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HomeMy WebLinkAboutMiscellaneous - Exception (551)1 cn 0 1 �- SSTCW : mrI Owen Bouchie I Corporate Sanitarian The Stop & Shop Supermarket Company 00 An Ahold USA Company P.O. Box 55888,Boston,MA 02205-5888 Telephone • 617.770.8784 Once Location: 1385 Hancock St. Fax • 617.770.6980 Quincy, MA 02169 Email • owen.bouchie@stopandshop.com www.stopandshop.com ST C)K am.* 4� Lorraine A. Marsden Construction Project Manager The Stop & Shop Supermarket Company An Ahold USA Company P.O. Box 55888,Boston,MA 02205-5888 Office Location: 1385 Hancock st. Telephone • 617.770.8153 Quincy, MA 02169 Fax • 617.770.6229 --stopandshop.00m Cell • 508.901.0723 Email • Lorraine.Marsden@stopandshop.com Stop & Shop Supermarket Company Compliance -Department V Ahold USA Retail 1385 Hancock St. Quincy, Mass 02169 June 14, 2013 Dear Town/City Representative, My name is Sally Russell, I am the Licensing Manager for the Stop & Shop Supermarket Company. The purpose of this letter is to inform you that, our Licensing Department has been working with our stores and local municipalities over the past year to transition licensing responsibilities from the stores to our central support office going forward. The goal in this endeavor is better compliance and more transparency into our licensing responsibilities. We ask that all future communications regarding licensing for our store location(s) be addressed to my attention at the address below: Should you have any questions now or in the future, please feel free to contact me at 617-770- 8708 or sally.russell@ahold.com. I appreciate your help with this transition. Sincerely, Sally Russell Manager, Licensing Stop & Shop Supermarket Company 1385 Hancock St. Quincy, Mass 02169 617-770-8708 617-689-4061 fax 617-770-6980 fax sally.russell@ahold.com RECEIVED JUN 2 4 2013 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT M E Food Establishment Plan Review Guide FOOD ESTABLISHMENT PLAN REVIEW APPLICATION IS TO BE MU COMPLETED BY THE OPERATOR AND SUBMITTED TO THE REGULATORY AUTHORITY — at least 60 days in advance before commencement of any food establishment planned openings. TOWN OF NORTH ANDOVER, MA Regulatory Authority 1600 Osgood Street, Building 20; Suite 2-36, North Andover, MA 01845 Date: NEW - New construction, not yet built REMODEL - partial or major renovation of existing establishment CONVERSION — existing establishment that you are purchasing Name of Establishment: S+o P Sbco St . e_./'n :), ut L L �-- 0 Corporate Name: Category: Restaurant , Institution ,Daycare , Retail Market , Other 4*e1ma/&,t- Establishment Address: � `—�y�n�/.�4 s �y. /I � �', /,)�/g ev py1— Phone: (at location if available) E-mail Contacts: /01_1'd/hc - 171.7r S 11 -CI -1 (P r>�V ,-)ncf ,ShW, PIM Name of Owner: Mailing Address: d 3 S[ f/z; S �- i Zj , /�► ��1c , f /"�, / �t% S Telephone: 7�' >' = -) yCJ Applicant's Name (if different than owner): f—o 6reLf1 ter_ M d / S dei) Title (owner, manager, architect, etc.): Mailing Address: x1 ci e .S f, , (�1 �,1 V1 C.S1, �� Telephone: 6-) a3 Town of North Andover, Health Department, 1600 Osgood Street, Building 20; Suite 2-36, North Andover, MA 01845 --Phone: 978.688.9540-- Fax: 978.688.8476 Page 1 of 20 Date Received ::BOH o�ceuse only . _ _ D toBevew cdznpleted BOH office use only Aplroved %Dud DateZee�v completed BOH office;use only_ Appro!ed / Demed Technical Assistance with the Permitting Process The Town Planning Department offers the option of attending a Technical Review Committee (TRC) meeting to all applicants. As the applicant, I acknowledge that I have received an explanation and understand that the purpose of the TRC meeting is it to assist me in the various town processes needed to open my establishment. If declined I understand that I have forfeited this opportunity to learn more about the North Andover permitting process. I wish to attend orAecline (circle one) participation in the TRC process. General Information Hours of Operation: Sun Thurs Mon Fri Tues Sat Wed ➢ Number of Seats for customers: ➢ Number of Staff- (Maximum taff(Maximum per shift) ➢ Total Square Feet of Facility: 3 L1116 3` ➢ Number of Floors on which operations are conducted ➢ Maximum Daily Meals to be Served: (approximate number) Type of Service: (check all that apply) ➢ Breakfast ➢ Lunch ➢ Dinner Sit Down Meals Take Out Caterer Mobile Vendor Other 1� Town of North Andover, Health Department, 1600 Osgood Street, Building 20; Suite 2-36, North Andover, MA 01845 --Phone: 978.688.9540-- Fax: 978.688.8476 Page 2 of 20 11 Please enclose the following documents: IfI l Proposed Menu (including seasonal, off-site and banquet menus) Manufacturer Specification sheets for each piece of equipment shown on the plan Site plan showing location of business in building; location of building on site including alleys, streets; and location of any outside equipment (dumpsters, well, septic system - if applicable) Plan drawn to scale of food establishment showing location of equipment, plumbing, electrical services and mechanical ventilation Equipment schedule CONTENTS AND FORMAT OF PLANS AND SPECIFICATIONS 1. Provide plans that are a minimum of 11 x 14 inches in size including the layout of the floor plan accurately drawn to a minimum scale of 1/4 inch = 1 foot. This is to allow for ease in reading plans. 2. Include: proposed menu, seating capacity, and projected daily meal volume for food service operations. 3. Show the location of each piece of equipment. Each must be clearly labeled on the plan with its common name. Each unit must be sequentially numbered and the numbers must correspond to the equipment specification sheets and an equipment schedule. All self-service hot and cold holding units must have sneeze guards. 5. Label and locate separate food preparation sinks when the menu dictates to preclude contamination and cross -contamination of raw and ready -to -eat foods. 6. Clearly designate adequate hand washing lavatories for each toilet fixture and in the immediate area of food preparation, cooking and ware washing. (a hand sink should be located within 10 feet of each area for easy access for all food handlers) 7. Provide the room size, aisle space, space between and behind equipment and the placement of the equipment on the floor plan. 8. On the plan, represent auxiliary areas such as storage rooms, garbage rooms, toilets, basements and/or cellars used for storage or food preparation. Show all features of these rooms. 9. Include and provide specifications for: a. Entrances, exits, loading/unloading areas and docks; b. Complete finish schedules for each room including floors, walls, ceilings and coved juncture bases; c. Plumbing schedule including location of floor drains, floor sinks, water supply lines, overhead waste -water lines, hot water generating equipment with capacity and recovery rate, backflow prevention, and wastewater line connections; Town of North Andover, Health Department, 1600 Osgood Street, Building 20; Suite 2-36, North Andover, MA 01845 --Phone: 978.688.9540-- Fax: 978.688.8476 Page 3 of 20 d. Lighting schedule with protectors; (1) At least 110 lux (10 foot candles) at a distance of 75 cm (30 inches) above the floor, in walk-in refrigeration units and dry food storage areas and in other areas and rooms during periods of cleaning; (2) At least 220 lux (20 foot candles): (a) At a surface where food is provided for consumer self-service such as buffets and salad bars or where fresh produce or packaged foods are sold or offered for consumption; (b) Inside equipment such as reach -in and under -counter refrigerators; (c) At a distance of 75 cm (30 inches) above the floor in areas used for handwashing, warewashing, and equipment and utensil storage, and in toilet rooms; and (3) At least 540 lux (50 foot candles) at a surface where a food employee is working with food or working with utensils or equipment such as knives, slicers, grinders, or saws where employee safety is a factor. e. Food Equipment schedule to include make and model numbers and listing of equipment that is certified or classified for sanitation by an ANSI accredited certification program (when applicable). f. Source of water supply and method of sewage disposal. Provide the location of these facilities and submit evidence that state and local regulations are complied with; g. A mop sink or curbed cleaning facility with facilities for hanging wet mops; h. Garbage can washing area/facility; i. Cabinets for storing toxic chemicals; j. Dressing rooms, locker areas, employee rest areas, and/or coat rack as required; k. Site plan (plot plan for new construction) PLEASE CIRCLE/ANSWER THE FOLLOWING QUESTIONS FOOD PREPARATION REVIEW Check categories of Potentially Hazardous Foods (PHF's) to be handled, prepared and served. CATEGORY* (YES)N(_O) 1. Thin meats, poultry, fish, eggs (hamburger; sliced meats; fillets) ( ) ( ) 2. Thick meats, whole poultry (roast beef; whole turkey, chickens, hams) ( ) ( ) 3. Cold processed foods (salads, sandwiches, vegetables) ( ) ( ) 4. Hot processed foods (soups, stews, rice/noodles, gravy, chowders, casseroles) ( ) ( ) Town of North Andover, Health Department, 1600 Osgood Street, Building 20; Suite 2-36, North Andover, MA 01845—Phone: 978.688.9540-- Fax: 978.688.8476 Page 4 of 20 5. Bakery goods (pies, custards, cream fillings & toppings) ( ) ( ) 6. Other FOOD SUPPLIES: 1. Are all food supplies from inspected and approved sources? YES / NO 2. What are the projected frequencies (daily, weekly, etc) of deliveries for Frozen foods , Refrigerated foods , and Dry goods 3. Provide information on the amount of space (in cubic feet) allocated for: Dry storage , Refrigerated Storage , and Frozen storage 4. How will dry goods be stored off the floor? COLD STORAGE: 1. Is adequate and approved freezer and refrigeration aMil foods at 41'F (5°C) and below? YES / NO 2. Will raw meats, poultry and seafood be stored in \esan eat foods? YES / NO If yes, how will cross -contamination be prev 3. Does each refrigerator/freezer have a thermometer? YES / NO Number of refrigeration units: Number of freezer units: frozen foods frozen, and refrigerated and freezers with cooked/ready-to- 4. Is there a bulk ice machine available? YES / NO Is ice packaged and sold for retail? YES/NO Town of North Andover, Health Department, 1600 Osgood Street, Building 20; Suite 2-36, North Andover, MA 01845 --Phone: 978.688.9540-- Fax: 978.688.8476 Page 5 of 20 THAWING FROZEN POTENTIALLY HAZARDOUS FOOD: Please indicate by checking the appropriate boxes how frozen potentially hazardous foods (PHF's) in each category will be thawed. More than one method may apply. Also, indicate where thawing will take place. Food Thawing Method*Thick or Bulk Frozen i *Thin/Portioned Frozen E I Refrigeration Running Water Less than 700 F(210 C) � Microwave (as part of cooking process) ' 1 Cooked from Frozen state 1 Other (describe) s *Frozen foods: approximately one inch or less = thin, and more than an inch = thick. PREPARATION: 1. Please list categories of foods 2. Will food employees be trained in good food Method of training: \1\ Number(s) of employees: Dates of completion: 12 hours in advance of service. practices? YES / NO 3. Will disposable gloves and/or utensils and/or food grade paper be used to prevent handling of ready -to -eat foods? YES / NO 4. Is there a written policy to exclude or restrict food workers who are sick or have infected cuts and lesions? YES / NO Please describe briefly: Town of North Andover, Health Department, 1600 Osgood Street, Building 20; Suite 2-36, North Andover, MA 01845 --Phone: 978.688.9540-- Fax: 978.688.8476 Page 6 of 20 Will employees have paid sick leave? YES / NO 5. How will cooking equipment, cutting boards, counter tops and other food contact surfaces which cannot be submerged in sinks or put through a dishwasher be sanitized? Chemical Type: Concentration: Test Kit: YES / NO 6. Will ingredients for cold ready -to -eat foods such as tuna, mayonnaise and eggs for salads and sandwiches be pre -chilled before being mixed and/or assembled? YES/NO If not, how will ready -to -eat foods be cooled to 41'F? 7. Will all produce be washed on-site prior to uke? Y% / PQ Is there a planned location used for washing produc? YP1S / NO If not, describe the procedure for cleaning and sanitizing multiple use sinks between uses. 8. Describe the procedure used for minimizing the length of time PHF's will be kept in the temperature danger zone (41'F - 140°F) during preparation. Town of North Andover, Health Department, 1600 Osgood Street, Building 20; Suite 2-36, North Andover, MA 01845 --Phone: 978.688.9540-- Fax: 978.688.8476 Page 7 of 20 9. Where raw meats, poultry and seafood are prepared in the same work area or using the same equipment as cooled/ready to eat foods, how will cross contamination be prevented? 10. Please list all PHF's you plan to serve which will/may not be cooked to the previously listed minimum temperatures. A proper "consumer advisory" warning notation must be printed on menu or menu boards. 11. Provide a HACCP plan for specialized processing methods such as vacuum packaged food items prepared on-site or otherwise required by the regulatory authority. 12. Will the facility be serving food to,,4 highly susceptible population? YES / NO If yes, List measures taken to comply with%code requirements. COOKING: 1. Will food product YES / NO What type of tem ➢ beef roasts ➢ solid seafood pieces ➢ other PHF's ➢ eggs: cooking/reheating temperatures of PHF's? and conduction heating epui, ➢ 130°F (121 min) ➢ 145°F (15 sec) ➢ 145°F (15 sec) ■ Immediate service 145°F (15 sec) pooled* 155°F (15 sec) (*pasteurized eggs must be served to a highly susceptible population) ➢ pork ➢ 145°F (15 sec) ➢ comminuted meats/fish ➢ 155°F (15 sec) ➢ poultry ➢ 165°F (15 sec) ➢ reheated PHF's ➢ 165°F (15 sec) 2. List types of cooking equipment. Town of North Andover, Health Department, 1600 Osgood Street, Building 20; Suite 2-36, North Andover, MA 01845 --Phone: 978.688.9540-- Fax: 978.688.8476 Page 8 of 20 HOT/COLD HOLDING: 1. How will hot PHF's be maintained at 140°F (60°C) or above during holding for service? Indicate type and number of hot holding units. 2. How will cold PHF's be maintained at 41 °F (5°C) or below during holding for service? Indicate type and number of cold holding units. COOLING: Please indicate by checking the. appropriate boxes (140°F to 70°F in 2 hours and 70°F to 41°F in 44 PHF w 1 lie cooled to 41'F (5°C) within 6 hours Als , 'ndi ate where the cooling will take place. REHEATING: 1. How will PHF's that are cooked, cooled, and reheated for hot holding be reheated so that all parts of the food reach a temperature of at least 165°F for 15 seconds. Indicate type and number of units used for reheating foods Town of North Andover, Health Department, 1600 Osgood Street, Building 20; Suite 2-36, North Andover, MA 01845 --Phone: 978.688.9540-- Fax: 978.688.8476 Page 9 of 20 COOLING THICK THI TS THIN SOUPS/ THICK RICE/ METHOD E MEATS RAVY SOUPS/ NOODLES GRAVY I Shallow Pans i t Ice Baths i Reduce Volume or Size I l ' � I Rapid Chill Other describe j� REHEATING: 1. How will PHF's that are cooked, cooled, and reheated for hot holding be reheated so that all parts of the food reach a temperature of at least 165°F for 15 seconds. Indicate type and number of units used for reheating foods Town of North Andover, Health Department, 1600 Osgood Street, Building 20; Suite 2-36, North Andover, MA 01845 --Phone: 978.688.9540-- Fax: 978.688.8476 Page 9 of 20 2. How will reheating food to 165°F for hot holding be done rapidly and within 2 hours? Alt '3 A. FINISH SCHEDULE ��� 1 r` a �,; ��- `_,�• P P" 41 -'-yi Materials selected must be durable and appropriate to the area and its intended use. High moisture and food splash areas must be non-absorbent, smooth and easily cleanable. All openings must be tight fitting, properly sealed and without voids. Applicant must indicate which materials (ie. quarry tile, stainless steel, 4" plastic coved molding, etc.) will be used in the following areas. (be specific) Kitchen FLOOR COVING i WALLS i CEILING Bar 1 I i j Food Storage i Other Storage j j ;Toilet RoomsJig? l j Dressing Rooms j i f ---I F_ , e� I Kitchen Garbage & Refuse Storage i Town of North Andover, Health Department,1600 Osgood Street, Building 20; Suite 2-36, North Andover, MA 01845—Phone: 978.688.9540-- Fax: 978.688.8476 Page 10 of 20 B: fNSBCT & RODENT CONTROT, APPLICANT: PLEASE CHECKAPPROPRL4TE BOXES. t NO N/A 1. Will all outside doors be self-closing and rodent proof? Mop Service l L Basin Area l � 2. Are screen doors provided on all entrances left open to the outside? � 3. Do all openable windows have a minimum #16 mesh screening? 1, Warewashing 5. Will all pipes & electrical conduit chases be sealed; ventilation systems exhaust and intakes protected? Area 6. Is area around building clear of unnecessary brush, litter, boxes and other harborage? I Walk-in 7. Will air curtains be used? If yes, where? Refrigerators and / i Freezers i B: fNSBCT & RODENT CONTROT, APPLICANT: PLEASE CHECKAPPROPRL4TE BOXES. Town of [North Andover, Health Department, 1600 Osgood Street, Building 20; Suite 2-36, North Andover, MA 01845—Phone: 978.688.9540--- Fax: 978.688.8476 Page 11 of 20 YES NO N/A 1. Will all outside doors be self-closing and rodent proof? 2. Are screen doors provided on all entrances left open to the outside? 3. Do all openable windows have a minimum #16 mesh screening? 4. Is the placement of electrocution devices identified on the plan? 5. Will all pipes & electrical conduit chases be sealed; ventilation systems exhaust and intakes protected? _ 6. Is area around building clear of unnecessary brush, litter, boxes and other harborage? 7. Will air curtains be used? If yes, where? 8. Do you have a plan to have a contract pest control company? If yes, list company name, describe frequency of inspection and type of service. 1"(\Pyr& / Town of [North Andover, Health Department, 1600 Osgood Street, Building 20; Suite 2-36, North Andover, MA 01845—Phone: 978.688.9540--- Fax: 978.688.8476 Page 11 of 20 C. GARBAGE AND REFUSE INSIDE YES NO N/A 9. Do all containers have lids? 10. Will refuse be stored inside? If so, where? 11. Is there an area designated for a garbage can or floor mat cleaning? OUTSIDE 12. Will a dumpster be used? Number: Size of: a. Number: b. Size of: c. Frequency of Pick -Up? Indicate days and how often 13. Will a compactor be used? Number: IV Size: Frequency of Pick -Up 14. Will garbage cans be stored outside? \� 15. Describe surface and location where dumpster/compactor/garbage cans are to be stored. 16. Describe location of grease storage receptacle 17. Is there an area to store recycled containers? 18. Is there any area to store returnable, damaged goods? Town of North Andover, Health Department, 1600 Osgood Street, Building 20; Suite 2-36, North Andover, MA 01845 --Phone: 978.688.9540-- Fax: 978.688.8476 Page 12 of 20 D. PLUMBING CONNECTIONS The FDA Food code and plumbing requirements do not replace or supersede the MA State Plumbing Code, which also must be fully met; instead, it highlights potential hazardous circumstances and particular types of equipment common to food service operations that, if through improper design or installation, could result in contamination.of food or water supply. Please indicate proposed properly installed equipment. 'Ila Town of North Andover, Health Department, 1600 Osgood Street, Building 20; Suite 2-36, North Andover, MA 01845 --Phone: 978.688.9540-- Fax: 978.688.8476 Page 13 of 20 Equipment Code ?Confirmed Describe/ Comments Requirements by Operator please initial Dish Machine �y� Backflow prevention device z �lQ iesfvre /,�,,cl� �v�..�,/�i.✓J' Indirect Waste --�- �+ Steam Jacketed � Backflow prevention � Kettle � device I � F I' ndirect Waste � Steamer Backflow prevention �- � t,✓��f � f� � device 3 L6 L✓ Y Indirect Waste Garbage Disposals � Backflow prevention or dish table device troughs; � Submerged inlets � At all hose Backflow prevention � �✓oo dI `connections device��Mol"ae.%L ✓�r�/�''� >31���! Garbage can Backflow prevention � washer device Carbonated j Carbonated BackfVO l ow r beverage i prevention device dispenser r g I�acc�i/ ��Co 0-' Refrigerator- ' Indirect Waste �- �-+'� condensate/ drain _l 3 � �� linesr�-A�r' / i Ice storage bins Indirec waste • ��c� rte► e- -_ _ ✓C � � , •� —�" � - All sinks Air Gap � ,4%��,Syte� ro ved y•�s� E 1 .•-� 3 " r r love Ice Cream dipper Air Gap wells %l Other �cSev,Ce•S� ✓e°�o " xk";Iell 19. Ar�floor drams o . &Basil Meana 1 f so, indicat locatio „✓ j` /e;i � � E. WATER SUPPLY 20. Is water supply public j) or private ( ) ? 21. If private, has source been approved? YES ( ) NO ( ) PENDING ( ) Please attach copy of written approval and/or permit. 22. Is ice made on premises ( or purchased commercially If made on premise, are specifications for the ice machine provided? YES (Y) NO ( ) Describe provision for ice scoop storage: Provide location of ice maker or bagging operation ?,,-.oJVC0- 23. What is the capacity of the hot water Z -u 4110 4C Town of North Andover, Health Department, 1600 Osgood Street, Building 20; Suite 2-36, North Andover, MA 01845 --Phone: 978.688.9540-- Fax: 978.688.8476 C, .,,) k, 2 Page 14 of 20 U 24. Is the hot water generator sufficient for the needs of the establishment? Provide calculations for necessary hot water vis 25. Is there a water treatment device? YES () NO If yes, how will the device be inspected & serviced? 26. How are backflow prevention devices inspected & serviced? F. SEWAGE DISPOSAL 27. Is building connected to a municipal sewer? 28. If no, is private disposal system approved? Please attach copy of written approval and/or permit. 29. Are grease traps provided? "AfF ►�/ /7Y f -Ka , 1�✓.ee�f Co 4. YES (V/ NO ( ) YES ( ) NO ( ) PENDING ( ) YES NO ( ) If s - where? d.'o 7 V.Q, — e Z. hYv d, A kiffet 4 clPele� p Note: GreasAraps must have the following sign. The language in bold Apecific; 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): 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). C�e<e //29 1410" G. DRESSING ROOMS `- a 30. Are dressing rooms provided? YES( )NO( ) 31. Describe storage facilities for employees' personal belongings (i.e., purse, coats, boots, umbrellas,etc.) Town of North Andover, Health Department, 1600 Osgood Street, Building 20; Suite 2-36, North Andover, MA 01845 --Phone: 978.688.9540-- Fax: 978.688.8476 Page 15 of 20 H.GENERAL 32. Are insecticides/rodenticides stored separately from cleaning & sanitizing agents? YES () NO ( ) Indicate location: 33. Are all toxics for use on the premise or for retail sale (this includes personal me ications), stored away from food preparation and storage areas? YES (VNO ( ) 34. Are all containers of toxics including sanitizing spray bottles clearly labeled? YES( ) NO ( ) NotP; 1VMaterial Safety Data Sheets (MSLZC) ara ra I -.reed to be rapt fnr all nki-miralc nn flea prary�2SeS. Where will the MSDS information be kept on display for easy access in an emergency? 35. Will linens be laundered on site? If yes, what will be laundered and where? If no, how will linens be cleaned? YES( )NO( ) 36. Is a laundry dryer available? YES( ) NO ( ) 37. Location of clean linen storage: 38. Location of dirty linen storage: 39. Are containers constructed of safe materials to store bulk food products? YES ( ) NO ( ) Indicate type: 40. Indicate all areas where exhaust hoods are installed: LOCATION FILTERS WOR SQUARE FEET I FIREAIR CAPACITY AIR MAKEUP EXTRACTION i ! PROTECTION CFM _ I CFM IDEVICES f 1 j Town of North Andover, Health Department, 1600 Osgood Street, Building 20; Suite 2-36, North Andover, MA 01845—Phone: 978.688.9540-- Fax: 978.688.8476 Page 16 of 20 41. How is each listed ventilation hood system cleaned? I. SINKS 42. Is a mop sink present? YES ( NO ( } If no, please describe facility for cleaning of mops and other equipment: 43. If the menu dictates, is a food preparation sink present? YES ( ) NO () detail answer J. DISHWASHING FACILITIES 44. Will sinks or a dishwasher be used for warewashing? Dishwasher( ) Two compartment sink( ) Three compartment sink ( ) 45. Dishwasher Type of sanitization used: Hot water (temp. provided) Booster heater. Chemical type Is ventilation provided? YES ( ) NO ( ) 46. Do all dish machines have templates with operating instructions? YES( ) NO ( ) 46. Do dish machines have temperature/pressure gauges as required that are accurate? YES( )NO( ) 48. Does the largest pot and pan fit into each compartment of the pot sink? YES( ) NO ( ) If no, what is the procec e for manual cleaning and sanitizing? Town of North Andover, Health Department, 1600 Osgood Street, Building 20; Suite 2-36, North Andover, MA 01845 --Phone: 978.688.9540-- Fax: 978.688.8476 Page 17 of 20 Mar 29 10 02:36p Richard Piscitelli 49. Are there drain boards on both ends of the pot sink? YES (� NO( ) type of sanitizer is used? ❑Chlorine ❑Iodine n4aternary ammonium ❑Hot Water ❑Other 508-559-0335 p.2 51. Are test papers and/or kits available for checking sanitizer concentration? YES k4'1<0 ( ) ILET 52. Is there a handwashing sink in each food preparation, cooking and warewashiag area? YES ('40 ( ) 53. Do )1 handwashing sinks, including those in the restrooms, have a mixing valve or combination faucet? YES (14 NO ( ) 54. Do self-closing metering f,,, dcets provide a flow of water for at least 15 seconds without the need to reactivate the faucet? YES ( NO ( ) 55. Is hand cleanser available at all handwashing sinks? YES (,/) NO ( } 56. Are hand drying facilities (paper towels, air blowers, etc.) at all handwashing sinks? YES (10 { ) 57. Are covered waste receptacles available in each restroom? YES (:�NO ( ) 58. Is hot and cold running water under pressure available at each handwashing sink? YES (VKO ( } 59. Are all toilet room doors self-closing? YES (✓)/O ( ) 60. Are all toilet rooms equipped with adequate ventilation? YES ( 110 ( ) 61. Are handwashing signs and instructions posted in each employee restroom? YES (/NO ( ) I � iTown of North Andover, Health Department, 1600 Osgood Street, Building 20; Suite 2-36, North Andover, MA 01845 --Phone: 978.688.9540-- Fax: 978.688.8476 Page 18 of 20 04/23/2010 15:55 FAX 617 770 6229 S.& S. TECH.SUPPORT L. SMALL EOURN ENT REQUIREMENTS 62. Please specify the number, location, and types of each of the following proposed for on site use: Slicers Cutting boards Can openers _ Mixers Floor mats — Other ************ CM 005/005 STATEMENT: I hereby certify that the above information is correct, and I fully understand that any deviation from the above without prior permission from this Health Regulatory Office may nullify final approval. Si-gnature(s) Print:di��p� owner(s) or responsible representative(s) Date: Approval of these plans and specifications by this Regulatory Authority does not indicate compliance with any outer code, law or regulation that may be required–federal, state, or local. It further does not constitute endorsement or acceptance of the completed establishment (structure or equipment). A precoustruction inspection with equipment in place and a preopening inspection of the establishment will be necessary to determine if it complies with the local and state laws governing food service establishments. Page Last Updated: 10/27/2009 Town of North Andover, Health Department, 1600 Osgood Street Building 20; Suite 2-36, North Andover, MA 01845 --Phone: 978.688.9540-- Fax. 978.688.8476 Page 19 of 20 Page 3 of 4 Floor pit in wash area of bake shop — area in decay verify design. Employee has no idea why and how and what it is Cc: Michele Grant, Health Inspector S S 6�'1 �5 ��is�VlGt�rl 2 �o4.E4 Chemical Coatings TME FA0.t tir��'U c SHERWIN WILLIAMS. Polane® 2K Acrylic Waterborne Enamel Monochromatics and Clears DESCRIPTION Polane® 2K Acrylic Waterborne Enamel HAPS free, <1.0 VOC (catalyzed), two - component high performance polyurethane coatings. All specifications are given on force - dried samples. Advantages: • Meets the Federal HAPS rule for wood finishes as packaged* [HAPS free] • Low VOC at <1.Olbs/gal • Good gloss and color retention • Interior and limited exterior use • Clear and Blend monochromatics • Can be used on metal, plastic, or wood with the appropriate primer, basecoat, or pretreatm ent • 4 + Hour potlife • Free of lead and chromate hazards • Can be blended with up to 8 oz/gal Kern Aqua colorants. *VOC compliance limits vary from state to state; please consult local Air Quality rules and regulations. *National Standards for Hazardous Air Pollutants (HAPS) Emissions for Wood Furniture Manufacturing Operations CFR40, Part 63, Subpart JJ CHARACTERISTICS Gloss 60°: Monochromatics: 30-40 units F63TLO500 Clear. 3040 units F63CLO500 Clear Full - 85 units Volume Solids: 36 t 2% as packaged and varies by color catalyzed & reduced Weight Solids: 40 ±1% as packaged and varies by color catalyzed & reduced White ................................... F63WL0504 Yellow Oxide ....................... F63YLO500 Full Gloss Clear ................... F63CLO500 Catalyst ............................... V66VL6 CHARACTERISTICS (cont.) Viscosity: 25-30 seconds #2 Zahn Cup Recommended film thickness Mils Wet 3.0-5.0 mils Mils Dry 1.1-1.8 mils Spreading Rate (no application loss) 591 sq ft/gal @ 1.0mils DFT (theoretical) Drying (77°F, 50% RH): To Touch: 20 — 30 minutes To Handle: 40 — 50 minutes Tack Free: 30 — 40 minutes To Sand: 50 — 60 minutes To Recoat: no critical recoat (sand between coats) To Topcoat: 60 minutes To Pack: overnight Force Dry: 15 minutes at 140°F Good air movement and humidity control are necessary for proper drying of water reducible coatings. Do not exceed the heat distortion temperature of the substrate. Baking Schedule: Flash off time 10 minutes 15 minutes at 140°F Flash Point: >299°FPer *Aartens Closed Cup Mixing Ratio: 10 part Part A 1 part Catalyst V66VL6 If you do not use plural component equipment you must mix at least five minutes with good agitation before s rain . Working Pot Life: Product Dependent Monochromatics: 4 — 5 hours Clears: 7 — 8 hours Package Life: 1 year, unopened Catalyst 9 month shelf life Black....................................F63BLO504 Red Oxide............................F63RL0500 30-40 Gloss Clear................F63TLO500 CHARACTERISTICS (cont.) Air Quality Data: Non-photochemically reactive Photochemically reactive Volatile Organic Compounds (VOC) as packaged, maximum 0.73 Ib/gal, 88 g/L Volatile Organic Emissions as packaged, maximum 0.27 Ib/gal, 33 g/L Hazardous Air Pollutants (HAPS) as packaged, is HAPS free. An Environmental Data Sheet is available from your local Sherwin-Williams facility. SPECIFICATIONS General: Substrate should be free of grease, oil, dirt, fingerprints, drawing compounds, any contamination, and surface passivity treatments to ensure optimum adhesion and coating performance properties. Consult Metal Preparation Brochure CC -T1 for additional details. Any use over metal must b primed and/or base coat. Product does not contain flash rust inhibitors so use over any metal must be tested thoroughly. Plastic/composites: Due to the diverse nature of plastic/composite substrates, a coating or coating system must be tested for acceptable adhesion to the substrate prior to use in production. Reground and recycled plastics along with various fire retardants, flowing agents, mold release agents, and foaming/blowing agents will affect coating adhesion. A filler or primer/barrier coat may be required. Please consult your Sherwin- Williams Chemical Coatings Sales Representative for system recommendations. Wood (interior): Must be clean, dry, and finish sanded. Use of Sherwood interior millwork primer is suggested for priming. Substrate should be free of grease, oil, dirt, fingerprints, and any contamination to ensure optimum adhesion and coating performance properties. Moisture content of wood should be 6 to 8%. i Wood (Exterior) — Must be clean, dry, and finish sanded. Use of exterior alkyd primer or Sherwood 90 day exterior primer is recommended for priming. Due to the nature of wood and use of various primers these products should be thoroughly tested for exterior performance. Testing: Due to the wide variety of substrates, surface preparation methods, application methods, and environments, the customer should test the complete system for adhesion and compatibility prior to full scale application. APPLICATION Typical Setups Plural Component Equipment for mixing is preferred May be applied by: Conventional Spray Airless Spray Air Assisted Airless HVLP Conventional Spray: Air Pressure ...................... 40 — 60 psi Fluid Pressure....................10 —15 psi Cap/Tip.................................... 797/FF Airless Spray: visual effect Pressure..............................>1500 psi Tip ................ Dependent on line speed Air Assisted Airless: Catsup....................................no Air Assist Pressure .....................20 psi Fluid Pressure ...................150-250 psi Capp......... Dependent on line speed HVLP: Gun ............................... Binks Mach 1 Air Pressure at the cap ........40 - 65 psi Fluid Pressure ......... ......... ....... 6-10 psi CapMp.................................... 95P/97 If You do not use plural component equipment you must mix at least five minutes with good agitation before Brain. Cleanup: Clean tools and equipment immediately after use with a mixture of water and butylcellosolve. Flush equipment with solvent to prevent rusting. Follow manufacturer's safety recommendations when using solvents. Product Limitations: • Product is designed for interior and limited exterior use. Please consult your SW Representative to disucss use for exterior applications. • Potlife may be different for each color or clear. Performance Tests Substrate: PVC Vinyl Panel Plaques and Fiberglass Pultrusion Panels • Passes AAMA 613 and AAMA 623 which include the following tests: o Pencil Hardness o Dry Adhesion o Wet Adhesion o Direct Impact o Muriatic Acid Resistance o Mortar Resistance o Detergent Resistance o Humidity Resistance (1500 hours) o Cold Check Cycles (15 cycles) Household Chemicals Test Panels were aged 21 days at room conditions, 5 drops of each item were placed under a watch glass for 24 hours. After removal, the finish was examined and the following results noted: Vinegar...................................no visual effect 50% Ethyl Alcohol..................no visual effect Soap Solution .........................no visual effect Detergent................................no visual effect Vegetable Oil..........................no visual effect Mustard .................................very slight stain Catsup....................................no visual effect Coffee.....................................no visual effect Tea.........................................no visual effect Water......................................no visual effect CAUTIONS Thoroughly review product label for safety and cautions prior to using this product A Material Safety Data Sheet is available from your local Sherwin-Williams facility. Please direct any questions or comments to your local Sherwin-Williams facility. Catalyst CONTAINS ISOCYANATES. People who have chronic (long-term) lung or breathing problems or have had a reaction to isocyanates must not be in the area where this product is being applied. Where overspray is present, a positive pressure air -supplied respirator should be wom. If unavailable, a properly fitted organic vapor/particulate respirator may be effective. Consult catalyst MSDS and product label for complete handling instructions. Do not store material that has been catalyzed. Pressure can build in closed containers. Use all catalyzed material. Note: Product Data Sheets are periodically updated to reflect new information relating to the product. It is important that the customer obtain the most recent Product Data Sheet for the product being used. The information, rating, and opinions stated here pertain to the material currently offered and represent the results of tests believed to be reliable. However, due to variations in customer handling and methods of application, which are not known or under our control, The Sherwin- Williams Company cannot make any warranties as to the end result. Wood and Composite Building Product Lab (Columbus, Ohio) Amber Miller 08/01/07 3* �s 61P . Nw U" 1, 11 vq/r Ataz O'l S,t-i�. k, Zvi L 51' m Job Name Job Location For Health Hazard Applications Contractor Approval Engineer Contractor's P.O. No Approval Representative Series 909 Reduced Pressure Zone Assemblies 909 Sizes: 3/4", 1 " (20, 25mm) 9091V11 Sizes:..! '%4", 11/2", 2" (32, 40, 50mm) Series 909 Reduced Pressure Zone Assemblies are designed to provide superior cross -connection control protection of the potable water supply in accordance with national plumbing codes and containment control for water authority requirements. This series can be utilized in a variety of installations, includ- ing health hazard cross -connections in plumbing systems or for containment at the service line'entrance. With its exclusive, design incorporating the patented "air-in/water-out" principle it provides maximum relief valve discharge during the emergency conditions of combined backsiphonage and backpressure with both checks fouled. Model 909QT, standardly furnished with full port, resilient seated and bronze ball valve shutoffs. Sizes 3/4" and 1 " (20 and 25mm) shutoffs have tee handles. Features • Modular design • Replaceable seats • Compact for installation ease • Horizontal or vertical (up or down) installation • No special tools required for servicing ' Specifications A Reduced Pressure Zone Assembly shall be installed at each cross -connection to prevent backsiphonage and backpres- sure of hazardous materials into the potable water supply. The assembly shall consist of a pressure differential relief valve located in a zone between two positive seating check valves. Backsiphonage protection shall include provision to admit air directly into the reduced pressure zone via a separate channel from the water discharge channel, or directly into the supply pipe via a separate vent. The assembly shall include two tightly closing shutoff valves before and after the assembly, test cocks and a protective strainer upstream of the No. 1 shutoff valve. The assembly (specify Model 909 for temperatures up to 140oF (60°C) or Model 909HW for temperatures up to 210°F (99°C)) shall meet the requirements of ASSE Std. 1013; AWWA Std. C-511-92 CSA 1364.4; FCCCHR of USC Manual Section 10. Listed by IAPMO (UPC). SBCCI (Standard Plumbing code). The assembly shall be a Watts Regulator Company Series 909QTS or 9090TSHW. 11/2" (40mm) Supply Presses Channel to Relief Valve Relief Valve Assembly Ball Valve Test Cocks Water Outlet Air Inlet and Check lodule sembly Now Aga...... . WattsBox Insulated :Enclosures For more tnformatton, send for Ilterature ES -WB Watts product specifications in U.S. customary units and metric are approximate and are provided for reference only. For precise measurements, please contact Watts Technical Service. Watts reserves the right to change or modify product design, construction, specifications, or materials with- out prior notice and without incurring any obligation to make such changes and modifications on Watts products previously or subsequently sold. %vWArM 4 Capacity As compiled from documented Foundation for Cross -Connection Control and Hydraulic Research of the University of Southern California lab tests. 3/a" (20mm) kPa psi 110 83 55 28 0 5 10 15 20 25 0 19 38 57 76 95 5 7.5 10 15 1.5 2.3 11/3'0(32mm) 4.6 kPa r ' 138 103 69 35 JU n gpm 0 5 10 15 20 25 30 35 40 45 50 " 55 60 gpm 114 133 Ipm 0 19 38 57 76 95 114 133 152 171 190 209 228 Ipm 20 fps 5 7.5 10 15 20 fps 6.1 mps 11h" (40mm) kpa pci 138 103 69 35 0 10 20 30 40 50 60 70 80 90 100 gpm 0 10 20 30 40 50 60 70 80 90 100 gpm. 0 38 76 114 152 190 228 266 304 342 380 Ipm 5 7.5 10 15 20 fps 0 38 76 114 152 190 228 266 304 342 380 Ipm 1.5 2.3 3.0 4.6 6.1 mps 5 7.5 10 15 fps 2" (50mm) kPa psi 138 2 103 1 69 1 35 U Zb bu 0 luu 125 1bu 175 200 gpm 95 190 285 380 475 570 665 760 Ipm 5 7.5 10 15 fps 1.5 2.3 3.0 4.6 mps Suffix HC - Fire Hydrant Fittings dimension "A" = 233/4" (603mm) '909QT. 9090T -S Dimensions 3/4" 143/8 365 18'/6 459 83/4 222 4 102 43/4 121 63/4 171 103/s 25975/,6 103/8 186 37/8 98 14 6.4 15.6 7.1 1" 153/a' 391 195/8 498 81/a 222 4 102 43/4 121 7 178 11 279 75/s 186 37/8 98 15 6.8 17.5 7.9 11/4M1 181/2 470 237/6 595 115/8 295 51/2 140 61/2 165 71/2 191 123/6 310 103/8 264 51/4 133 40 18.1 42.8 19.4 1'/2"M1 19 483 243/6 619 115/8 295 51/2 140 61/2 165 71/2 191 125/8 321 103/8 264 5'A 133 40 18.1 44.0 20.0 TV 19/2 495 2515/6 659 115/8 295 5'/2 140 6'/2 165 73/4 197 1315/6 354 103/8 264 51/4 133 40 18.1 47.4 21.5 "U909QT Dimensions - with integral body unions (Prefix "U") 3/4"145/8 371 191/16 484 83/a 222 4 102 43/4 121 63/4 171 103/6 259 75/6 186 37/8 98 14 6.4 15.6 7.1 1" 155/8 397 2015/6 532 83/4 222 4 102 43/4 121 7 178 11 279 75/6 186 37A 98 15 6.8 17.5 7.9 *FAE909QT - Dimensions with flanged adapter ends (Prefix TAE") 1''A 19 483 24'h 622 115/8 295 51h 140 61/2 165 71/2 191 123/6 310 103/8 264 51/4 133 40 18.142.8 19.4 1'/2 193/4 502 26'/8 664 115/8 295 51/2 140 61/2 165 71/2 191 125/8 321 103/a 264 51/4 133 40 1 8. 1 44.0 20.0 2" 21 533 283/8 721 115/8 295 51h 140 61/2 165 73/4 197 13"/16 354 103/a 264 51/4 133 40 18.1 47.4 21.5 Subscript 'S' = strainer model Job Name Job Location Engineer Approval Series 9 Dual Check Valve with Intermediate Atmospheric Vent SIZ,nS: 1/,°A/Ig2 11 rrnnij, 34°AA2 (2nrnrU111"N Series 9D is specially made for smaller supply lines and ideally suited for laboratory equipment, processing tanks, sterilizers, dairy equipment and similar applications. It is particularly recom- mended for boiler feed lines to prevent backflow when supply pressure falls below system pressure. Series 9D is suitable for use on hot or cold water and can be used under continuous pressure. It features a primary check valve utilizing a rubber disc seating against a mating rubber part to ensure tight closing. A secondary check valve utilizes a rub- ber disc -to -metal seating. In the event of fouling of the down- stream check valve, leakage would be vented to atmosphere through the vent port thereby safeguarding the potable water system. Construction is brass body with stainless steel working parts, integral strainer and durable rubber discs. Female union inlet and outlet connections. Sizes 1/2" (15mm) and 3/4" (20mm). Drain is Y2" (15mm) thread connection. Features • True line -sized construction allows the check modules to open further allowing dirt and debris to pass more freely reducing check fouling • Stainless steel internal parts • Maximum flow at low pressure drop • Furnished with union connections to facilitate removal and replacement for maintenance • Compact for economy combined with performance • Design simplicity for easy maintenance • Can be installed vertically or horizontally Specifications For Backflow Preventers with Atmospheric vents A Dual Check Valve with Atmospheric Vent shall be installed at referenced cross -connections. Valve shall feature stainless steel and rubber internals protected by an integral strainer. Primary check shall be rubber to rubber seated, backed by the secondary check with rubber to metal seating. The device shall be ASSE approved under Std. 1012 and shall be a Watts Series 9D. Contractor Approval Contractor's P.O. No Representative Union Secon, check ES-9DM3/M2 9D -M2 May also be installed vertically mesh ;reen mary valve drain tions Brass body construction and stainless working parts throughout Available Models Suffix: S— for 1/2" (15mm) union end solder connections. SC — for satin chrome finish LU — less union IMPORTANT INQUIRE WITH GOVERNING AUTHORITIES FOR LOCAL INSTALLATION REQUIREMENTS Watts product specifications in U.S. customary units and metric are approximate and are provided for reference only. For precise measurements, V"NWAOM please contact Watts Technical Service. Watts reserves the right to change or modify product design, construction, specifications, or materials with- out prior notice and without incurring any obligation to make such changes and modifications on Watts products previously or subsequently sold. U) w J 5 cVIV- O W 0 U 0 LL 0 0 LL 0 0 0 The Model 24 and B24 are anti -siphon, vacuum breaker protected wall faucets designed for use in mild climate areas. The Model B24 is enclosed in a flush mounted wall box. Both models are designed to blend with modern architecture for installation on or in homes, service stations, churches, motels, drive- in restaurants, etc. The Model Y24 is designed to be used on a stand pipe in the lawn and garden, etc. SPECIFICATIONS: VACUUM BREAKER -ANTI-SIPHON: • NIDELO Model 34HF with % inch male hose thread • ASSE Standard 1011 approved • IAPMOO listed • Canadian Standards Association EPDM PACKING: Prevents leaking. PACKING NUT: Adjustable brass nut with deep stem guard. VALVE SEAT: Standard "O" size washer. HANDLES: Furnished with polycarbonate wheel handle and loose tee key. Optional: Metal wheel handle. INLETS: Model 24 as shown below. Model B24: 24P— 1/ or 24P % only. Model Y24: 3/ " FPT. MAX PRESSURE: 125 p.s.i. MAX TEMPERATURE: 120° F SHIPPING WEIGHT: (per unit) MODEL 24 & Y24: 1 Ib MODEL B24: 13 lbs (brass or chrome box) 6 lbs (aluminum box) ©2007 WOODFORD Mfg. IVIUUtL. bZ4 Exterior Finish: Standard - Chrome (CH) Optional- Rough Brass (BR) or Polished Brass (PB) Other Options: Anodized Aluminum Box (AL) 0 0 0 m X 0 n T G7 0 0 colo A" Rev. 2/07 Form No. 24.105 D m Cn Job Name Job Location Engineer Approval Series LF008PCQT Health Hazard, Anti -Siphon, Snill-Resistant Rack -flow PrPventer Sizes: 3/srr, 1/2", 3/4" and 1 " (10, 15, 20, 25mm) Series LF008PCQT is designed for indoor point -of -use applica- tions to prevent backsiphonage of contaminated water back into the potable water supply. Separation of the water supply from the air inlet is accomplished by means of a diaphragm seal. This feature protects against any spillage during start-up or operation. The LF008PCQT features Lead Free* construc- tion to comply with Lead Free* installation requirements. Features • Standardly supplied with internal polymer coating • Standardly supplied with Tee handles • Available less Tee handle with stem wrench flats. For use where space is limited • Available in left-handed or right-handed outlet • Patented design • Spill -resistant design for indoor use • Affordable design • Modular cartridge for ease of service • Vent uses an O-ring for reliable operation • Lead Free* Bronze body for durability • Compact space saving design • Satin chrome finish available • Available with strainer Installation The LF008PCOT is designed to be installed at the point -of - use. When factory installed deck/machine mounted on machines or equipment, the critical level of the LF008PCOT shall be not less than 1 " (25mm) above the flood rim. If field applied for general plumbing applications, the critical level of the LF008PCQT shall be a minimum of 6" (150mm) above the flood rim. Specifications A spill -resistant vacuum breaker (SVB) shall be installed, in accordance with the manufacturer's instructions, as noted on the plans. The valve shall consist of a one-piece modular check and float assembly made of engineered thermoplastic and housed in a Lead Free* bronze body. Springs shall be stainless steel. The Health Hazard, Anti -Siphon, Spill Resistant Backflow Preventer shall be constructed using Lead Free* materials. Lead Free* Health Hazard, Anti -Siphon, Spill Resistant Backflow Preventer shall comply with state codes and standards, where applicable, requiring reduced lead con- tent. The valve shall be constructed with a molded diaphragm separating the air inlet from the potable water supply to pre- vent spillage. The valve shall be a Watts Series LF008PCOT. Contractor Approval Contractor's P.O. No. Representative ES-LF008PCQT w _ t ■t©--■ LF008PCQT-L (Left Handed) a Patent # 5125429 p ® U v _ LF008PCOT 4 LF008PCQT (Right Handed) ----- Hood Screws Hood ------------ - (2 Required) Bonnet Vent --------- - -- - --- Spring �,_ --- Air Bleed Screw 0 -ring ----------- Bleed 0 -ring Vent -------------- (not shown) 0 -ring Body ---------= " Retainer ------------ Test Cock Check ------- Assembly O Shutoff Valve Assembly (2 Required) Size: 3/e", 1/2" (10,15mm) _ --- Hood Screw Hood ------------- Vent Bonnet -------- ---- ----- Spring - --- Air Bleed Screw 0 -ring ----------- Bleed 0 -ring Vent------ --- ', (not shown) 0 -ring Body ----------- W, Retainer ------ Check------- Assembly ®-------------- Test Cock Shutoff Valve Assembly Size: 3/a", 1" (20, 25mm) (2 Required) *The wetted surface of this product contacted by consumable water contains less than one quarter of one percent (0.25%) of lead by weight. Watts product specifications in U.S. customary units and metric are approximate and are provided for reference only. For precise measurements, VEWWANM please contact Watts Technical Service. Watts reserves the right to change or modify product design, construction, specifications, or materials with- out prior notice and without incurring any obligation to make such changes and modifications on Watts products previously or subsequently sold. E ES -N9 Job Name Contractor Job Location Approval Engineer Contractor's P.O. No. Approval Representative Series N9 Dual Check Vacuum Breakers for In -Line Applications Size 1/4" and 3/x11 (8 and 10mm) Series N9 Dual Check Vacuum Breakers for In -Line Applications are used for continuous pressure, non -health hazard, applications. These valves have NPT female inlet and outlet connection and brass body construction. Models N9C — same as N9 except comes with chrome body Pressure -Temperature Temperature Range: 33°F — 140°F (5°C — 60°C) Maximum Working Pressure: 125psi (8.6 bars) Applications Series N9 should be installed on each parlor sink where a hose is attached. This series is for use on continuous pressure applications. Parlor Sinks Open End, -4-only outlet on fixture Mixed Water Line N9 Drain Dimensions — Weights Capacity kPa psi 345 50 310 45 276 40 ---- ,241 35 p 207 30 172 25 N ' 138 20 a` 103 15 "10 35 5 0 0 0 1 2 0 3.8 7.6 3 4 5 6 7 gpm 11 15 19 23 271pm Flow Standards CSA 864.8 USA: 815 Chestnut St., No. Andover, MA 01845-6098; www.wattsreg.com • 9001WAEM@ Canada: 5435 North Service Rd., Burlington, ONT L7L 5H7; www.wattscda.com CERTIFIED REGULATOR Watts product specifications in U.S. customary units and metric are approximate and are provided for reference only. For precise measurements, please contact Watts Technical Service. Watts reserves the right to change or modify product design, construction, specifications, or materials without prior notice and without incurring any obligation to make such changes and modifications on Watts products previously or subsequently sold. ES -N9 0314 ©Watts Regulator Company, 2003 Printed in U.S.A. in. mm A in. mm B n. mm in. B1 mm 16s. kgs. N9C 1/4 6 23/8 60 1 Y4 K 1 25 .38 .17 N9C 3/a 10 23/B 60 V/4 32 1 25 .38 .17 N9 '/4 6 2% 60 1'/4 32 1 25 .38 .17 N9 3/8 10 23/8 60 1'/4 32 1 1 25 1 .38 .17 Capacity kPa psi 345 50 310 45 276 40 ---- ,241 35 p 207 30 172 25 N ' 138 20 a` 103 15 "10 35 5 0 0 0 1 2 0 3.8 7.6 3 4 5 6 7 gpm 11 15 19 23 271pm Flow Standards CSA 864.8 USA: 815 Chestnut St., No. Andover, MA 01845-6098; www.wattsreg.com • 9001WAEM@ Canada: 5435 North Service Rd., Burlington, ONT L7L 5H7; www.wattscda.com CERTIFIED REGULATOR Watts product specifications in U.S. customary units and metric are approximate and are provided for reference only. For precise measurements, please contact Watts Technical Service. Watts reserves the right to change or modify product design, construction, specifications, or materials without prior notice and without incurring any obligation to make such changes and modifications on Watts products previously or subsequently sold. ES -N9 0314 ©Watts Regulator Company, 2003 Printed in U.S.A. THE COMMONWEALTH OF MASSACHUSETTS TOWN OF NORTH ANDOVER Massachusetts Department of Public Health Division of Food and Drugs . FOOD ESTABUSHMENT INSPECTION REPORT Name .. / !�) rt �/ Date / r T of ,pKdoi /E5:PoodService ❑ Retail of outine ❑ Re -inspection Address .. ~� Risk Level ❑ Residential Kitchen , Previous Inspection Tefephorm ❑ Mobile ❑ Temporary Date: ❑ Pre..operation Owner Y'❑ NACCP YIN �, :Caterer ❑ Bed ,& Breakfast ❑Suspect Illness p General Complaint Person to Charge ( C) me n: ❑ HACCP Inspector Out- Permit No. ❑ Other Each vie n checked req ' sjpnexplanation on the narrative page(s) and a citation of specific provisionlsl violated. � WM: �oflglated Ig LqgagM 010M 109MG&DI.OW Rlah F (Red l ) Acm.chOMM Tobaow Violations marked may an imminent health hazard and no•OR14 some tFl Q y pose require Immediate corrective action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT [1 1. PIC Assigned / Kna MedgeabMe / Duties EM"YEE HEALTH [] 2. Reporting of DIseases by Food Employee and PIC [] 3. Personnel with Infections RestrictedExcluded FOOD FROM APPROVED SOURCE [] 4. Food and Water from Approved Source ® 5. ReWMn0Monditn ® 8. Tags/Records/Accuracy of Ingredient Statements 0 T. Conformance with Approved Procedures/HACCP Plans PROTlmCT10N FROM cmAMINATiou [] a. Separation/ Segregation! Protection Q 9. Food Contact Surfaces Cleaning and Sanitizing Q 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices ® 12. prevention of Contaminate from Hands Handarash PROTECT ION FROM CHEMICALS e -L, ®14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIMErr EMPE KAttJRIE cowrtOL,s ptutaft Hawtious.Foods) p 16. Cooking Tenures ❑ 17. Reheating ❑ Is. Cooling ❑ 19. tint and Cold Holding 0 20. Time As a Public Health Control W0XtEMENTS FORNaKY GUSCEP71ILE POi4"InOW pSM ❑ 21. Food and Food Preparation for HSP CONSUMERADVISORY ® 22. Posting of Consumer Advisories Violations Related to Good Retail Practices (Blue Number of Violelted Provisions Related Items) Critical (C) violations marked must be corrected To Foodborne illnesses l 'oras immediately or within 10 days as determined by the Board and Risk Factors (Red items 1-2.2): of Health. Non-critical (N) violations must be comec ted Official Order for Correction,: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000Ifederai Food Code. This report, when signed below 23 Management and Personnel (FC -2)(5W.003) by a Board of Health member or its agent constitutes an 25 Food and Food Protection (FC-3)(5aa.004) order of the Board of Health. Failure to correct violations Equipment and Utensils (FC-4)(590DM cited in this report may result in suspension or revocation of the food establishment permit and cessation of food ater, Plumbing and Waste {Fc s){sea.00s) 6- establishment operations. If aggrieved. bythis order, you 27. Physical Facility (FC-e)(seo.007)AC cave a right to a. hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.OM) and submitted to the Board of Health at the above address 29. Special Requirements (s -0m) within 10 days of receipt of this order. 30. 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Andover Hello Lorraine, 0 rrW 5'Dv -qU The food inspection at the Stop and Shop located at 757 Turnpike Street was done on 2/20/10 1 have attached the inspection report that the inspector reviewed and provided to management. I found a few words hard to read, so I hope this copy is legible for you. In addition, as it is a large store you may need to speak to the manager for clarification as to the exact location of the violations. The Health Department expects that your application for your renovation will include corrective action on these matters in addition to your cosmetic improvements. Please call me with any questions you may have. Thank you Susan Sawyer Health Director Please review the entire report, but for convenience you will find listed below some highlights that are structural or equipment related issues: Page 1 of 4 Drainage strip (I assume near the fryolator) in decay Old deli cases — replace broken kick plates Salad bar walk-in replace rusty hinges and coving Sushi area, needs a dedicated prep sink and hand sink�— Bakery oven does not work K.w1/\w't ** remove any equipment not working Bakery floor drains not properly functioning Page 2 of 4 Floor drains throughout facility not functioning properly ( I spoke with the plumbing inspector, he is aware of this same problem in another store and will work with your plumber on a solution. Have them call Jim Diozzi 978 688-9545 between the hours of 7:30 and 9:OOAM) Raw food area — needs a prep sink i 3 -bay area — needs a hand sink Hand sink needed before entrance into prep back line area BBQ hood,, OM' A 1 Replace various tiles Replace decayed board in sandwich prep refrigerator Stopdhor April 7, 2010 Health Dept. Town of North Andover 1600 Osgood Street, Bldg. 20 Suite 2-36 No. Andover, MA 01845 Attn: Ms. Michelle Grant Public Health Inspector Dear Ms. Grant: Attached please find a revised Fixture Plan, Drawing F-1, Revision 10 indicating additional prep and hand sinks and modifications to hand sink as requested. Any questions, please contact me on my cell phone (1-508-901-0723). Thank you. Regards, G� Lorraine Marsden Construction Project Manager Enclosures Stop6hov April 2, 2010 Health Dept. Town of North Andover 1600 Osgood Street, Bldg. 20 Suite 2-36 No. Andover, MA 01845 Attn: Ms. Michelle Grant Public Health Inspector Dear Ms. Grant: RECEIVED OR -6 20'0 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Attached please find a revised Fixture Plan, Drawing F-1, Revision 9 indicating additional prep and hand sinks and modifications to hand sink as requested. In addition, attached please find sink cut sheets. Any questions, please contact me on my cell phone (1-508-901-0723). Thank you. Regards, Lorraine Marsden Construction Project Manager Enclosures Mar 2910 02:36p Richard Piscitelli �._.� ; a - - 7- R G`�''— � LO /cL.l- - 9 () Se'er 508-559-0335 p.1 4 °, FAX LORRAINE MARSDEN 3�-�n'1 4�%/ 75AC cT., � ,