?
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
hot water
25. Is there a water
If yes, how will the device be
sufficient for the\eeds of the establishment? Provide calculations for necessary
device? YES ( ) NO`( )
& serviced?
26. How are backflow prevention devices inspectN & serviced?
F. SEWAGE DISPC
27. Is building onnec
28. If no, is private
Please attach copy of
to a
system
approval and/or
29. Are grease traps provided?
If so - where?
YES( ) NO ( )
YES ( ) NO ( ) PENDING ( )
YES( ) NO ( )
Note: Grease Traps must have the following sign. The language in bis specific; please do not change it in any
way. If you have one or more interior grease traps please note the plumbin ode 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 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? ES ( ) NO ( )
31. Describe storage facilities for employees' perso l belongings (i.e., purse, c ts, boots, umbrellas,etc.)
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
H.
Are insecticides/rodenticides stored separately from cleaning & sanitizing agents? YES ( ) NO ( )
Indicate location:
33. Are all toxics for use on the premise or for retail sale (this includes personal medications), stored away from
food preparation and storage areas? YES( ) NO ( )
34. Are all containers of toxics including sanitizing spray bottles clearly labeled? YES( ) NO ( )
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 lauld red and where?
If no, how will linens be
36. Is a laundry dryer
37. Location of clean linen
38. Location of dirty linen storage:
39. Are containers constructed of safe
Indicate type:
YES( ) NO ( )
to store bulk food products? YES ( ) NO ( )
40. Indicate all areas where exhaust hoods are installed:
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
LOCATION
FILTERS WOR
SQUARE EET
FIRE
AIR CAPACITY
AIR MAKEUP
EXTRACTION
PROTECT ON
CFM
CFM
I
i
I
1
DEVICES
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
t
41. How is each listed,Xentilation hood system cleaned?
I. SINKS
42. Is a mop sink present? YES( ) NO ( )
If no, please describe facility \cleaningops and other e ipment:
43. If the menu dictates, is a food preparation sin resent? YES () () detail answer
J. D BHWASHING FACILITIES �-�
44. Will sinks or a dishwasher be used for warewashing9
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 ( )
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 ( ) NO ( )
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 0 1845— -Phone: 978.688.9540-- Fax: 978.688.8476 Page 17 of 20
49. Are there drain boards on both ends of the pot sink?
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 ( ) NO ( )
K.
52. Is there handwashing sink in each fo preparation, cooking and warewashing area? YES () NO ( )
53. Do all hand Shing sinks, including those in e restrooms, have a mixing valve or combination faucet?
YES( ) NO ( )
54. Do self-closing mete?iqg faucets provide a flow of w er for at least 15 seconds without the need to
reactivate the faucet? YES%ata
55. Is hand cleanser availabandwashing sinks? Y%ES( ) O ( )
56. Are hand drying facilities (paper towels, air blowers, etc.) at all
57. Are covered waste receptacles available)Reach restroom? YES ( ) NO
sinks? YES ( ) NO ( )
58. Is hot and cold running water under pressure available at each handwashing sin'V9 YES () NO ( )
59. Are all toilet room doors self-closing? YES ( )
60. Are all toilet rooms equipped with adequate ventilation?Y\ES ( ) NO ( )
61. Are handwashing signs and instructions posted in each em
YES( ) 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
L. SMALL EQUIPMENT REQUIREMENTS
62. Please`
Slicers
Cutting boards
Can openers _
Mixers
Floor mats
Other
ify the number, location, and types of each of the following proposed for on site use:
STATEMENT: hereby certify that the above information is correct, and I fully understand that any
deviation fro the above without prior permission from this Health Regulatory Office may nullify final
Signature(s)
Print:
owner(s) or responsible representative(s)
Date:
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
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
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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
—7 1600 Osgood Street, Building 20; Suite 2-36, North Andover, MA 01845
Date: / J0-"
NEW - New constructiai, not yet built � [
C/REMODEL. - partial or major renovation of existing establishment,.
CONVERSION — existing establishment that you are purchasing
NameofEstablishment: [al!%afe IaLAA&R- CLAI
Corporate Name: o 11 LL c
Category: Restaurant
Institution , Daycare , Retail Market , Other
Establishment Address: K✓ I �Q,A401g-4
Phone: (at location if available)
E-mail Contacts
Name of Owner:
Mailing Address
0 ✓ Gil C� (XWI���� . C�
-)33 A /'/A"
Telephone: x'66' q v — s 1
—ir
Applicant's Name (if different than owner): -,;&
Title (owner, manager, architect, etc.):
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
X
rT'^;-x.y..e•, �.4,. .-'`�"'F'p.— _ ._ 9 _.. _ �._^, r—. qy •b F [a ,,,: '� x 3'r�ys
: F _
-
�.�te�2e�i�*comp(�te�`�$OkI bffiee�use o�riy° Appi�ved ��snie
Technical Assistance with the PermittItte 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 or decline (circle one) participation in the TRC process ate of''RC (BOHsgnlf),
General Information
Hours of Oneratimt: Sun Thurs
Mon Fri
Tues at
Wed
➢ Number of Seats • customers:
➢ Number of Staff:
(Maximum per shift)
➢ Total Square Feet of Faci
➢ Number of Floors on which
operations are conducted
➢ Maximum Daily Meals to be Served: ➢ Breakfast
(approximate number) ➢ Lunch
➢ Dinner
Type of Service: Sit Doi 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
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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
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)
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 I I 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.
: proposed menu, seating capacity, and projected daily meal volume for food service operations.
3. Sow the location of each piece of equipment. Each must be clearly labeled on the plan with its common
3a ne. 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.
and locate separate food preparation sinks when the menu dictates to preclude contamination and
ntarnination of rativ and ready -to -eat foods.
¢. Clearly designate adequate hand washing lavatories for each toilet fixture and in the immediate area of food
p.•eparation, 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.
On the plan, represent auxiliary areas such as storage rooms, garbage rooms, toilets, basements and/or cellars
ell for storage or food preparation. Show all features of these rooms.
de and provide specifications for:
exits, loading/unloading areas and docks;
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
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d. Lig ting schedule with protectors;
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;
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
rnsils
least 540 lux (50 foot candles) at a surface where a food employee is working with food or working with
or equipment such as knives, slicers, grinders, or saws where employee safety is a factor.
hod Equipment schedule to include make and model numbers and listing of equipment that is certified or
Med for sanitation by an ANSI accredited certification program (when applicable).
of water supply and method of sewage disposal. Provide the location of these facilities and submit
that state and local regulations are complied with;
A,Xop sink or curbed cleaning facility with facilities for hanging wet mops;
Garbage can washing area/facility;
for storing toxic chemicals;
rooms, locker areas, employee rest areas, and/or coat rack as required;
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* (YES) (NO)
1. Thin meats, poultry, fish, eg (hamburger; sliced meats; fillets) O ( )
2. Thick meats, whole poultry (roa beef; whole turkey, chickens, hams) O ( )
3. Cold processed foods (salads, sande: ches, vegetables)
4. Hot processed foods (soups, stews, rice oodles, 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-- Pax: 978.688.8476 Page 4 of 20
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5. Bakery goods (pies, custards, creat fillings & toppings)
6. Other
FOOD SUPPLIESS:
I. Are all food supp`I'es from inspected and approve\et
ces? YES / NO
2. What are the project frequencies (daily, weeklyof deliveries for Frozen foods ,
Refrigerated foods and Div goods
3. Provide information on the tnount of space (in cubic
Dry storage ,
Refrigerated Storage and
for:
Frozen storage
4, ow will dr ds be stored off the floor?
A.
�3
f� A lv�
rnim cTnuArr.! 14wv
1. ' I"dequafe and approved freezer and refrigeration available to store frozen foods frozen, and refrigerated
foods at 41 °F (5°C) and below? YES / NO
2. Will raw meats, 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?
3. Does each refrigerator/fi-eezer have a thermometer? YES / NO
Number of refrigeration units:
Number of freezer units:
4. Is there a bulk ice machine available? YES / NO Is ice packaged and sold for retail? YES/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 5 of 20
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THAWING FROM POTENTIALLY HAZARDOUS FOOD:
Please indicate by checking a appropriate boxes how frozen potentially hazardous foods (PHF's) in each
category will be thawed. More an one method may apply. Also, indicate where thawing will take place.
Food Thawing Method
Thick or Bulk Frozen
*Thin/Portioned Frozen
Refrigeration
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.
11 food employees be trained in good food sanitation practices? YES /NO
Dd of training:
of employees:
of completion:
'ill disposable gloves and/or utensils and/or food grade paper be used to prevent handling of ready -to -eat
s? YES /NO
Is there a written policy to exclude or restrict food workers who are sick or have infected cuts and lesions?
:S /NO Please describe briefly:
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
employees have paid sick leave? YES / NO
5. w will cooking equipment, cutting boards, counter tops and other food contact surfaces which cannot be
merged in sinks or put through a dishwasher be sanitized?
Chemical Type:
Concentration:
Test Kit: YES / NO
6. Will ingredients r cold ready -to -eat foods ►ch as tura, mayonnaise and eggs for salads and sandwiches be
pre -chilled beforeber ►nixed and/or assembled YES/NO
If not, how will re=ods foods be cooled to 41°
7. W'fl all produce be washed on-site prior to use? YES / NO
?�
there a planned location used for washing produce? YES /NO � V
Describe �� r
If not, describe the procedure for cleaning and sanitizing multiple use sinks between uses.
8. Describe the procedure used for r 'nimizing the length of time PHF's will be kept in the temperature danger
zone (41T - 140°F) during preparatio
Town of North Andover, Health Department,1600 Osgood Stre , uildhig 20; Suite 2-36,
North Andover, MA 01845^ --Phone: 978.688.9540-- Fax: 978.688.8476 Page 7 of 20
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Where raw meats, poultry an eafood are prepared in a satne work area or using the same equipment as
c oled/ready to eat foods, how wi cross contamination be revented?
10. Please list all PHF's you bl�n to serve which wil may not be cooked to the previously listed minimum
temperatures. A proper "consum r advisory" warningRotation must be printed on menu or menu boards.
�1I. Provide a HACCP plan for�specia\HW processing methods such as vacuum packaged food items prepared`"
on=sitp or otherwise required by the regulatory authority.
�2. Will the facility be serving food to a highly susceptible population? YES / NO
If yes, List measures taken to comply with code requirements.
COOKING:
1. WIII fooroduct thermometers be used to measure final cooking/reheating temperatures of PHF's?
YES/NO What pe of temperature measuring device:
➢ eefroasts ➢ 130°F (121
Mill)
➢ soli afood pieces ➢ 145°F (15 see)
➢ other PH ➢ 145T (15 sec)
➢ eggs:
■ Immediate se ' e 145T (15 sec) pooled` 155T (15 sec)
(*pasteurized eggs muX
ly susceptible population)
➢ pork➢ 1450F (15 sec)
➢ commin➢ 155T (15 see)
➢ poultry➢ 165°F (15 sec)
➢ reheated ➢ 165°F (15 sec)
�2. List types of cooking equipment.
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
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HOT/COLD HOLDING:
1. How will hot PI F's be maintained at 140°F (60°C) or above during holding for service? Indicate type and
number of hot holding units.
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,
COOLING:
Please indicate by checking the appropriate boxes how PHF's will a cooled to 41°F (5°C) within 6 hours
(140°F to 70°F in 2.� 7rs and 70°F to 41°F in 4 hours), Also, indic e where the cooling will take place.
COOLING
THIC
THIN MEATS
THIN SOUP /
THICK
RICE/
METHOD
MEAT
GRAVY
SOUPS/
NOODLES
GRAVY,
Shallow Pans
Ice Baths
Reduce
Volume or Size
Rapid Chill
--___.---
--
-----
------_�__
I. Other (describe)
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 t 1 .5°F for hot holding be a rapidly and within 2 hours?
- tii �
A. NISH 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)
%MFOff [FLOORCOVINGWALLS CEILING
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
Bar(6� � �~ ��
t� �
tFCfbd'�Ctorage
Othe Storage
Toilet Rooms
L
Dressing Rooms
Kitchen
Garbage &
Refuse Storage
O
3.
Mop Service
Basin Area
Warewashing
Area
Walk-in
Refrigerators and
Freezers
INSECT & RODENT CONTROL
APPLICANT., PLEASE CHECKAPPROPRIATE BOXES
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
YES
NO
N/A
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2. Are screen doors provide n all entrances Left open to ie outside?
3. Do all openable windows have a num #16 mesh screens ?
4. Is the placement of electrocution devic identified on the plan?
5. Will all pipes & electrics[ conduit chases be sea d; ventilation systems
exhaust and intakes protected?
6. Is area around building clear of unnecessary brash, litter, b •es and other
harborage?
7. Will air curtains be used? If yes, where?
8. Da you have a plan to have a contract pest control company? If yes, list
company name, describe frequency of inspection and type of service.
3.
Mop Service
Basin Area
Warewashing
Area
Walk-in
Refrigerators and
Freezers
INSECT & RODENT CONTROL
APPLICANT., PLEASE CHECKAPPROPRIATE BOXES
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
YES
NO
N/A
1. Will all outside doo Ueself-closing and rodent p • of?
2. Are screen doors provide n all entrances Left open to ie outside?
3. Do all openable windows have a num #16 mesh screens ?
4. Is the placement of electrocution devic identified on the plan?
5. Will all pipes & electrics[ conduit chases be sea d; ventilation systems
exhaust and intakes protected?
6. Is area around building clear of unnecessary brash, litter, b •es and other
harborage?
7. Will air curtains be used? If yes, where?
8. Da you have a plan to have a contract pest control company? If yes, list
company name, describe frequency of inspection and type of service.
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C. GARBAGE AND REFUSE
INSIDE
YES
NO
N/A
9. Do all containers have lids?
10. Will refuse b stored inside? If so, where?
11. Is there an area esignated for a garbage n or floor mat cleaning?
OUTSIDE
12. Will a dumpster be 1111d? Number: Size of-.—
fa.
a.Number:
b. Size of: \ V
c. Frequency of Pick -Up? Indicate ays 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 a to
be stored.
16. Describe location of grease storage receptacle
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, Building 20; Suite 2-36,
North Andover, MA 01845 --Phone: 978.688.9540-- Fax: 978.688.8476 Page 12 of 20
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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 nitial
Dish Machii
Backflow prevention
^
device
Indirect Waste
Stearn Jacketed
ackflow prevention
Kettle
de 'cc
Indirect Vaste
Steamer
Backflow preve tion
device
Indirect waste
Garbage Disposals
Backflow prevention
_M
or dish table
device
troughs;
Submerged inlets
At all hose
Backflow prevention
connections
device
Garbage can
Backflow prevention
washer
device
Carbonated
Carbonated Backflow
beverage
prevention device
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
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Refrigerator Indirect waste
condensate/ dram
lines
Ice storage bins
rdirect waste`
All sinks
Air Gap
Ice Cream dipper
Air Gap
wells
Other
Are floor drains ovided & easily cleanable, if so, ' dicate to tion:
E. WAT SUPPLY
20. water suppl ublic O or private O ?
21. If private, has source en approved? YES () NO {)PENDING ( )
Please attach copy of written ap val and/or permit.
22. Is ice made on premises O or pure ed commercially (}7
If made on premise, are specifications for the ice mac ' ie provided? YES O NO ( )
Describe provision for ice scoop storage:
Provide location of ice maker or bagging operation
23. What is the capacity of the hot water generator?
Town of North Andover, Health Department, 1600 Osgood Street, Building 20; Suite 2-36,
North Andover, MA 01845 --Phone: 978.688.9540-- Pax: 978.688.8476 Page 14 of 20
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24. Is the hot wate%eneeratorhot water
25. Is there a wate
If yes, how will the device be
sufficient for theeed
device? YES () NO\(,
insp ted & serviced?
of the establishment? Provide calculations for necessary
26. How are backflow prevention devices inspected & serviced?
T. SEWAGE DIS]
27. Is building oni
28. If no, is private
Please attach copy
toamu
system
approval and/or
29. Are grease traps provided?
If so - where?
YES( ) NO ( )
YES () NO () PENDING ( )
i
YES ( ) NO ( )
Note: Grease Traps must have the following sign. The language in bis specific; please do not change It in any
way. If you have one or more Interior grease traps please note the plumbin ode 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 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? ES ( ) NO ( )
31. Describe storage facilities for employ\persoingings (i.e., purse, c ts, boots, umbrelIas,etc.)
Town of North Andover, Health Department, 1600 Osgood Street, Building 20; Suite 2-36,
North Andover, MA 01845—Plione: 978.688.9540-- Fax: 978.688.8476 Page 15 of 20
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Are insecticides/rodenticides stored separately from cleaning & sanitizing agents? YES ( ) NO ( )
Indicate location:
33. Are all toxics for use on the premise or for retail sale (this includes personal medications), stored away from
food preparation and storage areas? YES ( ) NO ( )
34. Are all containers of toxics including sanitizing spray bottles clearly labeled? YES( ) NO ( )
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 1 undered on site? YES( ) NO ( )
If yes, what will be lau dered and where?
If no, how will linens be cl ned?
36. Is a laundry dryer available YES O NO (' )
37. Location of clean linen storag
38. Location of dirty linen storage:
39. Are containers constructed of safe ma rials to store bulk food pro cts? YES ( ) NO: ( )
Indicate type:
40. Indicate all areas where exhaust hoods are installed:
LOCATION
FILTERS WOR
EXTRACTION
DEVICES
SQUARE BEET
FIRE
PROTECTON
AIR CAPACITY
CFM
AIR MAKEUP
CFM
Town of North Andover, Health Deparhnent,1600 Osgood Street, Building 20; Suite 2-36,
Forth Andover, MA 01845 --Phone: 978.688.9540^-- Fax: 978.688.8476 Page 16 of 20
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41. How is each listed ventilation hood system cleaned?
I. SINKS
42, Is a mop sink present? YES () NO ( )
If no, please describe facility for cleaning f mops and other a iipment:
43. If the menu dictates, is a food preparation sin resent? YES O O detail answer
J. D HWAS GFACILITIES
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 ( )
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 O NO ( )
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()NO()
50. What type of sanitizer is used?
nChlorine
alodine
oQuaternary
ammonium
oHot Water
nOther
51. Are test papers and/or kits available for checking sanitizer concentration? YES ( ) NO ( )
K.
52. Is there handwashing sick in each fda preparation, cooking and warewashing area? YES O NO ( )
53. Do all handy shing sinks, including those i\restrooms, have a mixing valve or combination faucet?
YES()NO54. Do self-closing meter' g faucets provide a flor at least 15 seconds without the need to
reactivate the faucet? YES NO ( )
55. Is hand cleanser available at a\asinking sinks? YES ( ) 0 ( )
56. Are hand drying facilities (patoair blowers, etc.} at all han washing sinks? YES (} NO ( }
57. Are covered waste receptacleeach restroom? YES O NO
58. Is hot and cold running water ure ailable at each handtivashing sin YES O NO59. Are all toilet room doors self -S O NO }60. Are all toilet rooms equipped te ventilation? S( ) NO (
61. Are handwashing signs and instructions posted in each employerrestroom? YES ( ) NO ( )
Town of North Andover, Health Department, 1600 Osgood Street, Building 20; Suite 2-36,
North Andover, MA 01845 --Phone: 978.688.9540-- rax: 978.688.8476 Page 18 of 20
C
L. SMALL EQUIPMENT REQUIREMENTS
62. Please ecify the number, location, and types of each of the following proposed for on site use:
Slicers
Cutting boards
Can openers
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Mixers
Floor mats
Other
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STATEMENT: Y hereby certify that the above information is correct, and I fully understand that any
deviation fro the above withor t prior permission from this Health Regulatory Office may nullify final
approval
Signature(s) (moi
Print:� o l� 1
owner(s) or responsible representative(s)
Date:. 7 0 t
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 Iocal, It further does not
constitute endorsement or acceptance of tine 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
Town of North Andover, Health Deparhnent,1600 Osgood Street, Building 20; Suite 2-36,
North Andover, MA 01845 --Phone: 978.688.9540-- Fax; 978.688.8476 Page 19 of 20
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PROPOSED FLOOR PLAN
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DINING ROOM RENOVATION
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2, T.� MULLANEY DR. T.DESIGN ®COMCAST.NET
RANDOLPH, MA. 02368 6'17-797-6637
733 TURNPIKE STREET
NORTH ANDOVER MASSACHUSETTS
CHECKED: 7N
DATE: O6/0
APPROVED: INH