HomeMy WebLinkAboutBuilding Permit #295-2011 - 19 High Street 10/8/2010 pORTH
BUILDING-PERMIT �Ftt�E� fbq�o
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
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Permit NO. -,2o
ll Date Received
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Date Issued: �VIPORTANT:
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building One family
Addition ' Two or more.family Industrial
iteratio No. of units: Commercial
Repair, replacement Assessory Bldg Others:
Demolition Other a.�>:�-->
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SCRIPTION OF WORK TO B REFORMED:
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OWNER: Name: CZ
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ARCHITECT/ENGINEER Jar Phone:
Address: �w fs'Y`�S S Q ;,ocJ Reg. No. / d
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FEE SCHEDULE.BULDING PERMIT-'$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$123.00 PER S.F.
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Total Project Cost: $ S Z FEE:
Check No.: d �' b Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
{ � at �of_ gn /'Oanmer J - F; _r.Signa -ure�ooraor'
1
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
[Public
YPE OF SEWERAGE DISPOSAL
Sewer Tanning/MassageBody Art Swimming Poolsell Tobacco Sales
Food Packaging/Sales
Private(septic tank,etc. Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Si nature
COMMENTS
HEALTH Reviewed on o S�o�Q/d Si nature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Pi&ining Board Decision: Comments
Conservation Decision: Comments
Water$ Sewer Connection/Signature Qate
Driveway Permit
DPW Town Engineer: Signature:
;. _. Located 3 ood Street
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Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
---------------
ELECTRICAL: Movement of Meter location, mast or service drop requires a rov
Electrical Inspector Yes No
PP al of
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 section 21A—F and G min.s1o0-s1000 fine
NOTES and DATA—(For de artmenf
P use
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❑ Notified for pickup - Date
L
Doc.Buitding Perrriit Revised 2010
i
Building Department
The following is•a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of N.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or..Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract -
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
----New Construction (Single and Two Family)
❑ Building Permit Application
s:r_r r- r►i L Plan..
❑ Cei i'l le: Proposed Ploy P
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
. ❑ Mass check Energy-Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc:Building Permit Revised 2008
Location = t' r`
No. a y S' d11 Date
NORTh TOWN OF NORTH ANDOVER
O
9
L �o : ; Certificate of Occupancy $
Building/Frame Permit Fee $ �Z!51e—_
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 7Y
23535T�
Bw�iri�lnspector
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SS7CN115�
CERTIFICA'T'E OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER.
Building Permit Number 295-2011 Date: December 6, 2010
THIS CERTIFIES THAT
THE BUILDING LOCATED ON Good Day Cafe, 19 High Street
North Andover, MA 01845 John Santoro
MAY BE OCCUPIED AS a cafe IN ACCORDANCE WITH THE PROVISIONS OF THE
MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY
APPLY.
Certificate Issued to: John Santoro
19 High Street
North Andover,MA 01845
Building Inspector
Fee: 100.00
Receipt: 23766
y
i
Y Massachusetts- Depall' atent of Public Safet..
.Board of$utltiino$Q; Ilitions and Standards
GQn #ru.Cttan Aupotvisor Liceni;
License: cs 6633.4
Restricted.to:.Ot).
ltIERAN T VVH' i
•;31 RICHMOND St'
NVEYMO`WTH, MA 03188
--- _ 'Expiration: 9/2&XI1
C'�nwiia�iouer
Tr#: 3612
s
i -
Standard Form of Agreement between Owner and
RCG LLC where the basis of payment is the Cost
of the Work Plus a Fee without a Guaranteed
Maximum Price
Date: September 3, 2010
Owner: :,"RCG North Andover Millslbt'
",bo RCG LLC "
17 ,WMoo Street Suite 100
Somerville, MA 02143
Contractor: RCG LLC
17 Ivaloo Street, Suite 100"
Somerville, MA 02143
Architect: Btjii Hill
Project Name: Good Day Cafe
The Owner and Contractor agree to the terms stated by this contract. This contract
supersedes any prior agreements, representations, or negotiations, oral or written. No
liquidated damages shall apply to this agreement. This contract consists of the following
documents:
1. Obligations of the Parties
2. Contract Sum
3. Project Schedule
4. Signatures
Exhibits
Exhibit A: Estimated Cost of Work
Exhibit B: Project Schedule
Exhibit C: Drawings
Page 1 of 6
1. Obligations of the Parties
Obligations of the Contractor:
The Contractor accepts the relationship of trust and confidence established by this Agreement and
covenants with the Owner to cooperate with the Architect and exercise the Contractor's skill and
judgment in furthering the interests of the Owner; to furnish efficient business administration and
supervision; to furnish at all times an adequate supply of workers and materials; and to perform
the Work in an expeditious and economical manner consistent with the Owner's interests and in
compliance with all applicable governmental codes and regulations.
The Contractor shall keep full and detailed accounts and exercise such controls as may be
necessary for proper financial management under this Contract.
The Contractor shall keep full and detailed records of all books, records, permits, licenses,
correspondence, receipts, instructions, data, and drawings associated with the Project including all
Subcontractor contracts, invoices, vouchers, insurances, lien waivers, and other correspondence.
The Owner and Owner's Accountants shall have access to review, audit, and copy all Contractor
documentation. The Contractor shall retain these documents for a period of three years after final
payment.
The Contractor shall maintain insurance at the following levels with the Owner listed as a co-
insured:
Type of Insurance Limit of Liabilit
Cornrr%ercial General Liability $1.1000,000.00„ x
Upon request, and at the cost of the Owner, the Contractor shall obtain a performance bond up to
the total Cost of Work. Such costs shall be added to the Construction Volume.
The Contractor understands that the Project will be financed by a construction lender and, then, by
a permanent lender. The Owner may assign any of its rights under this Contract to the construction
lender and the Contractor hereby consents to any such transfer provided no such assignment shall
relieve the Owner of any of its obligations under this Contract, unless agreed to in writing by the
Contractor. The Contractor shall execute any certificates, lien waivers, releases, receipts, and other
documents as may be reasonably required by the construction lender or permanent lender including
a subordination of its mechanic's lien rights to the construction lender's and permanent lender's
mortgage or deed of trust. The construction lender for the Project will be:
� t
Obligations of the Owner:
The Owner agrees to furnish or approve, in a timely manner, information mation required by the
Contractor and to make payments to the Contractor in accordance with the requirements of this
Agreement.
Dispute Resolution:
Claims, disputes or other matters in question between the parties to this Agreement shall be
resolved by mediation or by arbitration. Prior to arbitration, the parties shall endeavor to reach
settlement by mediation.
Page 2 of 6
n
t
2. Contract Sum
Cost of Work:
The Contractor shall provide a detailed estimated Cost of Work to the Owner(see Exhibit A). The
sum of these costs, including the fee is as shown below:
$65,205.00
�F
Change Orders:
The Contractor does not guarantee the Contract Sum in any form. In the event of changes to the
Contract Sum, the Contractor will present written changes to the owner for costs that exceed the
Contract Sum in the form of a Change Order. The Contractor will review all Subcontractor Change
Orders before submittal to the Owner and Architect and make a recommendation for payment or
non-payment. The Contractor's Fee will be calculated including any approved Change Orders.
The Owner, Architect and Contractor will negotiate disputed Change Orders in good faith.
Contractor's Fee:
15% of total construction volume up to$1 million, and 10% of construction volume over$1
million. This includes pre-construction and project management services, and field personnel and
associated management overhead. The fee is based on actual costs incurred, with final true up,
and is booked monthly in arrears. Specifically,
1. The cost of pre-construction and construction management services provided by RCG
personnel is booked monthly in arrears based on the hours reported by each employee.
2. Hours are billed at the standard hourly billing rate established from time-to-time for each
employee. The hourly billing rates effective 1/1/2007 are shown below.
3. The cost of pre-construction and construction management services provided by
independent contractors is booked when invoiced and carried within the fee.
4. RCG Builders personnel functioning as tradesmen outside their management duties will
be charged according to their hourly billing rate.
5. If a project is terminated or suspended by the Owner prior to completion, RCG Builders
LLC is compensated for the actual cost of services provided prior to receipt of notice of
termination or suspension from the Owner.
6. Total Construction Volume includes all construction trades, general requirements,
insurance, bonds and miscellaneous costs deemed necessary to perform the
construction of the project, but excludes permits and fees. Permits and Fees shall be
paid directly by the Owner.
7. Construction management labor, standard tools and equipment, and labor-related
overhead are covered "within the fee". Specialty tools or equipment, trade labor supplied
by Builders personnel and approved transportation and meals costs shall be charged
directly to the Owner without a fee.
Employee Rate
David Steinber h $125/hr
Kieran Whelan $125/hr
Jason Downing $50/hr
Subcontractors:
The Contractor plans to hire Subcontractors to perform the majority of construction associated with
this project. The Contractor shall provide the Owner and Architect information on all of the bids
Page 3 of 6
s
received by Subcontractors and the names of the Subcontractors selected. Owner shall have the
right to reject a proposed Subcontractor- however, in the event that this leads to a higher Cost of
Work, the Owner shall pay for the difference. The Contractor reserves the right to reject any
Subcontractor, even if it is the lowest bid, and to dismiss Subcontractors from the job that have
been previously approved by the Owner.
Payments:
The Owner shall make progress payments on the Contract Sum according to the Requisition
process described below.
The Contractor shall, at the conclusion of each calendar month on the project, present to the
Owner an application for payment(Requisition) for costs incurred during that month. The
Requisition shall include all invoices, vouchers, partial releases of liens, expense reports, and any
other evidence to support the validity of the Requisition amount. The Contractor may requisition
for completed, but unpaid work based on an expectation of payment upon receipt of funds. The
Owner, the Architect, or their representatives shall be afforded five (5) business days to review
such application and question the Contractor about its contents. In the event there are no
disputes, the Owner shall pay the Contractor within 10 business days of receipt of the Requisition.
Payment by the Owner does not represent that the Owner or Architect have made a detailed
examination of the documentation, inspection of the work, or verification of the accounting.
At the completion
of the project, the Owner shall make a final payment to the Contractor based on
a final Cost of Work with a truing up of fees. If further corrections to work are required that are not
covered under warranties with Subcontractors, or that are not the outcome of negligence or poor
workmanship by the Contractor, the Owner shall pay the Contractor for any work associated with
performing the corrections based on the hourly rate agreed to in this contract.
Retainage:
The Owner shall not hold back any fees to the Contractor to ensure completion of the work. The
Contractor will be expected to hold back fees from Subcontractors to ensure their performance
based on the terms below:
1Q0$.of billed costs, unless otherwise approved„by the Owner
Termination of Contract:
The Owner shall reserve the right to terminate or suspend the Contract at its sole discretion.
Within 15 days of termination or suspension, the Contractor shall present an accounting of all its
costs incurred for reimbursement by the Owner. If the Owner elects to proceed with the project
without the Contractor, the Owner shall have the right to assume the Subcontracts and
agreements related to the Project.
Working Capital:
RCG Builders shall not bear the costs of Working Capital for the project. If the Owner would like
the Contractor to gain beneficial pricing on its behalf by paying subcontractors ahead of the
Requisition schedule, the Owner shall either(1) put on deposit with the Contractor a sufficient
amount of Working Capital for the Contractor to pay these Subcontractors, or(2) make immediate
payment upon request from the Contractor outside of the normal Requisition process. Provision of
Working Capital shall entitle the provider to all discounts and savings associated with that capital.
Page 4 of 6
3. Project Schedule
Date of Commencement:
The Contract Time shall be measured from the date of commencement. The date of
commencement of the Work shall be the date of this Agreement, unless a different date is stated
below or,provision is made for the date to be fixed in a notice to proceed issued by the Owner.
September 3, 2010,or"such time that Notifica#W,to Proceed is iven b `'Owner
I
Contract Time:
The Contractor shall provide to the Owner a Project Schedule(see Exhibit B). This Schedule is
based on assumptions reached prior to the signing of this contract, which assumptions the
Contractor shall attempt to clarify in the Schedule. However, the Schedule always assumes the
Owner and the Architect respond promptly to requests for information and do not request any
significant changes to the construction program. In the event that the Owner or Architect find any
discrepancies with the Schedule or its Assumptions, they will promptly notify the Contractor, who
shall make adjustments to the Schedule as necessary.
According to the attached Schedule, the Contractor shall achieve Substantial Completion of the
entire Work as follows:
Date of SubstantialCom letion to be"no later'than October 15,2010
The Contractor does not guarantee the date of completion. However, the Contractor shall not be
entitled to additional fees based on delays in the project unless those delays can be shown to
incur extra costs for the Contractor and were caused by the actions or requests of the Owner or
Architect.
The Contractor shall present an updated Project Schedule to the Owner and Architect on a weekly
basis for their review.
Page 5 of 6
s
4. Signatures
The Owner's representative is:
i
David Stein bergh, Manager
RCG North Andover Mills CLC
17 Ivaloo Street, Suite 100
Somerville, MA 02143
§ 14.4 The Contractor's representative is:
Kieran Whelan
Construction Supervisor
RCG LLC
17 Ivaloo Street;-Suite 100'
Somerville, MA 02143
This agreement is entered into as of the day and year first written above and is executed in at
least thre original copies, one for the Owner, one for the Contractor, and one for the Architect.
Owner Contractor
Sign ture Signature
Printed Name and Title VPrinted Name and Title S'v srcw owC
Page 6 of 6
Santoro Cafe Estimated Cost
Fit Out Schedule 9/3/2010
Demolition Demo existing flooring, lighting and select walls per plan $ 5,000.00
Doors&Windows Install new glass doors and windows to lobby; provide all doors per
Ian with locksets keyed to East Mill master $ 3,000.00
Ceiling Install recycled plank ceiling with acoustical barrier or painted drywall
subsitute $ 5,000.00
Frame&Insulate Walls Frame and insulate new walls per plan $ 4,000.00
Tape/Prime/Paint Provide painted finish for all drywall finish walls per plan $ 3,000.00
Kitchen and Storage Area Flooring Provide new VCT flooring per plan $ 4,000.00
Customer Area Flooring Sand and finish existing hardwood flooring per plan $ 1,200.00
Plumbing Provide dedicated water service with hookups at all designated
locations and install Tenant provided fixtures. $ 6,000.00
Electrical Provide dedicated,submetered electrical service with panel on
Premises. Provide outlets and service to equipment locations and
lighting locations to satisfy code and customer equipment&lighting
Ian and install Tenant provide fixtures. $ 11,000.00
Sprinklers Update sinklers to satisfy code per plan. $ 2,500.00
HVAC Provide new dedicated heat pump and distributed ductwork to heat
and cools ace. $ 12,000.00
General Conditions Dum sters,cleaning,supplies $ 1,000.00
Sub-total Sub-total $ 56,700.00
RCG Builders fee RCG Builders fee $ 8,505.00
Total
Total $ 65,205.00
Plus Building
Permit
Plus Building Permit
$ 792.00
ORTW
Town of
Oc.*.Yw l ti 6• j�^��i re.. V
No.
Y _ - —_ T
dower, Mass., lel 1
Q ^— LAKE
A— COCMICKEWICK V
ADRATED PC
`sS BOARD OF HEALTH
Food/Kitchen
.PERM IT T D Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT............ ...... ��":....... � ���.:. ��:.�1- ....h.. ................................................................ Foundation
f .
has permission to erect... ................................... buildings on. 1I... f................................................... Rough
r
1T.'.0 Chi
mney
to be occupied as...... .... ....P...... .. c. G . ................... ..... ..... �. . i�., /.�i .....
provided that the person accepting this p mit shall in every respect conform tot a terms d the application on file in Final
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION STARTS Rough
................................ ........... ......:.......................... Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Ocatpy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the- Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner.
- Street No.
SEE REVERSE SIDE smoke Det.
OFFICE OF-BUILDING INSPECTOR
TOWN OF NORTH ANDOVER
' CONSTRUCTION CONTROL
dSwCNt13 .
PROJECT NUMBER: 07804.17
PROJECT TITLE: aQad Day,,Caf.,. . .
PROJECT LOCATION.
East Mills, 19 High Strut
NAME OF BuILt wo: .Buildina I. 1 st Floor
NATURE OF PROJECT: Cafe
IN ACCORDANCE WITH ARTICLE 116 OF THE MASSACHUSETTS STATE BUILDING CODE,
I, Linda S. Smiley REGISTRATION NO,: 1031
I
BEING A REGISTERED PROFESSIONAL ENGINEERJARCHITECH HEREBY CERTIFY THAT I` HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, �
COMPUTATIONS AND SPECIFICATIONS CONCERNING:
ENTIRE PROJECT I❑ ARCHITECTURAL 0 STRUCTURAL n MECHANICAL n
FIRE PROTECTION CD ELECTRICAL ❑ OTHER(SPECIFY)
FOR THE ABOVE NAMED PROJECT AND THAT,TO THE BEST OF MY KNOWLEGE,SUCH PLANS;
COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISION OF THE MASSACHUSETTS
STATE BUILDING CODE;ALL.ACCEPTABLE ENGINEERING PRATICES.
AND APPLICABLE LAWS AND ORDINANCESFOR THE PROPOSED USE AND OCCUPANCY
I FURTHER CERTIFY THATJ SHALL PERFORM THE NECESSARY PROFESSIONALSERVIC'EES AND B
EPRESENT ON THE CONMUCTION SITE ON A REGULAR,AND PERIODIC BASIS TO DETERMINE THAT
THE WORK IS PROCEEEDING:IN ACCORDANCE WITH THE DOCUMENTS APPROVED FOR.THE BUILDING
PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED 1N SECTION 116.0
I, Review,for coo formance to.the design concept,shop dravrrngs,samples and other submittals
which are submitted by the c6ntractor'in aocordance with the requirements of the construction
documents -
2. Review and approval of the quality control procedures for all code-required Controlled materiels.
3. Be pr+eserd at Intervals 8 riate to the
i>i�p stage of cons#nrctk,n to b+acome,generally familiar
whheft progress:and.4uallty of the iris;and to determine,In general,if the work it being
performed in a manner consistent with'the construction documents.
PURSUANT TO SECTION 11&2.2. !SHALL SUBMIT WEEKLY, A PROGRESS REPORT
TOGETHER WITH PERTINENT COMMENTS TO THE NORTH ANDOVER BUILDING INSPECTOR.
UPON COMPLETION OF THE WORK, t SHALL SUBMIT A FINAL REPORT AS TO THE
SATISFACTORY COMPLETION AND READINI=SS'OF THE PROJECT'I=OR QCC PANCY,
y,
I >'
SUBSCRIBED AND SWORN TO BEFORE IVIS TH1 4 ,�9,.4, AY OF s
�' e r��
� f77
NOT PUBLIC MY COMMISSION EXPIRES �'.) 5,/0.2 aZ
Department of Industrial Accidents
Office of Investigations
kqir 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): e 6— L,L, c--
Address: �A ut c� ��' ... V I i ( 0 0
City/State/Zip: SO Ms�i lf V4 O-L Phone #:
i
Are you an employer?Check the appropriate box: Type of project(required):
1.Zr I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole
ro rietor or partner-
listed on the attached sheet. t 7• ❑ Remodeling
P P
ship and have no employees These sub-contractors have 8. ❑ Demolition
workingfor me in an capacity. workers' comp. insurance.
Y P h'• 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
officers have exercised their ]0.❑ Electrical repairs or additions
required.]
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.]
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name: 4mo 1
Policy#or Self-ins.Lic.#: W W 3 ® 3 Expiration Date:qI
rZ—
Job Site Address: I"V�Gr 1 l�w�Jt?�.f City/State/Zip: n w o vU o-'�-, �Yi_,&
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cerci y under the pains and penalties of perjury that the information provided above is true and correct.
Si nature: Date: d
Phone#: " S' 2- �
Official use only. Do not write in this area, to be completed by city or town officiaL
City or Town: Permit/License#
i
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: - Phone#:
ACORD- CERTIFICATE OF LIABILITY INSURANCE610212010 DATE(MMIDD/YYYY) i
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
INSURANCE MARKETING AGENCIES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
306 MAIN STREET HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
WORCESTER,MA 01608 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
f
508 753-7233 INSURERS AFFORDING COVERAGE NAIL#
INSURED INSURERA Wesco Insurance Company 25011
RCG LLC
17 Ivaloo Street,Suite 100 INSURER B:
Somerville,MA 02143-3656 INSURERQ
INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR LTR N TYPE OF INSURANCE POLICY NUMBER DPO�Y CTIVE POLICY E RATION LIMA
GENERAL LIABILITY
EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDSESIE $
CLAIMS MADE OCCUR MED EXP(Arty one per^.,on) $
PERSONAL&ADV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $
POLICY JEo- LOC
AUTOMOBILE LIABILITY
ANY AUTO COMBINED SINGLE LIMB $
(Ea accident)
ALL OWNED AUTOS
SCHEDULED AUTOS (PeDIL�Y-I n)URY $ -
HIRED AUTOS
NON-OWNED AUTOS BODILY INJURY $
(Perac6denQ
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO
OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESSJUMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR FICLAIMS MADE AGGREGATE $
$
DEDUCTIBLE $
RETENTION $
$
A WORKERS COMPENSATION AND W WC3010833 05/15110 05/15/11 ,( we STATU OTH-
EMPLOYERS'LIABILITY II ER
ANY PROPRIETOPJPARTNERIEXECUTIVE E.L.EACH ACCIDENT $500,000
OFFICERIMEMBER EXCLUDED? YES EL.DISEASE-EA EMPLOYEE E500,000
I yes, c pbe under
SPECIAL PROVIS'O'S below E.L-DISEASE-POLICY LIMIT $500,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
FOR INFORMATIONAL PURPOSES DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL _2f) DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LL48IL FTY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACORD 25(2001108)1 of 2 #S188839/M788838 GCE o ACORD CORPORATION 1988
� Ahl "
PUBLIC HEALTH DEPARTMENT
Community Development Division
i
October 8, 2010
Kathy and John Santoro
198 Abbott Street
North Andover, MA 01845
Re: Good Day Cafe, 19 High Street,North Andover,MA 01845
Dear Mr. and Mrs. Santoro,
The Health Department received your revised application submitted on October 5, 2010 for the
new food establishment to be known as"Good Day Cafe". All items noted on the previous
review have been addressed satisfactorily. This plan dated October 4, 2010 has been approved.
Looking forward to pre-opening,prior to receiving your permit to operate you must have two (2)
Health Department inspections at minimum; a construction inspection and a final inspection.
When all equipment is in place, a construction inspection should be requested. This will ensure
that the establishment was built to plan. At that time, a complete punch list will be provided.
Once the correction list is satisfied the Building permit will be signed off.
When approval is granted by the Health Department, you may begin bringing in food.No
cooking or serving may be conducted without Health Department permission or until you receive
you final inspection and have your"Food Establishment Permit"given to you by the Health
Office.
To receive the approval to begin to operate, at minimum:
1) The establishment will be clean of all construction workers and materials
2) The hand sink and bathroom will be stocked with a wall mounted paper towel dispenser
and soap dispensers
3) Handsinks should be labeled"hand wash only"
Page 1 of 2
North Andover Health Department, 1600 Osgood Street, Building 20, Suite 2-36,
North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476
a 4
Good Day Cafe—Food Establishment Plan Review Approval Letter October 8, 2010
�I
4) There must be test strips for the sanitizer on site
5) There must be Sanitizer on site. Directions on mixing the sanitizer should be posted.
6) The three(3)-bay sink should be labeled "wash, rinse, sanitize" .
7) Gloves must be on site. Please note that the state does not recommend the use of latex
gloves due to some person's sensitivity to latex that may cause them illness.
8) At minimum, employees should be trained on the sick policy and sanitation basics.
9) The Material Safety Data sheets must be located in a conspicuous location
10)There must be thermometers in all refrigeration units
11)The grease trap must be labeled. The language in bold is specific;please do not change it
in any way. If you have one or more interior grease traps please note the plumbing code
248 CMR 10.09(m):
1. A laminated sign shall be stenciled on or in the immediate area of the grease trap or
interceptor in letters one-inch high. The sign shall state the following in exact language:
IMPORTANT This grease trap/interceptor shall be inspected and thoroughly cleaned
on a regular and frequent basis. Failure to do so could result in damage to the piping
system, and the municipal or private drainage system(s).
You must meet the state code requirements to be allowed to be open for business including, but
not limited to,the list above. This correspondence is a Health Department plan approval only.
Please be advised that other town departments may have specific requirements. This approval
does not supersede any other department's request regarding other town or state regulations.
Please contact this office if you have any questions regarding this correspondence. We look
forward to working with you in the continuous effort to provide safe food the public.
Thank you for your continued cooperation. We look forward to working with you.
Sincer
Z�usan Sa e
wy /
Cc: /Gerry Brown, Inspector of Buildings,North Andover Building Department.
Michele Grant, Health Inspector,North Andover Health Department
Page 2 of 2
North Andover Health Department, 1600 Osgood Street, Building 20, Suite 2-36,
North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476