The URL can be used to link to this page

Home My WebLink Aboutb. good - 2017 - Permits - 99 TURNPIKE STREET 11/30/2021 ' COMMONWEALTH OF MASSACHUSETTS NUMBER BHP-2017-0018 North Andover FEE BOARD OF HEALTH $185.00 b.good DATE ISSUED NAME March 01,2017 99 Turnpike Street Suite 202 NORTH -AN-DOVER, 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:20 food employees,35 seats,2420 square ----- -- -- --- -- --- -- -- ---- -- --- - - -- BOARD OF feet ------------ r---ci--------------------------------- HEALTH NOTES:Contact:John Mawson General Manager 603-508- _-----------------___-_--------------__ 1306 -- HOURS ACTIVE:Mon-Sat 11-9, Sun 11-8 ---------------------- - -------------------------- BOARD OF HEALTH CHAIRMAN TOWN OF NORTH ANDOVER '} Community and Economic Development HEALTH DEPARTMENT 120 Main St. NORTH ANDOVER, MASSACHUSETTS 01845 Phone: 978.688.9540 Fax: 978.688.9542 E-mail: heal thdeptAnorthandoverma.gov FOOD ESTABLISHMENT PERMIT APPLICATION (/f new establishinent.application nnrst be subndtted 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: b, 9 J a *k— Date: 3 2. Establishment Address c1 T,/ n p ,kL S+ A n�p f eT M A D\g�rj GG GD 3. Establishment Mailing Address(if different) RGCG,v 4. Establishment Telephone#: C1(7. 5 nn_ C 6 `t01i 5. Applicant Name&Title: 'J&5-4A tAo,.L e p I e�' 1' �} �'t�R PN�pVER P6. Applicant Address: (D (7q �!� Q f . &t rr l o3 O 3 8 �D OF��N NEE SNtENS 7. Applicant Telephone No.: I g, �Cj:k, 3`t 24-Hour Emergency No.: 8. Owner Name&Title(if different form applicant): 6, 9.3,J_ � 1 C p 9. Owner Address(if different from applicant): 3 S e Itc-S a,. �' S+• tAa t7�u� M k 10. Establishment Owned By: 11. If a corporation or partnership,give name,title,and An Association;:]A Corporation;t_i An individual home address of the officers or partner: � Name Title Home Address ❑A partnership;Cy6thcr legal entity L I-^ 12. Person Directly Responsible for Daily Operations(owner, Person in Charge,Supervisor,Manager, c. Name&Title: �--Gb l\r'S S G-t ntTj-k M�1`°` Address: S g c on C tS JV\1Z N 03 1 0t Telephone No.: o 3 Z ' Z Fax No.: E-mail: Emergency Telephone No.: b D3. Ig(o p . .Z t i Z 13. District or Regional Supervisor(if applicable) Name&Title: J 0.SJ, CA 6-,L 4- �--- Address: (o 6*N ;Az, r, Qerr� N 3 a3 g Telephone No.: I a-g, b 9 't 3 3 Fax No.: E-mail: 14. Water Source: 15. Sewage Disposal: DEP Public Water Supply No.:(if applicable) V v � ' t C. 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 bt accordance with 105 CMR 590.003 (A)please attach copy of certiricate): 19. Person Trained in Anti-Choking Procedures(if 25 seats or more: []Yes ❑No) NAME: 21. Length of Permit: (check one) 20. Location: (check one) O Annual ❑Permanent Structure ❑Seasonal/Dates: ❑Mobile Temporaiy/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(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 ❑ 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 ❑ 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: **1F YOU DO NOT RENEW BY FEBRUARY 28Tu,THE FEE WILL DOUBLE" Please include copies of current Serve Safe/Allergen Training/Croke 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 59 .0�and the Federal Food Code. 24. Signature of Applicant: ignature Print Name Pursuant to MGL Ch. 62C,sec. 49A,1 certify under the penalties ofperjury that 1, 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 I 3 Print Name i i I i i I Page 3 of 3 * , J CERTIFICATE OF �= ALLERGEN AWARENESS TRAINING � h Name of Recipient: Jason MacLeod Certificate Number. 2069630 Date of Completion: 9/25/2015 Date of Expiration: 9/25/2020 P � 51 VI 0 ' Issued By: P�4 The above-named person is hereby issued this certificate e l for completing an allergen awareness traini}Jg program MRa NATIONAL . recognized by the Massachusetts Department of Public Health RESTAURANT ASSOCIATION, in accordance with IOS CR�1R 590.009(G)(3)(a). Massachusetts Restaurant Association 800.765.2122 333 Turnpike Road,Suite 102 Www.restaurant.org Dhis certificate will be validfor five(S)yearsfrom date ofcompletion. Southborough,MA 01772 VA 508-303-9905 www.mares taurantassoc.org P�.S ;,<+'.`.',.'.`"'✓..:'...t•.F`.,.; •,•.}•,..y:^'';. :':<"'J,`.°',/,,:•,x:I.`.,v':'.,sJ °i.,`..•`::.':'.:.f;•.Y' :.+,',•,::•::'\'., ...e•*'X,•,.•.r, •,:: .,,r...:. Nore tonal Ftod ManagerqA 0 v designation has peen conferred upon W { JASON MACLEOD _ - v= == who has met aCCthe pH r f requirements for certification - _ an food service safety and sanitation. SERF IMAM mw i qN Ail _ Exam 26fl Rio mzed By Conference For Food Protection P-1 tat _ _ Certificate No: 1841118 - = = _ Exam Date: 02/06/15 t - - - - - - - _ - _ Zy 1VIcMilIM GI e_A Sovi 4anager- - Test Code: 62030426 f — Certificate expires no later than: 02/06/20 - - Choke/Save Participant j Tits'3 Has successfully completed a Choke/Save class for Ad t Conscious&Unconscious i Beth D.Oleson AHA Instructor Trainer 508-758-3188 America S fet.�Health Institute Inst. bdol�eso @ a� .com Issue Date Expiratilo-n�D-ate l --i From: INVOICE Town of North Andover Health Department 120 Main Street DATE: 02/28/2017 North Andover, MA 01845 To: B.Good 99 Turnpike Street North Andover, MA 01845 Att.Jason MacLeod,District Manager DESCRIPTION Inspections RATE AMOUNT Food Establishment Permit Application $185.00 TOTAL $185.00 Thank you for your business.