44, 48, 50 Application to Operate Food Establishment BOARD OF EFALTE
DATE RECE34ED•
II- -S-0b
DATE ISSUED.
2.9-0b
PERMIT NO
FsE I )-
'EAR 2007 I
e61�1� Y�3k+ i�'P � +I��Tp�
NORTHAMPTON CHCKMYA 5
NORTFAMPTON MA 01060 LICENSE FEE; Variable 212MAM STREET
(413)687- 1214
CASH n
Date (/AR y/ 06
me of Establishment t Spot.E 77, R&s �i��wRtebur
siness Address .Tb m,HA7 ...lire /V/JR/Z.antg ion MA
.ding Address (If different)) 6? �0 . LJOx f /2; N�.Q nip n
me&Title of Applicant `/A�c Di0 G a ea 2A'
dress ofAppliea.nt tp?5 /lo li!!/C7S /f ac4 F/04ed c e , "n9- 0/06 ,2
me of Owner (If different)
;orporation or partnership, give name title &home address of officers or partners.
Name Title Home Address //
P/7%$4 �pa7 C/eRIG l of/and lee AJ #041 71,y), MA Nolo
,ME OF CERTIFIED FOOD MANAGER(If required): n, p�L eitwevS,2 A
TE: As of October 1,'2001, at least one Certified Food Manager is required for all Food Service Establishments which handle potentially
.ardous foods (PHFs). A COPY OF THE INDIVIDUAL'S CERTIFICATE MUST BE ON FILE AT THE BOARD OF HEALTH OFFICE. PLEASE
MIT THIS CERTIFICATE WITH THIS APPLICATION IF YOU HAVE NOT ALREADY SUBMITTED IT.
NO LICENSE CAN BE ISSUED WITHOUT A CERTIFIED FOOD MANAGER CERTIFICATE ON FILE.
Type of Establishment Fee Duration of Permit Amount to be Paid
Total Fee(s):
Retail Food
Food Service
Bar Service
Caterer
Mobile Food
Mobile Retail
Residential
U
Bed&Breakfast ❑
Annual
Seasonal
U
Temporary ❑
$ 0.00.00
NEW
Pag•2 must be
filled out
OCCUPANCY PERMIT SEATING CAPACITIES'.
ESTABLISHMENT SEATING CAPACITIES MUST
BE LISTED ON PAGE 2 OF THIS APPLICATION.
Water Source Sewage Disposal
e 'f 3030 607
Social Security or Federal ID#
Signature o
C/e2,r
di dal or Corporate Officer
4/ - 32 - 63 a 3
Telephone #
LEASE MAKE ALL CHECKS PAYABLE TO THE CITY OF NORTHAMPT01'
Page 1 of 2
OR BOARD OF HEALTH
DATE RECE1vr,D•I & -6-06
I DATE ISSUED:
112--6-e6-L-e12--6-e6
PERMIT
005
I YEAR 2007
fame of Establishment
usiness Address
Ca thug Address (If different)
'ame&Title of Applicant
NORTRAMRTON BOARD OF HEAT TE
212 MAIN STREET
NORTHAMYrON,MA 01060
(413)887-1214
Date
CASH 0
CHECK
ciable
LICENSE FEE:
1
`i
u . �t sad p✓m/4. HH4- • oia6 °
4413 '
ddress of Applicant
'ame of Owner (If different)
corporation or partnership, give name, title €3 home address of officers or partners.
Name Title Home Address
AME-OFCER-TIFIED-FOOD-MANAGER(If-required$-
OTE: As of October 1,'2001, at least one Certified Food Manager is required for all Food Service Establishments which handle potentially
izardous foods(PHFS). A COPY OF THE INDIVIDUAL'S CERTIFICATE MUST BE ON FILE AT THE BOARD OF HEALTH OFFICE. PLEASE
EMIT THIS CERTIFICATE WITH THISAPPLICATIONIFYOU HAVE-NOT-ALREADY SUBMITTED IT.
NO LICENSE CAN BE ISSUED WITHOUT A CERTIFIED FOOD MANAGER CERTIFICATE ON FILE.
Fee Duration of Permit - Amount to be Paid
Total Fee(s):
Type of Establishment
Retail Food
Food Service II
Bar Service ❑
Caterer ❑
Mobile Food ❑
Mobile Retail ❑
Bed&Breakfast ❑
Residential
Annual
Seasonal
Temporary ❑
$ 100.00
NEW
Page 2 must be
filled out
OCCUPANCY PERMIT SEATING CAPACITIES:
ESTABLISHMENT SEATING CAPACITIES MUST
BE LISTED ON PAGE 2 OF THIS APPLICATION.
Water Source
Sewage Disposal
002. - -6 -Sfi 09
Social Security orYederaI ID#
4-14 ; 5 co z °�
at or Corporate Officer Telephone #
LEASE MAKE ALL CHECKS PAYABLE TO THE CITY OF NORTHAMPTOPi Page 1 of 2
?LEASE MAKE ALL CHECKS PAYABLE TO 1'hJ;CITY OF i\ORTIL&M 'T011
F0= BO<,-.36 r-"`=
I2.- 8-o5
12- -rd CS
BR S Nn
FsE- 148
YEAR 2006
NOR7P-A1C6TON BOARD OF K W T TE
212 MAIN 6T1R3Er
NORTON,MA 01060
(413)557-1214
/J Date ��
Name of Es tablishments/Nrf f rle-1 sans /drJ-t �Nt<' �'3F, 77iyL/�/F14
Business Address /
cASw
CEECE
fflooSS Cgl„b.
LICENSE FEE: Variable
Mailing Address (If differ=nt)
Name &This of Applicant �,(�j%//! /e4lM -t-[%.f—��(/ �f/y.�A/1 1/1
Address of Applicant 377 �//I/6 sr a4 -e4
Name of Oder (If different)
If corporation or partnership, give name title&home address of officers or partners
Name Title Home Address
Ma JE1 re 1,5/ T>�i;
& me Al 44 di-46-
/,
NAME OF CERTIFIED FOOD MANAGER(If required):
NOTE: As of October 1, 2001, at least one Cerfined Food Manager is required for all Food Service Establishments which handle potentially
hazardous foods(PHFs). A COPY OF THE INDIVIDUAL'S CERTIFICATE MUST BE ON FILE AT THE BOARD OF HEALTH OFFICE. PLEASE
REMIT THIS CERTIFICATE WITH THIS APPLICATION IF YOU HAVE NOT ALREADY SUBMITTED R.
NO LICENSE CAN BE ISSUED WITHOUT A CERTIFIED FOOD MANAGER CERTIFICATE ON FILE.
Tyoe of Establishment Fee Duration of Permit
Retail Food ❑.
Food Service , III
Bar Service ❑ Annual .
Caterer
Mobile Food 0 Seasonal ❑
Mobile Retail ❑
Residential ❑ Temporary ❑
Bed&Breakfast ❑
Amount to be Paid
Total Fee(s):
$ 1 50 co
NEW
Page 2 must be
fin-out
OCCUPANCY PERMIT SEATING CAPACITIES_
ESTABLISHMENT SEATING CAPACITIES MUST
BE LISTED ON PAGE 2 OF THIS APPLICATION.
Water Source
Sewage Disposal
/L
Social Security o Federal fl#
Signature of
ual or Corporate Officer
'74 _s776 7/tc/
Te'ephon= °
P^2e 1 oft