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HomeMy WebLinkAboutb. good - 2018 - Permits - 99 TURNPIKE STREET 11/30/2021 F4i ,�a;U, COMMONWEALTH OF MASSACHUSETTS NUMBER BHP-2017-0903 North Andover BOARD OF HEALTH FEE b. ood $1as.00 NAME DATE ISSUED March 01,2018 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 28,2019 unless sooner suspended or revoked. RESTRICTIONS:20 food employees,35 seats,2420 square feet NOTES:Contact:Jerry Rose,General Manager 617-780-2239 _________ BOARD OF ----------__-------------------------------------------------- _ .-_- ---------- HEALTH - ----------------------- ----•------------ HOURS ACTIVE:Mon-Sat 11-9, Sun 11-8 --------i -- , --------------------------------------------------- BOARD OF HEALTH CHAIRMAN TOWN OF NORTH ANDOVER Community and Economic Development PNowER HEALTH DEPARTMENT NpR�N ��,EN� 120 Main St. �0` o"N�vN" NORTH ANDOVER, MASSACHUSETTS 01845 Phone: 978.688.9540 Fax: 978.688.9542 E-mail: healthdept(@northandoverma.gov FOOD ESTABLISHMENT PERMIT APPLICATION (if new establishment,application nmsl be submitted at least 30 days before the planned opening date) FEE: Depends on type of food establishment—Refer to Vour current permit or call the Health Department for fee amount , 1. Establishment Name: _b;GAO 6p Date: l2.Ij ZI 2. Establishment Address lCA T„'V r p t tz-- 454 3. Establishment Mailing Address(if different) LOq 5 �� f`{ is �/ /��7 0 `��4�/�- v4 f f} 4. Establishment Telephone#^ 5. Applicant Name&Title: A�`� v S lie C6L& " ' 6. Applicant Address: 169 Ktv ,,5'l 3 rd �� 6o5L>N,, M A- O L l 1 7. Applicant Telephone No.: GL--f- 193 467�0 24-Hour Emergency No.: ( °'3',S(o° - Z t,-r-� 8. Owner Name&Title(if different form applicant): LLLC_. Roh_l,%S 6n 9. Owner Address(if different from applicant): 10. Establishment Owned By: 11. If a corporation or partnership,give name,title,and J ❑An Association;❑A Corporation;a An individual home address of the officers or partner: Name Title Home Address ❑A partnership;67o er legal entity �L—� 7 /-o 'A d_,t . 12. Person Directly Responsible for Daily Operations( caner, erson to Charge,supervisor,manager, Name&Title: j(2Cn l / ��v1�.�0.Y AkG,V'C'Y----\, Address: V_e�� Gt`rc 8� (tri c0.� MA v( Telephone No.: (-ekes-— Fax No.: MA E-mail:c)r `reC o pact,C d,✓V { Emergency Telephone No.: I 13. District or Regional Supervisor(if applicable). . Name&Title: GP" (4h(�k o 11, ( -D Address: S99 �•��c.••� CrQ W .% ( o_ (0 4 Telephone No.: (¢ 6(e o Z(-4 :x-- Fax No.: E-mail: 14. Water Source: -6� A- r. ,�tLl/ 15. Sewage Disposal: DEP Public Water Supply No.:(if applicable) K4\4 L, ` �'-u�✓� 16. Days and Hours of Operation: 17.No.of Food Employees Pagel of 3 NAME OF ESTABLISHMENT: ©D j t 18. Name of Person in Charge—Certified in Food Protection Management(required as of 101112001 in accordance I with 105 CMR 590.003(A)please attach cony of certiTcate): �-e re, v-1 A, S i 19. Personj Q Trained in Anti-Choking Procedures(if 25 seats or more: Aes f❑NNo) NAME: (e un G� `_t S'� �tU 21. Length of Permit: (check one) 20. ation:(check one) WAnnual g'Permanent Structure ❑Seasonal/Dates: ❑Mobile ❑Temporary/Dates/Time: a 22. Establishment Type(check all that apply): ❑ Retail( square feet) V'_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); 1, ➢ 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 TG PHF Cooked to Order ❑ Hot PHF Cooked and Cooled or Hot Held for More than a Single Meal Service i ❑ 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 ❑ Iee 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 FEBRUARY 28TH,THE FEE WILL DOUBLE** Please inchrde 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 105 CMR 590.000 and the Federal Food Code. 24. Signature of Applicant: Si ature Print Name / p c& V1 s a I Pursuant to MGL Ch. 62C,sec. 49A,I certijy under the penalties ofpeijwy that I, to my best knowledge and belief, have filled all state tax returns and paid state tares required under the law. //�� 25. Signature of Individual or Corporate Name: E (1 LL �^ Signature Print Name I� Page 3 of 3 12/4/2017 Jeremiah Rose Servsafe 6-7-2022.jpg 1;ervSaf e� CERTIFICATION JEREMIAH ROSE for successfully mrT"g 4u,t—6ds yet lath 6 the ServSale`F-A P-N-fi—Ma—w C-"c-hoo[nannxl+cxi, wfu<h is acuedited by the Arnen<on Not—A St-6ds Institute(ANW-Con(em.irc For Fund°"edion KFP}. 226593 5268 UMBER EXAM FORM NUMBER 6/7/2 6/7/2022 DATE OF E DATE OF EXPIRATION .,., lord 6-gply.C Far recrlKimlion requirement:. Sh �#t+•f ' ♦0&55 __. n O . � https://drive.google.com/drive/u/l/folders/OB2xzgrgCYjsBSnQ2bDhlTkRlQmM 1/1 12/4/2017 Jeremiah Rose Allergy 4-22-2022.jpg AMM,p'i l!P�yOr iti 1J Fj�.�r y� `1i �Y,F M� 'J 4 hi1 .i il ' F.-'�....,.......u., .o........�.�� .Qn :.:.�� ��� ................... �= C E RT I F I CAT E OF t ": ALLERGEN AWARENESS TRAIN I NG 9 L�Cr • e 1 1 8 [tame of Recipient-.t aEMWI s,sa srs s Certificate Number: { w Date of Completion urtt' n�, qr9 Date of Expira'm: arzn� r t I.suai BY_ / a -0 fi �` >• ;1> -non dperren isArreby uuueJthh re rite P1,gTIONAL`. r. -vrf(rrin�anstlrr�rn anwrmm narnin�program ` RESTAURANT •'�1 rJby th Al:wadbru,atf Departmw of P,tftir Health ASSOCI.NTION,. :n ur-rdanrr with 105 GUR 590.009(Q)(3)?a). Reru—t.Uso wwn 800 765 i 333 T—pike R 1 S h 102 .v..w Sourhbonwgh.NIA UV 2 x a a 9 r-. i/rrrtra:rllhrivtraft frca/5/Yarejrorn.frttouj'--mp4twn cob30a490 WW https://drive,google.com/drive/u/l/folders/OB2xzgrgCYjsBRDhgaUExdml KMXc 1/1 12/4/2017 Jeremiah Rose Choke 3-20-2019.jpg + , American Red Cross Jeremiah Rose l has successfully completed rerluiremenis for , ! Restaurant Emergency Training for Massachusetts.valic.2 Years Date Completed:03/2012017 conducted by: American Red Cross Instructor:Christine Carter (M o:GUB07J Scan code or visit: redcress.or !confirm https://drive.google.com/drive/u/1/folders/0B2xzgrgCYjsBanRPVlpIYIVPSmM 1/1 Commonwealth of Massachusetts • BOARD OF HEALTH North Andover 120 Main Street NORTH ANDOVER,MA 01845 DATE PRINTED 11/06/2017 ESTABLISHMENT NAME: b.good b.good 99 Turnpike Street File Number: BHF-2015-000012 Suite 202 NORTH ANDOVER MA 01845 LOCATED AT: ,Commonwealth of Massachusetts OWNER: Anthony Ackil PHONE:(978)681-4000 PERMIT TYPE FEE Food Est.-Restaurant Permit $185.00 Hours Active: Mon-Sat 11-9,Sun 11-8 Manager 603-508-1306 Total Fees: $185.00 4L