Loading...
HomeMy WebLinkAboutJimmys Famous Pizza - Permits - 1591 OSGOOD STREET 3/9/2020 COMMONWEALTH OF MASSACHUSETTS NUMBER • �flll�� / i BHP-2018-0641 North Andover BOARD OF HEALTH FEE $185.00 Jimmy's Famous Pizza j DATE ISSUED t NAME March 01,2019 h 1595 Osgood Street Attn: Permit Renewals NORTH ANDOVER, MA 01845 1 ---------------------- - - .------------ ADDRESS IS HEREBY GRANTED A Food Est. -Restaurant Permit Food Establishment-Restaurant This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires February 28,2020 unless sooner suspended or revoked. RESTRICTIONS: Food Service:44 seats;Takeout;Delivery; 7 food employees ----------------------------------------------------- BOARD OF NOTES: Contact:Frank Stamos 978.685.7776 — HEALTH -- �. -- info@jimmysfamouspizza.com - �n HOURS ACTIVE: Open 7 days loam-IOpm BOARD OF HEALTH CHAIRMAN i FRI 0AUuX06NdS8HPL0A690Nnm=j 4—fd/sluewAed/woD-odijls*pjeoqt4sep//:sdllq Reference No: BHF-2002-000060 ................................... Permit No- BHP-2018-0641 Department, ................................... North over BOARD OF HEALTH ......................................................................................... 0 Account No: 2031207.1.5.0510.0 Fee Type: ................................... Food Est. -Restaurant Rec6pt No; REC-20,19­000162 ......................................................................................... ................................... Paid By.- Paid in FtA On: Mon Jan 28,2019 ................................... W-elats,,Inc., ...........0.............................................................................. Check No: 2016 Received By: .................................... Toni Wolfenden ........................................................................................ DEPARTMENT'S COPY Amount: $185.00 L....................................................................................................................................... . ....................j E)dij)S—A06'eWJ0A0pU8qjJ0U—pjeoqqsea OZOV94 TOWN OF NORTH ANDOVER �� ' ,,,'. 61Community and Economic Development d� HEALTH DEPAI2TMI'ENT 120 Main St. NORT14 ANDOVER,MASSACHUSETTS 01845 'u�4ykr+ Phone: 978.688,9540 Fax: 978.688,9542 E-mail:healthdept@northandoverma.gov FOOD ESTABLISHMENT PERMIT APPLICATION (If neiv establishment,application must be submttled at least 30 days before the planned opening date) FEE: Depends on type of food establishment—Refer to your current permit or call the Health Department for fee amount 1. Establishment Name: 7i lV) -'.S 1YUq1S A T2"'X Date: 2. Establishment Address 15e1 5 (9!"& )OD sr Pv.,'N- 3, Establishment Mailing Address(if different) 4. Establishment Telephone#: '� 5, Applicant Name&Title: fleApVc Twgol&/ L71�tYL 6. Applicant Address: ;�j c466!' ram) or)7-4-44, !4 01 Y A 3 7. Applicant Telephone No.: Nr ' ,L 127 24-Hour Emergency No.: vY" ,C 8. Owner Name&Title(if different form applicant): 9. Owner Address(if different from applicant): 10. Establishment Owned By: 11. If a corporation or partnership,give name,title,and 0 An Association;E1A Corporation; An individual home address of the officers or partner: Name 'Title Home Address ❑A partnership;0 other legal entity tr144}7 Nk k A' 5^5hA CA 0i GC 12. Person Directly Responsible for Daily Operations( wner,Person in Charge,Supervisor,Manager, c. Name&Title: v. 57V' 5 Address; Telephone No,: Fax No.: E-mail: Emergency Telephone No.: j 13. District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No.: Fax No.: E-mail: 14. Water Source: 15. Sewage Disposal: DEP Public Water Supply No.:(if applicable) 16. Days and Hours of Operation: 17.No.of Food Employees Page I of 3 i i �` • 9 q tiA''9` 7w �eA -«�' +'J �, e +d F�. }M +�d y �Ar i-T a0 'g'lY�- -- -�' f...... ------- � - -;- ------- '���.%.�- .�..rd�G:JtE7r�"� !:.-;txFy----------- CERTIFICATE OF r� ALLERGEN E . i t V;:.,., Fotio8 Staino» j/\ , ..,� r%' r.`•.� ter,,}; 12 1. U v�Jlti ''11�d4�UV� r. �'e1 r)��yy��� `-��A EZ`��r'y �-•��'F?f -r 1•�.�i}�,�,g�'%{ ��:�'ci�(�1,rrTj..,.'``"..-'���..^'r� '"•�'���t7"�.'r� C"�`�'�,.'�u4'��T' r ,� :` ,. r'-_�'� •♦ •'�,;��- �e•� �tirati `u,. i?R>. ��� shy. `G �' k., ERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: FOTIOS STAMOS Certificate Number: 3748350 Date of Completion: 1/28/2019 Date of Expiration: 1/2812024 ® r Issued By: ✓r'ri%lir Zhe above—named person is hereby issued this certificate �, or completing an allergen awareness trainin ro amMIN 1�1 STAU�w� f p 8 8p ' ' R "r . recognized by the Massachusetts Department of Public Health _ _.. Am wN110, A S CIAT ION O in accordance with 105 CMR 590.009(G)(3)(a). 1Vlassachusctts Restaurant Association 800.765.2122 333 Turnpike Road,Suite 102 www.restaur.int.org Southborough,MA 01772 ?his certificate will be valid for five(5)years from date of completion. 508-303-9905 www.marestaurantassoc.org , - a afn...�:�.....sa_...��;us:._r.:�.._s�*..__.m;_ .�_..✓.. :._.e.:..�. .:u__s,�..�:�.._t:�_.:;�.___.r.:e��e._ra_s�-16 Tirstmald ( 100 jty nd Proudly presents this "Certificate of Attendance"to Frmw k S+ames For participating in the training and demonstrating rogram Sponsor: skills S.A.F.E.—NS he Port Tavern Training Agenc 4 State St No. 62555 ewburyport,N A 01950 For www.choksaver.co A � 2 Hr Program conducted by � This 12th day of May, 2014. -Mn— /G r n Gunther Wellenstein, EMT Re *X,f)Meets Mass DPH 105 CMR 590.009 Instructor (No. 0489749) a ter. I' ervSafe CERTIFICATION NICHOLAS PAPANTONAKIS For successfully completing the standards set forth for the ServSofe®Food Protection Manager Certification Examination, & which is accredited by the American National Standards Institute(ANSI)-Conference for Food Protection(CFP). 1 i "�Yrva 3q t 4 5285 4 ER EXAM FORM NUMBER 1/11/2018 1/11/2023 5 DATE OF EX t, . DATE OF EXPIRATION Local laws apply.Cha q cy For recertification requirements. Sheri ciation Solutions Ell In aawrt3a� S-6 69.are tr cl &of it.Wff.Nmi "Resi—t A—id h.& r.J the me deign Contact—Uh questronz of 233 S.W d.06iv,Suit.3600,Chid,iL 6060G6363 or SercSate®mslourant atg. �4 CERTIFICATION ervSafe7 For successfully completing the standards set forth for the ServSafe®Food Protection Manager Certification Examination, which is accredited 6y the American National Standards Institute(ANSI-Conference for Food Protection(CFP). �� 44 5285 ER EXAM FORM NUMBER 1/11/2018 1/11/2023 DATE OF EX DATE OF EXPIRATION Local laws opply.Che cy for recerfification requirements. Sher action Solutions 17� 0 A in acm:dor� e ServSafe lap ors kodanado�dta hQtAEF.Nalioral Reslaxanl Auai afion�and ilre arc dmi� C bd.With qu.6—ar 233 S.W-6rDma,&AW UW,Chicago,L 6D606-6383wSarvSde@rashwonrorg. .............................. .......... ........................................................... tt COMMONWEALTH OF MASSACHUSETTS NUMBER BHP-2019-0118 North Andover BOARD OF HEALTH FEE $60.00 Jimmy's Famous Pizza DATE ISSUED NAME May 14,2019 1595 Osgood Street Attn: Permit Renewals NORTH ANDOVER, MA 01845 ---------------------- --------1--------------------------—- ------------- ------------------------- ADDRESS IS HEREBY GRANTED A Food Est. - Seasonal Permit Food Establishment-Seasonal PERMIT This permit is granted in conformity with the Statutes and ordinances relating thereto,and expires October 01,2019 unless sooner suspended or revoked. RESTRICTIONS: Carl Thomas Field-60 Dana Street North Andover,MA 01845 -----.... ------ ----------------- mr, BOARD OF ......... HEALTH NOTES: Contact: Frank Starnes 978-685-7776 i r ------------------------------- ---------------------------- ----------- HOURS ACTIVE:weekends-close at dusk BOARD OF HEALTH CHAIRMAN ............. .......... .............. ................................... --—------- ---—-------------- ZiZ 6 WZ/LZ/Z b TOWN OF NORTH ANDOVER d Commun>iity and Economic Development HEALTH DEPARTMENT 120 Main St. NORTH ANDOVER,MASSACHUSETTS 01845 Phone: 978.688.9540 Fax: 978.688.9542 E-mail:healthdept,@northandoverma.gov FOOD ESTABLISHMENT PERMIT APPLICATION (Ifnew establishment,application must be submitted at least 30 days before the planned opening date) FEE: Depends on type of food establishment•-Refer to your current permit or call the Health Department for fee amount 1. Establishment Name: ""-n lvl o ° i u"el Date: 2. Establishment Address r o '")a,, 3. Establishment Mailing Address if different) 4. Establishment Telephone#. el7i, 6t15­'7,34-(. 5. Applicant Name&Title: 6• Applicant Address: 7. Applicant Telephone No.: (F° _ 24-Hour Emergency No.: 5 8. Owner Name&Title(if different form applicant): < dk wLk 9. Owner Address(if different from applicant): 10. Establishment Owned By: 11. If a corporation or partnership,give name,title,and ❑An Association;O A Corporation;o An individual home address of the officers of partner Name Title Home Address ❑A partnership;❑other legal entity 12. Person Directly Responsible for Daily Operations( wner,Person in charge,Supervisor,Manager, c. Name&Title: :�k V,t '.. (I l" 0J. Address: is"( r i' t'W41Am Telephone No.: bd° " ,..`"l 3 5S1.4 Fax No.: E-mail: Emergency Telephone No.: 13. District or Regional Supervisor(if applicable) Name&Title: Address; Telephone No.: Fax No.: E-mail: 14. Water Source: 15. Sewage Disposal: DEP Public Water Supply No.:(if applicable) 16. Days and Hours of Operation: 17,No.of Food Employees Page 1 of 3 NAME OF ESTABLISHMENT: 18. Name of Person in Charge—Certified in Food Protection Management(regnirerl as of 101112001 in accor(lance Wth 105 CMR 590.003(A)please attach copy of cerliTcate): 19. Person Trained in Anti-Choking Procedures(if 25 seats or more: OYes ONo) NAME: 21. Length of Permit:(check one) 20. Location: (check one) ❑Annual ❑Permanent Structure 0 Seasonal/Dates: ❑Mobile 1 _ U� ❑Temporary/Dates/Time: 22. Establishment Type(check all that apply): � ❑ Retail( square feet) ❑ Food Service—( seats) ❑ Food Service—Takeout ❑ Food Service—Institution( Meals per day) ❑ Caterer ❑ Food Delivery ❑ Residential Kitchen for Retail Sale ❑ Residential Kitchen for Bed and Breakfast Home ❑ Residential Kitchen for Bed and Breakfast Establishments ❑ Frozen Dessert Manufacturer J3 Other(Describe) 23. Food Operations(check all that apply)—DEFINITIONS: ➢ PHI+—potential hazardous food(time/temperature controls required); ➢ Non-PMIs—non-potentially hazardous food(no time/temperature controls required); ➢ RTE—ready-to-eat foods(Ex,sandwiches,salads,muffins,which need no further processing 1� Sale of Commercially Pre-Packaged Non-PHF's ❑ PHF Cooked to Order ❑ Hot PET Cooked and Cooled or Hot Held for More than a Single Meal Service ❑ Sale of Commercially Pre-Packaged PHFs ❑ Preparation of PHFs for Hot and Cold Holding for Single Meal Service ❑ PET and RTE Foods Prepared for Highly Susceptible Population Facility ❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to be prepared by Consumer ❑ Vacuum Packaging/Cook Chill ❑ Reheating of Commercially Processed Foods for Service within 4 hours ❑ Customer Self-Service ❑ Use of Process Requiring a Variance And/Or HACCP Plan(including bare hand contact alternative,time as a public health control) ❑ Customer Self-Service of Non PHF and Non-Perishable Foods Only ❑ Ice Manufactured and Packaged for Retail Sale ❑ Offers Raw or Undercooked Food of Animal Origin ❑ Preparation of Non-PHFs ❑ Juice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single Meals for Catered Events of Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage,Out-of-Date or Reconditioned Food ❑ Other(Describe): Page 2 of 3 NAME OF ESTABLISHMENT; **IF YOU DO NOT RENEW BY FEBRUA'RY 28",THE FEE WILL DOUBLE" Please include copies of current Serve Safe/Allergen Trahsin,g/C/role Saver Certifications I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and Article X of the State Sanitary Code,and all other applicable law. I have been instructed by the Board of Health on how to obtain copies oF10 MR 590.000 and the Federal Food Code. a. 24. Signature of Applicant: Signature Print Name Pursuant to MGL Ch. 62C,sec.49A,1 cerfy under the penalties ofpe)jwy that 1, to my best knou,ledge and belief,havefilled all state tax returns and paid state taxes required under the law 25. Signature of Individual or Corporate Name: Signature Print Name l c 11 il 4i ke vo l L7 Page 3 of 3 k-... t- RTIFICATE OF ALLERGEN AWARENESS TRAINING Dame of Recipient: FOTIOS STAMOS Certificate Dumber: 3748350 Date of Completion: 1t28/2019 Date of Expiration: 1/28/2024 O ❑ r�'� Issued By: r�l� The above-named person is hereby issued this cert#7cate - E`dATIONA,L for completing an allergen awareness training program �END R4W tlW@�4I E RESTAURANT � recognized by the Massachusetts Department of Public Health s ! ASSOCIAT1CN in accordance with 105 CMP,59O.009(G)(3)(a). Massachusetts Restaurant Association 800.765.2122 333 Turnpike Road,Suite 102 .xwwvrestaurant.org Southborough,MA 01772 This certificate will be valid for five(5)years from date ofcompletion. 508-303-9905 vwwvmarestaurantassoc.org f ♦ ♦ ♦ ♦ ♦ ♦ *A -Ed U ccl st aw tin d 1w f Proudly presents this "Certificate of Attendance"to Fr&%% k shines For participating in the training and demonstrating ro rain 5 onsor: skirls S.r�.F.E.—ITS �a he Port Tavern Training Agent e 4 State St No. 62555 ewburyport,MA 01950 e For www.choksaver.ca g s w of er Rw 2 Hr Program conducted by (Q This 12th day of Q May, 2014. - - Gunther Wellenstein, EMT Re � Oftets Mass DPx 105 CMtz 590.009 Instructor (No. 0489749)NIV ( l N4V •r----��---a ;--v«�--~�;�---�;�—�:;��--�•r----v:�—wc+----vr--er--vr-�r��--��s:�---•cr----»---�,;r--.::�r-^�wv--ar--e�---.,ice f t p t I r I' ervSafeo CERTIFICATION NICHOLAS PAPANTONAKIS for successfully completing the standards set forth for the ServSafe®Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute(ANSIKonference for Food Protection(CFP). 5285` s �t ER EXAM FORM, NUMBER 1/11/2018 1/11/2023 xasss DATE OF EX „ ' (, ,- DATE OF EXPIRATION A„TmMsl Local laws apply.Ch cy For recertification requirements. t � to ( Sher F' ciation Solutions p in acmrdonctr o ServSofe logo are trademarks d IhoNRAEF.Notiano(ReslouronlAssaiatior�and the arc design Contvd.:Vah ci—r—a 233 S.Wadrer Dri,.,Suite 3600,Chimgo,IL 60606-6383 or ServSote@res1—torg. ervSafee CERTIFICATION F T' V/ STAMOS : A for successfully completing the standards so forth for the ServSafee Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute(ANSI)-Conference for Food Protection(CFP). 5285 G ER EXAM FORM NUMBER d 1/11/2018 '^ 1/11/2023 -qd5� DATE OF EX + + il ,m'^f, DATE OF EXPIRATION c" �59a local laws apply.Ch cy for recertification requirements. b�Y Sher ciation Solutions In accordanoa wi , e ServSofe logo arahademoda aF the NRAEF.tdatiatml Reslaur tAssogotiort9 and the arc design Contest us with questions of 233 S.Wack=r N.,Suite 3600,CN go,II_60606-6383 or ServS.W-tuumntorg. pw n Y Town of.North Andover HEALTH DEPARTMENT 1'SSACNUSYy CHECK#: 3 DATE: ". o/ LOCATION � w� ) w H/O NAME: 141 CONTRACTOR NAME: Type of Permit or License: (Check box) 0 Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ Food Service-Type: w ��w. °i $ 66 ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems; ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $� ❑ Title 5 Report $ ❑ Other;(Indicate) $ HeeaX'tIAgentInitials White-Applicant Yellow d Health Pink A Treasurer 12/26/2019 2/2 / ) / � This permit is granted in conformity with the Statutes and ordinances relating thereto, and | | 12/2412019 .............. ...... ........ Reference No- BHF-.2002-000060 .................................. Permit No- BHP-2017­0966 Department- ................................... North Andover BOARD OF HEALTH ......................................................................................... Account No: 2031207.1.5.0510.00 FeeType- .................................... Food Est. - Restaurant Receipt No: REC-20,18-.000381 ........................................................................................ .................................... PaW By: Paid in FU Ow Mon Jan 29,2018 .................................... Jimmy's Famous Pizza ...................B...................................................................... Check Cho; 1739 Received y- .................................... To Wolfenden ........................................................................................ DEPARTMEN'r,s copy Amount- $185.00 ................ L....................................................................................................................................................... ......... 2/2 tt TOWN OF NORTH ANDO'VEI21�161�N„ n,', Community and Economic Development 00 %% HEALTH DEPARTMENT 120 Main St. 1 NORTH ANDOVER,MASSAC14USETTS 01845 Phone: 978.688.9540 Fax: 978.688.9542 E-mail:healthdept@iiorthandoverma.cov FOOD ESTABLISHMENT PERMIT APPLICATION (/f neu,establishment,application must be subinlued at least 30 days before the planned opening dale) FEE: Depends on type of food establishment—Refer to your current permit or call the Health Department for fee amount 1. Establishment Name: J i M !S Ica u S' 1012 M Dater 2. Establishment Address /51 _5' 0�6 b 0 P 5'-(, /16070 0--,�JPej VC—C 3. Establishment Mailing Address(if different) 4. Establishment Telephone#: , + 6 v�; " T7 7 6 5. Applicant Name&Title: Fykv, 1, 'S"l-ci Y'HaY Ce o W^Z"Z '2_ 1,ty �+.to � � p� �l W 6. Applicant Address: ��� ��� b 7. Applicant Telephone No.: 6 0 1-13 95.,5 7 24-Hour Emergency No.: S u WQ_ 8. Owner Name&Title(if different form applicant): 9. Owner Address(if different from applicant): 10. Establishment Owned By: 11. If a corporation or partnership,give name,title,and ❑An Association;KA Corporation;0 An individual home address of the officers or partner: Name Title Home Address ❑A partnership;0 other legal entity. k 3'"���vs Pis U b tive 0 1 c L, 12. Person Directly Responsible for Daily Operations(Owner,Person in Charge,Supervisor,IvianagerfE e. Name&Title: � 'S'jtyr'03 - (,(,) - owft-e- Address: ,�Gtl Gil' a6v-( Telephone No.: Fax No.: E-mail: Emergency Telephone No.: 1.3. District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No.: Fax No.: E-mail: 14. Water Source: 15. Sewage Disposal: DEP Public Water Supply No.:(if applicable) s ey 4 C 16. Days and Hours of Operation: 17.No.of Food Employees Page 1 of 3 NAME OF ESTABLISHMENT: 18. Name of Person in Charge—Certified in Food Protection Management(regnh-ed as of 101112001 in accordance Wth 105 CMR 590.003(A)Please attach com of certificate): � 19. Person Trained in Anti-Choking Procedures(if 25 seats or more: ❑Yes ❑No) NAME: 21. Length of Permit: (clieck one) I 20. Location: (check one) mival ❑'f,ermanent Structure ❑Seasonal/Dates: ❑Mobile ❑Temporary/Dates/Tine: 22. Establishment Type(check all that apply): ❑ Retail( square feet) 9—Food Service—( Ll 5 seats) ❑ Food Service—Takeout ❑ Food Service—Institution( Meals per day) ❑ Caterer ❑ Food Delivery ❑ Residential Kitchen for Retail Sale j ❑ Residential Kitchen for Bed and Breakfast Home ❑ Residential Kitchen for Bed and Breakfast Establishments ❑ Frozen Dessert Manufacturer ❑ Other(Describe) i 23. Food Operations(check all that apply)—DEFINITIONS: ➢ PHF—potential hazardous food(time/temperature controls required); ➢ Non-PHFs—non-potentially hazardous food(no time/temperature controls required); RTE—ready-to-eat foods(Ex.-sandwiches,salads,muffins,which need no further processing ❑ Sale of Commercially Pre-Packaged Non-PHF's P� PHF Cooked to Order ❑ Hot PHF Cooked and Cooled or Hot Held for More than a Single Meal Service ❑ Sale of Commercially Pre-Packaged PHFs ❑ Preparation of PHFs for Hot and Cold Holding for Single Meal Service ❑ PHF and RTE Foods Prepared for Highly Susceptible Population Facility ❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to be prepared by Consumer ❑ Vacuum Packaging/Cook Chill ❑ Reheating of Commercially Processed Foods for Service within 4 hours ❑ Customer Self-Service ❑ Use of Process Requiring a Variance And/Or HACCP Plan(including bare hand contact alternative,time as a public health control) I ❑ Customer Self-Service of Non PHF and Non-Perishable Foods Only ❑ Ice Manufactured and Packaged for Retail Sale ❑ Offers Raw or Undercooked Food of Animal Origin ❑ Preparation of Non-PHFs ❑ Juice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single Meals for Catered Events of Institutional Food Service ❑ Offers RTE PHF in Bull<Quantities ❑ Retail Sale of Salvage,Out-of-Date or Reconditioned Food ❑ Other(Describe): Page 2 of 3 NAME OF ESTABLISHMENT: ( f jyVr -1"1. �(Z&4 **IF YOU DO NOT RENEW BY FEI3RUARY 28"',THE F"EE WILL DOUBLE** Please include copies of crrrrerrt Serve Safe%Allergen TraininglChoke Saver Cerlificatiotts I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and Article X of the State Sanitary Code,and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of III LR 90.000 and the Federal Food Code. 24. Signature of Applicant: signatur Print Name Pursuant to 11GL Ch. 62C, sec. 49A,1 certify under the penalties ofperjzny that I, to my best knowledge and belief, have filled all state tax returns and paid state taxes required under-the law. 25. Signature of Individual or Corporate Name: Signature Print Name E Page 3 of 3 �y y ervSafe CERTIFICATION FOTIOS STAMO for successfully completing the standards set forth for the ServSafee food Protection Manager Certification Examination, which is accredited lay the American National Standards Institute(ANSI)-Conference for Food Protection(CFP). " 5285 ` ? ER EXAM FORM NUMBER ' 1/11/2018 � �� t � � 1/11/2023 ass DATE OF EX �� DATE OF EXPIRATION Iler ofr Local laws apply.Che ct ry for recertification requirements. r � � Sher $t � v +s " c rs tciation Solutions per, ❑ In ' 'anoF a ServSaie logo aro krdema,6 of the NRAEF.Nationni Restaurant Assodatio .d and the arc design r a Concoct us wish q—tiiom at 233 S.Wadu;r Drive,Suite 3600,Chicogo,IL 60606-6383 or S—Saf -nauraN.org. } a� ervSafee CERTIFICATION N ICHOLAS PAPANTONAKIS for successfully completing the standards set forth for the ServSofe®Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute(ANSIKonference for Food Protection(CFP). 5285 ER EXAM FORM NUMBER t t» 111112018 N 1111/2023 DATE OF EX DATE OF EXPIRATION Local laws apply.Ch cY for recertification requirements. Sher �� r ciation Solutions L In oxd ry data�¢R�}: ' �� � x ie ServSa(e Ipgo ore nadanor.of the NRAEF.National Ere arc design Cantatl us witit questions at 233 S.Wacker Drive,Suite 3600,Chimp,IL 60606-6363 or 5en3aFeareslouranrorg. Vy DI Ogg XO f '4P irs ool 1 I-H r7i d� �lJ buy Ike wall ��VF go, coup �76 4,J i-Oo ae 0 4 P ...................................... -------.................... ...........- ------- COMMONWEALTH OF MASSACHUSETTS NUMBER BHP-2017-0135 North Andover BOARD OF HEALTH FEE $185.00 JipM's Famous Pizza DATE ISSUED NAME March 01,2017 ----------- 1595 Osgood Street Attn: Permit Renewals NORTH ANDOVER, MA 01845 ------------------------------------------------------------------------------------------------------------------ --------------------------------------------- ADDRESS IS HEREBY GRANTED A Food Est. - Restaurant Permit Food Establishment-Restaurant This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires February 28,2018 unless sooner suspended or revoked. RESTRICTIONS: Food Service:44 seats;Takeout;Delivery; 7 food employees ------------------------------------------------------------ BOARD OF ----------------------�7�----------------------------------- HEALTH NOTES: Contact:Frank Stamos 978.685.7776 ------------ ------I-------- -------------- ------------- ----------- HOURS ACTIVE: Open 7 days l0am-I Opm ------ ----- --------------------------- ------------------- BOARD OF HEALTH CHAIRMAN ........... ................ ziz �.................. ...... .. ... .. .......... ... ................ ................... .................................... , Reference No- B11F-2002-000060 Permit No: BlIP-2017-0136 Department:nt: ............... ............... North Andover BOARD OF EALT Type, ...................................................................... Account 1001001.1.5.0510.00 Fee ter PERMIT Receipt No, .EC-201 -001218 ReceivedPaid By: Paid in FuH Ow Thu Feb 23,2017 Triplets, Inc. s Check : 1474 ........................... Toni Wolfenden Amouft DEPARTMENT'S COPY $60.00 .......................................................................................................................................::::::::::::::::::::::::::..........; ...........................................................................................................................................................................� q Reference BlIF-2002-000060 Peat Pao: - . epa tm°�m nt: North Andover BOARD OF HEALTH ......................................................................................... Account t 6m : 7« �� IFe : .................................... Food Est. ,_Restaurant Receipt : EC-20,1"7- 01, . ............................................................................•---......... .................................... ; a Paul in FU On: '17hu Feb 23,2017 11`rq ................................... Check No-, 1474 Toni Wolfenden DEPAIRTMENT'S COPY' Amount- $185.00 �. ..................................................................................................................................:::::::::::::::::::::::::::.,. 6 b001Z/Z 4 TOWN OF NORTH ANDOVER Wm Community and Economic Developmenit HEALTH DEPARTMENT 120 Main St. NOWN-1 ANDOVER,MASSACI-IUSETTS 01845 Phone:978.688.9540 Fax: 978.688.9542 E-mail:healilideot namodhandoverma.ptov FOOD ESTABLISHMENT PERMIT APPLICATION (t(new est(ibllshtnent,qpplicallon inusl bessibintiled(st lease M days before the planned opening date) FEE: Depends on type of food establishment—Refer to your current permit or 611 the Health Department for fee amount 1. Establishment Name: :51'"43 Date: 2. Establishment Address I SIC, osczook". Sj 04-1RAKjO4l'�- /V)4- ojpy� 3. Establishment Mailing Address(if different) 4. EstablislimentTelephoneM 5. Applicant Name&Title: P J\CL P Pra(,YT U KK-\Y-'Is 6. Applicant Address: q S A-,,"1.4- C' 10-C 7. Applicant Telephone No.:'161-6,' ,A-oG L_ 24-Hour Emergency No.: 8. Owner Name&Title(if different form applicant): 9. Owner Address(if different from applicant): 10. Establishment Owned By: 11. If a corporation or partnership,give name,title,and n An Associatioa;Jn<Corporafloji;U An individual ]ionic address of the officers or partner: 0 A partnership;0 other legal entity_ NM Title Home Address 12. Person Directly Responsible for Daily Operations,( caner,Person in Charge,Supervis-orTM—nager,E tc.) Name&Title: ppp/:"O-Tomnk4� Address: " *siAr-)- C, (P-C LC e 0?2�-6(j 1-:> C) 60 Telephone No.: 73(-6'3;1- 04,14- Fax No.: E-mail: Emergency Telephone No.: 13. District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No.: Fax No.: E-mail: 14. Water Source: 15. Sewage Disposal: DEP Public Water Supply No.:(if applicable) 16. Days and Hours of 0 at*,,),per o 1: 17.No,of Food Employees AO 7 Page 1 of 3 r NAME OF ESTABLISHMENT: -/,✓)UNS 18. Name of Person in Charge—Certified in Food Protection Management(regtfired as of 10/1/2001/a creca•dnnce wRh 105 CMR 590.003(A)please affach conv of cerfll7cofe): 19. Person Trained in Anti-Choking Procedures(if 25 seats or more:, es ElNo) NAME: 1 �,4jqo�9 4 21. Length of Permit:(check one) 20. Lo ation;(check one) annual ermanent Structure ❑Seasonal/Dates: ❑Mobile i ❑Temporary/Dates/Time: i 22, Establishment Type(cheek all that apply): ❑ Retail L square feet) ta' Food Service.—( seats) A Food Service—Takeout ❑ Food Service—Institution LMeals per day) Caterer Wr Food Delivery ❑ Residential Kitchen for Retail Sale ❑ Residential Kitchen for Bed and Breakfast Home ❑ Residential Kitchen for Bed and Breakfast Establishments t ❑ Frozen Dessert Manufacturer ❑ Other(Describe) 23. Food Operations(check all that apply)—DEFINITIONS: ➢ PHF—potential hazardous food(time/temperature controls required); ➢ Non-PHFs—non-potentially hazardous food(no time/temperature controls required); ➢ RTE—ready-to-eat foods(Ex.-sandwiches,salads,muffins,which need no further processing it Sale of Commercially Pre-Packaged Non-PHF's ,�o PHF Cooked to Order 0 Hot PHF Cooked and Cooled or Hot Held for More than a Single Meal Service ❑ Sale of Commercially Pre-Packaged PHFs i r Preparation of PHFs for Hot and Cold Holding for Single Meal Service ❑ PHF and RTE Foods Prepared for Highly Susceptible Population Facility fd' Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to be prepared by Consumer ❑ Vacuum Packaging/Cook Chill ❑ Reheating of Commercially Processed Foods for Service within 4 hours ❑ Customer Self-Service ❑ Use of Process Requiring a Variance And/Or HACCP Plan(including bare hand contact alternative,time as a public health control) ❑ Customer Self-Service of Non PHF and Non-Perishable Foods Only ❑ Ice Manufactured and Packaged for Retail Sale ❑ Offers Raw or Undercooked Food of Animal Origin ❑ Preparation of Non-PHFs Cl Juice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single Meals for Catered Events of Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage,Out-of-Date or Reconditioned Food ❑ Other(Describe): 1 PaEe-2 o NAME OF ESTABLISHMENT: w � **1F YOU DO NOT RENEW BY FEBRUARY 28rn,THE FEE WILL DOUBLE** Please include copies of current Serve Safe/Allergen Training/Choke Saver Certifications I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and Article X of the State Sanitary Code,and all other applicable law. I have been instructed by the Board of Health on how to obtain c9p es t 105 CMR 590,000 and the Federal Food Code. 24. Signature of Applicant: C t Signature Print Name 3 Pursuant to MGL Ch.62C,sec.49A,t certify under the penalties ofpejary thol--1,—lo my best knowledge and belief,have filled all stale lax returns and paid state taxes required under the law. 25. Signature of Individual or Corporate Name: I/Signature Print Name i i i i i I i Page 3 of 3 l�un�Texc E1941 IZT. 12 TOWN OF NORTH ANDOVER Community & Economic Development HEALTH DEPARTMENT 120 Main St. NORTIJ ANDOVER,MASSACFIUSETTS 01845 Phone: 978.688.9540 Fax: 978.688.9542 E-mail: healthder)t@tiortliatidovei-nia.gov APPLICATION FOR DUMPSTER PERMIT PURSUANT TO SECTION 31A AND 31 B OF CHAPTER III OF THE GENERAL LA WS, AND R ULES AND REG ULATIONS OF THE NORTHANDOVER BOARD OF HEALTH DATE: Application is hereby made for a permit to maintain a dumpster(s) on property located at in accordance with the rules and regulations of the Board of Health. Applicant:J V : fAmws (TZA Property Owner: 1511 OS60W Q(lortOIC- s Name of Contact: �'4 AWS Owners Address: 1' q57 05GOvP sr; Address: 1515 W 0000 51 i\JO170 tO46v" MA 0/9K 0. At4dY ft ft 015(f"; Owners Phone#: � 0- W • 895"1 Telephone#: 9-4s - T)1 (. Email address: F97A-KOS 'R)6W7AIL- Dumpster Company:Pdal iy;oF wan1G. Telephone#: 9-'F' 6 g6. 060'7 Pick-Up Schedule: MOVON 1 On the back of this form, please sketch an outline of property, showing the proposed location of the dumpster(s). Give distance from dumpster to other buildings and lot lines or boundaries. Annual Dumpster Permit Fee: $60.00 per establishment Payable to: Town of North Andover. LATE FEE AFTER FEBRUARY 28TH BE DOUBLED -$120.00 *Please note that all contact information and the associated fee is required upon application submittal. Page 1 of 1 2/22/2017 Allergen Certification 001.jpg V4. IX, A 7, aIq $_6 .......... .......... vv Id https:HmaiI.google.com/mail/u/0/4Anbox/l5a67573d86cf2al?projector=I 01 I N O � 15h, w ace a �a ms m �aa• a¢ a w a�, c>w a� mm aaw am 3 a e r, ✓ --__s _r.�s �� ✓.. w_ :.�...✓,.:._.r �:,._ aw ..., ram ' V ,4nd Firs ffsaid g aS, slet duca Proudly presents this"Certificate of Attendance"to Frsaw k S+ane O. Wry Wtl- o � For participating in the training and demonstrating hhi " rogram Sponsor: skills S.A.F.E.—NS he Port Tavern 'Training Agenc � 4 State St No. 62555 ( Wr ° �a'R= ewburyport,MA 01950ID W For www.choksaver.co "y Po 0 �� � �W Wes{ .� � �v �➢ p m�w. 1 m" ' .,� ° 9a 2 Hr Pro m conducted b � 6'Tn Y 04 This 12th day of May, 2014. _ -inn-- A'a" ' Gunther Wellenstein, EMT Re, �ageetsMassL?P111X( C Instructor O. Q4tg97 I 49ACy ") �r �. � * W �i , R9A te� "fro �r mY N _ O � V tU 3 EXAM FORM NO. 4776 c` CERTIFICATE NO. 9641946 36 So, X V v co fr'^ : CJ tJ 8 O �I TO FOTIOS STAMOS CD for successfully completing the standards set forth for the ServSafe'Food Protection Manager Certification Examination, @ which is accredited by the American National Standards Institute(ANSI)-Conference for Food Protection(CFP). — m o 0 12/1 6/2012 DATE OF EXAMINATION 12/16/2017 DATE OF EXPIRATION Local lawns apply.Check v.ith.your local Vogul.toty8geticyfor recertification requirements. ®RO, . ,Paul Hinman - E%gcupve Vice President National Restaurant Association 40655 W2012 NYJ IP Wyr tFe w.ixhnnEd ee�b IFwad.tia(NRAEFI A71tIR1 tOrei tV d.52 Saic lsarcr,larcdtndemark al the NRAEr,,iud�u,d rli�,n�xc GY Nalanni ltnstoitanY Acso<iatlon Selutionc.LLC Thn bGw Pp InL nc.ttat S fch 4�p 1 of the NniwnalR haeanl A,xWaN Thls'k�dcument uinncCno Npt diwdaraitCicd. 4 Commonwealth of Massachusetts J'/" 9Hy '• BOARD OF HEALTH North Andover 120 Main Street NORTH ANDOVER,MA 01845 DATE PRINTED 12/19/2016 ESTABLISHMENT NAME: Jimmy's Famous Pizza Jimmy's Famous Pizza 1595 Osgood Street File Number: BHF-2002-000060 Attn:Permit Renewals NORTH ANDOVER MA 01845 LOCATED AT: ,Commonwealth of Massachusetts OWNER: Triplets,Inc. PHONE:(978)685-7776 PERMIT TYPE FEE Dumpster Permit $60.00 NOTES: Contact: Nikolas Papantonakis 978.685.7776 Food Est.-Restaurant Permit $185.00 Hours Active: Open 7 days l0am-IOpm Delivery;7 food employees Total Fees: $245.00 Application MCTST be submitted with fee in order to be processed. Applications can be found at www.northandoverma.;;ov 12/23/2019 2/2 1 E ,. ,ar11"1. I. E 1 A I ry I' E N"I" '.,. Susan Y. Saw CPOD STREET; SUITE 2035y a aa � 1if t 6'"ubfic Ileaahh Director NORITI ANDOVER, M/h SM"I.l'1..1sL°rrs 01845 l'lac net 978.688. 540 Fax: 978,688. 476 1. maaiL;tw tit d iau(i�a Arigftutrti.8a�aam<�(:G.v_�1...<ca�t� FOOD ESTABLISHMENT PERMIT APPLICATION (f new establishment;application must be submitted at least 30 days before the planned opening date) FEE: Depends on type of food establishment—Refer to your current permit or call the Health Department for fee amount 1. Establishment Name: irai. ", t l rJC - "A ah S V711y►aaetS" 1/Z,zA Date: (� ��� �� 2. Establishment Address 1.,5�l5 ()�600U '51, Noett`{I0iV'kV(-V' MA 01811! 3. Establishment Mailing Address(if different) 4. Establishment Telephone#: }tJ' - 6��. .7 7 7 5. Applicant Name&Title: -FOIoV 5"WV410S -. l7`An0 664 6. Applicant Address: 8Z,. j g c p1,j 6` L,6o­� m to o l f 6 0 7. Applicant Telephone No.: C 11" `2 q'3' S'7 24-Hour Emergency No.: 8. Owner Name&Title(if different form applicant): 5c,M 9. Owner Address(if different from applicant): 10. Establishment Owned By: 1.1. If a corporation or partnership,give name,title,and ❑An Association;kA Corporation;❑An individual home address of the officers or partner: Name Title Home Address A partnership;❑other legal entity t✓lck PE1-ftgN'it�c-ntct5 1'ecs 4 51+511n c.rOct~e- 1�Cc O-A 61c+t6ca t1Nlt �S'7r1 N+fs�" VP o 6 adtj S . 12. Person Directly Responsible for Daily Operations(owner,Person in Charge,Supervisor,manager, c. Name&Title: fVAfjl4 5-M N1 O S Address: c cs c/ Telephone No.: Fax No.: E-mail: Emergency Telephone No.: 13. District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No.: Fax No.: E-mail: 14. Water Source: 15. Sewage Disposal: DEP Public Water Supply No.:(if applicable) 16. Days and Hours of Operation: 17.No.of Food Employees � 61 � 1 u'� C'm 1l 7 Pagel of 3 NAME OF ESTABLISHMENT: 18. Name of Person in Charge—Certified in Food Protection Management(required as of 101112001 in accordance with 105 CMR 590.003(A)please attach copy of certificate): 19. Person Trained in CAnti-Choking Procedures(if 25 seats or more:❑Yes ❑No) NAME: 1 zt h- J � S 21. Length of Permit:(check one) 20. Location: (check one) A AAnnual Kfermanent Structure ❑Seasonal/Dates: ❑Mobile ❑Temporary/Dates/Time: 22. Establishment Type(check all that apply): ❑ Retail(_square feet) `t Food Service—( qLI seats) (3 Food Service—Takeout ❑ Food Service—Institution( Meals per day) ❑ Caterer ❑ Food Delivery ❑ Residential Kitchen for Retail Sale ❑ Residential Kitchen for Bed and Breakfast Home ❑ Residential Kitchen for Bed and Breakfast Establishments ❑ Frozen Dessert Manufacturer ❑ Other(Describe) 23. Food Operations(check all that apply)—DEFINITIONS: ➢ PHF—potential hazardous food(time/temperature controls required); ➢ Non-PHFs—non-potentially hazardous food(no timettemperature controls required); ➢ RTE—ready-to-eat foods(Ex.-sandwiches,salads,muffins,which need no further processing Ur Sale of Commercially Pre-Packaged Non-PHF's it PHF Cooked to Order e' Hot PHF Cooked and Cooled or Hot Held for More than a Single Meal Service ❑ Sale of Commercially Pre-Packaged PHFs .0' Preparation of PHFs for Hot and Cold Holding for Single Meal Service ❑ PHF and RTE Foods Prepared for Highly Susceptible Population Facility ❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to be prepared by Consumer ❑ Vacuum Packaging/Cook Chill ❑ Reheating of Commercially Processed Foods for Service within 4 hours ❑ Customer Self-Service ❑ Use of Process Requiring a Variance And/Or HACCP Plan(including bare hand contact alternative,time as a public health control) ❑ Customer Self-Service of Non PHF and Non-Perishable Foods Only ❑ Ice Manufactured and Packaged for Retail Sale ❑ Offers Raw or Undercooked Food of Animal Origin ❑ Preparation of Non-PHFs ❑ Juice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single Meals for Catered Events of Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage,Out-of-Date or Reconditioned Food ❑ Other(Describe): Page Y o NAME OF ESTABLISHMENT: .......... ............ **IF YOU DO NOT RENEW BY JANUARY 1ST,THE FEE WILL DOUBLE" Please do not combine fees for various permits in one check— (Example—dumpster fees should not be combined with a food permit fee) Please include copies of current Serve Safe/Allergen TraininglChoke Saver Certifications ............ 1,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and Article X of the State Sanitary Code,and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of t 105 C 000 and the Federal Food Code. 24. Signature of Applicant: Signature' - YAV)1k S,�WLC> Print Name Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties ofperjuty that I, to my best knoivledge and belief, have filled all state tax returns and paid state taxes required under the law. 25. Social Security Number or Federal I.D.#: Dq - 26. Signature of Individual or Corporate Name: � Signature c Print Name Page 3 of 3 2 0 _ _ n4, -Ar- M4, Mw-" _ N Cot) � o * 0 Proudly presents this "Certificate of Attendance"to Ell. Fmvik S+ames l ` For participating in the training ��zl* and demonstrating s rogram Sponsor: skills S.A.F.E.—NS he Port'Tavern Training Agene � ewbte St ,MA 01950 No. 62555 (j �. For www.choksaver.co a o E4 B � 2 Hr Program conducted by This 12th day ofJm— a May, 2014. — - — An4r 641- : i Gunther Wellenstein, EMT Re R Meets Mass DPH 105 CMR 590.009 Instructor (No. 0489749) � �v�:�--1r.�—sr--arm;<—�,;r-�-ti�-�-r -�:�rv� ,;�� �-��•� -•;s--w,:,--1r---„• -�-r.��er--.;• .:•r� �to �tr- N1,Aw M-�-74-'RT- 4nd -F-irstmans Educa at ateo Proudly presents this "Certificate of Attendance"to M m4r 6� u e For articipating in the training m ) and demonstrating a rogram Sponsor: skills S.A.F.E,—NS ' he Port Tavern Training Agenc a 4 State St No. 62555 , ewburyport MA 01950 a For www.ch®ksaver.co ` 2 Hr Program conducted by 4 � This 12th day of ,EB a May, 2014. -�-- c Gunther Wellenstein, EMT Re eets Mass DPH 105 CMR 590.009 Instructor (No. 0489749) �.........-v ,--orb T 4 t t",- ekmm Ilk Q 0 a � And Firstmaid Educ,t, 4 a Proudly presents this "Certificate of Attendance" to a *1a) For participating in the training a and demonstrating a rogram Sponsor: skills S.A.>F.E. —N1k W"Phe fort Tavern Training Agee Q 4 State St No. 6255 ewburyport,MA 01950 a For www.choksaver.c( S. � q rI 2 Hr Program conducted by o . This 12th day of May, 2014. /dunfpur a Gunther Wellenstein, EMT Meets Mass DPH 105 CMR 590.009 Instructor (No. 048974.9) �,�—,r •.r—�.--,,.r—��.r ;s--�: �.��;:�--.r—Aso—�,:� � ,•r :r'�:o--�;�r . ,—� - - - - - - i G t EXAM I:OR I N O. 4770 CERTIFICATE NO, 9641946 Serv' Saf:le E , "C I' F �, J ,,, - ICA Y ON RT , III TO FOTI'D'S for successfully completing the standards set forth for the ServSafe"Food Protection Manager Certification E; which is accredited by the American National Standards Ins#itu#e(ANSI)»Conference for Food Protection DATE yArlaNt ,. 12/16/2®i17 ; DATE OF E)fP�IRATht?N :� Local laws apply Chec or recertification requirements, r Ya K� r 4t N r � �aLr1.�Ntrtpmar SRuive 1(iCQ Prdsldent ailonal R*sNaurant Association - #0655 Q201zN ti rat Rasta gAntp�ac�dfly ducats atFa r 1 ' . Theny+Rfr7t GRe&Etd9 iSgPclsja adamptirgilhe N4}(ona(q t�uaalAs ocin(Ir�,ad�r'Safa GiarEg ster�dtr9demack at the NRAEF,—dundcritcense by National8rstaurantRclatlon Solutions,LLC. s�s:r^ ,_Tit.tin dm�Ot nllot 66 mprpduged i71tEr ,..._. t,.. sso_ _ CERTIFICATE OF ALLERGEN AwARENESs TRAINING Name of Recipient: Fotios Stamos Certificate Number: 1275384 Date of Completion: 12/5/2013 > Date of Expiration: 12/5/2018 r +�\ Issued By: The above-named pez5on is hereby issued this certificate NATIONAL r for completing an allergen awareness fivining grog ram A RESTAURANT rero izedb r the 1Ulassarhusetts De artment a Public Fleaith ��"�_�^^I ASSOCIATION $ 3 7z . f ,, in accordance with 105 1.AJR 590.009(G)(3)(a). Massachusetts Restaurant Association 303.765.2122 333 Turnpike Road,Suite 102 wwwrestaur nt.org This ce cote wil ar l he valid five 5 ears rorn date o coon-letion Southborough,990 01772 rti r '�� 1§'WlY.R1arCStaUT«nt38SUGblg ' r9�' ............. ............. ................... ................---- ---—-----------------.......- —................... COMMONWEALTH OF MASSACHUSETTS NUMBER BHP-2015-0862 North Andover BOARD OF HEALTH FEE $130.00 The Cork Stop DATE ISSUED............. NAME January 01,2016 1593 Osgood Street NORTH ANDOVER, MA 01845 ---------------------- -------- ------------- ---------------- ----------------------------------------------------------------- -------------------- ADDRESS IS HEREBY GRANTED A Food Est. - Small Retail Store Permit Food Establishment-Small Retail Store PERMIT This permit is granted in conformity with the Statutes and ordinances relating thereto,and expires..............February 28,2017 unless sooner suspended or revoked, RESTRICTIONS: Retail store, 1000 square feet ------------ BOARD OF ------------------------------------------------------------ HEALTH NOTES:Contact:Nick Papantonakis 978.655.8699 ----- - ---------------------- --------------- ------------------- --------- -------- HOURS ACTIVE:Open 7 days I Oam-I Opm ------------------ ---------- ------------------------------ BOARD OF HEALTH CHAIRMAN ................................................................ —----- .......... 12/23/2019 2/2 Office of CO 4MUNITY DEVELOPMEN,r AND) Sll,.R 1C q,S ` HEALTH DEPART l+eN°l" Stisari Y, Sawyer,R1;i YRS 1600 OSGOOD S°I"11111.ET; SUITE 203 Public;@lwn lth Dircetor NORTI I A '1`iO"` E , d`v ASSACG 11.1Sf;"1`TS 01845 11hone: 97 .688,9 540 1`atx: 978,688.8476 E" aiatiL hea tlidgtti�i)tcr�vttc�Or�ttws 9w�����cia�vt� c oln FOOD ESTABLISHMENT PERMIT APPLICATION (If new establishment,application must be submitted at least 30 days before the planned opening date) FEE: Depends on type of food establishment—Refer to your current permit or call the Health Department for fee amount 1. Establishment Name: ke, G rL,& Date: 111d il- // 5— 2. Establishment Address t�S VW, :> `.,�'.'J N '(.q �Q0 J � M 1°4 QIT � 3. Establishment Mailing Address(if different) 4. Establishment Telephone#: en t 6 s s - 6 9 1 5. Applicant Name&Title: N C-(V_ 6. Applicant Address: S A' S)AA C 1e C �6A 60J-1 ,0 11 6 t� � 7. Applicant Telephone No.: 24-Hour Emergency No.: M pP P �" (, ( f g y $. Owner Name&Title(if different form applicant): �Cl� (11 \0 (.� 1���� 9. Owner Address(if different from applicant): ( Al 10. Establishment Owned By: 11. If a corporation or partnership,give name,title,and ❑An Association;4 A Corporation;BAn individual home address of the officers or partner: ❑ Name Title( a Home Address A partnership; �pk4w ,SiAv,,G5 C QSIJ�ov� "�L- I�� 5+ �vt�trA ►Yv� 13C to 1 ( r Apt-�30 12. Person Directly Responsible for Daily Operations( wnet,,Person in Charge,Supervisor,manager,U c. Name&Title: Address: .`x�wl c` a J J` Telephone No.: Fax No.: E-mail: r Emergency Telephone No.: " A i p(^ 13. District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No.: Fax No.: E-mail: 14. Water Source: 1.5. Sewage Disposal: DEP Public Water Supply No.:(if applicable) 16. Days and Hours of Operation: 17.No.of Food Employees Pagel of 3 NAME OF ESTABLISHMENT: 18. Name of Person in Charge—Certified in Food Protection Management(required as of 101112001 in accordance with 105 CMR 590.003(A)please attach copy of certificate): 19. Person Trained in Anti-Choking Procedures if 25 seats or more: Dyes �) NAME: N-0 21. Length of Permit:(check one) 20. Location:(check one) --rrWnnual 0'Permanent Structure ❑Seasonal/Dates: ❑Mobile ❑Temporary/Dates/Time: 22. Establishment Type(check all that apply): ',� Retail( fact) square feet) ❑ Food Service—( seats) ❑ Food Service—Takeout ❑ Food Service—Institution( Meals per day) ❑ Caterer ❑ Food Delivery ❑ Residential Kitchen for Retail Sale ❑ Residential Kitchen for Bed and Breakfast Home ❑ Residential Kitchen for Bed and Breakfast Establishments ❑ Frozen Dessert Manufacturer ❑ Other(Describe) 23. Food Operations(check all that apply)—DEFINITIONS: ❑ PHF—potential hazardous food(time/temperature controls required); ❑ Non-PHFs—non-potentially hazardous food(no time/temperature controls required); ❑ RTE—ready-to-eat foods(Ex.-sandwiches,salads,muffins,which need no further processing ,W Sale of Commercially Pre-Packaged Non-PHFs ❑ PHF Cooked to Order ❑ Hot PHF Cooked and Cooled or Hot Held for More than a Single Meal Service ❑ Sale of Commercially Pre-Packaged PHFs ❑ Preparation of PHFs for Hot and Cold Holding for Single Meal Service ❑ PHF and RTE Foods Prepared for Highly Susceptible Population Facility ❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to be prepared by Consumer ❑ Vacuum Packaging/Cook Chill ❑ Reheating of Commercially Processed Foods for Service within 4 hours ❑ Customer Self-Service ❑ Use of Process Requiring a Variance And/Or HACCP Plan(including bare hand contact alternative,time as a public health control) ❑ Customer Self-Service of Non PHF and Non-Perishable Foods Only ❑ Ice Manufactured and Packaged for Retail Sale ❑ Offers Raw or Undercooked Food of Animal Origin ❑ Preparation of Non-PHFs ❑ Juice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single Meals for Catered Events of Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage,Out-of-Date or Reconditioned Food ❑ Other(Describe): Page 2 o NAME OF ESTABLISHMENT: ............ **IF YOU DO NOT RENEW BY JANUARY I",THE FEE WILL DOUBLE" Please do not combine fees for various permits in one check— (Example—dumpster fees should not be combined with a food permit fee) Please include copies of current Serve Safe/Allergen Training/Choke Saver Certifications .............. .... 1,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and Article X of he State Sanitary Code,and all other applicable law. I have been 'c instructed by the Board of Health on how to obtain copi s of t 5 CNIR 590.000 and the Federal Food Code. 24. Signature of Applicant: P\ Signature (k J'ec''I�VLG (S' VPrint Name Pursuant to MGL Ch. 62C, sec. 49A,.1 certijy under the penalties ofperjuty that I, to my best knowledge and belief, have filled all state tax returns and paid state taxes required under the lmv. 25. Social Security Number or Federal I.D.#: 26. Signature of Individual or Corporate Name: A L Signatur X Print Name Page 3 of 3 12/23/2019 ............ ........*..............*...... Reference No �`-2002-000060 ................................... Permit No: BTIP-2014-1 184 Department: .................................. North Andover BOARD OF HEA1,311 ......................................................................................... Account No: 2031207.1.5.0510.00 Fee '"Type- .................................... Food Est. -Restaurant Receipt No: REC-2015-000606 ......................................................................................... .................................... Paid By: Paid in FU On' Mon Nov 10,2014 Tl , like. .................................... ivBy:ripets ......................................................................................... Check No: 8341 Receed ................................... Lisa Blackburn ......................................................................................... DEPARTMENT'S COPY Amount� $185.00 ........................... ........................................................................................................................................................................... 2/2 TOWN OF NORTH ANDOVER Office of COMMUNITV DEVEL PMEN,r AND SERVICES HEALTH DEPARTMENT Susan Y. Sawyer,1Z1 1-1SJ16 1600 OSGOOD STREET; SI,Si1:1'I+:"t 203 Paabhc I-lealth Mrcclor NORTH ANDOV ER, MASSAC'1-1U SE`TT'S 01 45 Phone: 978.688.9540 lax: 978.688.8476 E-mail: liealtltde t ctftcawnofi7E:arthaiidover.com FOOD ESTABLISHMENT PERMIT APPLICATION (Zf new establishment,application must be submitted at least 30 days before the planned opening date) FEE: Depends on type of food establishment— Refer to your current permit or call the Health Department for fee amount 1. Establishment Name: �.',%, ',A �w7°`' T t"°t'� Date: / 2. Establishment Address: 3. Establishment Mailing Address(if different) 4. Establishment Telephone#: 5. Applicant Name&Title: V. (° ' `"'l`s 1,, C:( 6. Applicant Address: �4 5:,A� l .i q Al '4�" o ("16 � 7. Applicant Telephone No.: 24-Hour Emergency No.: 8. Owner Name&Title(if different form applicant): 9. Owner Address(if different from applicant): Ow ned By: 11. If a corporation or partnership,give name,title,and ❑An Association;0 C r„ home address of the officers or partner: 10. Establishment orpo�ta�On;0 An individual Name Title Home Address ❑A partnership;0 other legal entity SA AC­ 12. Person Directly Responsible for Daily Operations(Owner,Person in Charge,Supervisor,Manager,E te.) Name&Title: 9` �t"'.. , Address: Telephone No.: 4,m. 6 t Fax No.: E-mail: '1' l PUS 62 l 1' Emergency Telephone No.: 13. District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No.: Fax No.: E-mail: 14. Water Source: 15. Sewage Disposal: DEP Public Water Supply No.: (if applicable) 16. Days and Hours of Operation: 17.No. of Food Employees Page 1 of 3 NAME OF ESTABLISHMENT: 18. Name of Person in Charge—Certified in Food Protection Management(required as of 101112001 in accordance rvlth XOS CMR 590.003 (A)please attach copy of certzffcate): "°"w ( jAIM 6 19. Person Trained in Anti-Choking Procedures(if 25 seats or more:I SIe )DNo) NAME: 21. Length of Permit: (check one) 20. Location: (check one) nual ermanent Structure ❑Seasonal/Dates: ❑Mobile ❑Temporary/Dates/Time: 22. Establishment Type(check all that apply): ❑ Retail(_square feet) Food Service—( seats) 4er Food Service—Takeout ❑ Food Service—Institution( Meals per day) 0 Caterer Food Delivery ❑ Residential Kitchen for Retail Sale ❑ Residential Kitchen for Bed and Breakfast Home ❑ Residential Kitchen for Bed and Breakfast Establishments ❑ Frozen Dessert Manufacturer ❑ Other(Describe) 23. Food Operations(check all that apply)—DEFINITIONS: > PHF—potential hazardous food (time/temperature controls required); ➢ Non-PHFs—non-potentially hazardous food(no time/temperature controls required); �, RTE—ready-to-eat foods(Ex.-sandwiches,salads,muffins,which need no further processing ❑ Sale of Commercially Pre-Packaged Non-PHF's off PHF Cooked to Order ,u" Hot PHF Cooked and Cooled or Hot Held for More than a Single Meal Service ❑ Sale of Commercially Pre-Packaged PHFs ❑ Preparation of PHFs for Hot and Cold Holding for Single Meal Service ❑ PHF and RTE Foods Prepared for Highly Susceptible Population Facility �Fgr Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to be prepared by Consumer ❑ Vacuum Packaging/Cook Chill ❑ Reheating of Commercially Processed Foods for Service within 4 hours ❑ Customer Self-Service ❑ Use of Process Requiring a Variance And/Or HACCP Plan(including bare hand contact alternative,time as a public health control) ❑ Customer Self-Service of Non.PHF and.Non-Perishable Foods Only ❑ Ice Manufactured and Packaged for Retail Sale ❑ Offers Raw or Undercooked Food of Animal Origin ❑ Preparation of Nan-PHFs ❑ Juice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single Meals for Catered Events of Institutional Food Service Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage,Out-of-Date or Reconditioned Food ❑ Other(Describe): Page 2 o u NAME OF ESTABLISHMENT: IF YOU DO NOT RENEW BY JANUAl2Y Is'a'�THE FEE W.��,o ..,�,�M—.e,.�. ** ILL DOUBLE** Please do not combine fees for various permits in one check— (Example—dumpster fees should not be combined with a food permit fee) Please include copies of current Serve Safe/Allergen Training/Choke Saver Certifications I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and Article X of the State Sanitary Code,and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of t 10 CMR 590.000 and the Federal Food Code. 24. Signature of Applicant: & Signature Print Name Pursuant to MGL Ch. 62C, sec. 49A, I certo�under the penalties of perjury that 1, to my best knowledge and belief, have filled all state tax returns and paid state taxes required under the laiv. t S25, Social Security Number or Federal I.D.#: 26. Signature of Individual or Corporate Name: Signature Print Name Page 3 of 3 .��, rstmald Educati (00 g � 6 g Proudly presents this "Certificate of Attendance"to Fax k S+aries g � a g For participating in the training � g and demonstrating g g rogram Sponsor® skills S.A.F.E.—NS ` g he Port Tavern Training Agence 4 State St No. b2555 g ewburyport,MA 01950 For www.choksaver.co a AWK I* E- A.I-Ri'.E. �C'h o k e S a v e r, a 6 � 2 Hr Program conducted by R This 12th day of 'fig g� May, 2014. g Gunther Wellenstein, EMT of)�eets Mass DPH 105 CMR 590.009 Instructor (No. 0489749) g And._esa___r.:.__1s_.:;�ou_/.�O.a�:a_._r,. ,�Ja._r.�-...- ,mi� t— Aw.��:e�_.-.."Aw,.��a�a..� $ 40) `ff115 ° Proudly presents this "Certificate of Attendance"to e ° For articipating in the training and demonstrating 1 ° :1rogram Sponsor: skills S•A.F•E. —NS " he Port Tavern Training Agene ; 4 State St No. 62555 w1f ewbuxyport,MA 01950 For www.choksaver.co jj° ° 4 1 2 Hr Program conducted by 1 This 12th day of 1 1 May, 2014. 1jingr ° Gunther Wellenstein, EMT ° 1Meets Mass DPH 105 CMR 590.009 Instructor (No. 0489749) � 1 i a°�h_f.:!_✓.O_..1,6�/.\._J'�_.l.�d.:�r:s�..-.✓.�® �.\_J.'�'�'�'�9.'\_.v,;d-....-. �® _ .m �� m. .® _ .i"®"o -t-firsAmald Educatj p p Anc 0 Proudly presents this"Certificate of Attendance"to p p � For participating in the training ° and demonstrating p rogram Sponsor: skills S.A.F.E.—lea he Port Tavern Training Agen p 4 State St No. 6255 ewburyport,MA 01950 For www.choksaver.ct � p B [ p � 2 Hr Program conducted by This 12th day of May, 2014. p Gunther Wellenstein, EMT *04) eets Mass DPH 105 CMR 590.009 Instructor (No. 0489749) /�`�-r-�:r—,:s---�:r--ir^--.:�---v;✓—�:r---\;�—ti;;i--�;.---�/—`�.:r—'�.:�----tir—�;�--,r---.�---V%'--ma's-11:r-�--�.;v---`l�-eP I i r EXAM FORM NO. 4770 CERTIFICATE NO. 9641946 I � � Serv' Safue o CERTIFICATION for successfully completing the standards set forth for the ServSafe"Food Protection Manager Certification E: which is accredited by the American National Standards Institute(ANSI)-Conference for Food Protection r , DATE OF EXAMINATION 12I16/20�17 i DATE OF EXPIRATIC7IV - Local Taws apply Cheeit�Wakh ypur;local repUjatoty�gehcy';for recertification requirements. s #0655 ® „ f7secut7veVgcePYeslc�enf,,nlaonal Restabranf Association F ,12e72Natl nal RastaG 1nt �i a.-. t p lF TI )o o G PPuc(dGo�{gdueaH nal Fotln�gyon(Nft/(E��II slBhtdre rvodrSetvSafo Isar Hrstcred:traddnurk ai tieNRAEF,usodander Ocense by NatlanalRestaurant AssoNatbn Solutions,LLC. r H eari��',Reytto�eaSrj(1sa @ademAri§f the NattunalRut�m'ant A556 Ia�I R T,;, ;.r Th s�doe m��jteanhot y3 ropradused or altEFed .,. �'TIMMYt� ZZ4r �, ` . -------------------- ERTIFICAMTE OF ALLERGEN AWARENESS TRAINING r Name of Recipient: Fotios Stamos Certificate Number: 1275384 Date of Completion: 12/5/2013 Date of Expiration: 12/5/2018 Issued Byt The above-named person is hereby issued this certificate — for completing an allergen awareness training program NATIONAL i RESTAURANT recognized by the Massachusetts I3epartment ofPublie Health _���� j ASSOCIATION, � in accordance with 105 CMR 590.009(G)(3)(a). Massachusetts Rrstaurant rlssoaation 800.765.2122 333 Turnpike Road,Suite 102 wwwrestaurant.org Southborough,MA 01772 This eer l ficate will lie valid fo71 ive(5)years from date of completion. 508-303-9905 1 iN nemarestaurantassoc.org i COMMONWEALTH OF MASSACHUSETTS NUMBER » BHP-2014-0272 North Andover • BOARD OF HEALTH FEE $185.00 Jimmy's Famous Pizza DATE 1ssuED NAME January 01,2014 ------------------- 1595 Osgood Street Attn: Permit Renewals NORTH ANDOVER, MA 01845 ADDRESS IS HEREBY GRANTED A Food Est. - Restaurant Permit Food Establishment-Restaurant This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires " -- - --December-31'2014--------- unless sooner suspended or revoked. - - ------- - - -- - RESTRICTIONS:Food Service: 62 seats;Takeout;Delivery; 8 food employees BOARD OF HEALTH NOTES: Contact:Nikolas Papantonakis,Manager; -____ .__ _____` 978.685.7776 HOURS ACTIVE: Sun-Thurs 10am-9pm;Fri&Sat l0am- lOpm BOARD OF HEALTH CHAIRMAN 12/19/2019 Dashboard—north an doverma.gov—Stripe ........................................................................................................................................................................... Reference No: BHF-2002-000060 ................................... Permit No: BHP2014-0272 Department.- ...........-......................... North Andover BOARD OF HEAL'I'll Fee A ......................................................................................... 0 203. ,1,207.1.5.0510.0'"Fype� CCOUnt No: ..... .............................. Food Est. - Restaurant Receipt No: REC-2014-000901 ......................................................................................... .................................. Paid By: Pad in FuH Om We Dee 04,2013 'Triplets, Ine. .................................... i ................d B......................................................................... Check No-, 8031, Recevey� ................................... Lisa Blueliburn ......................................................................................... DEPARTMENT'S COPY Amount� $185.00 L....................................................................................................................................... ......... https://dashboard.stripe.com/payments/py_l FqgfAGgVQ7dHaSppmxhg2LM 212 TOWN OF NORTH ANDOVER �. Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT Susan Y, Sawyer,REHS/RS 1600 OSGOOD STREET; SUITE 2035 Public Health Director NORTH ANDOVER,MASSACHUSETTS 01845 Phone: 978,688.9540 Fax: 978.688.8476 E-mail:healthdept@townofnorthandover,com FOOD ESTABLISHMENT PERMIT APPLICATION (If new establishnnent,application nuist be submitted at least 30 days before the planned opening date) FEE: Depends on type of food establishment—Refer to your current permit or call the Health Department for fee amount 1. Establishment Name: /A M Is F AM"u I p Date: I .2. Establishment Address a l �` I 1�l( ` l -0 0 5 i n 1 ✓k�t 6 a✓vx/l_ ✓�i 4 cd 1 gys-- 3. Establishment Mailing Address(if different) 4, Establishment Telephone#: 9,1 1'5'a\ Ui O�u f 5. Applicant Name&Title: CrD T i p l (G All 6,( 6. Applicant Address: l ,j 9.� C) S C,0o � S ( AnC(� 6 J. ..�� ✓t 'A 0 1 ( y 7. Applicant Telephone No.: 9-1 e-5�( _q,b�y 24-Hour Emergency No.: 8. Owner Name&Title(if different form applicant): 9, Owner Address(if different from applicant): 10. Establishment Owned By: 11. If a corporation or partnership,give name,title,and ❑An Association;)A Corporation;❑An individual home address of the officers or partner: Name Title Home Address ❑A partnership;0 other legal entity , t I�C �l( 6 tr-ad A f oT 1.D S S`I firm 6.S r 2c l., <� �� 02 ria ,1^/, c Od4 12. Person Directly Responsible for Daily Operations(Owner,Person in Charge,Supervisor,Manager, c.)1 ,qv UY 4Atjj l Name&Title: r 0 1. I o S Slthmoj Address: 15.. 1 O SG-cra t Telephone No.: �' " �� `�� �` Fax 14 , "��m"` n �9 E-mail: Emergency Telephone No,: i 13. District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No,: Fax No,: E-mail: 14. Water Source: 15. Sewage Disposal: DEP Public Water Supply No.: (if applicable) ,, ' 19 1"1 f 16. Days and Hours of Operation: 17.No. of Food Employees C",S Page 1 of 3 NAME OF ESTABLISHMENT: ! /� ! /,� J I/1'�M- ��41 �✓�-A'ev 18. Name of Person in Charge—Certified in Food Protection Management(required as of 101112001 in accordance with 105 CMR 590.003(A)please attach copy of certificate): 19. Person Trained in Anti-Choking Procedures(if 25 seats or more:Wes ❑No) NAME: P L L0 S - /I—M:L) 21. Length of Permit: (check one) 20. Location: (check one) Annual Permanent Structure ❑Seasonal/Dates: ❑Mobile ❑Temporary/Dates/Time: 22. Establishment Type(check all that apply): ❑ Retail(_square feet) Ue"'food Service—( seats) C�'` Food Service—Takeout ❑ Food Service—Institution( Meals per day) ❑ Caterer ❑ Food Delivery ❑ Residential Kitchen for Retail Sale ❑ Residential Kitchen for Bed and Breakfast Home ❑ Residential Kitchen for Bed and Breakfast Establishments ❑ Frozen Dessert Manufacturer ❑ Other(Describe) 23. Food Operations(check all that apply)—DEFINITIONS: ➢ PHF—potential hazardous food(time/temperature controls required); ➢ Non-PHFs—non-potentially hazardous food(no time/temperature controls required); ➢ RTE—ready-to-eat foods(Ex.-sandwiches,salads,muffins,which need no further processing ❑ Sale of Commercially Pre-Packaged Non-PHF's PHF Cooked to Order tW Hot PHF Cooked and Cooled or Hot Held for More than a Single Meal Service ❑ Sale of Commercially Pre-Packaged PHFs C Preparation of PHFs for Hot and Cold Holding for Single Meal Service ❑ PHF and RTE Foods Prepared for Highly Susceptible Population Facility ❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to be prepared by Consumer ❑ Vacuum Packaging/Cook Chill ❑ Reheating of Commercially Processed Foods for Service within 4 hours ❑ Customer Self-Service ❑ Use of Process Requiring a Variance And/Or HACCP Plan(including bare hand contact alternative,time as a public health control) ❑ Customer Self-Service of Non PHF and Non-Perishable Foods Only ❑ Ice Manufactured and Packaged for Retail Sale ❑ Offers Raw or Undercooked Food of Animal Origin ❑ Preparation of Non-PHFs ❑ Juice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single Meals for Catered Events of Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage, Out-of-Date or Reconditioned Food ❑ Other(Describe): Page7—oTT— NAME OF ESTABLISHMENT: '7-d- (4' 7 R **IF YOU DO NOT RENEW BY JANUARY IST,THE FEE WILL DOUBLE" Please do not combine fees for various permits in one check— (Example—dumpster fees should not be combined with a food permit fee) Please include copies of current Serve SafelAllergen TraininglChoke Saver Certifledtions 1,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CN4R 590.000 and Article X of the State Sanitary Code,and all other applicable law. I have been instructed by the Board of Health on how to obtain clics of t 105 CMR 590.000 ano,the Federal Food Code. 24. Signature of Applicant: Signature Fo 7(9� /1q.6 1 Print Name Pursuant to MGL Ch. 62C, see, 49A, I certify under the penalties ofpetjwy that 1, to my best knowledge and belief, have filled all state tax returns and paid state taxes)-equh-ed under the law. 25, Social Security Number of Federal I (A 26. Signature of Individual or Corporate Name: R- T- Signature Print Name Page 3 of 3 EXAM FORM NO. 4770 CERTIFICATE NO. 9641946 ServSafe O CERTIFICATION ro FVTIVS S 1 !'1MO for successfully completing the standards set forth for the ServSafe"Food Protection Manager Certification E. which is accredited by the American National Standards Institute(ANSI)-Conference for Food Protection t 12/16I2412.= DATE OF E- XAMhNATI,ON 12/16/201 DATE OF EXPkIRA.'FIDN Local laws apply. for recertification requirements. I ` Paul Hneman ® ExecuttveV�cq Ptes dent Na(lonal Restaurant Association i #0655 LhZeR Nadoroi Restaurant0.ssoaa8uti F,ducationarradndatlon(NRAE�:�Alfctxht5 rrserved ServSafe isa:registorcdtcddemack of Me NRAEF,used under Ileense by National RestaurantAssoclatton Sohrtions,U.C. Th logo ppearitrgne%ito5erv5ptcJs�pademnYk bf�lYcNaS onalR sfagtantAs9a�atibpi � _ Tl�isdowmeryt cannnk_¢orepreduced:Dr'dtered , j-lmfy CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: Fotios Stamos Certificate Number: 1275384 Date of Completion: 12/5/2013 Date of Expiration: 12/5/2018 Issued By: 7be above-named person is hereby issued this cert�&ate For" �� S(YrT C for completing an allergen awareness training prograns � � „�, RANT recognized by the Massachusetts Department of'Public Healtb 1. . ASSOCIATION, in accordance with 105 CMR 590.009(G)(3)(a). Massachusetts Restaurant Association 800.765.2122 333 Turnpike Road,Suite 102 www.restaurant.org Dais cet tcate will be valid for five(5)years from date of completion. Southborough,Mtn.01772508-303-9905 1 www.maresmurantassoc.org And - Firstmwa Educc, 0 S rE 4r Proudly presents this "Certificate of Attendance"to k S+ahos ' For participating in the training and demonstrating rogram Sponsor: skills S.A.F.E. —NS he Port Tavern Training s Agenc , `a,. 4 State St No. 62555 ewburyport,MA 01950 For www.choksaver.co i � 2 Hr Program conducted by � [ E This 12th day of � May, 2014. �nt� _�3C�� � p n Gunther Wellenstein, EMT Re ' Meets Mass DPH 105 CMR 590.009 Instructor (No. 0489749) Cs —vv—w i--�r ii��--vr— v —�a�—��r—^tr a ,. .u—/.. ���..r. �,.����J:m�.aa.._.�:s_.,✓.:+..___i'��iuti���1. And rst aw Educc, Proudly presents this Certificate of Attendance to M M4 For articipating in the training ! and demonstrating ( ! rogram Sponsor: skills S.A.F.E. —N S > he Port Tavern Training Agenc !. ! 4 State St No. 62555 ! ! ewburyport,MA 01950 For www.choksaver.co S VAS KE 0 & N3 A ! 2 Hr Program conducted by l A ! This 12th day of ! d ! � May, 2014. n ! Gunther Wellenstein, EMT Re� ! W.Reets Mass DPH 105 CMR 590.009 Instructor (No. 0489749) RIO � �u---°���:i�'--�i—�,:r'—�::--tr—�;r—�r�^c,---�;:�---�:�—`s✓—\s-1;�^-:v—l:r----�i----•::r----v^r-0;r--vr—.-"av"_�er—o• r :tMz tee.✓ __..— 5-1 e � And IFIrstmaid Educ:c Proudly presents this "Certificate of Attendance"to 604 For participating in the training and demonstrating rograrn Sponsor: skills S.A.F'.E.—N1 he Port Tavern Training Agen 4 State St No. 6255 ewburyport,MA 01950 For wvwv.choksaver.cc t4 2 Hr Program conducted by This 12th day of 3 May, 2414. — /i�tlnThw' W�w Gunther Wellenstein, EMT �eets Mass DPH 105 CMR 590.009 Instructor (No. 0489749) ���„�—ri--a.--�;�—�;r—�r~'�:�—�::r-1r-�•r—�¢>--�:�'—,:•�•r—�:r�-ar.—�.�—�•r--�:�--vs—°c-s—�r-�.•r-1.—�; ---------- ---—------ .. ......................... -- ------------------------------------ ---------- COMMONWEALTH OF MASSACHUSETTS NUMBER BHP-2013-0401 North Andover ----- ............................... BOARD OF HEALTH FEE $185.00 Jimmy's Famous Pizza DATE ISSUED NAME January 01,2013 1595 Osgood Street Attn: Permit Renewals NORTH ANDOVER,MA 01845 -------------1111-1-1-11--------".."--- ------1-1-- -------------I------------------------- .......... .. --------- ADDRESS IS HEREBY GRANTED A Food Est. - Restaurant Permit Food Establishment-Restaurant This permit is granted in conformity with the Statutes and ordinances relating thereto,and expires December 31,2013 unless sooner suspended or revoked. RESTRICTIONS:Food Service: 50 seats;Takeout;Delivery BOARD OF NOTES: Contact:Nikolas Papantonakis,Manager; ti- HEALTH 978.685.7776 ---------- ---------------------------- ---------- --------------I-- --------------------------- ...I---------------1-1-1-------------I........ BOARD OF HEALTH CHAIRMAN -----------—------------------------------ ...... ......................... - ------------- 12/19/2019 Dashboard—northandoverma.gov—Stripe ............. ...... ....... ........ ....... .........****......... Reference No: BIIF-2002.-000060 .................................. Permit No- BHP-2013-0401 Department: ................................... Nofth Andover BOARD OFHEALTH e: ......................................................................................... Account No: 2031207..A5.0510.00 Fee "T"yp .............. .................... Food Est. ­ Restaurant Rec6pt No: REG-2013­000700 ........................................................................................ ................................... Paid lBy: Paid in FuH On: Mon Nov 26,201 riplets, ite. 2 .................................... T l ......................................................................................... Check No: '7764 Received By: ................................... Usa Blackburn ........................................................................................ DEPARTIMEN"rs copy Amount: $185.010 ........................... L...........................................................................................................................................................................j https:Hdashboard.stripe,com/payments/py_l FqgfAGgVQ7dHaSppmxhg2LM 2/2 YWP' NUR Offi T11 ANI)OVIU1 ' 0[11%ce of OMMUNITY DJ�,1 4 ENTAN 1) SE11VK,',ES HEALTH DEPARTMENT 160I'; III,Jll.,D[N(l20; 1�NI035 k,Ath NOR111 ANDOVU,A, MASSACHUSE11"I'S 01845 .......................... Vhone 978.088,9540 i,',vc 978,688,8476 111­niaiL N e,, 10 FOOD ESTABLISHMENT PERMIT APPLICATION (If new establishment,application must be submitted at least 30 days before the planned opening date) EEE., 2013 reacnala pay samc ke, as 2012 permit Da 1. Establishment Name: -T1MAAq'6 F-x)Mil W5, 2. Establishment Address ji;;iG 0660131) -5>­T7 Norr A (Imi)OVCR, I'Y'04- 3. Establishment Mailing Address(if different) 4. Establishment Telephone#: 5. Applicant Name&Title: riZol"te- -5­rAAAD,S — /0A 04 6('re 6. Applicant Address: 64-49 WJ -;4 Z36 , P66 96061 , M4 Olel(po NOV 26 11112, 7. Applicant Telephone No.: 61-7 24-Hour Emergency No.: c. 8. Owner Name&Title(if different form applicant): 9. Owner Address(if different from applicant): 10. Establishment Owned BY: 11. If a corporation or partnership,give name,title,and An Associatio<ACorporation; An individual home address of the officers or partner: ___­7 Name Title 14orne Address A partnership; other legal entity_ 12. Person Directly Responsible for Daily Operations(Owner,Person in Charge,Supervisor,Manager,Etc.) Name&Title: retitjv— -10-al t-t&s /tv\'q' 'JA 6(-,e Address: 54A( 65 f),Bo/(' Telephone No.: I-) 2 q 3 K51 Fax No.: E-mail: F­;;TMAO� 0 604U., 4DM Emergency Telephone No.: 781 - 4�'2-— 06 12. PaOA"TowAV-%�p 13. District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No.: Fax No,: E-mail: 14. Water Source: 15. Sewage Disposal: DEP Public Water Supply No.:(if applicable) 57c.-P-C 1 C 16. Days and Hours of Operation: 17.No.of Food Employees SUNPAq W0 'M­6416041 I o 1,�% Pagel of NAME OF ESTABLISHMENT: 18. Name of Person in Charge-Certified in Food Protection Management(required as of 10/1/2001 in accordance with 105 CMR 590.003(A)please attach copy of certificate): ° -i-04 19. Person Trained in Anti-Choking Procedures(if 25 seats or more Yes ) No) NAME: eiyi y- 21. Len th of Permit: (check one) 20. Loc tion• (check one) Annual ermanent Structure) asoaa1/Dates: Mobile Temporary/Dates/Time: 22. Establishment Type(check all that apply): ❑ Retail(_square feet) y Food Service-( seats) it Food Service-Takeout ❑ Food Service-Institution( Meals per day) r Caterer Food Delivery ❑ Residential Kitchen for Retail Sale ❑ Residential Kitchen for Bed and Breakfast Home ❑ Residential Kitchen for Bed and Breakfast Establishments ❑ Frozen Dessert Manufacturer ❑ Other(Describe) 23. Food Operations(check all that apply)-DEFINITIONS: ➢ PHF-potential hazardous food(time/temperature controls required); ➢ Non-PHFs-non-potentially hazardous food(no time/temperature controls required); ➢ RTE-ready-to-eat foods(Ex.-sandwiches,salads,muffins,which need no further processing ❑ Sale of Commercially Pre-Packaged Non-PHF's >• PHF Cooked to Order V Hot PHF Cooked and Cooled or Hot Held for More than a Single Meal Service ❑ Sale of Commercially Pre-Packaged PHFs ❑ Preparation of PHFs for Hot and Cold Holding for Single Meal Service ❑, PHF and RTE Foods Prepared for Highly Susceptible Population Facility Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to be prepared by Consumer ❑ Vacuum Packaging/Cook Chill ❑ Reheating of Commercially Processed Foods for Service within 4 hours ❑ Customer Self-Service ❑ Use of Process Requiring a Variance And/Or HACCP Plan(including bare hand contact alternative,time as a public health control) ❑ Customer Self-Service of Non PHF and Non-Perishable Foods Only ❑ Ice Manufactured and Packaged for Retail Sale ❑ Offers Raw or Undercooked Food of Animal Origin ❑ Preparation of Non-PHFs ❑ Juice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single Meals for Catered Events of Institutional Food Service Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage,Out-of-Date or Reconditioned Food ❑ Other(Describe): Page 2 of 3 NAME OF ESTABLISHMENT: ***IF YOU DO NOT RENEW BY JANUARY 1ST,THE FEE WILL DOUBLE*** Please do not combine fees for various permits in one check— (Example—dumpster fees should not be combined with a food permit fee) I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and Art1clq X of the State Sanitary Code,and all other applicable law. I have been instructed by the Board of Health on how to obtain copie o 5 CMR 590.000 and the Federal Food Code. 24. Signature of Applicant: ignature Print Name Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filled all state tax returns and paid state taxes required under the law. 25. Social Security Number or Federal I.D.#: �`�I I � 26. Signature of Individual or Corporate Name: Signature Print Name Page 3 of 3 EXAM FORM NO. 4770 CERTIFICATE NO. 9641938 ServSafe CERTIFICATION To KHALIL AB KABLI for successfully completing the standards set forth for the ServSafe"Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute(ANSI)-Conference for Food Protection(CFP). 1 116/2-012 DATE OF.EXAV:l',tVA'TfON-, ., 12/16/2017 DATE OF EXP.IRATIO'N ' Local laws apply.ChecK,*khyour]ocall regufati�ry agency for recertification requirements. Pau i Hineman' ® ExeSutive Vice Presidentr National`Restaurant Association #0655 ©2472NationalR tauCaat The loo a eiVSafe i. d nihucatignai foyndakion(ryRgEFI.AlY4igClG ieserved 5eni5afe isaregistered trademark of the NRAEF,used under l'cense 6y National Restaurant Assonation Solutions,LLC, ring to Serrakradeiria k ftKenatinnal Re`staurantA45oaahop: i,Thts documen[canoot 0e ieprnduoad araiGered: , EXAM FORM NO. 4770 CERTIFICATE NO. 9641944 ServSafe CERTIFICATION TO NICHOLAS PAPANTONAKIS for successfully completing the standards set forth for the ServSafe Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute(ANSI)-Conference for Food Protection(CFP). 12/16/2�012 DATE OF EXA,jNAT'ION DATE OF EXP.I=RAT(Ohl` Local laws apply.ChecKwith your local regula#gry`agencyforrecertification requirements. ,'.Paul Hineman ® Lxeciative` ce Rresident'National Restaurant Association #0655 :' z2012 Nat'onal RestauranCAssyc a4on Educa�iopaliF u AIL�afwn(NftAEH tighks gservea,ServSafeLS aregistered badenarkaf the NRAEF,used under license by National Restaurant Association Solutions,LtC, The logo appcacins nenttoServSafeis aErademarkbf theNaEional Resfaurant gssonetion, "Thlsdacumant<annoC tre reprnducad;ar altdrad" , EXAM FORM NO. 4770 CERTIFICATE NO. 9641946 ServSafe CERTIFICATION To FOTIOS STAMOS for successfully completing the standards set forth for the ServSafes Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute(ANSI)-Conference for Food Protection(CFP). 1�/16/2012 DATE OF4E-XAMi_NATtI0N' 12/16/2017 DATE OF EXP(RAT O', Local laws apply.ChecfCwtth your'local regu2itfSCya$enhy-for recertification requirements. i Paul fitilertap. Exeout ve Vice Presldent Natitipal Restaurant Association #0655 @2012 National RestauraetA6snaahot[,Eduwtinnaf fottnAat on,(NRAEFI AlI rigljts peserved 5ervSaFa is a raglst9redtrademark of the NRAEF,used under license by National ResWurant Associatwn SaWtwos,U.C. The logo appeynng ne#tp SsN$afojsa tradematk of=ttie National Reskaurantll%sociation. :This documenf:cadnotbereprdduced o,Aekeidi , • Commonwealth of Massachusetts % OOj �• North Andover ' BOARD OF HEALTH 1600 OSGOOD STREET BUILDING 20;SUITE 2-36; South NORTH ANDOVER,MA 01845 DATE PRINTED: 12/19/2011 ESTABLISHMENT NAME: Jimmy's Famous Pizza Jimmy's Famous Pizza 1595 Osgood Street Attn:Permit Renewals File Number:BHF-2002-000060 NORTH ANDOVER MA 01845 LOCATED AT: , MA Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes Dumpster Permit BHP-2012-0332 Jan 1,2012 Dee 31,2012 $60.0f m 1.800.720.3034;Mondays/ Contact: ,onaky; 978.685.7776 Food Est.-Restaurant BHP-2012-0073 Jan 1,2012 Dec 31,2012 $185.00 Food Service: 50 seats;Takeout; Permit Delivf—i Onntact:l Manager; 978.685.7776 Total Fees: $245.00 — .. ......_ . .-....-__ ..... ............... — - PERMIT EXPIRES F ecernber 31,2012 BOARD OF HEALTH Page 1 TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT Susan Y. Sawyer,REHS/RS 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 Public Health Director NORTH ANDOVER, MASSACFRJSETTS 01845 Phone: 978.688.9540 Fax: 978.688.8476 E-mail:healthd ei).townofiiot-tliandover.coiii bg��� FOOD ESTABLISHMENT PERMIT APPLICATION (If new establishment,application must be submitted at least 30 days before the planned opening date) EEE: 2012 renewals pay same fee as 2011 permit Date: 1. Establishment Name: JtAA&i 1.$ 'FAAAk4_S PIVA 2. Establishment Address 1'515 0'5600C) Doti 4JjDbV&z0 3. Establishment Mailing Address(if different) 4. Establishment Telephone#: 7 (195- -7-7 7 E.,C 2' 112011 5. Applicant Name&Title: f�--nts S-rxAk os /^4rh()6,e- ['I'OVW��N4 7(0>FNC0RT1'i4 AlYDOVE13 6. Applicant Address: F)q +90aw SIC e6.4-&t>j, AMA. 0066 PlEAL,"TH 1)EPAf4TMEf4T 7. Applicant Telephone No.:4012'(Pig. 777(a 24-Hour Emergency No.: &1'7 215- 13!;:5'7 8. Owner Name&Title(if different form applicant): 9. Owner Address(if different from applicant): 10. Establishment Owned By: 11. If a corporation oi-partnership,give name,title,and E]An Association;*Corporation;11 An individual home address of the officers or partner: Name litte Horne Addregs E]A partnership;Cl other legal entity_ 12. Pei-son Directly Responsible for Daily Operations(Owner,Person in Charge,Supervisor,Manager,Etc.) Name&Title: F'b*To o-5 —*>' -rA go'> / AA,+#J A 6 eA Address: 84 "OJU4 4-C- P64466 04, 1%44 0 1*1 L Telephone No.: CIIVI Fax No.: E-mail: Emergency Telephone No.: �11'7 215 &:557 C.M 13. District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No.: Fax No.: E-mail: 14. Water Source: 15. Sewage Disposal: DEP Public Water Supply No.:(if applicable) 16. Days and Hours of Operation: 17.No.of Food Employees 540- 0-r to *44— ID res Page 1 of 3 i p NAME OF ESTABLISHMENT: 18. Name of Person in Charge—Certified in Food Protection Management(required as of 10/1/2001 in accordance with 105 CMR 590.003(A)please attach copy of certificate): ;0_TiW5, !TA&Abs 19. Person Trained in Anti-Choking Procedures(if 25 seats or more:DYes DNo) NAME: ®'TlaS -r�-MuS 21. Length of Permit:(check one) 20. Location:(check one) XAnnual Permanent Structure ❑Seasonal/Dates: ❑Mobile ❑Temporary/Dates/Time: 22. Establishment Type(check all that apply): ❑ Retail( s uare feet) A Food Service—( seats) d Food Service—Takeout ❑ Food Service—Institution( Meals per day) ❑ Caterer *E Food Delivery ❑ Residential Kitchen for Retail Sale ❑ Residential Kitchen for Bed and Breakfast Home ❑ Residential Kitchen for Bed and Breakfast Establishments ❑ Frozen Dessert Manufacturer ❑ Other(Describe) 23. Food Operations(check all that apply)—DEFINITIONS: ➢ PHF—potential hazardous food(time/temperature controls required); ➢ Non-PHFs—non-potentially hazardous food(no time/temperature controls required); ➢ RTE—ready-to-eat foods(Ex.-sandwiches,salads,muffins,which need no further processing ❑ Sale of Commercially Pre-Packaged Non-PHF's :& PHF Cooked to Order ❑ Hot PHF Cooked and Cooled or Hot Held for More than a Single Meal Service ❑ Sale of Commercially Pre-Packaged PHFs ;' Preparation of PHFs for Hot and Cold Holding for Single Meal Service ❑ PHF and RTE Foods Prepared for Highly Susceptible Population Facility A Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to be prepared by Consumer ❑ Vacuum Packaging/Cook Chill ❑ Reheating of Commercially Processed Foods for Service within 4 hours ❑ Customer Self-Service ❑ Use of Process Requiring a Variance And/Or HACCP Plan(including bare hand contact alternative,time as a public health control) ❑ Customer Self-Service of Non PHF and Non-Perishable Foods Only ❑ Ice Manufactured and Packaged for Retail Sale ❑ Offers Raw or Undercooked Food of Animal Origin ❑ Preparation of Non-PHFs ❑ Juice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single Meals for Catered Events of Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage,Out-of-Date or Reconditioned Food ❑ Other(Describe): Page 2 of 3 NAME OF ESTABLISHMENT: d(AAAAj i5 �iq ( S tZ1,A **IF YOU DO NOT RENEW BY JANUARY 1ST,THE FEE WILL DOUBLE*** Please do not combine fees for various permits in one check— (Example—dumpster fees should not be combined with a food permit fee) I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and Article X of the State Sanitary Code,and all other applicable law. I have been instructed by the Board of Health on how to ob i o ies of t 105 CMR 590.000 and the Federal Food Code. 24. Signature of Applicant: Signature F-t)®5 5-c"5 Print Name Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that 1, to my best knowledge and belief, hai,e filled all state tax returns and paid state taxes required under the lain. 25. Social Security Number or Federal I.D.#: 3 S 5 l L1 5 2 26. Signature of Individual or Corporate Name: ignature Fo-(105 �IVbS Print Name Page 3 of 3 TOWN OF NORTH ANDOVER oa Na�T►, , Office of COMMUNITY DEVELOPMENT AND SERVICES F� 001 �'°�0a HEALTH DEPARTMENT 20••1600 OSGOOD STREET BUILDING SUITE 2-36 Susan Y. Sawyer, REHS/RS � � Public Health Director NORTH ANDOVER, MASSACHUSETTS 01845 �ssncHus�t Phone: 978.688.9540 Fax: 978.688.8476 E-mail: healthdeptp_townofnorthandover,com APPLICATION FOR DUMPSTER PERMIT PURSUANT TO SECTION 31A AND 31B OF CHAPTER II „ OF THE GENERAL LAWS, AND R ULES AND REGULATIONS ,T NORTHANDOVER BOARD OF HEALTH DATE: 7"hWWN OF NORTH ANDOVER NE 1_'rll Dr.-'F 'rl WENT Application is hereby made for a permit to maintain a dumpster(s) on property located at 150f5, o y GCM O 5'r. n ZI 4 AIJ!D j A14 01&'Y'5 in accordance with the rules and regulations of the Board of Health, r r Applicant:J104 S !*' S T1 Property Owner: CVVQA 5 Name of Contact: N%GV- bit- K Owners Address: '5? s"r&° 47; `9302 Address: 1595 D 5(4 n0 51 OWT 9.0 5''zw, 44. C>2lzw N0W14- -ojo6&yt Owners Phone#: tfa17 • ?• Telephone#: C09-• �► $�j• �?'�?f� Federal ID or SS#: '0'+' 551(1Sz Dumpster Company: Po it-.r 4 S IpE ors Cq Telephone#: q 19 • Pick-Up Schedule: MOM DAY 6 On the back of this form, please sketch an outline of property, showing the proposed location of the dumpster(s). Give distance from dumpster to other buildings and lot lines or boundaries. Annual Dumpster Permit Fee: $60.00 per establishment Payable to: Town of North Andover. LATE FEE AFTER JANUARY 1"WILL BE DOUBLED - $120.00 *Please note that all contact information and the associated fee is required upon application submittal. Page 1 of 1 n � � � 1 � .................................................. ------........................ COMMONWEALTH OF MASSACHUSETTS NUMBER '40RT4 BHP-2010-0698 "40 North Andover Board of Health FEE .................. Jimmy's Famous Pizza DATE ISSUED NAME August 03,2010 ............ 1595 Osgood Street Attn: Permit Renewals NORTH ANDOVER,MA 01845 ----------------- ------------- -------------------------------------- -------------------------------------—-------------------------------------------- ------- ADDRESS IS HEREBY GRANTED A Food Est. -Temporary- TAX EXEMPT Food Service This permit is granted in conformity with the Statutes and ordinances relating thereto,and expires -___.-_-.-___August 04,2010 -------------unless sooner suspended or revoked. RESTRICTIONS: PIZZA ONLY Board of ----------- --------- --------- Health NOTES:Frank Stamos;978.685.7776 ---------------- -------- --- - -- -- - --------- HOURS ACTIVE:North Andover Middle School-6:00- ---- ------I-------------- ------- ------- - 8:00 p.m. Board of Health Chairman ....................................... ...................... ------------------------------ 12/16/2019 3/3 Commonwealth of Massachusetts North.Andover a Board of Health „ 1600 OSGOOD STREET �►ra BUILDING 20;SUITE 2-36; South NORTH ANDOVER,MA 01845 DATE PRINTED: 12/13/2010 ESTABLISHMENT NAME: Jimmy's Famous Pizza Jimmy's Famous Pizza 1595 Osgood Street Attn:Permit Renewals NORTH ANDOVER MA 01845 File Number:BHF-2002-000060 LOCATED AT: ,MA Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes Food Est.-Restaurant BHP-2011-0242 Jan 1,2011 Dec 31,2011. $185.00 Food Service: 50 seats;Takeout; Permit Delivery/Contact:Nikolas Papantonakis,Manager; 978.685.7776 Total Fees: $185.00 PERMIT EXPIRES December 31,2011 Board of Health Page 1 TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT Susan Y. Sawyer,REFISIRS 1,600 OS GOOD STREET; BUILDING 20; SUITE 2-36 Public Health Director NORTI I ANDOVER, MASSACHUSETTS 01845 Phone: 978.688.9540 Fax: 978.688.8476 E-mail:healthde�townofiiorthando r.con 'c liv P')�i o FOOD ESTABLISHMENT PERMIT APPLICAT (If new establishment,application must be submitted at least 30days before the planned oplfi N flit NORDIAN OVER N FEE: 2011 renewals pay same fee as 2010 permit pj 1. Establishment Name: Jjjn1$ TAmot4S ejUA k0004&e, AAA. 0104'9 2. Establishment Address 165 1 042GOOD 3. Establishment Mailing Address(if different) 4. Establishment Telephone#: `7 5. Applicant Name&Title: 6. Applicant Address: 9q R(Ye,/Y 5'7 7. Applicant Telephone No.:Cj 13 �(S� )?7 24-Hour Emergency No.: q 3 8. Owner Name&Title(if different form applicant): 9. Owner Address(if different from applicant): 10. Establishment Owned By: 11. If a corporation or partnership,give name,title,and 0 An Association;�A Corporation;0 An individual home address of the officers or partner: Name, Tjtjc Home Address 0 A partnership;0 other legal entity_ Ota L4 �Aiertt dll-; FtaAoy Otx- @'rj0',55-rAA6$ C 84 Ai%aij -�­( ft-Ary ,M4. 12. Person Directly Responsible for Daily Operations(Owner,Person in Charge,Supervisor,Manager,Etc.) , A A 6—u� Name&Title: VU (16 A(Address: 60,O(t(\( cUiJ�dY Telephone No,: ct"-78 Fax No.: E-mail: Emergency Telephone No.: 13. District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No.: Fax No.: E-mail: 14. Water Source: 15. Sewage Disposal: DEP Public Water Supply No.:(if applicable) 16. Days and Hours of Operation: 17.No.of Food Employees 0 fvo-t to P/q 3 Pagel of 'NAME OF ESTABLISHMENT: 18. Name of Person in Charge—Certified in Food Protection Management(required as of 10/l/2001 in accordance with 105 CMR 590.003(A)please attach copy of certificate): ro Tt U.f '' AI14 19. Person Trained in Anti-Choking Procedures(if 25 seats or more:' Yes DNo) NAME: "FG T/ US S 7 A A o J 21. Length of Permit: (check one) 20. Location:(check one) TfAnnual Permanent Structure ❑Seasonal/Dates: ❑Mobile 11 Temporary/Dates/Time: 22. Establishment Type(check all that apply): ❑ Retail( square feet) 4 Food Service— seats) C� Food Service—Takeou ❑ Food Service—Institution( Meals per day) ❑ Caterer Food Delivery ❑ Residential Kitchen for Retail Sale ❑ Residential Kitchen for Bed and Breakfast Home ❑ Residential Kitchen for Bed and Breakfast Establishments ❑ Frozen Dessert Manufacturer ❑ Other(Describe) 23. Food Operations(check all that apply)—DEFINITIONS: ➢ PHF—potential hazardous food(time/temperature controls required); ➢ Non-PHFs—non-potentially hazardous food(no time/temperature controls required); ➢ RTE—ready-to-eat foods(Ex.-sandwiches,salads,muffins,which need no further processing ❑ Sale of Commercially Pre-Packaged Non-PHF's PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held for More than a Single Meal Service ❑ Sale of Commercially Pre-Packaged PHFs t% Preparation of PHFs for Hot and Cold Holding for Single Meal Service ❑ PHF and RTE Foods Prepared for Highly Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be prepared by Consumer ❑ Vacuum Packaging/Cook Chill ❑ Reheating of Commercially Processed Foods for Service within 4 hours ❑ Customer Self-Service ❑ Use of Process Requiring a Variance And/Or HACCP Plan(including bare hand contact alternative,time as a public health control) ❑ Customer Self-Service of Non PHF and Non-Perishable Foods Only ❑ Ice Manufactured and Packaged for Retail Sale ❑ Offers Raw or Undercooked Food of Animal Origin ❑ Preparation of Non-PHFs ❑ Juice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single Meals for Catered Events of Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage,Out-of-Date or Reconditioned Food ❑ Other(Describe): Page 2 of 3 NAME'OF ESTABLISHMENT: ***IF YOU DO NOT RENEW BY JANUARY 1ST,THE FEE WILL DOUBLE *** Please do not combine fees for various permits in one check— (Example—dumpster fees should not be combined with a food permit fee) I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and Article X of the State Sanitary Code,and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of t 105 CMR 590,000 and the Federal Food Code. 24. Signature of Applicant: z Signature vv_ v S-TA M o S Print Name Pursuant to MGL Ch. 62C, sec. 49A,I certify under the penalties of perjury that I, to my best knowledge and belief, have filled all state tax returns and paid state taxes required under the law. 25. Social Security Number or Federal I.D.#: 26. Signature of Individual or Corporate Name: Signature 'AAA US Print Name Page 3 of 3 Commonwealth of Massachusetts a North Andover Board of Health %�� ^'" 1600 OSGOOD STREET r Nor BUILDING 20; SUITE 2-36; South NORTH ANDOVER,MA 01845 DATE PRINTED: 10/28/2009 ESTABLISHMENT NAME: Jimmy's Famous Pizza Jimmy's Famous Pizza 1591 Osgood Street NORTH ANDOVER MA 01845 File Number:BHF-2002-000060 LOCATED AT: , MA Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes Food Est.-Restaurant BHP-2010-0233 Jan 1,2010 Dec 31,2010 $185.00 Food Service: 50 seats;Takeout; Delivery/Contact:Nikolas Papantonakis,Manager; 978.685.7776 Total Fees: $185.00 PERMIT EXPIRES December 31, 2010 Board of Health Page 1 TOWN OF NORTH ANDOVE Office of COMMUNITY DEVELOPMENT AID S HEALTH DEPARTMENTS Susan Y. Sawyer, REHS/RS 1600 OSGOOD STREET; BUILDING 20; S IT Public Health Director NORTH ANDOVER, MASSACHUSETTS Q;„1 qs CHUSEt d t�45 Qf i ��t a ti Aa�1q Q f i..dtiN.TH DEPARINENT Phone: 978.688.9540 Fax: 978.688.8476 E-mail: healthdepoa,ownof orthandovei.com FOOD ESTABLISHMENT PERMIT APPLICATION (If new establishment,application must be submitted at least 30 days before the planned opening date) FEE: Depends on type of food establishment - Refer to the current fee schedule 1. Establishment Name: J Q1,P 74 1 1 M e— aI IV 4— �St k ,'y j- "P,4/24J,✓:.A 2. Establishment Address ( '5'0( ® S G--dd 3. Establishment Mailing Address(if different) 4. Establishment Telephone#: .7 9 &A � �7 7 5. Applicant Name&Title: G C-1C ��Pdl-d�( 7,0N'+�l 6. Applicant Address: t 5 C1 ( ' ' S i� />I. +f/d AtA 64 q 7. Applicant Telephone No.: l, t� �' 24-Hour Emergency No.: 8. Owner Name&Title(if different form applicant): 9. Owner Address(if different from applicant): 10. Establishment Owned By: Pomeaddress a corporation or partnership,give name,title,and El An Association;�Corporation;❑An individual of the officers or partner: Name Title H me Address U A partnership;C!other legal entity b 12. Person Directly Responsible for Daily Operations(Owner,Person in Charge,Supervisor,Manager, c. Name&Title: N (6"(1 POP N Zl/, ltfft Address: l ,j V 0j 6-0-66 S-7 Ix{ , AAt d ille ( ft,4 a(� y r � t Telephone No.: q ) e & d,5- Fax No.: -mail Emergency Telephone No.: 13. District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No.: Fax No.: E-mail: 14. Water Source: 1 ewage D-isposal: DEP Public Water Supply No.: (if applicable) 'I W va �� 16. Days and Hours of Operation: 17 No. of Food Employees NOTE: THERE WILL BE A$50.00 CHARGE FOR ANY REQUIRED RE-INSPECTIONS AFTER AN UNSATISFACTORY INSPECTION Page 1 of 3 n NAME OF ESTABLISHMENT: ( P� _( / G- 1k ,4 ,iycl '� J z 18. Name of Person in Charge—Certified in Food Protection Management(required as of 101112001 in accordance with 105 CMR 590.003(A)please attach copy of certificate): 19. Person Trained in Anti(-�Choking Procedures(if 25 seats or more: ❑Yes &o) NAME: 21. Length of Permit: (check one) 20. Location: (check one) )'Annual ermanent Structure ❑ Seasonal/Dates: ❑Mobile ❑ Temporary/Dates/Time: 22. Establishment Type(check all that apply): ❑ Retail�_ square feet) Food Service— seats) OFood Service—Takeout Food Service—Institution( Meals per day) ❑ Caterer ❑ Food Delivery ❑ Residential Kitchen for Retail Sale ❑ Residential Kitchen for Bed and Breakfast Home ❑ Residential Kitchen for Bed and Breakfast Establishments ❑ Frozen Dessert Manufacturer ❑ Other(Describe) 21 ood Operations(check all that apply)—DEFINITIONS: ➢ PHF—potential hazardous food(time/temperature controls required); ➢ Non-PHFs—non-potentially hazardous food(no time/temperature controls required); ➢ RTE—ready-to-eat foods(Ex.-sandwiches,salads,muffins,which need no further processing ❑ Sale of Commercially Pre-Packaged Non-PHF's PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held for More than a Single Meal Service ❑ Sale of Commercially Pre-Packaged PHFs `l� Preparation of PHFs for Hot and Cold Holding for Single Meal Service ❑ PHF and RTE Foods Prepared for Highly Susceptible Population Facility ❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to be prepared by Consumer ❑ Vacuum Packaging/Cook Chill ❑ Reheating of Commercially Processed Foods for Service within 4 hours ❑ Customer Self-Service ❑ Use of Process Requiring a Variance And/Or HACCP Plan(including bare hand contact alternative,time as a public health control) ❑ Customer Self-Service of Non PHF and Non-Perishable Foods Only ❑ Ice Manufactured and Packaged for Retail Sale ❑ Offers Raw or Undercooked Food of Animal Origin Preparation of Non-PHFs o Juice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single Meals for Catered Events of Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage,Out-of-Date or Reconditioned Food ❑ Other(Describe): N age 2 o NAME OF ESTABLISHMENT: C. blAIA *** IF YOU DO NOT RENEW BY JANUARY 1ST,THE FEE WILL DOUBLE*** '— Please do not combine fees for various permits in one check— (Example—dumpster fees should not be combined with a food permit fee) I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and Article X of the to Sanitary Code,and all other applicable law. I have been instructed by the Board of Health on how to tain pies oft 105 C R 59 .000 and the Federal Food Code. 24. Signature of Applicant: "tign'atture 1 & Print Name Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties ofpeijuiy that I, to my best knowledge and belief, have filled all state tax returns and paid state taxes required under the law. 25. Social Security Number or Federal I.D.#: V/,-*, O LA 26. Signature of Individual or Corporate Name: /C'j'j �/L Signature Print Name NOTE: THERE WILL BE A$50.00 CHARGE FOR ANY REQUIRED RE-INSPECTIONS AFTER AN UNSATISFACTORY INSPECTION Page 3 of 3 Commonwealth of Massachusetts ®�."'° `�'�°o Board of Health North Andover 1600 OSGOOD STREET * ' BUILDING 20; SUITE 2-36 SAEMtl'�i NORTH ANDOVER,MA 01845 FOOD ESTABLISHMENT DATE PRINTED 10/21/2008 ESTABLISHMENT NAME: Jimmy's Famous Pizza File Number: BHF-2002-000060 1591 Osgood Street NORTH ANDOVER MA 01845 RE: 2009 LICENSE RENEWAL LOCATED AT: ,MA OWNER: Triplets,Inc. PHONE:(978)685-7776 RENEWAL FEE DUE-Amount depends on type of license(see fee schedule) LATE FEE AFTER JAN. 1st-FEE DOUBLED PERMIT TYPE FEE DURATION ANNUAL SEASONAL TEMPORARY Food Est.-Restaurant $185.00 NOTES: Contact:Nikolas Papantonakis, Manager;978.685.7776 Total Fees: $185.00 COURTESY RENEWAL REMINDER..........Your 2008 license expires on December 31 st. In order to renew this license you must be in compliance with the State Sanitary Code 105 CMR 590.000. To ensure timely processing,please return your application and payment by November 30th. Your renewal fee for the calendar year is indicated above. Please submit the following documents and appropriate fee: 1. []Completed application for 2009; 2. ❑Check for renewal fee payable to the Town of North Andover; 3. ❑Copies of all current Certified Food Manager Certifications; Renewal permits will not be issued unless ALL COMPLETED DOCUMENTS are submitted. This means that your license will not be issued until we receive all required documents. Please note that the Board of Health will levy a penalty of an additional fee if your license is not renewed by January 1st. For example, if your license fee is$185.00,our cost for being late will be $370.00. If this is disregarded,the North Andover Board of Health may revoke your license,and/or levy an additional fine. Please be advised that your Annual Food Service Permit must be conspicuously posted within the establishment at all times,and that at least one Certified Food handler must be on site at all times when the facility is open to the public. All necessary forms and regulations may be found on the Town of North Andover website:www.townoftiorthandover.com-Town Departments- - Health Department-Permits&Regulations. If you have any questions,please e-mail the Health Department at: healthdept@townofnorthandover.com,or call at 978.688.9540. Thank you for your cooperation during the annual renewal process. Eric: Application TOWN OF NORTH ANDOVER Of pORTH '1'%.16" Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT --CEIV Susan Y. Sawyer,REHS/RS 1600 OSGOOD STREET; BUILDING 20; SUI 2-36 0 0 Public Health Director NORTH ANDOVER, MASSACHUSETTS 01 45 NOV CH 0 6 G Phone: 978.688.9540 Fax: 978.688.8476 E-mail: healthdept@t )VER I R FOOD ESTABLISHMENT PERMIT Pt-1'166464�!' (If new establishment,application must be submitted at least 30 days before the planned opening date) FEE: Depends on type of food establishment - Refer to the current fee schedule 1. Establishment Name: 2. Establishment Address C;,b,,6 N, 3. Establishment Mailing Address(if different) 4. Establishment Telephone#: I� (0 t�5 5. Applicant Name&Title: Rt (,K PAA4N _t(J1\tAkCk_f 6. Applicant Address: t 5­1 0 7 A-Al (411L 7. Applicant Telephone No.:qi? ,y6d5—*-,?.7'I, 24-Hour Emergency No.: 8. Owner Name&Title(if different form applicant): 9. Owner Address(if different from applicant): 10. Establishment Owned By: 11. If a corporation or partnership,give name,title,and 0 An )Association; Corporation;0 An individual home address of the officers or partner:(IKk Name Title Home Address 0 A partnership;0 other legal entity (4 0 &,2 Uladob_ A-6,kK 12. Person Directly Responsible for Daily Operationscaner,Person in Charge,Supervi-sor,Manager,Etc.) Name&Title: 'N�L'&q Pk'PJ47mA4j Address: 146)QA( 1)dUrA_ Telephone No.: Fax No.: E-mail: Emergency Telephone No.: 13. District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No.: Fax No.: E-mail: 14. Water Source: v-8 L' C. 15. Sewage Disposal: DEP Public Water Supply No.: (if applicable) -S J- 0//)-^�f 'g- 16. Days and Hours of Operation: 17.No.of Food Employees 0 NOTE: THERE WILL BE A$50,00 CHARGE FOR ANY REQUIRED RE-INSPECTIONS AFTER AN UNSATISFACTORY INSPECTION Pagel of NAME OF ESTABLISHMENT: �I-( 4 A t Y P�4 '4t(l i/.l 18. Name of Person in Charge-Certified in Food Protection Management(required as of 101112001 in accordance with 105 CMR 590.003(A)please attach copy of certificate): 19. Person Trained in Anti-Choking Procedures(if 25 seats or more: ❑Yes ❑No) �3 NAME: 21. Length of Permit: (check one) 20. Location: (check one) `6knnual Permanent Structure ❑ Seasonal/Dates: ❑Mobile ❑Temporary/Dates/Time: 22. Establishment Type(check all that apply): ❑ Retail( square feet) Food Service-( D- 'D- seats) ❑ Food Service-Takeout ❑ Food Service-Institution( Meals per day) ❑ Caterer ❑ Food Delivery ❑ Residential Kitchen for Retail Sale ❑ Residential Kitchen for Bed and Breakfast Home ❑ Residential Kitchen for Bed and Breakfast Establishments ❑ Frozen Dessert Manufacturer ❑ Other(Describe) 23. Food Operations(check all that apply)-DEFINITIONS: ➢ PHF=potential hazardous food(time/temperature controls required); ➢ Non-PHFs-non-potentially hazardous food(no time/temperature controls required); ➢ RTE-ready-to-eat foods(Ex.-sandwiches,salads,muffins,which need no further processing ❑ Sale of Commercially Pre-Packaged Non-PHF's *Sk PHF Cooked to Order ❑ Hot PHF Cooked and Cooled or Hot Held for More than a Single Meal Service ❑ Sale of Commercially Pre-Packaged PHFs ❑ Preparation of PHFs for Hot and Cold Holding for Single Meal Service ❑ PHF and RTE Foods Prepared for Highly Susceptible Population Facility .Wq, Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to be prepared by Consumer ❑ Vacuum Packaging/Cook Chill ❑ Reheating of Commercially Processed Foods for Service within 4 hours ❑ Customer Self-Service ❑ Use of Process Requiring a Variance And/Or HACCP Plan(including bare hand contact alternative,time as a public health control) ❑ Customer Self-Service of Non PHF and Non-Perishable Foods Only ❑ Ice Manufactured and Packaged for Retail Sale ❑ Offers Raw or Undercooked Food of Animal Origin .d Preparation of Non-PHFs oJuice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single Meals for Catered Events of Institutional Food Service ❑ Offers RTE PET in Bulk Quantities ❑ Retail Sale of Salvage,Out-of-Date or Reconditioned Food ❑ Other(Describe): N Page 2 o NAME OF ESTABLISHMENT: ***IF YOU DO NOT RENEW BY JANUARY 1ST,THE FEE WILL DOUBLE*** Please do not combine fees for various permits in one check— (Example—dumpster fees should not be combined with a food permit fee) I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and Article X of the State Sanitary Code,and all other applicable law. I have been instructed by the Board of Health on how too Cain copies oft 105 CNM 590.0#and e Federal Food Code. l 24. Signature of Applicant: Signature Print Name Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties ofpetjury that I, to my best knowledge and belief, have filled all state tax returns and paid state taxes required under the law. 25. Social Security Number or Federal I.D.#: c 26. Signature of Individual or Corporate Name: Signature �t--( P A p Print Name NOTE: THERE WILL BE A$50.00 CHARGE FOR ANY REQUIRED RE-INSPECTIONS AFTER AN UNSATISFACTORY INSPECTION Page 3 of 3 Commonwealth of Massachusetts North Andover Board of Health 1600 OSGOOD STREET BUILDING 20; SUITE 2-36 NORTH ANDOVER,MA 01845 DATE PRINTED: 12/12/2007 ESTABLISHMENT NAME: Jimmy's Famous Pizza File Number:BHF-2002-000060 1591 Osgood Street NORTH ANDOVER MA 01845 LOCATED AT: NORTH ANDOVER, MA 01845 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes Food Est.-Restaurant BHP-2007-0510 Jan 1,2008 Dec 31,2008 $185.00 Food Service: 50 seats;Takeout; Delivery/Contact:Nikolas Papantonakis,Manager; 978.685.7776 Total Fees: $185.00 PERMIT EXPIRES December 31, 2008 Board of Health Page 242 of 499 '40Rys Commonwealth of Massachusetts North Andover ° Board of Health 1600 OSGOOD STREET BUILDING 20; SUITE 2-36 rs CH e3� NORTH ANDOVER,MA 01845 F lqflv 1 /1, ?nn7 FOOD ESTABLISHMENT DATE PRINTED 11/01/2007 TOWNt) ORTH NW)VERHEALTH ESTABLISHMENT NAME: Jimmy's Famous Pizza File Number: BHF-2002-000060 1591 Osgood Street NORTH ANDOVER MA 01845 RE: 2008 LICENSE RENEWAL LOCATED AT: NORTH ANDOVER,MA 01845 OWNER: Triplets,Inc. PHONE: (978)685-7776 RENEWAL FEE DUE-Amount depends on type of license(see fee schedule) LATE FEE AFTER JAN.1st-FEE DOUBLED PERMIT TYPE FEE DURATION: ANNUAL SEASONAL TEMPORARY Food Est.-Restaurant $185.00 ❑ RESTRICTIONS:Food Service:50 seats;Takeout; Delivery NOTES: Contact:Nikolas Papantonakis, Manager;978.685.7776 Total Fees: $185.00 COURTESY RENEWAL REMINDER..........Your 2007 license expires on December 31st. In order to renew this license you must be in compliance with the State Sanitary Code 105 CMR 590.000. To ensure timely processing,please return your application and payment by November 30th. Your renewal fee for the calendar year is indicated above. Please submit the following documents and appropriate fee: 1. ❑Completed application for 2008; 2. ❑Check for renewal fee payable to the Town of North Andover; 3. ❑Copies of all current Certified Food Manager Certifications; Renewal permits will not be issued unless ALL COMPLETED DOCUMENTS are submitted. This means that your license will not be issued until we receive all required documents. Please note that the Board of Health will levy a penalty of an additional fee if your license is not renewed by January 1st. For example,if your license fee is$185.00,our cost for being late will be $370.00. If this is disregarded,the North Andover Board of Health may revoke your license,and/or levy an additional fine. Please be advised that your Annual Food Service Permit must be conspicuously posted within the establishment at all times,and that at least one Certified Food handler must be on site at all times when the facility is open to the public. All necessary forms and regulations may be found on the Town of North Andover website:www.townofnorthandover.com-Town.Departments- - Health Department-Permits&Regulations. If you have any questions,please e-mail the Health Department at: healthdept@townofnorthandover.com,or call at 978.688.9540. Thank you for your cooperation during the annual renewal process. Enc:Application TOWN OF NORTH ANDOVER Office of COMMIJNITYDEVELOPMENT HEALTH DEPARTME T Susan Y. Sawyer,REHS/RS 1600 OSGOOD STREET; BUILDING 20 SUI Public Health Director NORTH ANDOVER, MASSACHUSEI TS OTIN-If 40 -8ACHU Q kIII ANDOVER Phone: 978.688.9540 Fax: 978.688.8476 E-mail: health tOLA co 1 FOOD ESTABLISHMENT PERMIT APPLICATION (If new establishment,application must be submitted at least 30 days before the planned opening date) FEE: Depends on type of food establishment - Refer to the current fee schedule 1. Establishment Name: 71'1�k mom- Fk/K6 i(,i kA , 2. Establishment Address [ IS 44 (�'S �i"VS OL/s, 3. Establishment Mailing Address(if different) 4. Establishment Telephone#: 5. Applicant Name&Title: q IV 7 41 A J 14 kfO 6. Applicant Address: I Z C 6 � 6­41d 6 7. Applicant Telephone No.: 24-Hour Emergency No.: v 8. Owner Name&Title(if different form applicant): "'Clb J) 9. Owner Address(if different from applicant): 10. Establishment Owned By: 11. If a corporation or partnership,give name,title,and 0 An Association;TEA Corporation;D An individual home address of the officers or partner: Name Title Home Address 0A partnership,1-1 other legal entity .4 Alt. 4 12. Person Directly Responsible for Daily Operations(Owner, Person in Charge,Supervisor, Manager, Etc.) Name&Title: Nte,fi6LAf () A- Address: (' c)3 Telephone No.: Fax No.: E-mail: Emergency Telephone No.: 13. District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No.: Fax No.: E-mail: 14. Water Source: Sewage Disposal: DEP Public Water Supply No.:(if applicable) TO"W 4q _rj 16. Days and Hours of Operation: 17. No. of Food Employees NOTE: THERE WILL BE A$50.00 CHARGE FOR ANY REQUIRED RE-INSPECTIONS AFTER AN UNSATISFACTORY INSPECTION Page 1 of 3 NAME OF ESTABLISHMENT: ( ./L 111 PAC4 -t°"A 18. Name of Person in Charge—Certified in Food Protection Management (required as of 101112001 in iccordance Wilt 105 CUR 590.003(A)please attach copy of certificate): NOV14 2007 19. Person Trained in Anti-Choking Procedures(if 25 seats or more: OYes `NOR-rHANDOVFR Lb��/�LDLr�r�Ak�T° 'T— _,-- .- NAME: � �,t�(✓ .. " (' r/itf` 21. Length of Permit: (check one) 20. Location: (check one) Annual 0 Permanent Structure "�T' Seasonal/Dates: 0 Mobile ❑Temporary/Dates/Time: 22. Establishment Type(check all that apply): ❑ Retail(_ square feet) r Food Service—(_ .8 seats) ❑ Food Service—Takeout ❑ Food Service—Institution( Meals per day) ❑ Caterer ❑ Food Delivery ❑ Residential Kitchen for Retail Sale ❑ Residential Kitchen for Bed and Breakfast Home ❑ Residential Kitchen for Bed and Breakfast Establishments ❑ Frozen Dessert Manufacturer ❑ Other(Describe) 23. Food Operations(check all that apply)—DEFINITIONS: > PHF—potential hazardous food (time/temperature controls required); > Non-PHFs—non-potentially hazardous food(no time/temperature controls required); > RTE—ready-to-eat foods(Ex.-sandwiches,salads,muffins,which need no further processing ❑ Sale of Commercially Pre-Packaged Non-PHF's ';;a PHF Cooked to Order ❑ Hot PHF Cooked and Cooled or Hot Held for More than a Single Meal Service ❑ Sale of Commercially Pre-Packaged PHFs Preparation of PHFs for Hot and Cold Holding for Single Meal Service ❑ PHF and RTE Foods Prepared for Highly Susceptible Population Facility ❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to be prepared by Consumer ❑ Vacuum Packaging/Cook Chill ❑ Reheating of Commercially Processed Foods for Service within 4 hours ❑ Customer Self-Service ❑ Use of Process Requiring a Variance And/Or HACCP Plan(including bare hand contact alternative,time as a public health control) ❑ Customer Self-Service of Non PHF and Non-Perishable Foods Only ❑ lee Manufactured and Packaged for Retail Sale ❑ Offers Raw or Undercooked Food of Animal Origin ❑ Preparation of Non-PHFs ❑ Juice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single Meals for Catered Events of Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage,Out-of-Date or Reconditioned Food ❑ Other(Describe): N Page 2 o NAME OF ESTABLISHMENT: k (A Al IF YOU DO NOT RENEW BY JANUARY 1ST,THE FEE WILL OUBLE Please do not combine fees for various permits in one heck NOV 14 2007 (Example—dumpster fees should not be combined with afo 499W PAH ANDOVE I HEAL11-1 DEPARTMEW 1,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590,000 and Article X of the State Sanitary Code,and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of t 105 CMR 590.000 and the Federal Food Code. 24. Signature of Applicant: Signature 6(A Print Name Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties ofpeijuty that I, to my best knowledge and belief, have filled all state tax returns and aid state taxes required under the law. 25. Social Security Number or Federal I.D.#: 26. Signature of Individual or Corporate Name: /aD SigildLUIC V(U wa, 4 Print Name NOTE: THERE WILL BE A$50.00 CHARGE FOR ANY REQUIRED RE-INSPECTIONS AFTER AN UNSATISFACTORY INSPECTION Page 3 of 3 ✓ ;, � /��///✓✓y r✓1 � ✓// v ,iy � ,��� ern .;k;.,�;,w n y , N ✓ ray✓ � ,; ✓i✓� ����///� ��s//i/ �i� �, // ✓' ✓i / ✓ ✓✓///✓�//// (� � � �i✓ fj ✓ice//� �// �, ✓✓�� �,✓. ,� i✓✓� � �,�� ✓✓.,�� ✓ ,✓l. ✓ ✓r rrr/�11�1�✓✓� �it,� //%// ,,, f✓i!ii )Ji%%%✓,. /;✓ f ✓i„ ✓��i//%�- �c, % % 1 ,,.,,,,,,,✓✓ //✓//%, y,,✓✓✓m%//� //�/✓✓, ���/„�✓i,,,, �„ ,, � ��-� ir� ��✓✓ ✓ail,✓ „/��✓i ,,,,„.. �,,� �i/ ✓,%%/✓ „„y, %✓ ,✓, ,G � i �. � /, ,✓/�� ,,,,,,,,, ,,,, ,,�o:,✓/%/// ✓✓„✓✓�� iiiiiiiii ,, ✓�, ,.; li � fF r�iti c ynyr�/%i% ,.. ✓ ��✓✓i✓ � /� �� ✓ %,,,, ////✓ii.. �i ..,,,,,✓✓���'„�i,� �/. ..� ✓.. ail ,.... ✓ ,,,, ,ter✓ ✓� ✓ ✓i tea✓ ,, a ✓ / ,rF,,r �r ✓rr l ✓� � � � � � lr�,r , ,, ,. „l✓mac err„wig ���,✓ ✓U ,. / „, ✓✓ ✓goo , ,,, / �, ✓ , ,� ,. ,,,,,,, ..� ✓ err✓//,,. ,,, i✓,'�'✓.�✓���.. �/... ✓ ,.. ,,. ,,,,,,. /.. r✓ ✓///,,,........ �... ,✓ if�...... i. / /,,,,,� a ..,,.. � ✓ / ✓ ✓✓ ✓✓ ,,,,,,,/� � ,,,�� %%/✓✓/ of � i ✓.. ✓ ,,,✓ ✓i ,. ./> ,,,,✓ % ,,,, ✓.✓� - ✓ ,,,,/✓✓✓//,,, :. ✓/ of i ✓ ✓ -, /, ✓✓i / /// is ✓✓✓ ✓✓ % ✓, ✓ .✓, ice✓ , ✓„ �,✓i ✓✓✓✓✓✓✓✓✓✓✓✓✓✓ ✓// ✓ „✓ ,,,, ✓✓ ✓✓,,,� oil✓✓✓ ✓✓// ✓ / ,,,✓ ✓ ✓ ,,, ooi ✓ ,✓ ✓ ✓ % / /////,,,,,- ✓ioiii / ✓✓✓✓ ✓ ✓ All ✓ ✓ ,,✓✓ of 00/ ✓✓ o /✓ ✓� is 26 ✓✓✓✓✓, of ✓„ f ✓ �� ✓/ � ✓ fill✓ ✓�� /✓. / ✓ � ✓� / %/// ✓i ✓ ,,, ic,, ✓pia /✓, / ,., / //„ . , ,- oi,�✓ <... ✓� oil / / ✓✓ ✓✓ ✓mac ✓,,,, ✓✓ ✓ ✓✓ ✓ o ✓ ✓ i ✓%//,ail✓✓✓ ✓ �, /, ✓ „.. / ✓i „„ ✓�, �i �%%/i/ ,,, ✓ /,,, ✓� ✓✓✓ r/ DID✓,,,, ✓�� / ✓i/ ✓ ,� f,✓ ,✓,,,, � �..✓i„j��!/�✓, „a- ✓ ✓ /.�✓,✓✓off. i i...r /✓, ,,,,, ✓� ✓'✓/✓�� �� ,,,, ,,,, ,,,,,,,,,, ✓ice„ //`/✓ % / ,✓i / ✓✓ //✓✓ ai / �✓n�i✓rWG ✓ � r, ✓ r.,w�„ ✓✓////✓ ���� n� /,l/,r,✓ l„/1��,,,l✓ ✓ rrrr,,,h,nt,n/,� rrr;`s,rG ✓✓x„✓✓w� r����✓r.✓✓rs✓ �.✓,✓�,�,r�..r �t rF✓�,:,� �,�r ,il;�✓fr.,� ✓/ ✓'%,✓✓l l✓.�rnr' ,✓ri ..✓r, ✓ ✓�✓✓'✓vi��rri,,r ✓, ✓ ,r7f,y 1✓/✓ 1���r�l, ,� � J ✓✓ ,,,,l ,J ✓i/���✓i f✓, ✓ r fin..,� ✓ ✓i✓ s � �% ,,, ✓i ✓✓�/, ✓ ✓ ✓iiiii,,, o,,,Rio // ✓��/� %/of ✓i // ✓✓✓ ✓i ,�� / ✓, / ✓i a ✓v ✓ , /o ✓!!!,,,%,✓iiiii„✓ %// ,,,,,,✓%%%/ �� ✓i„ ✓,,,,,,, ✓, a ✓i, - /✓loll/ ;��,,, /// / ,,, N N O_ N N TOWN OF NORTH ANDOVER %AOHT#1 Office of COMMUNITY DEVELOPMENT AND SERVICES 0 HEALTH DEPARTMENT Susan Y. Sawyer, REHS/RS 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 1 41 '4�1111 0' llublic I lealth Director NORTH ANDOVER, MASSACHUSETTS 01845 .19 C 14U1111 Phone: 978.688.9540 Fax: 978.688.8476 E-mail: healtlider))t ottoNviiofnortliaii(lovct-.coni FOOD ESTABLISHMENT PERMIT APPLICATION (ff new establishment application must he submitted at least 30 days bqlbre the planned opening date) FEE: Depends on type of food establishment - Refer to the current fee schedule 1. Establishment Name: 2. Establishment Address 0 S G-aUn s-;r,,ee6-7 At "tjo -t1'L9L 3. Establishment Mailing Address(if different) 4. Establishment Telephone 4: k�---'7'77 Cep RECENED 5. Applicant Name&Title: NOV ­ 3 2006 6. Applicant Address: 16- o3 &-c/0,� ,,, " 7. Applicant Telephone No.: '774> /(,24-Hour Emergency No.: TOWN OP NOR TII Ali"OVE�1�] 11-I[`W �H )EPARTIMENT 8. Owner Name&Title(if different forelplicant): 9. Owner Address(if different from applicant): 10. Establishment Owned By: 11. If a corporation or partnership,give name, title,and i 1 An Association,IXA Corporafioa,�I An individual home address of the officers or partner: Name Title Home Address I A partnership, l other legal entity /\1Q-K PA0A-(Z(/,,tAXj i 5,-"Ct 12. Pei-son Directly Responsible for Daily Operations(Owner, Person in Charge,Supervisor, Manager, Etc.) Name&Title: t'k 0-C r/A "Aw"7-6'wm.� Address: 6N '0 Telephone No.: (9&,s Fax No.: E-mail: Emergency Telephone No.: 13. District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No.: Fax No.: E-mail: 14. Water Source: 15. Sewage Disposal: DEP Public Water Supply No.: (if applicable) 5 c;. 1"& 16. Days and Hours of Operation: 17. No.of Food Employees Pagel of NAME OF ESTABLISHMENT: J t, PI ? VA F . Name of Person in Charge—Certified in Food Protection Management(required as of 10/1/2001 in accordance th 105 CMR 590.003(A) please attach copy of certificate): 14ICK P P4' v7 tv'�-d,� V- 19. Person Trained in Anti-Choking Procedures(if 25 seats or more: ❑Yes ❑No) NAME: � �Pn�1{/6(Ll 21. Length of Permit: (check one) 20. Location: (check one) Annual '�Iermanent Structure ❑Seasonal/Dates: ❑Mobile ❑Temporary/Dates/Time: 22. Establishment Type(check all that apply): ❑ Retail(__square feet) A Food Service—( !'O seats) Food Service—Takeout ❑ Food Service—Institution( Meals per day) ❑ Caterer °0 Food Delivery ❑ Residential Kitchen for Retail Sale ❑ Residential Kitchen for Bed and Breakfast Home ❑ Residential Kitchen for Bed and Breakfast Establishments ❑ Frozen Dessert Manufacturer ❑ Other(Describe) 23. Food Operations(check all that apply)—DEFINITIONS: PHF—potential hazardous food (time/temperature controls required); ➢ Non-PHFs—non-potentially hazardous food(no time/temperature controls required); ➢ RTE—ready-to-eat foods(Ex.-sandwiches,salads, muffins,which need no further processing ❑ Sale of Commercially Pre-Packaged Non-PHF's C 0 PHF Cooked to Order ❑ Hot PHF Cooked and Cooled or Hot Held for More than a Single Meal Service ❑ Sale of Commercially Pre-Packaged PHFs T Preparation of PHFs for Hot and Cold Holding for Single Meal Service ❑ PHF and RTE Foods Prepared for Highly Susceptible Population Facility ❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to be prepared by Consumer Ll Vacuum Packaging/Cook Chill ❑ Reheating of Commercially Processed Foods for Service within 4 hours ❑ Customer Self-Service ❑ Use of Process Requiring a Variance And/Or HACCP Plan(including bare hand contact alternative,time as a public health control) ❑ Customer Self-Service of Non PHF and Non-Perishable Foods Only ❑ Ice Manufactured and Packaged for Retail Sale ❑ Offers Raw or Undercooked Food of Animal Origin �r Preparation of Non-PHFs ❑ Juice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single Meals for Catered Events of Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage, Out-of-Date or Reconditioned Food ❑ Other(Describe): Page 2 of 3 NAME OF ESTABLISHN/TENT: /t, °ti S �4A, UvA 1 � ,IF YOU DO NOT RENEW BY JANUARY Isr THE FEE xYx DOUBLE **x Please do not combine fees for various permits in one check— (Example—dumpster fees should not be combined with a food permit fee) I,the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and Article X of the State Sanitary Code, and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of t 1 CM 590.000 and the Federal Food Code. 24. Signature of Applicant: Signature /,�,#KL3 Print Name Pursuant to MGL Ch. 62C, sec. 49A, I certi)5,under the penalties oj'peijwy that I, to my best knoivledge and belief, have filled all state tax returns and paid state taxes required under the lain. _ 25. Social Security Number or Federal I.D.#: 26. Signature of Individual or Corporate Name:'/ �� 6 Signature Print Name Page 3 of 3 TOWN OF NORTH ANDOVEI2 pf`�p oT"nip Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT Susan Y. Sawyer, REH.S/RS 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 Public Health Director ��s NORTH ANDOVER, MASSACHUSE'I'TS 0I845 -SA S�CFaus Phone: 978.688.9540 Fax: 978.688.8476 E-mail: healthdept(iDtownol'northandover.coni GREASE TRAP QUESTIONNAIRE Dear Food Establishment Manager: Please complete the following questionnaire and return it along with your Food Service Application. ➢ Food Establishment: �/V[/I-, Vj PA1, 6 d ➢ Address: S C2 f S(J ➢ Phone: 17 y L -7 1. Does your facility have a grease trap? If yes, please answer the following: a. How many grease traps are located in the establishment? ` b. Where are the grease traps located (inside, outside, or both)? U [ c. What are their capacities? ,/-u 6 (;) d.Are they pumped regularly or as needed? �'� e. How often are they pumped? f. What company performs this? S � �`� g. Do you keep maintenance records on site? '3'5�� Commonwealth of Massachusetts North Andover Board of Health k T;e 1600 OSGOOD STREET ° BUILDING 20; SUITE 2-36 NORTH ANDOVER,MA 01845 FOOD ESTABLISHMENT DATE PRINTED 10/16/2006 ESTABLISHMENT NAME: Jimmy's Famous Pizza File Number: BHF-2002-000060 1591 Osgood Street NORTH ANDOVER MA 01845 RE: 2007 LICENSE RENEWAL LOCATED AT: NORTH ANDOVER,MA 01845 OWNER: Triplets,Inc. PHONE: (978)685-7776 RENEWAL FEE DUE-Amount depends on type of license(see fee schedule) LATE FEE AFTER JAN. 1st-FEE DOUBLED PERMIT TYPE FEE DURATION: ANNUAL SEASONAL TEMPORARY Food Est. -Restaurant $185.00 RESTRICTIONS:Monday-Sunday: 10:00 a.in.-9:30 p.m. NOTES: Contact:Nikolas Papantonakis, Manager;978.685.7776 Total Fees: $185.00 Your 2006 license expires on December 31st. In order to renew this license you must be in compliance with the State Sanitary Code 105 CMR 590.000. Please complete the enclosed permit application and related paperwork and return it to the above address by Monday,November 13,2006. Your renewal fee for the calendar year is indicated above. Please submit the following documents and appropriate fee: 1. I 'Completed application for 2007; 2. Check for renewal fee payable to the Town of North Andover; 3. 1Copies of all current Certified Food Manager Certifications; Renewal permits will not be issued unless all documents are submitted. This means that your license will not be issued until we receive all required documents. Please note that the Board of Health will levy a penalty of an additional fee if your license is not renewed by January 1st. For example, if your license fee is$185.00,our cost for being late will be$370.00. If this is disregarded, the North Andover Board of Health may revoke your license,and/or levy an additional fine. Please be advised that your Annual Food Service Permit must be conspicuously posted within the establishment at all times, and that at least one Certified Food handler must be on site at all times when the facility is open to the public. All necessary forms and regulations may be found on the Town of North Andover website: www. townofnorthandover.com-town offices- Conmiunity Development-Health-square box in upper left hand corner. If you have any questions,please e-mail the Health Department at: healthdept@townofnorthandover.com, or call at 978.688.9540. Thank you for your cooperation during the annual renewal process. Enc: Application N N N O_ N N ` EA 1111 � ��� ���� � r e ... �« 1 /i i iiJiiiiiiiiiiiii ...,, ,,,/� ;;;iiiiiiirf/,,,,,1�/„��/�jj/�yta�FG,rI+',�r/r�, BWlr�.f,/✓//�NHh/,,�r 5emns1„ Ny ✓i,(I�r./wwi.� ,f�,rlm/frffi�r/l( .�r, rvii/ ,�r wwr�x,�/eni i,::rrinf✓�(/ ,,i,,,es,w ,w.rF,,, °��,,ll '�;f r 1 rvirr r rirrr' rrr r�° . ^rr /iiii,, ,. „�//// ;rr" %/%/,r,,, ,,, /i%%�� n rii,rrrr rr irrr,j i %////// , / r / /i r, r /,;" /i% /irk r///.o/// / r ✓;, r /r r ,, rr/ /i w ;,� ,,,rr�,rm +,,,lir „/ire,%Mi fr„/r,,�l° ��for /rl/for yr� '%i!r>'lrr✓i�i,r,,,r 1,, i �� //!f /rU;.�l//,f U /rYl ri!/an/� r✓h,,, ,r✓ �,�,.,��.rr rr,,,, <;r, ;� EBY ,, o/ rrr" f Will ! f " ,,,,, .,' /i ///////ni. ri!� "i, ////irr rrr r '+✓ � ,.. ,,,/� ���//%��� //%'I' ,,, ,,s,,,,, // ",o r/%// rrr �// r r/%%r,%�//// %/✓ ri////// r „���//�r o, /�, ///i/�i / ,rrrr NOT „i/ii,,.. i0iiii //r /„ /i// ✓ a l///f r l//s�/ ////// r l '� r s ,,;� riioiiii/f y r✓/�v FJ �/ f r r //fr✓ r r/il Yt 1 1 �r r �✓r rr ✓r r „r �, rr r rr ✓ rir iG 1 jo r ,r ,/r /rr i. /ice✓///r,rrrr/� / J J t. / r rr rr/ r ; ;'rrr» nll'r,yre fr✓�,,✓err, rr�a✓'rrrr,or�,r nr-' r ,,sr<//iv/,t)�„,rrrr rr+r° „rrl,ri.rxr iris ,r come ;°n...a�,��f r✓,,Yr Xir,,,, rl%°wr,G,H✓dl,H�,,,lre,:,lfr rr rmyr✓,,;rF3r.�;;/war r�;,^ ,rr ter»»,sir M ��q,h,,/l;, / �%/ MON, ' .rrrr, LETTER OF TRANSMITTAL., RTH North Andover Health I)epartment , 'F ��0 e ,L,b 400 Osgood Street �;�' �'� � 0 North Andover, MA 01845 0rA 978.688.9540 - Phone 978.688.8476 - Fax 'r healtliclept(ii),townofnorthanclover.com - E-mail tivww.townof'northandover.com - Website Page of S�cNus TO: ATE. � o ° sr. FROM: Pamela DelleC&dale, Health Department Assistant COMPANY a Phone: Fax: We are se"eng your OCopy of Letter OPlans OOther ill in below) These are transmitted as checked below: y OApprowd(asNoted y OForReviewandconurtrent v MtibnR copiesfor 4a Regriested y OFor Your Use (list. r MsRegtdred y ORestihmit copiesfor OForApprowd approval REMARKS: 1. American Food Safety -arnerlcanfoodafety.corr 2. Eastern Mass Food Safety -www.easteI'nmassfoodsafety.com 3. Morrell Associates, Inc. - ,morrell- a o i t s.com 4. Brunetta Associates - brunetta@worldnet,att.net 5. Also, Allen Grornko, our former Food Consultant offers courses: ARG Associates www,argassociates.com COPY TO: COPY TO: COPY TO: SIGNED: .. TRANSMISSION VERIFICATION REPORT TIME 01/23/2006 11:05 NAME HEALTH FAX 9786888476 TEL 9786888476 SER.0 000B4J120960 DATE DIME 01/23 11:04 FAX NO. /NAME 89785219024 DURATION 00:00:40 PAGE(S) 02 RESULT OK MODE STANDARD ECM Commonwealth of Massachusetts ' North Andover Board of Health 400 Osgood Street SACWH4 1, NORTH ANDOVER,MA 01845 DATE PRINTED: 01/23/2006 (:(DPI WHO'S PLACE OF BUSINESS IS: Jimmy's Famous Pizza File Number:BHF-2002-0060 1591 Osgood Street NORTH ANDOVER MA 01845 LOCATED AT: NORTH ANDOVER, MA 01845 Permit Type Permit Issued Permit Expires Fee Restrictions/Notes Food Est.-Restaurant Jan 23,2006 Dec 31,2006 $185.00 Monday-Sunday: 10:00 a.m.-9:30 p.m./Contact:Nikolas Papantonakis,Manager; 978.685.7776 Food Est.-Restaurant a Jan 23,2006 Dec 31,2006 $185.00 Monday-Sunday: 10:00 a.m. -9:30 p.m./Contact:Nikolas Papantonakis,Manager; I ° � 978.685.7776 Total Fees: $370 00 PERMIT EXPIRES December 31,2006 ri Board of Health a� ��l Town of T rth Andover Health Department pate: ,: Lacation:� � � . / w.ro Name�ofi"Csr�„ (Indicafe ddress z Resider al or r s ) Check#• 9 Type of Permit or License:(Circle) Animal $ > Dumpster $ F ➢ ,Food Service-Type: �� . � e > Funeral Directors � ° � ` $ > Massage Establishmenf ( ,w $ > Massage Practice $ ➢ Offal(Septic)Hauler $ > Recreational Camp $ ➢ SEPTIC PERMITS: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(D WC)$ ❑ Septic Disposal Works Installers(DWI) $ > Sun tanning $ ➢ Swimming Pool $ ➢ Tobacco $ ➢ Trash/Solid Waste Hauler $ ➢ Well Construction $ ➢ OTHER:(Indicate) Health Agent Initials IIII gg 3 White-Applicant Yellow-Health Pink-Treasurer N N N O_ N N 01/20./2006 16:25 9786888476 HEALTH PAGE 01/03 TOWN OF NORTH ANDOVER �aaRrti Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT �T.. Susan Y. Sawyer,PEHS/RS 400 Osgood Street Public Health Director NORTH ANDOVER, MASSACHUSETTS 01545 +�Nu Phone:978.688,9540 Fax; 978.698.$476 8-mail:healthdent(&,townofnorthandover.com FOOD ESTABLISI3MENT PERMIT APPLICATION (Itneiv establishment,application must he submitted at least 30 clays before the plaroted opening date) FEE: Depends on type of food establishment - Refer.to the current fie schedule 1. Establishment Name: '.S ►tl!\ M S ( ` ✓lf1 c i/ ( 2. Establishment Address' q ( G S -I .T,2 l 3. Establishment Mailing Address(if different) ay S 4. Establishment Telephone#: q '7 S 1� _7`' 769 5. Applicant Name&Title: N I K O LA-S P() PA/`/ '7" 0N4 /-k l s M./I n.Iq j G=�2 6. Applicant Address: ��� � FII AAII<c� ail 5'�i f '�n/l�l �/u'l r� 0 7. Applicant Telephone No.: 24-Hour Emergency No..S. Owner Name&Title•(if different forth applicant): 9. Owner Address(if different from applicant): �J 10. Establishment owned lay; I I- If a corporation or partnership,give name,title,and 0 An Association;)A Corporation:f. An individual home address of the officers or partner: 1legal Name Title homeAddress A artnorshi ;fa Other antitY — Rl l I'C t?_LtSl t yy 1 - .%��"✓ r'l S /l 1 G v' L"z-M /Mo ` f /,j/)At) 6K, 12. Person Directly Responsible for Daily Operations(Owner,-Person w n Charge,Supervisor,Manager,Etc.) l 03 k2Z Name&Title: j\�( I<0�!�S �� t- N 'T 6N Address: IS q( C) Cr GCS A S"7 1\1 - A/�(/)v vL,✓L 4t./T 0 W t e' S" Telephone No.: It 7 ' 4a � r7 (r 'Fax No.: E-mail: ` Emergency Telephone No.: . 13. District or Regional Supervisor(if applicable) fQ Name&Title: Address: Telephone No.: Fax No.: E-mail: 14. Water Source. 15. Sewage Disposal: DEP Public Water Supply No.:(if applicable) ` �'o 16. T]ays and Hours of Operation: 17.No.of Food Employees Page 1 of 3 01/20/2006 16:25 9786888476 HEALTH PAGE 02/03 NAME OF ESTABLISHMENT' '/S � '� �'l u<i S �r 2� •'3- 18. Name of Person in Charge—Certified in Food Protection Management(required as of 10/I/200I in flccordance with 105 CMR 590.003(A)please attacb OPY of certificate): Q l C AOUl t Cv r LC \ l 19, Person Trained in Anti-Cbolking Procedures(if25 seats or'more:f s ONo) NAME: `"�` ���ti� e� `��(�� �. �Ci ). C �,, j L C.. ( ,-- 21, Length of Permit.(check one) 20, Location:(check one) Annual 1j�Perrnanent Structure ❑Seasonal/Dates: 0 Mobile 0 Temporary/Dates/Time: 22. Establishment Type(check all that apply); ❑ Retail(_square feet) ❑ Food Service—( tj a seats) ❑ Food Service—Takeout ❑ Food Service—institution( Meals per clay) at Caterer ❑ Food Delivery * Residential Kitchen for Retail Sale ❑ Residential Kitchen for Bed and Breakfast Home ❑ Residential Kitchen for Bed and Breakfast Establishments ❑ Frozen Dessert Manufacturer ❑ Other(Describe) 23. Food Operations(check all that apply)--IDEFINiTiONS. ➢ PH —potential hazardoas food(time/temperature controls required); > Non-PHFs—non-potentially hazardous food(no time/temperature controls required); . ➢' RTE—ready-to-eat foods(Ex.-sandwiches,salads,muffins,which need no further processing ❑ Sale of Commercially Pre-Packaged Non-PHF's W PHF Cooked to Order M Hot PHF Cooked and Cooled or Hot Held for More than a Single Meal Service Q Sale of Commercially Pre-Packaged PHFs ;W Preparation of PHFs for list and Cold Holding for Single Meal Service ❑ PHF and RTE Foods Prepared for Highly Susceptible Population Facility oDelivery of Packaged PHFs Sale of Raw Animal Foods Intended to be prepared by Consumer ❑ Vacuum Packaging/Cook Chill .Q, Reheating of Commercially Processed Foods for Service within 4 hours ❑ Customer Self-Service ❑ Use of Process Requiring a Variance And/Or 14ACCP flan(including bare hand contact alternative,time as a public health control) * Customer Self-Service of Non PI-IF and Non-Perishable Foods Only ❑ Ice Manufactured and Packaged for Retail Sale ❑ Offers Raw or Undercooked Food of Animal Origin ' C Preparation of Nan-PHFs Q Juice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single Meals for Catered Events of Institutional Food Service ❑ Offers RTE P14F in Bulk Quantities ❑ Retail Sale of Salvage,Out-of-Date or Reconditioned Food { ❑ Other(Describe): Page 2 of 3 01/20/2006 16:25 9786888476 HEALTH PAGE 03/03 NAME OF ESTABLISHMENT: ***IF YOU DO NOT RENEW 13Y JANUAttY 1ST,THE FEE WILL DOUBLE*** ,Please do not combine fees for various permits in one check-- (example—dumpster fees should not be combined with a food permit fee be in a separate check) 1,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590'.000 and Article X of the State Sanitary Code,and all other applicable law. I have been instructed by the Hoard of Health on how to obtain copies of t 105 CM I;5 0.000 and the Federal Food Code. 24. Signature of Applicant: sr ---- ✓� -- Signature r�llK PAS 7 yN(AK Print Natne Pursuant to MOL Ch. 62C,sea. 49A, I certify under the penalties of perjury that.1, to n y hest knowledge and belief, havefflled all state tax returns and paid state taxes required tender the law, 25. Social Security Number or Federal Y.D.#: J 5 1 1 j 26, Signature of individual or Corporate Name; Signature !"IL Print Name t Page 3 of 3