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Home My WebLink Aboutb. good - 2015 - Permits - 99 TURNPIKE STREET 11/30/2021 COMMONWEALTH OF MASSACHUSETTS NUMBER • BHP-2015-0102 North Andover FEE BOARD OF HEALTH $185.00 b.good DATE ISSUED NAME July 15,2015 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 ___December 31,2015-------------unless sooner suspended or revoked. RESTRICTIONS: 15 food employees,48 seats,2420 square feet BOARD OF -------E HEALTH NOTES:Contact:James Pinho 978.681.4000 ------- c � ---- ------------------------------------------------------------ HOURS ACTIVE: IOa.m. - I Ip.m. --------------------------------------- ------- BOARD OF HEALTH CHAIRMAN TOWN OF NORTH ANDOVER .J I 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(wtownofnorthandover.com FOOD ESTABLISHMENT PERMIT APPLICATION (If new establishment,application must be submitted at least 30 days before the planned opening date) I FEE: Depends on type of food establishment—Refer to your current permit or call the Health Department for fee amount 1. Establishment Name: FRFSN e4l o/ens �AC�El�4b�, L L C Date: 2. Establishment Address oC6Q- 8..9000/ 4_4�/Ew O o,J Ro O J iVa/1Tit/ 4Ag� o ve-/z_ /LtQ 3. Establishment Mailing Address(if different) /OD ' . '60w'-/1 15Y'0As:5 .So,TE 2a'2 Al"/1/—//41)eve,2 /f� 4. Establishment Telephone#: / 97,f .Gf/ ` <l000 o6l/cF #' -,T 'I7�F L4 C —7IZ.S 5. Applicant Name&Title: -\7-4h4ES /0/1/1/0 - /;,I11,J4 4P-7— Applicant Address: �ik��3F� 6. A PP /0 0 ��t/t�Vl,/L /.�y�i0 S S .S�E�O.Z .�o2T�tl .�✓f�v2� �,O o i yv s' 7. Applicant Telephone No.: SDk 6vl 9 33 9 24-Hour Emergency No.: N 6 8 053 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;71 A Corporation;❑An individual home address of the officers or partner: / L Name Title Home Address A partnership;Pother legal entity - �.9,uEs ��/,�lv �tE��Fc �9�r C.�,�cas�'/i 4) 12. Person Directly Responsible for Daily Operations(owner,Ferson in Charge,Supervisor,Manager, c. Name&Title: �4d S '/✓hel 0 / A,--A0 cc/ Address: Lh'it/ci9� Telephone No.: q71 �S/ y000 Fax No.: if 79 ��/ 7��p E-mail: Emergency hone No.: � 6�� , G g Y Telephone 93 3/ YGh. o/'QACLr7CR. eeA 13. District or Regional Supervisor(if applicable) Name&Title: F rr� 2015 Address: Ta F Telephone No.: Fax No.: E-mail: 14. Water Source: 15. Sewage Disposal: 1114,13 ee*- s�v/jc,c c DEP Public Water Supply No.:(if applicable) 16. Days and Hours of Operation: 17.No. of Food Employees /5' Pagel of 3 NAME OF ESTABLISHMENT: U" 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): �SO�(/ /`�`(ON Z/ 19. Person Trained in Anti-Choking Procedures(if 25 seats or more:❑Yes ❑No) NAME: V/Q E D/V /Q�O I✓2/ 21/. Length of Permit: (check one) 20. ation: (check one) ;� ual N'Permanent Structure ❑Seasonal/Dates: ❑Mobile ❑Temporary/Dates/Time: 22. Establishment Type(check all that apply): ❑ Retail( Spa o square feet) e/Food Service—( y8 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 VPHF 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 V 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: 0 D **IF YOU DO NOT REN&BY JANUARY 1ST,THE FEE WILL DOUBLE** Please do not combine fees for various permits in one check— (Ezample—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 f the State Sanitary Code,and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 590.000 and the Federal Food Code. 24. Signature of Applicant: Signature, 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. 2 t!�/ 25. Social Security Number or Federal I.D.#: y — J 7 � 7 / 26. Signature of Individual or Corporate Name: � ASignature / Print Name Page 3 of 3 ar Student Name Class Number rs:7!ja - EXAM FORM NO. 10202 Exam Date aExpiration Date Instructor Name CERTIFICATE NO. 7670695 Sponsor Name ® Exam Location Exam Form Name Overall Point Score Overall%Score Passing%Score SefvSafe@ Cer i icati-on Status Domain Names I.Foods TO J A S O N M I C H A E L A L O N Z I I I.Clean/Sa III.Facilities tize/Maint. IV.Monitoring Food Person for successfully completing the Standards set forth for the ServSafe"Food Protection Manager Certification Examination, V.Temp.Measuring Device which is accredited by the American National Standards Institute(ANSI)-Conference for Food Protection(CFP). VI.AllergensVII.High-Risk Populations VIII.Legal/Regulatory Issue: IX.Facility Layout/Design X.Training Employees 3/28/2011 To have a certificate reprinted,complete a C DATF OF EXAMINATION Web site at uvww.ServSa/e.com(click on Cu j ' 3/2 8/2 0 1 6 02010 Notional Restaurant Aaacciation Educational Four 10070201 DATE OF EXPIRAI 'ON Local laws apply.Check witt-your local regulatory agency for recertification requirements. fed Exam Fa Cart Nc NATIONAL ServSafe Certificatioi American National ACUEDITED' -JINIoRESTAURANT To JASG "ad the Conference for Food Protairlinn 4 ASSOCIATION fata�n4ugycortal i.pge itmduds..hashbrdle N.t Paul Hineman ® FowdatcnI.ty.S-Sitata Food naacti Menage rCei #06bb 5xecutive Director,Natioral Restaurant Association Solutions Date of Examination:3/28MI1 YJ'2010 National Rerieurant AssocMtlnn rduaalUmal rixuxlation A0 ripMs r ry eseed.ServSafe and the ServSafe logo are registered trademarks cf the National Restaurant Association Educational Foundation, Date of Expiration: 3/28/2016 and used under license by National Rsalaul Ud Aaaunlatio i Solutions,LLC,a wholly owaed subsidiary of the National Restaurant Associetior. Local lms apply.Check with yaur bcel regulatory agency tar a This document cannot be mandated tit aina ad WD1D NatKml Reslatram Anaarlatim Eruratlotel Fourdahon, 10010201 v.1012 rryynn Fyn � Fyn ryn �+ �y, vV� .___________________`-----'--_____________`_____J_______________`_____J ----__`__-__J_______-__•_-__`----__------___--______`____•/•--."._'...-..\ �j ___-----' ___•, 11�S CERTIFICATE OF r � ) S , ALLERGEN AWARENESS TRAINING Name of Recipient:Jason M. Alonzi )� ' Certificate Number. CW3917 Date of Completion: 03/30/2011 Date of Expiration: 03/28/2016 Issued By: t The above-named person is hereby issued this certiXcate Cot11 works for completing an allergen awareness training program p recognized by the Massachusetts Department of Public Health CompuWorks Systems,Inc. j in accordance with 105 CMR 590.009(G)(3)(a). 591 North Avenue,Door 2 u. Wakefield,MA 01880 •a P:781-224-1113 ?his certi6cate will be valid for five(5)years from date of completion. F:781-224-0504 �� `�l wwwcompuworks.com ( �