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Home My WebLink Aboutb. good - 2019 - Permits - 99 TURNPIKE STREET 11/30/2021 COMMONWEALTH OF MASSACHUSE:TTS NUMBER • BHP-2018-0506 North Andover BOARD OF HEALTH FEE $370.00 b.good DATE ISSUED NAME March 01,2019 99 Turnpike Street Suite 202 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 28,2020 unless sooner suspended or revoked. RESTRICTIONS: 10 food employees,40 seats,2420 square feet,annual permit *----CDP ------ --- -- BOARD OF NOTES:Contact:Jose Ponce-Director 305-562-7718,ChadF - HEALTH ------------------------------------------------------------ Robinson District 603-860-2102 ------------------------------------------------------------ HOURS ACTIVE:Mon-Sat 10:30am-9pm,Sun 10:30am-8pm ------------------------------------------------------ ----- BOARD OF HEALTH CHAIRMAN � , 0 P o oc(__ C� TOWN OF NORTH ANDOVER Community and Economic Development p�Np�QP��ME HEALTH DEPARTMENT .gyp ��Np 120 Main St. NORTH ANDOVER,MASSACHUSETTS 01845 Phone:978.688.9540 Fax: 978.688,9542 E-mail:healthdept n,northandovetma.gov FOOD ESTABLISHMENT PERMIT APPLICATION ff new establishment,application inus/be anbodiled a!frail 30 days before the planned opening dale) FEE: Depends on type of food establishment—Refer to your current permit or call the Health De artment for fee amount 1. Establishment Name: G('Ovo �o ) n 2. Establishment Address 9 9 1 u r nip 3. Establishment Malling Address(if different) 4. Establishment Telephone#: 1-4 8 6 b i 1 1 * 5. Applicant Name&Title: F0n0- , 01 Tr ct' ,(71µS)n(b) XF`JL�( v, 6. Applicant Address: j b q �4nO 4 J,\ 4' U0"""'✓ M� C)�L)1 lr ? r� P r 7. Applicant Telephone No.: 305 )�,6 7 }_?16 24 Hou,��rl/nnEmergencyNo.: � t 8. Owner Name&Title(if different form applicant): a&bu L«- 9. Owner Address(if different from applicant); QGOQD L L,C, 10. Establishment Owned By: 11. If a corporation or partnership,give name,title,and ❑An Assoclaflon;0 A Corporation;0 An individual home address of the officers or partner: Name Tom' q Home Address ❑A padnenhip�aher legal entity. L L( _ 12. Person Direetl Responsible for Daily Operati ns( rner,Person n Charge,Supervisor,Manager—, c. Name&Title, el a G�)r`,£o+, ✓ bt ��S I C� (N`.u�w Address: q7 I 01(t'z A l. 0 y t- "kA dckk /M A TelephoneNo,: 6(t, 0,, O—t, Fax No,: E-mail: L;)m Emergency,Telephone No.: --- 13, District or Regional Supervisor(if applicable Name&Title; Sd,Nn (M u.r1s Dn j �tTt-1r) 'O Address: 109 (c t n tun Sly Q A," AAA ) GAL))) Telephone No,: 60 3 3� 76-j3 Fax No.: — &mail: =n �•plrkl 01 14. Water$our": 15. Sewage Disposal: DEP Public Water Supply No.:(if applicable) 6'))/)rWf'.I" e nv i N r-eaA k) 16. Days and Hours of Operat on; ( 17.No.of Food Employees to;3,,o A rt —1;Doe M Y, , "S°�i}•t� 1 0 u iJ0 A DU /v. L LA/\V1 Page I of 3 i i NAME OF ESTABLISHMENT. MOOD� b I i is. Name of Person in Charge—Certified In Food Protection Management(required as of 101112001111 acoor a11ee I with 10S CMR 590,003(A)please altacb copy of cerl!/leare): � � ► ��n i 19. Person Trained in Anti-Choking Procedures(if 25 seats or more: es ONo) � I NAME: OoA:11A 21, Length of Permit:(check one) 20, Location: (check one) XAnnual 'Permanent Structure ❑Seasonal/Dates: n Mobiie n 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 ❑ Other(Describe) 23. Food Operations(check all that apply)—DEFINITIONS: ➢ PHF—potential hazardous food(timeltemperature controls required); ➢ Non-PHFs—non-potentially hazardous food(no time/temperature controls required); ➢ RTIE—ready-to-eat foods(Ex.-sandwiches,salads,muffins,which need no further processing ❑ Sale of Commercially Pre-Packaged Non-PHF's pC 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 >I-Preparation of PHFs for Hot and Cold Holding for Single Meal Service ❑ PIIF 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 Undcrcooked 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): I age o NAME OF ESTABLISHMENT: �6C4..-..LAV **IF YOU DO NOT RENEW 13Y FEBRUARY 287t,THE FEE WILL DOUBLE"* 1 Please include copies of current Serve SnfalAllergen T'raining/Cltoke Saver Certiflcadons 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 Ajkle X of the St a Sanitary Code,and all other applicable law, I have been instructed by the Board of Health on how to obt ' opies of t IO R 590,000 and the Federal Food Code, 24, Signature of Applicant Signature Print Name Pursuant to MGL Ch. 62C,sea 49A,I cert fy tinder the penalties of perjttry that 1, to my best knowledge and belief,have filled all slate tax returns and paid state tares required tinder the law, 25, Signature of Individual or Corporate Name: ,ppSignature Print Name i Page 3 of 3 Sery a e National Re urant Association ry e ae CERTIFICATION CHAD ROBINSON for successfully completing the standards set forth for the ServSafe®Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute(ANSIKonferenee for Food Protection(CFP). 14509801 10518 CERTIFICATE NUMBER EXAM FORM NUMBER 12/20/2016 12/20/2021 DATE OF EXAMINATION DATE OF EXPIRATION Local laws apply. Check with your local regulatory agency for recertification requirements. ACCRE01TED P. Sherman Brown SVP, National Restaurant Association Solutions #0655 w vit-,r,,r�i itime Law!r Carrvenlion 2006,Rewlufion ADM N 068-2013(Regulation 3.2,Standard A3.2(. �k .101`N d �I Pe.Wurant Association Educational foundation(NRAEFi.All rights reserved.ServSa(eg and the S—ry(& t-:nF ti,r.ri .�r{..ch}lie NRAEf National Restaurant AssociatioriS and the arc design are trademarks of the National Restaurant Association. this document cannot be reproduced cr altered. IAt02901 v.1401 Conn„-t -6'J—hans nt I Inck, n Bbd Ste 1500 Chicn4to.11, 60604 nr Ser.Snfe4 rrsKwmnt orb Pi North Andover Health Department fommunity and Economic Development Division March 13, 2019 B.Good,North Andover 99 Turnpike Street North Andover, MA 01845 RE: 2019 Food Permit Application- 3rd Attempt Dear Sir or Madame: The 2019 Food permit application was due on February 28, 2019. B. Good Restaurant is no longer in compliance with State Sanitary Code 105CMR 590.000. In order to complete your 2019 food permit, The Town of North Andover Health Department needs to following: 1. Allergen Certificate 2. Choke Saver Certificate pOSTEC 3. Payment plus late fee total - $370.00 > The 2019 food permit cannot be completed without the missing documents. Please submit your fee and all requested paperwork immediately. If you do no submit the requested items, The North Andover Health Department will issue a Cease and Desist Order and the restaurant will not be allowed to operate. Please mail, f ,or email back the documents prompt. W4 Brian J. LaGrasse Director of Public Health Enlc. Page 1 of 1 North Andover Health Department, 120 Main Street North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.9542 � _ i k .f i � _ _ ' .. �_ �' 4 r �, .. ° "T M; °M, ., .k._ j.,, . �`,. if TOWN OF NORTH ANDOVER Community and Economic Development HEALTH DEPARTMENT 120 Main St. NORTH ANDOVER,MASSACHUSETTS 01845 Phone:978,688.9540 Fax: 978.698,9542 E-mail:healthdept(@northandoye g.Zoy FOOD ESTABLISHMENT PERMIT APPLICATION Agnew ertabllalnnenb application inasl be Sabo deed at lean!30 days before the planned opening dale) FEE: Depends on type of food establishment—Refer to your current permit or call the Health De artment for fee amount I. Establishment Name: GGoUo dor& A01 1e- Date: 2. Establishment Address 3. Establishment Malling Address(if different) TO 4. Establishment Telephone#: 1-}8 to b l 1 1 ;k,� 5. Applicant Name&Title: y � l at je-c r b L,3111C,0 6. Applicant Address: t 1 � 7. Applicant Telephone No.: 30 24-Flour Emergency No.: —� S. Owner Name&Title(if different form applicant): acroui/ LU 9. Owner Address(if different from applicant). Q6-00D 2-LC, 10. Establishment Owned By: 11. If a corporation or partnership,give name,title,and 0 An Association;❑A Corporation;11 An individual home address of the officers or partner: ❑A padnenhipX"r legal entity L_LC____ Name Tjljg Home Address 12. Person Direct) Responsible for Daily Operatl ns( vner, erson n arge,Supervisor, anage ,E G Name&Title: Une,.a ►•.UF�i r`�j,, / bt srt C� (1titAn_+- Address: TelephoneNo,: �03 6et, jqu'L Fax No,: ___, E-mail: Jntklo�i,�•`ti7L+. UM Emergency Telephone No.: G 13, District or Re tonal Supervisor(if applicable Name&Title; S n M U.rts Dln �t Vielrj o(Y�)4�J Address; 1 Uri (,ct n,Lj�Lr\ 57, �7�Q`1 / AA ) e e—M ) Telephone No,: 603 3� 33 Fax No.: E-mail: n � b D) 14. Water Source: r r� 15. Sewage Disposal: DEP Public Water Supply No.:(ifapplicable) (A)i')rl e5- en111 Tb/'-� tl 16. Days and Hours of Operat on: 17.No.of Food Employees to;3o ^m —9;a>� Mn,o ,"S�Uty� f u;3o A Lkf\ Page t of 3 1 NAME OF ESTABLISHMENT: moo Anc�VAR-C 19. Name of Person in Charge—Certified in Food Protection Management(required as Of 101112001111 actor ante r 1th 105 CMR 590,003(A)please attach copy of cerfi lcafe): '► ��n 19, Person Trained in Anti-Choking Procedures(if 25 seats or more: es ❑No) / I NAME: fLPf I I� 21. Length of Permit:(check one) 20, Location: (check one) ,'Annual 'Permanent Structure 0 Seasonal/Dates: ❑Mobile _ fl 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 o Residential Kitchen for Bed and Breakfast Home U Residential Kitchen for Bed and Breakfast Establishments ❑ Frozen Dessert Manufacturer ' ❑ Other(Describe) 23. Food Operations(check all that apply)—DEFINI'CIONS: ➢ 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 pC 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 ❑ PIIF and RTE Foods Prepared for Highly Susceptible Population Facility ❑ Delivery of Packaged P111s ❑ 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 U 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 SolMervice of Non PHF and Non-Perishable Foods Only ❑ Ice Manufactured and Packaged for Retail Salo ❑ Offers Raw or Undercooked Food of Animal Origin O Preparation of Non-PHFs ❑ Juice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single Meats for Catered Events of Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities O Retail Sale of Salvage,Out-of-Date or Reconditioned Food ❑ Other(Describe): Page 2 o NAME OF ESTABLISHMENT; LJ� **IF YOU DO NOT RENEW BY FEBRUARY 20r,THE FEE WILL DOUBLE** j Please include copies of current Serve Safe/Allergen Training/Cltoke Saver Certy1catiotrs 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 to X of the St a Sanitary Code,and all other applicable law. I have been Instructed by the Board of Health on how to obt ioXopies of t 10 R 590,000 and the Federal Food Code, 24, Signature of Applicant; Signature Print Name Pursuant to MGL Ch.62C,sea 49A,I certo under the penalties of perJ:rry that/,to my best knowledge and belief,haveJllled all state tax returns and paid state taxes regrdred tinder the law, 25. Signature of Individual or Corporate Name ,pSignature Print Name Page 3 of 3 . �._ � . 'w. 3 s 2 .' .. ._., .__�. � ,_�_ _. . .,.. � `tea .�#��'ek�`�t `' ... + F, . � t.� .-,rid-�',a..��D.Y"..,t`.�. vE;.N-.Fi y � .5"§". a..-� �k ��6 iY'... _ *:�. .. :FEi<�i�:i�� t _ e ._ .. .. { � T. ��3ax ?i" '� � � ewe • £, _ ., - t �', y ,. :.. i .;"�r...a.�- '..`� � _ .-- _ x .r. - .Stye ._^;FC � a5.. t,t _sTi � .�`.'> �. -. - �. . .. ,.. . �. ,. , ., - , c ,. FF.. 1 � .. .. ". 4 r. .. • _ .. .. .; - 4. _ ....._...._... .._....._..... ..�-y..,-- ... . Sri .. -� t� _ Y .. � j i_ •i_ - - .. - i �{ - 3 ..f i 4 i. S ` ..�. S, -Tv,Sa e. O ServSafe CERTIFICATION CHAD ROBINSON for successfully completing the standards set forth for the ServSafe®Food Proledion Manager Certification Examination, which is accredited by the American National Standards Institute(ANSI}Lonferenoe for Food Protection(CFP). 14509801 10518 CERTIFICATE: NUMBER EXAM FORM NUMBER 12/20/2016 12/20/2021 DATE OF EMINATION DATE OF EXPIRATION Local laws apply.ChVk with your local regulatory*Qency for recertification requirements. s ® -- Sherman Brown SVP,National Restaurant Association Solutions .,#0655., . .. ❑O t —do -,C Nn,—L4. ,_...mrtrn 2006,R—k—ADM N 068-2013(Ragdmoe 3.2,Sbedmd A3 2) -,?^I;wmonal Reswurae A+vociatian Edre�«+d Foun�non INRAEFI.AI r�reword.SavSokE and dx 5 s ., ..- - � - N.,i k--A..oci—&P and die or<design—nod,—,6 d d,e Notion l Reo...a AmcuFior� The d«ument nova be repodxed or drorod. t A102901 v.1401 Ga a us weh q-0i.,a 175 w bdeon Blvd.Sro 1500,Chcogo,L 6060A o S—Sde0resburaa arg. 4/16/2019 IMG_2376.jpeg American j Red Cross Certificate of Completion J. I _ Marcelo Porencio has successful) completed requirements for r - Y P 9 rant Emergency Training for Massachusetts valid 2 Years u conducted by " a American Red Cross 0 Date Completed: 09/17/2018 Instructors: Greg P Sheehan Certificate 10:GWQIGH To verify,scan code or visit: redcross.or Jconfirm �p0 RECEIVED TOWN OF NORTH ANDOVER HEALTH DEPARTMENT https://mail.google.com/mail/u/0/#search/stephen+/FMfcgxwCgCPCIHvkHpTKRCcfCRxPrQbW?projector=l 1/1