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Home My WebLink Aboutb. good - 2016 - Permits - 99 TURNPIKE STREET 11/30/2021 COMMONWEALTH OF MASSACHUSETTS NUMBER BHP-2016-0050 North Andover BOARD OF HEALTH FEE $185.00 b.good DATE ISSUED NAME March 25,2016 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 28,2017--------------unless sooner suspended or revoked. RESTRICTIONS:20 food employees,35 seats,2420 square feet - -- -------- -------- -------- BOARD OF - - - = HEALTH NOTES: Contact:John Mawson General Manager 603-508- ----------_____________________________________________T___ 1306 - y x 1 -------------------- HOURS ACTIVE:Mon-Sat 11-9, Sun 11-8 ------------------------------------------------------------ BOARD OF HEALTH CHAIRMAN 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:bealthde t a�townotiiorthandover.com 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 l 1. Establishment Name: fj 9 0 O G' Date: 2. Establishment Address 99 3. Establishment Mailing Address(if different) RECEIVED 4. Establishment Telephone#: 77S MAR 2 4 2016 5. Applicant Name&Title: JOA A M Q G✓s�n 6. Applicant Address: 99 T vrn/oiKe S%r e e-f TOWN OF NORTH ANDOVER 7. Applicant Telephone No.: 9 7 S .681-9/1�' Emergency HEALTH DEPARTMENT 24-Hour Emer enc No.: J 7 - �.? `l-2 C c3 7 8. Owner Name&Title(if different form applicant): 4 A Y- ),A y 4 c k i l 9. Owner Address(if different from applicant): -�'3�1 /`�/ea.S4n t S Tr ec'-T /1*'A 10. Establishment Owned By: 11. If a corporation or partnership,give name,title,and ❑An Association; Corporation;❑An individual home address of the officers or partner: Name Title Home Address U A partnership;❑other legal entity PresiolelT 33`t P/ectsu„ r i-'rr i MG 141e.. MA az y,y 12. Person Directly Responsible for Daily Operations(Owner,Person in Charge,Supervisor,Manager, c. Name&Title: 74,.4n /AlCi1,✓�pg GeAera ( Mrt^ t?3cr Address: 99 Tvrapil<,e 5Tree-7 Telephone No.:976-68 Fax No.: E-mail: cod Emergency Telephone No.: 6 c 3 j` c✓$ -/306 13. District or Regional Supervisor(if applicable) /� p Name&Title: Doti"i �G. L v C� Dt S rp t c T A' �'O5 r �( ,,QII�I-1 (� f. Addres : ectS � /ys - 7J91�� Telephone N .. o - p Fax No.: E-mail. 14. Water Source: 7a w/y 15. Sewage Disposal: j 0 j,^ DEP Public Water Supply No.: (if applicable) 16. Days and Hours of Operation: 17.No.of Food Employees ^ ov--s,4 r 2- 0 SU/7 I!-8 1"age 1 of 3 luss Oki 04, IT WSW- 1 I NAME OF ESTABLISHMENT: h A D oaf 18. Name of Person in Charge—Certified in Food Protection Management (required as of10/1/2001 in accordance with 105 CMR 590.003(A)please attach copy of certificate): JdF A MQ tV50/1 19. Person Trained in Anti-Choking Procedures(if 25 seats or more: []Yes []No) NAME: 21 Length of Permit:(check one) 20. L!P ion:(check one) prrAnnual "ermanent Structure ❑Seasonal/Dates: ❑Mobile ❑Temporary/Dates/Time: 22. Establishment Type(check all that apply): ❑ Retail( s uarc feet) ood Service—( f— 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 ❑ ale of Commercially Pre-Packaged Non-PHF's CY 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 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 Z'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 � Q =-rnr�� r rriwi7 Scanned by CamScanner EXAMINATION FORM NO: 10Z0? CIUMFICAMON NO: n71T7! �` ® R Certirica tion . tar auomiatuiy oQmpie*ig the ata ndwds aat forth by Via Noicnal Rnt"vra Aaodaton E&aYonrr Foundatlon for the Swvelk&Food Protodon ANaagar Cugxsgon ExvnUatton Jahiah R amodked by tho Amrtm n National 8tandarde ht ftde(ANSI)-Corderrnea tar Food Protaatton(CFP) Prwwftd by the iVRUOrta/Restow"t ASSOCkdw E&Xad W FotWdeftn Mardi A 2011 DATE OF EXAMINATION March 21k 2016 DATE OF EXPfRAT ION LOW 1 W .Cheoa rft yw barl raytiVaq>Gawy br raprlbdw m4p*wanM car oarwro�t Goat Netiona! Restanrnnl:lssociantmn P 9fTvtRee!ataattASSOcktlwtEdLcokrWFCUP.490n rr ] nor rTr�a:i .r n tTln�t Scanned by CamScanner 0 3 CERTIFICATE OF ALLERGEN AWARENESS TRAINING E f Name of Recipient:JONN—SON Certificate Number: ISOM$ 9 Date of Completion: r113M1$ Date of Expiration: 11177120 .14 lhr ohotr-nrmrdl+rson it hrrrbp i+rurJ this t rlJvrr mRa; NATIONAL %or rornrbting an allergen avwrrnrr+rrainigprogrrnr RESTAURANT recognizedhr the Alaswthusem Dt fwrtmerri q%Nblie Health ASSOCIATION in arrordaner with IOS CAIH SSKJ.(XJu(CI(.?1(al. Ma. hu.em Rc*aunnt A+awiafio wui765 2122 333TwnjIRud,Suitc1W www.mt—ant,nx SouthbutmgK MA 01772 Mis rertifirate wil/he wliJ%r/ivt(S)vears ranr date o%romrletion. 51M-103 9405 www.m ai caaa.„nru. t. S Scanned by CamScanner COMMONWEALTH OF MASSACHUSETTS NUMBER • C�sitr,iaa ' North Andover BHP-2015-0717 BOARD OF HEALTH FEE $185.00 b.good DATE ISSUED NAME January 01,2016 99 Turnpike Street to 202 NORTH ANDOVER, MA 01845 --------------------------------------------------------------------- ------------------------------------------------------ ADDRESS IS HEREBY GRANTE Food Est. -Restaurant Pe T Food Establish ent-Restaurant This permit is granted in conformity with the St tes and ordinances relating thereto, %d expires-------------February 28,2017---------- --unless oner suspended or revoked. RESTRICTIONS: 15-20 food employees,48 seats,2420 square feet BOARD OF -- ------ --- ----- - ------- ----- s----- HEALTH NOTES: Contact:James Pinho 978.681.4000 ---------------------- ---------------------------------------------_ HOURS ACTIVE: 1 Ia.m.- IOp.m. --------_ ---- --------------- BOARD OF HEAL CHAIRMAN 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:healthdeptgtownofnorthandover.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 your current Dermit or call the Health Department for fee amount 1. Establishment Name: �,�ESH C�o i�c�3 ��l eoJl LLC Date: 2. Establishment Address 99 �2,�/p//!� ST �p/LT,�/ �i✓�oi2r2 /1?/a 3. Establishment Mailing Address(if different) !�� r�✓ ,(.PAS J �rEao� �e�?!�/ �N�cdc��!/� 4. Establishment Telephone#: eg,y> kl- 5. Applicant Name&Title: 'jl-Mrrj ` /1•)/{�,J 6. Applicant Address: /9� L,¢N c.4 5TZ ,, / �. /✓mzcrA 4A.OoVz-w 7. Applicant Telephone No.: 47� 6*/- Vo 0 0 24-Hour Emergency No.: Sd y 6 Y/ - JS 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 C An Association;D A Corporation;❑An individual home address of the officers or partner: ❑A partnership;soother legal entity Name Title Home Address L�L _S �AJtla M-,-1"eX 19 f L•4,,cal sv�x � Al Ivb-► rX_A..A- 12. Person Directly Responsible for Daily Operations( wner,Person in Charge,Supervisor,Manager,Etc.) Name&Title: �el1/c-,%4 l /YJ AMA FX Address: q9 �i�l/✓fNl� S' /(/�2�iSi�,.17>0✓�� /L//� // Telephone No.: Fax No.: E-mail: JoN.�I)9/�aM� 6980Gt Emergency Telephone No.: 13. District or Regional Supervisor(if applicable) Name&Title: Address: ( Q / Telephone No.: Fax No.: E-mail: 14. Water Source: w� / 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: (�GvOD�� LLB 18. Name of Person in Charge—Certified in Food Protection Management(required as of 10/1/1001 in accordance with 105 CMR 590.003(A)please attach copy of certificate): 1XA4j�4/✓ 19. Person Trained in Anti-Choking Procedures(if 25 seats or more: es ElNo) NAME: 21. Length of Permit:(check one) 20. Location:(check one) "nnual Y9 ermanent Structure ❑Seasonal/Dates: ❑Mobile L Temporary/Dates/Time: 22. Establishment Type(check all that apply): o Retail( square feet) Food Service—( V seats) a?" 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(timettemperature 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 ❑ 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: �• OD C!� &LG **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 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 t 1 91IR 590.000 and the Federal Food Code. 24. Signature of Applicant: or Signature P„J4 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 7 _ ✓n,� P� 6 Print Name Page 3 of 3 � i'T Si b � Yi bi ii fir iP� Yr �—. x-.. ..--y'g;�:�'rriwxr�rwraxxxwxcrwr�gggpx'x'rx'xx'irxixwawrr rxwpaFxcrnrrtt 4lEffJ.lfi/i..•.FSS'rxxwYexYariLlCXS!'�!'�d![i-4' 1.33%rxWrxsti.w..x.. CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: JOHN MAWSON .� Certificate Number: 1987828 Date of Completion: 7113,2015 Date of Expiration: 7/13/1020 Ci Issued By: 41 The above-named person is hereby issued this eertj*ate �--� NATIONAL for completing an allergen awareness training program +r' #�# RESTAURANT recognized by the Massachusetts Department of Public Health 1 ASSOCIATION„ in accordance with 105 CMR 590.009(G)(3)(a). Massachusetts Restaurant Association 800.765.2122 333 Turnpike Road,Suite 102 www.mtaurant.org This certificate will be validforfive(5)yrarsfront date ofcomplrtion. Southborough,MA 01772508-303-9905 www.marestaurantassoc.org r s�rr-.rr:----•---� m��c+ « 04 j .^fir EA . ��J %NieY+ yr>�!`5�,� r � J ` y u, :Y ,444 ��' b��:''•.' � �° < i.is - � '� 1 r% a� bra �,_, e !Q; •c i t ry s b 4 _ p F 8 R , ey % .+� E`r3'. E`!}.'f"v.�v+, 8 1 •' ;,,,>< +. � ,fit .... *,4 e...- s '�h� � 4r. Y..- y;p.�.,:'" `"`�.. 3 7%^ s, �..�„ ',r •�4. ,�1 �� .. g.' tot, ? f, i x .; ,g >, ,+�,fix* "' m �o m m N 00 Ca 00 EXAMINATION FORK!NO: 10203 CEPiTIPICATION NO: 7073772 Q, -4 cil m LD CS) CD 00 saft C-etfift"cation s .f 10 for suaea+wiuliy ainorsung the standarda Wt forth by the Nattonal ResWurent Association Educational Foundefton for tho Servaa&6 Food Pratedon Manager CertHicadan Examinat}onof ch is accredited by the Amedcan Nalfonal e Standards lnaftlute(ANSI)-Conference for Food Protection(CFP) Presented by the Nattional Restaurant Association Edu atlonal FodndsUon b March 20, 201'1 � DATE OF EXAMINATION March 2% 2016 DATE OF EXPIRATION Local app .Cheok Mh your local ragcdatory opncy for recertiftsdam mquimmente �. ' d Daym Gibert National Restaurant A880CIc`ittt3j1,� Chief operating Moor ... o.-- � Nallonat Rest want Assoafaton Educalfcnal Foundation ��',� � 1l_':� C1 r1T I N m y 1 cat �k vivo Amy # 4 ��;# 1 �� a. .;';;r. ..thFx:' � .,hk.:' �r. �.ft as=S $i •. ��.psit wI �;y iCs�`.-�,,,:::. oe 07. 5 pus opt 3, r ; whoA�