HomeMy WebLinkAboutMiscellaneous - Exception (659))eMoulas/Market Bsk.Bakery
50`WinOrOP Ave. \(�
forth Andover, MAO 1.845
}F TOWN OF NORTH ANDOVER �
27 CHARLES STREET
NORTH ANDOVER, MA 01845
TELEPHONE# (978) 688-9540
a
FOOD SERVICE APPLICATION, ---
Name of Establishment: ///,
LocationOS2 Zzd/G � -- Telephone#:
Name of Firm: G�
Address of Firm: /�"4Ji elephone#: f S
Owner(s)/Operator(s):
Type of Business: Corporation Owner( )
Days and Hours of Operation :7-,9 -� 4 7
Type of Establishment: Food Service (Retail ( )
Mobile( ) Limited Retail ( ) Home Cook ( ) Catering ( )
Farm Stand ( )
Corporation Officers Telephone#
President:
Treasurer: JIaZLIMIU
Clerk: 'n -0)0//W ed
Please list licenses, permits, or registrations issued by
other municipal, state or federal agencies:
Seating Capacity: -�
Size of Establishment (Square Footage):'7k
Names and positions of employees trained and -certified in
choke saving technique and dates of certification as on
certificate (attach copies of certifications):
Names and positions of certified Food Handlers (attach
copies'of certifications):
Describe your insect/rodent control program, including the
name and address of exterminator and how many times a month
the establishment is serviced:
Type of Food Sold (check all that apply):
bulk food ( ) Consumed on Premise ( ) Salad Bar ( )
Shell Food ( ) Pre -Packaged ( ) take-out ( ) Baked Goods )
I, the undersigned, have obtained and reviewed Article X of
the State Sanitary Code.
Date:
e of Person Completing Form
A LATE FEE WAS IMPLEMENTED BY THE BOARD OF HEALTH THIS YEAR.
IF YOU DO NOT RENEW BY JANUARY IT THE FEE WILL DOUBLE.