HomeMy WebLinkAboutJimmy's Pub & Restaurant - 12/31/2020FOR BOARD OF HEALTH USE ONLY
Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
9 2019
Establishment Name ��OtiU�S
Establishment Address j4kW0-%-tP4$3 T'
Establishment Mailing Address (if different)
Establishment Telephone No j[ _ 3Zj • �i ss
Applicant Name & Title:n-
A r�S
Applicant Address o23 ��-t�tcF�wl � 1. h'�
Applicant Telephone No.: 'j0b 3VN ' 6 444 24 Hour Emergency No.: 9-Y3 4S"I •SS"'7S
Applicant Email Co i>4W'CGS is) 3 e, C>HO4 cic"
Owner Name & Title (If different from applicant)
Owner Address
Owner telephone number
Owner email:
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
;A An Association
partner.
A Corporation
Name Title Address
D An Individual
DG? SOS Z�S
OkL ief
Id A Partnership
D Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:JfIV�
Address:
Telephone No: 5'Ir�' 24 Hour Emergency No:
FAX:
E-mail:
Alt E -Mail:
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
E-mail:
Food Establishment Information
WATER SOURCE:
SEWAGE DISPOSAL:
No. of Food Employees:
DEP Public Water Supply No: (If applicable)
DAYS/HOURS:
Name of Person(s) In Charge Certified in Food Protection Management:
E�iltivc�
Name of Person(s) In Charge Certified in Allergen Awareness Training
V=02
inspecting the for evidence of iZX%
Name of pest control company routinely premises pests
If there is seating for 25 pestle or more, a person trained in manual choke saving procedures will be onsite at all times
food is being prepared. KYes
Does this establishment require a FOG permit? If yes, please attach the FOG permit application.
of Permit:
Establishment Type:
�Lenngth
R Nnnual
Retail Food $125.00 [U Mobile Food Consession
n Temporary
F=3 Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00 Manufacture Frozen Desserts/Ice Cream
Temporary Start Date:
��od Service up to 101 -200 $250.00 $25.00lfreezer
Temporary End Date:
❑-3 Food Service up to 201 + $300.00 ❑7 Pushcart $50.00 # of Pushcarts:
Temporary Time:
Supermarkets $400 Residential Kitchen $100.00
Rain Date:
Milk &Cream $10.00 ❑Q Caterer $35,00
Food Operations: Definitions:PHF - Potentially hazardous food (fimeRempendure controls required)
(Check all that apply): Non-PHFs- non -potentially hazardous/ood(no time/temperature controls required)
RTE - ready400-eat foods (Ex. sandwiches, salads, muffins which need no /udherpracessing)
Q Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held
Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service
Cold Holding For Single Meal Service ] PHF and RTE Foods Prepared For Highly
Q Delivery of Packaged PHFs Susceptible Population Facility
Sale of Raw Animal Foods Intended
Reheating of Commercially to be Prepared by Consumer Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand
0 Customer Self -Service of Non PHF and Non- 0 Customer Self -Service contact alternative, time as a public health
Perishable Foods Only Ice Manufactured and Packaged for control)
J Preparation of Nan-PHFs Retail Sale ED Offers Raw Or Undercooked Food Of
Q Juice Manufactured and Packaged for Animal Origin
Other Food Operations Retail Sale
Vacuum Packaging !Cook Chill
0 Offers RTE PHF in Bulk Quantities 0 Prepares Food/Single Meals for
Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service
or Reconditioned Food
I, the undersigned, attest to the accuracy of th information provided in this application and affirm that the food
establishment operation will comp 5 MR 590.000 and all other applicable law. I have been instructed by the
board of health on how to obtain .es 41 CMR 590.000 and the federal Food Code.
Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have fled all slate tax returns
and paid state taxes required under law. %^\ i
Social Security Number or Federal ID:
Signature of Individual or Corporate Name:
TAX CERTIFICATION FORM
I certify under the penalties of perjury that I, to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
under law.
4k_�_
S' dividual or Corporate Name By: Corporate Officer (Mandatonj, if Applicable)
**Social Security No. (Voluntanj) or Federal
Identification Number
*This license will not be issued unless this certification clause is signed
by the applicant.
** Your social security number will be furnished to the Massachusetts
Department of Revenue to determine whether you have met tax filing or
tax payment obligations. Licensees who fail to correct their non -filing or
delinquency will be subject to license suspension or revocation. This
request is made under the authority of Massachusetts General Law
Chapter 62C, section 49A.
C:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
Town of Mansfield Health Department
APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT
RESTAURANT& FOOD PREPARATION ESTABLISHMENTS
Business/ Food Establishment
Address: N l W HINZ "KT m"y.' e4— puw,,) 6WAt'
Mailing Address: SSC
Phone/Fax Number:
Email: G f7Wtv'C % GOAg I • ct-W-N
Contact Person/Title for Grease Traps: 6111@a"11-
Name
7' 11@a 11
S-17,67—
Email:
1t,6Z
Name of Company scheduled to pump internal grease trap(s) monthly: A BIZ COANO( ZIc-S
Name of Company scheduled to pump external grease trap quarterly:
Please attach the following documents to this application:
• Most recent waste hauler receipt or waste hauler manifest
• Appropriate permit fee based on new fee schedule (Checks can be made out to the Town of
Mansfield)
Food Establishments
Fee
3 grease interceptors/traps or less and/or 1 yellow grease collection
$50
container
Each grease interceptor/trap over 3
$50 ($200 max)
I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND
GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018.
In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit
and ackno e a he information submitted in these documents is true, accurate and complete.
Signed Date
Print Name 6GOIMA DWON t ®5
Grease Trans and Grease Removal
Internal Grease Traps
How many indoor Grease Removal Units (GRU/trap) are on site?
External Grease Traps
Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)?
Yes t/ No Size gallons
Where is the existing outdoor GRU located?
If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of
the property owner below: �1
Property Owners Name: a"t
Property Owner's Address: ' ql -W 94A;r16V
Property Owners Telephone Number: 51-i3' U SI - i sly
Yellow Grease Waste
Do you store yellow grease waste from fryolators? e��T
Where is the grease storage unit located? &y—tStDi
How often is this grease storage unit er
Please list the vendor who removes the
Please list fixtures attached to each grease trap
Grease Trap 1
4 -
Grease Trap 2
Grease
Grease Trap 3
Grease Trap 4
Grease Trap S
External Grease Traps
Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)?
Yes t/ No Size gallons
Where is the existing outdoor GRU located?
If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of
the property owner below: �1
Property Owners Name: a"t
Property Owner's Address: ' ql -W 94A;r16V
Property Owners Telephone Number: 51-i3' U SI - i sly
Yellow Grease Waste
Do you store yellow grease waste from fryolators? e��T
Where is the grease storage unit located? &y—tStDi
How often is this grease storage unit er
Please list the vendor who removes the
Facility Operational Information
Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise
specified, please print or type. /`
Seating Capacity (per Fire Department Regulation): I 0
Seating Capacity (Actual Count):
Normal Hours of Food Preparation/Service:
Monday Tuesday Wednesday
Thursday Friday
Sunday
Saturday
APP
Ntow 7/w 50V'V 10•'30 To //"Gl p _%
Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease
Removal Units (GRU/trap)
Number in
establishment
Attached to
GRU
compartment sink
Handwashing sink
Commercial Dishwasher
Bar sink
Mop Sink
0
Garbage Disposal
Ice Making Machines
7,
Fryolators
Grills or Ovens
Exhaust Hoods
�.
Floor drains
Other:
How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company):
Is dinnerware pre -rinsed before being washed? ✓ Yes No
If yes, at what station/sink? &W "fom
R
The Commonwealth of Massachusetts
Department oflndustrialAceidents
Office of Investigations
a 600 Washington Street
o Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:71#4mgS Put)
Address:
City/State/Zip:
t% Phone #: j cIS7 , S 95 -
Are you an employer? Check the appropriate box: Business Type (required):
1.1 I am a employer with _*?d employees (full and/ 5. E] Retail
or part-time).* 6. eoitestaurantBar/Eating Establishment
2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp, insurance required] 8• ❑ Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, § 1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]**
4. ❑ We are a non-profit organization, staffed by volunteers, 11.Q Health Care
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
**If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should check box #1.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company
Insurer's Address: O'S MAIN 67
City/State/Zip: A)O ZFk'gfA% /-94 S s
Policy # or Self -ins. Lic. # y j y oao ro a 4 z 1 i s' Expiration Date: < < L t)
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 c tify er re pains and penalties ofperjury that the information provided above is trite and correct.
Sivnature• Date: F
Ofjicial use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone #:
wwv .mass.gov/dia
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and phone number along with a certificate of insurance.
Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members
or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that
must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this
affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
Fomt Revised 5-26-05
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
TeL # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
To; 15033395982 Fromt 15082387281 Date: 10/17/19 Tilne% 1155 PM Page: C1/01
�y°e1 eDATE:MhVDDNYYYt
CERTIFICATE OF LIABILITY INSURANCE
__ 333 3333
THIS CERTIPICATE IS ISSUED AS A MA1•TER.OF INFORMATION ONLY AND CONFER I NO ROHt-5 UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND ORAL TER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: It the certificate holder Is an ADDITIONAL INSURED, the poilcy(leS) mumu: t have ADDITIONAL INSURED provisions of be of be endorsed.
It SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, Cerra' T policies may r riuhe an endorsement. A statement on
this mititicate does not confer rights to the certificate holder In lieu of such endorser ent(s).
PRODUCER Tow
NAME:Conno
PHONE1 FAX
85 Main
ytreurance Agency, Inc. y, ExiF• >O6•?.36_6776 _ __ Ax:. Not: 36.08-2336-7261_
83 Main Street - � —' - --
North Easton, MA 02356 ADDREss.,
INSURERJS) AKpOnDING COVERAGIir-.__.�,_ NAIC k
INSURE.R A t ove Risk Services LLC
Jimmy's Pub R{SU uH!C:
Mr. George P INSURERER D
141 N. Main Sheet
Mansfield, MA 020413 INSURER E:_L '—
_ INSURER.:
r.OVERAPFS CERTIFICATE N U MRFR: •��� REVISION NUMRER•
THIS
LS TO CERTIFY THA" FIFE POLICIES OF
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THEEAPIN %TION DATE THEREOF, NOACE WILL BEOELIVERED IN
LISTED BELOW HAVE BEEN{ ISSUFO
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DESCRIpTiON OF OPERATIOH5 / LOGATtONS rVEhIICLE6 (ACORD 101, Addlaon4l Pimmns Schcpule, may Ue eae h�tl if ma• apa:r is rvgvbaCi
CERTIFICATE HOLDER CIANCEI I. A rUIN
u 1960.20111 ACORD CORPORATION. All rights reserved.
A --ORD 26 (2016/03) - The ACORD name and logo are registered narks of ACORD
SHOULD A 1Y OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THEEAPIN %TION DATE THEREOF, NOACE WILL BEOELIVERED IN
Town of Mansfield
ACCOROA ICE WITH THE POLICY PROVISIONS.
6 Park Row
AUTHORVEDI EPRESENTATIVE
Mansfield, MA 02048
u 1960.20111 ACORD CORPORATION. All rights reserved.
A --ORD 26 (2016/03) - The ACORD name and logo are registered narks of ACORD
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WPC PEST AND TERMITE CONTROL
P.O. BOX 876
WESTBORO, MA 01581
Phone: 508-366-1820 508-879-1441
INVOICE / SERVICE REPORT
INVOICE # 65815 DATE: Tuesday, November 05, 2019 BILLING ACCT #: 11234 ROUTE: 2
BILL TO. SERVICE FOR:
PANTOS GEORGE JIMMY'S PUB
23 FREEDOM TRAIL 141 NORTH MAIN ST
NORFOLK MASS 02056 MANSFIELD MASS 02048
PHONE: 508-451-5575 PHONE: 508-451-5575
MATERIALS USED/EPA # Z — cA-`',„/
Phantom - 241-392 1.5oz. per 1 gal. water = 25% gal used���� t �'1Le f��
Termidor SC 7969-210/.8 Oz/1 gal water = .06% gal use
Tempo 1% Dust 432-1373_ oz. used / y�" � �� �,
Gentrol IGR 2724-351 (1"- oz. used /
CB -80 Extra -9444-175/1 can = 20 oz.= 4 --oz. useds X2/�7/b�
Advion roach bait 100-1484 30gr. per tube. gr. used Gt�
Talstar 279-3206 1 oz per 1 gal. water = 0.06% s)�gal used j
B1ueMax Mini Blocks 7173-288 - used in Tamper Proof Bait Station
Termidor HE 7969-329/.8oz./lgal water = .06% gal used GLI/ y
suspend 432-763/.75oz/galwater= .03% gal. used Y
LAST MATERIAL USED: �a144 ) y e /lt-
SERVICE DETAIL L �/ (f� j fvY
INTERIOR EXTERIOR
I. Cr ck & Crevice II. s of Treatment _Perimeter �o�� CIP
Kitchen Baseboards _underneath
Bathroom _Cupboards _one foot up and outl .40-� (J1
other _Closets from foundation
Basement _Garage
EQUIPMENT USED: --A&G sprayer -,LAeresol Can
_Dust Bulb _Balt Gun _other
LAST SERVICE: 10/29/2019 ROACH FOLLOW UP
COMMENT: 06/10/19 PREVIOUS BALANCE -$170.00
TERMS: CASH/CHECK/CREDIT C ROACH FOLLOW UP $0.00
AGREEMENT: 1 YEAR WARRANTY
CUSTOMER TYPE: COMMERCIAL
REFERENCE: CALL IN
THIS INVOICE TOTAL SCHEDULED AMOUNT $0.00
TOTAL DUE (INCLUDES PREVIOUS BALANCE) -$170.00
ADDED SERVICE
ADDED AMOUNT
<< TOTAL AMOUNT DUE
�� 104-
4-
OTE: �Lc AMOUNT PAID
SC
Please allow at least 5-6 weeks for materials to be ec ve on all treatments. if after that time
there is still activity, please call the office ediat THANK YOU MUCH FOR YOUR BUSINESS!
SERVICEMAN SIGNATURE/LICE SE# IGNATURE
WPC PEST AND TERMITE CONTROL
P.O. BOX 876
WESTBORO, MA 01581
Phone: 508-366-1820 508-879-1441
INVOICE / SERVICE REPORT
INVOICE # 65738 DATE: Tuesday, October 29, 2019 BILLING ACCT #: 11234 ROUTE: 2
BILL TO SERVICE FOR:
1 PANTOS GEORGE JIMMY'S PUB
23 FREEDOM TRAIL 141 NORTH MAIN ST
NORFOLK MASS 02056 MANSFIELD MASS 02048
PHONE: 508-451-55175 PHONE: 508-451-5575
MATERIALS USED/EPA #C-ejij l ala'Y e—fC4 c.4e-I
Phantom - 241-392 1.5oz. per 1 9a water = 25% gal used
Termidor Sc 7969-210/.8 oz/1 gal water = .06% gal used •�pa'w�
Tempo 1% oust 432-1373_ oz. used
Gentrol IGR 2724-351 oz. used
CB -80 Extra -9444-175/1 can = 20 oz.= oz. used Lwll�
Advion roach bait 100-1484 30gr. per tube. gr. used(/b
Talstar 279-3206 1 oz per 1 gal. water = 0.06% gal used
ll
B1ueMax Mini Blocks 7173-288 - used in Tamper Proof Bait 5tatio s /
Termidor HE 7969-329/.8oz./1gal water = .06% gal used s Qlf
Suspend 432-763/.75oz/gal. water= .03% gal. used ��_�/ t
LAST MATERIAL USED: 4d.2i eAi rEetrr�ej% &qi k w / o _/tlp/ / 4) oo�K rq
SERVICE DETAIL /Z ya p�//I1�S'UUyy�/ �'7
INTERIOR EXTERIOR ✓Y"'
I. crack & Crevice II. Spot Treatment _Perimeter
_Kitchen _Baseboards _underneath
Bathroom Cupboards _one foot up and out ��Zt4s
other _Closets from foundation
_Basement _Garage/`GAJ
EQUIPMENT USED: _B&G Sprayer _—Aeresol Can
_Dust Bulb _Bait Gun _other
to IrO
LAST SERVICE: 10/25/2019 PAYMENT t
COMMENT: 06/10/19 PREVIOUS BALANCE -$170.00
TERMS: CASH/CHECK/CREDIT C ROACH FOLLOW UP $0.00
AGREEMENT: 1 YEAR WARRANTY
CUSTOMER TYPE: COMMERCIAL
REFERENCE: CALL IN
/j/ THIS INVOICE TOTAL SCHEDULED AMOUNT $0.00
TOTAL DUE (INCLUDES PREVIOUS BALANCES -$170.00
ADDED SERVICE
ADDED AMOUNT
11 5 l 71L AMOUNT DUE
� /y @G ` NT PAID
SCHED NOTE:
Please allow at least 5-6 weeks for materials = ' be of i on all treatments. if after that time
there is still activity, please call the offi'c' A a ate . THAN ,OU MUCH FOR YOUR BUSINESS!
SERVICLRAN SIGNATURE/LICENSE# GNATURE
I/
M
WPC PESTAND TIERNARTE CONTROL
P.O. BOX 876
WESTBORO, MA 01581
Phone: 508-366-1820 508-879-1441
INVOICE/ SERVICE REPORT
INVOICE # 65629 DATE: Tuesday, October 22, 2019 BILLING ACCT #: 11234 ROUTE: 2
BILL TO: SERVICE FOR:
PANTOS GEORGE JIMMY'S PUB
23 FREEDOM TRAIL 141 NORTH MAIN ST
NORFOLK MASS 02056 MANSFIELD MASS 02048
PHONE: 508-451-5575 PHONE: 508-451-5575
MATERIALS USED/EPA #U,f
t
Termidor SC479692210/ 8 oz/1 galawatert=r.06%25%ggaluused %)1%% J�N�C2it/i6�s
Tempo 1% Dust 432-1373_ oz. used
CB-80Gentrol 2724-351 0,'4 oz. used
CB -80 a'�r `�1 LUP✓/�E� ��
Extra
-9444-175/1 can = 20 oz.= oz. used
Advion roach bait 100-1484 30gr. per tube. gr, used '1GlG
Talstar 279-3206 1 oz per 1 gal. water = 0.06% gal usedp
B1ueMax Mini Blocks 7173-288 - used in Tamper Proof Bait oh t
r•'
Termidor HE 7969-329/.8oz./igal water = .06% gal used �Xr✓C
Suspend 432-763/.75oz/gal. water= .03% gal. used �� / I
LAST MATERIAL USED 'JA- /,��• �IL/`l—S Z lhdi = �(' v !!
SERVICE DETAIL
INTERIOR EXTERIOR
I. l
C & crevice II. Sp t Treatment _Perimeter
Kitchen Baseboards _Underneath
Bathroom cupboards _one foot up and out
_other closets from foundation
_KBasement_Garage
EQUIPMENT USED: _Z2�8&G Sprayer _j�_Aeresol can
_Dust Bulb _Bait Gun _other
LAST SERVICE: 10/14/2019 PAYMENT
COMMENT: 06/10/19 PREVIOUS BALANCE -$85.00
TERMS: CASH/CHECK/CREDIT C FOLLOW UP $0.00
AGREEMENT: 1 YEAR WARRANTY
CUSTOMER TYPE: COMMERCIAL
REFERENCE: CALL IN
THIS INVOICE TOTAL SCHEDULED AMOUNT $0.00
TOTAL DUE (INCLUDES PREVIOUS BALANCE) -$85.00
ADDED SERVICE
ADDED AMOUNT
TOTAL AMOUNT DUE
AMOUNT PAID
SCHED NOTE: (%Il
Please allow at least 5-6 weeks for materials to be effective on all treatments. If after that time
there is still activity, please call the office ilatq4. THANK YOU MUCH FOR YOUR BUSINESS!
SERVICEMAN STGNATURE/LiceNSE# SIGNATURE
A, NlYrERMITE CONTROL
�-- P.O. BOX 876
WESTBORO, MA 01581
Phone: 508-366-1820 508-879-1441
INVOICE / SERVICE REPORT
INVOICE # 65324 DATE: Tuesday, October 01, 2019 BILLING ACCT #: 11234 ROUTE: 2
BILL TO: SERVICE FOR:
PANTOS GEORGE JIMMY'S PUB
23 FREEDOM TRAIL 140 NORTH MAIN ST
NORFOLK MASS 02056 MANSFIELD MASS 02048
PHONE: 508-451-5575 PHONE: 508-451-5575
MATERIALS USED/EPA #
Phantom - 241-392 1.5oz. per 1 al. water = 25% gal used 1 `"� ac
Termidor sC 7969-210/.8 Oz/1 gal water = .06% gal used Tempo 1% Dust 432-1373- oz. used
41
Gentrol IGR 2724-351 _0,_-j!C-oz. used
CB -80 Extra -9444-175/1 can = 20 oz.= __4L__OZ. used
Advion roach bait 100-1484 30gr. per tube. gr. used
Talstar 279-3206 1 oz per 1 gal. water = 0.06% gal used
B1ueMax Mini Blocks 7173-288 - used in Tamper Proof Bait Stationscw Jkl&. 0-
Termidor HE 7969-329/.Boz./lgal water = .06% gal used �((.
suspend 432-763/.75oz/gal. water= .03% gal. used _o
LAST MATERIAL USED: n� 4 µAL b¢ Q'(J /& 8r?,r (/Qe
SERVICE DETAIL Q
INTERIOR EXTERIOR �J
I. Crack & Crevice II. !rt Treatment _Perimeter !
VKitchen Baseboards _Underneath > U��)a
A Bathroom Cupboards _one foot up and out
tOther Closets from foundation
Basement _Garage C,V-Q1
QUIPMENT USED: <B&G Sprayer _.�dAeresol Can
Dust Bulb _Bait Gun _Other Ak) t 0-0i AArv'-
-,4, 6%.e""
LAST SERVICE: 9/24/2019 ROACH FOLLOW UP
COMMENT: 06/10/19 PREVIOUS BALANCE<$18.'00
0.0
TERMS: CASH/CHECK/CREDIT C MONTHLY TREATMENT
AGREEMENT: 1 YEAR WARRANTY
CUSTOMER TYPE: COMMERCIAL
REFERENCE: RESCHEDULE
THIS INVOICE TOTAL SCHEDULED AMOUNT $85.00
Il(1Fp'ArAv/ 1`/16'U_ TOTAL DUE (INCLUDES PREVIOUS BALANCE) $85.00
/` ADDED SERVICE
/O` 1 C(/4 ADDED AMOUNT
TOTAL AMOUNT DUE
AMOUNT PAID
SCHED NOTE:
Please allow at least 5-6 weeks for materials to be effective on all treatments. If after that time
there is still activity, please call the office 'WME,6iatfly. THANK YOU MUCH FOR YOUR BUSINESS!
SERVICSTAN SIGNATURE/LICE SE# CU 0 R SIGNATURE
PEST AND TERMUE CONTROL
P.O. BOX 876
- WESTBORO, MA 01581
,.
Phone: 508-366-1820 508-879-1441
INVOICE / SERVICE REPORT
INVOICE # 65206 DATE: Tuesday, September 24, 201 G.BILLING ACCT #: 11234 ROUTE: 2
BILL TO: SERVICE FOR:
PANTOS GEORGE JIMMY'S PUB
23 FREEDOM TRAIL 141 NORTH MAIN ST
NORFOLK MASS 02056 MANSFIELD MASS 02048
PHONE: 508-451-5575 PHONE: 508-451-5575
MATERIALS USED/EPA # FANi
Phantom - 241-392 1.5oz. per 1 al. water = .25% gal used
Termidor SC 7969-210/.8 oz/1 gal water = .06% gal used7V (jf7cty2
Tempo 1% Dust 432-1373_ oz. used J
Gentrol IGR 2724-351 oz. used
CB -80 Extra -9444-175/1 can = 20 oz.= oz. used -
Advion roach bait 100-1484 30gr. per tube. gr. used
Talstar 279-3206 1 oz per 1 gal. water = 0.06% gal used /-
B1ueMax Mini Blocks 7173-288 - used in Tamper Proof Bait Stat' ns/� ,(�C-e<�
Termidor HE 7969-329/.8oz./lgal water = .06% gal used ;�
suspend 432-763/.75oz/gal. water= .03% gal. used 7-�i�_Q) q ,
LAST MATERIAL USED: _ ( (641q05 --_ y a
SERVICE DETAIL
INTERIOR EXTERIOR
I. crack & crevice II. Spot Treatment _Perimeter
!LKitchen _Baseboards _underneath
Bathroom _cupboards _One foot up and out
mother _closets from foundation
_Basement _Garage
EQ IPMENT USED: _B&G Sprayer --Aeresol Can
Dust Bulb _Bait Gun _other
LAST SERVICE: 9/18/2019 PAYMENT
COMMENT: 06/10/19 PREVIOUS BALANCE $0.00
TERMS: CASH/CHECK/CREDIT C ROACH RECALL $0.00
AGREEMENT: 1 YEAR WARRANTY
CUSTOMER TYPE: COMMERCIAL
REFERENCE: CALL IN
THIS INVOICE TOTAL SCHEDULED AMOUNT $0.00
TOTAL DUE (INCLUDES PREVIOUS BALANCE) $0.00
11641L��� ADDED SERVICE
/ ADDED AMOUNT
TOTAL AMOUNT DUE
AMOUNT PAID
5CHED NOTE:
Please allow at least 5-6 weeks for materials to be a ctive on all treatments. if after that time
there is still activity, please call the office imm lat ly. THANK YOU MUCH FOR YOUR BUSINESS!
SERIIGNALICENSE# GNATURE
G
'L
' WPC E S'11
5 VT '1TM
CONTROL
P.O. BOX 876
WESTBORO, MA 01581
Phone: 508-366-1820 508-879-1441
INVOICE / SERVICE REPORT
INVOICE # 65119 DATE: Tuesday, September 17, 201&BILLING ACCT #: 11234 ROUTE: 2
BILL TO: SERVICE FOR:
PANTOS GEORGE JIMMY'S PUB
23 FREEDOM TRAIL 141 NORTH MAIN ST
NORFOLK MASS 02056 MANSFIELD MASS 02048
PHONE: 508-451-5575 PHONE: 508-451-5575
MATERIALS USED/EPA #Tl: jecl A
Phantom - 241-392 1.5oz. per 1 gal. water = 25% gal used
Termidor SC 7969-210/.8 OZ/1 gal water = .06% gal used
Tempo 1% Dust 432-1373 m,k oz. used Lim
Gentrol IGR 2724-351 - oz. used
CB -80 Extra -9444-175/1 can = 20 oz.= oz used �/u ,'
Advion roach bait 100-1484 30gr. per tube._ gr. used
Talstar 279-3206 1 oz per 1 gal. water = 0.06% gal used �( 7r W ly
B1ueMax Mini Blocks 7173-288 - used in Tamper Proof Bait Stations //l((ll��e�,
Termidor HE7969-329/.Boz./lgal water = .06% gal used
Suspend 432-763/.75oz/gal. water= .03% gal. used
LAST MATERIAL USED: AlIg CG
SERVICE DETAIL
INTERIOR EXTERIOR
I. crack & crevice II. !pot Treatment _Perimeter
Kitchen Baseboards _underneath
Bathroom (cupboards _one foot up and out
q,other .Closets from foundation
_Basement _Garage
EQUIPMENT USED: _B&G Sprayer --Aeresol Can
Dust Bulb ,Bait Gun _Other
LAST SERVICE: 9/6/2019 MONTHLY TREATMENT
COMMENT: 06/10/19 PREVIOUS BALANCE 85.00
TERMS: CASH/CHECK/CREDIT C ROACH FOLLOW UP $0.00
AGREEMENT: 1 YEAR WARRANTY
CUSTOMER TYPE: COMMERCIAL
REFERENCE: CALL IN
THIS INVOICE TOTAL SCHEDULED AMOUNT $0.00
��� Z �'TOTAL DUE (INCLUDES PREVIOUS BALANCE) $85.00
GIJ ADDED SERVICE
u) UOADDED AMOUNT
TOTAL AMOUNT DUE
qAMOUNT PAID
SCHED NOTE:
Please allow at least 5-6 weeks for materials to be effective on all treatments. If after that time
there is still activity, please call the office immediately. THANK YOU MUCH FOR YOUR BUSINESS!
SERVI MAN SIGNATURE/LI ENSE# ST ER IGNATURE
Im
ell's _ -- TERMITE _ I
P.O. BOX 876
WESTBORO, MA 01581
Phone: 508-366-1820 508-879-1441
INVOICE I SERVICE REPORT
INVOICE # 64871 DATE: Friday, August 30, 2019 BILLING ACCT #: 11234 ROUTE: 2
BILL TO: SERVICE FOR:
PANTOS GEORGE JIMMY'S PUB
23 FREEDOM TRAIL 14//440 -NORTH MAIN ST
NORFOLK MASS 02056 MANSFIELD MASS 02048
PHONE: 508-451-5575 PHONE: 508-451-5575
MATERIALS USED/EPA # I—�y�V��iEIj�S(/i�`L7
Phantom - 241-392 1.�'y
Soz. per 1 al. water = .25% gal used f �.ry
Termi dor Sc 7969-210/.8 OZ/1 gal water = .06% gal used �w` `i
Tempo 1% Dust 432-1373' oz. used ��n
Gentrol IGR 2724-351 Citi oz. used -00
CB -80 Extra -9444-175/1 can = 20 oz.= hoz. used
Advion roach bait 100-1484 30gr. per tube.gr, used �1�
Talstar 279-3206 1 oz per 1 gal, water = 0.06s gal used / / _A PJ
B1ueMax Mini Blocks 7173-288 - used in Tamper Proof Bait Stationy,tLe
Termidor HE 7969-329/.8oz./1gal water = .06% gal used /�
suspend 432-763/.75oz/gal. water= .03% dj5' gal. used pc` c/� ✓TO��vl( I
LAST MATERIAL USED:
SERVICE DETAIL
INTERIOR EXTERIOR
I. Cr ck & crevice II. Spot Treatment _Perimeter
-K-Kitchen if
_Underneath
Bathroom _Cupboards _One foot up and out V�761�
other _closets from foundation
Basement _Garage
EQUIPMENT USED: _B&G Sprayer Aeresol Can
_Y_-DUSt Bulb _Bait Gun _Other
LAST SERVICE: 8/19/2019 MONTHLY TREATMENT
COMMENT: 06/10/19 PREVIOUS BALANCE $85.00
TERMS: CASH/CHECK/CREDIT C ROACH RECALL $0.00
AGREEMENT: 1 YEAR WARRANTY
CUSTOMER TYPE: COMMERCIAL
REFERENCE: CALL IN
THIS INVOICE TOTAL SCHEDULED AMOUNT $0.00
TOTAL DUE (INCLUDES PREVIOUS BALANCE) $85.00
ADDED SERVICE
ADDED AMOUNT
TOTAL AMOUNT DUE
AMOUNT PAID
SCHED NOTE:
Please allow at least 5-6 weeks for materials to be effective o all treatments. If after that time
there is Still activity, please Call the Offi ediately. TH K YOU MUCH FOR YOUR BUSINESS!
SERVICEMAN SIGNATURE/L CENSE# SIGNATURE
Xt
Baker Commoditles Inc
1348 Mllledca Ave
Pis Billerica, MA M62
Phone: (D78)464-8811 ext M PAX: (97$) 404-044€
Acct;q OJ3 -S /}
J ," M019 s
�y1 lt� 114a
10'(m f' ,�,.I d Av� n aye
Bate l/3a I �-iiakak�i:
Time In ..e _.._ Time Out
Special Instructions: I Last Service
/U(J z icjc.a7')dn d GOh(,;4l (in
G301 -VI S4' z _ - Er,
RETAIN I R ORDER FOR YOUR RECORDS ttt INVOICE WILL BE MAILED
No. of Trapa Trap Sixes D
Locations
Iv
Qallt ns� Removed
All Grease Pumped from Grease Traps
will be Disposed of in ars
kinvironmengaily Safe Procedure at,.
Baker Crarram adides Inc
334Rear Billerica Ave
At Wyedca, KA 01862
Cornment3 -OpeAs 11"3o
0 Trash and/or Garbage in Trap
Overflowing
Blockage
More Frequent Service Recommended
0 Recommend Inlet / Outlet Repair .
0 Recommend Baffle Repair
EJ Recommend `Trap rlgiiation
0 Recommend Line Jetting or Cabling
Gustorner
Drivers Skinature
-:a:1.-9-.11
1 m -ry°s Pub & Hemurant
141 M Mn 5t
lit ms'i'leld, MA 02048
i•10. 01'I`ra;us, iTrap .Sires:
(i)ca iom 411'1) 2 bat s ii(
(o
1
SpFcial instructions: 1-.3�-t Sarvice; 1/310Ptt
1 Inside I rap - fi ondAy 5122,00 - Cori act George S08-41 S L-5575
(SICK! SERVICE LOU) Onsite 8:00-9:30
*": BILL ILL BE f >lAIL ID
GaHons Remand10
U .:_ — _�— � �7 7rislt aliCi/bf 6e9tSz7gt tr ria}>
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anhiILSY
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IYeenmrnpnnl iril€tr Quihot `stepair
i"..� I:,nUiy.}rter5!1 �.�f�1r ki<3 rt �P
. ill/ ewr.,osgr t'terr)KdAwn Gwwa 7rr�r,s
will £ir, 01"posed of in so L1
i .`.'nvirt3fam�+b2zlly Sr3,fe f!r�cedtEe�ar:
1pc
L_I
.slpi€:li 2it(It'pka, SEs 0226LI
f
ti°lcpmmcn[J -! ra , Aei-anion
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t_..1!_Gut�Y Slg iarUr'C
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Ohic
_�/ds�z/�
%(4iJdBaker
_
4� g
334Rear BillericaAver A4
1 onh Mak, a MA 01062
Time 1w
4req:
I I.-iie+t,.
31 Days LEOW
Phone: (9 78) 454,2811 Fan (978) 454.0-1-18
,.�
-:a:1.-9-.11
1 m -ry°s Pub & Hemurant
141 M Mn 5t
lit ms'i'leld, MA 02048
i•10. 01'I`ra;us, iTrap .Sires:
(i)ca iom 411'1) 2 bat s ii(
(o
1
SpFcial instructions: 1-.3�-t Sarvice; 1/310Ptt
1 Inside I rap - fi ondAy 5122,00 - Cori act George S08-41 S L-5575
(SICK! SERVICE LOU) Onsite 8:00-9:30
*": BILL ILL BE f >lAIL ID
GaHons Remand10
U .:_ — _�— � �7 7rislt aliCi/bf 6e9tSz7gt tr ria}>
Fan-
Pow
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......
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. ill/ ewr.,osgr t'terr)KdAwn Gwwa 7rr�r,s
will £ir, 01"posed of in so L1
i .`.'nvirt3fam�+b2zlly Sr3,fe f!r�cedtEe�ar:
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Baker Commodities
Billerica134 Rear
North Billerka,
Phone; (978) 454-9911 Fax: d -1 r1
ITMZP M
141 N. Main St
Mansfield, MA 02M
1 !Wrap sizes:
.) 2 bay sink
67
Ticketfl.- 12097
NNA
if
M1
1 Inside Trap - Monthly $125.00 - Contact George 505-451-5575
(SIGN SERVICE LOG) Onsite 5:30 - Cali Ahead
/Ulu v,6 f Wd Y•`3O
4 d%
Gallons ifernoved
i
Comments
S
® Trash and/or Garbage In Trap
OvertloyAng
Blockage
® More Frequent 5erdift Recomrmendcoi
Recommend IrRet / Outlet Repair
Recommend saw Repair
® Recommend Trap Agitation
F] Recommend UneJettingorCabling
Customer Signature
Driver Signature ✓L1,�2t (i�2> j
Baker ..
�h134North Billerlea, MA 01862
Rear Billerica Avenue
r ,.
&A
ny's Pub & Restaurant
N. Main St
isfield. MA 02048
of Traps: I 1 ITrap Sizes:
»tion: (tpl) 2 bay sink
Gallons Removed
16
Date:
6/VS/2019
ITIcket it: 12102379
Time In:
Time Out:
Freq:
31 Days
I DOW: Wednesday,
I Inside Trap - Monthly $12S.00 - Contact George 549-4Si-5575
(SIGN SERVICE LOG) Onsite 0 - Call Ahead - Mon or
Tuesday Only *NOTE SURFACE & SLUDGE % ON PAPERWORK*
q:10 -io:. -So 60s:j ,
I WJ Yq—e—
��lil�iCl1
All Grease Pumped from Grease Traps
will be Disposed of to an
Environmentally Sade Procedure eat:
Baker Commodities Inc
134 Rear Billerica Ave
North Billerica, ARA 02862
Comments
S
® Trash and/or Garbage In Trap
® overflowing
® Blockage
® More Frequent Semite Recommended
® Recommend Inlet /.Outlet Repair
® Recommend Baffle Repair
® Recommend Trap Agitation
® Recommend Line lettingorCabling
J
CustomerSlgnature
Driver Signature Yl4'a'^'I�'�
Baker Commodities Inc
1'.-14 Rear Billerica Avenue
North Bikrkj, MA 0-1862
Phone; (978) 4154-9211 Fay: (979) 454-0448
firnaw's Pub & Resiaurant
14! IN, Main S�
hiia--itsfield. MA 02048
[}it7f /7013 Ticket It: 12104237
e.
Time In: Time OuU
7----' —
I req, 33 1 Days y,
Special Instructions: Last Service: (1/10/201
1 Inside Trap - Monthlyt2s.00 - contact. Geovge 508-451-5,571S.
(SIGN SERVICE LOG) Onsita 9:30 -10:30 Call Ahead - Mon or
TUesday Only "NOTE SURFACE 8, SLUDGE % ON PAPERWORje*
RETAIN THIS WORK ORDER FOR YOUR RECORDS -"':
of Traps: I rt #'rap sizes: 10
Ilion: (tpl) 2 bay 'it-,
C,flbil' Itek-riaved
All urease Putupedfewn Greage 'naps
will he 01spaged of in an
stqfa Prac�dura at:
thekr Commoditif- lffc
'f:'--'%' 'm"' gea r a Werim --," Vc
Wilh Billerfev, fWA 01867
BILL IYUPIL L BE P% fil A I LE D
I
S
0 lvndi and/car Garbage 1r, Trop
LJ ovCrfle%uh)8
rj Blockage
W10fe Feeqkje
El
HuruffunUrld Ifilet I Quitri
0 P.oconinwnd Baffle Repniv
0 RocommeAnd'-fuap Agiiwictn
F -,i Ratornfr1pnd Une IeWng 01
01storrter slgll;W
Driver Signature
Baker Commodities Inc
134 Rear Billerica Avenue
North Billerica, MA 01862
Phone: (978) 454-8811 Fax: (978)454-0448
Jimmy's Pub & Restaurant
141 N. Main St
Mansfield, MA 02048
S
Date: 11/ /2019
Ticket 8: 12111979
Time In: --
Time Out:
Freq: 31 Days
DOW: Wednesday,
Instructions:
Inside Trap - Monthly $125.00 - Contact George 50R -4S1-5575
IGN SERVICE LOG) Onsite 9:30 -10:30 Gall Ahead - Mon or
resday Only *NOTESURFACEL1DziZ'ON PAPERWORK*
No. of Traps:
1
Trap Sizes:
1 10
Location:
(tpl) 2 bay sink
Gallons Removed
All Grease Pumpedfrom direase Traps
will he Disposed of in an
Env;ronmantally Safe Pnwedura at.
Baker Commodities Inc
134 Wear alllerim Ave
North Biiterlraa, FWA 08862
Comments
S
® Yrash and/or Garbage In Trap
® overflowing
® Blockage
® More reequent Service Recommended
® Recommend Inlet J outlet Repair
® Recommend Baffle Repair
Recommend Trap Agitation
❑ Recommend line Jetting or Cabling
Customer Signature
DriverSignature
Baker Commodities Inc
114 Rear Billerica Avenue
North Billerica, MA 01862
Phone: (978) 454-8811 Fax: (978) 454-0448
Jimmy's Pub & Restaurant
141 N. Maln St
Pv niria$ield. MA vtEl"m8
Fate: 1%/2019 Ticket 4' x12109832
Time In: Time Out:
Freeq: 31 Lays DOW: Wednesday,
Special Instructions: Last Service: 9/10/201
t Inside Trap - Monthly $125.00 - Contact George 508-451-5575
(SIGN SERVICE LOG) Onsite 9:30 -10:30 Call Ahead - Mon or
Tuesday Only W NUT E Si F:fACe & SLUDGE 51 iliv PAPERWORK'
5e 6h4'
RETAIN THIS WORK ORDER FOR YOUR RECORDS Y** BILL WILL BE MAILED
Pio. of Traps:
Location;
Gallons Removed
I ITrap Sizes:
2 bay
i 1c4e /fit 'e )o
All Grease Pumped from Grease Traps
will he Disposed of in an
Environmentally Safe Procedure at.,
Bakke Com modifies inc
134 Rear Billerica Ave
North 8111arica, IVIA 01862
Comments
s
Trash ah for Garbage In Trap
overflowing
17A Blockage
F1 more Frequent serviw flveommended
E) Recommend Inlet I Outlet Repair
® Recommend aaeffle Repair
® Recommend TrapP%itation
El R@co m5end Llne !etling or Crshilrng
Customer Signature
4-
DrKier Slgnatine-1164 /'?
CIE "
Baku Inc Vale In: My
r eMewa AMM
1,34 Rea �7o—w
f,40(th
MA (11962 ea q
54-o449
4,2811 Fax: (97814
Phone: J97S) 45 L,)pt
Instn'tetio"w
A
Ins L)SM0 Call Aheld i�A'I)il
M - 6N SERVIC'E U -)C;)) Onsite 9:30 10:3€3 y FT (sl
W Main SrSURFACE E5 51 UDGE -5A ON PAPURWORK'
ue�,daV Only "FJO1 E
IMA 07042
ORDER OIL* "Up
Gln. of TR
Wabl)n:
2 bz3Y
I Al -,j
All CrdLtS, puklijed fr0n, oreflso
win he aposed of in an
"�(gfa "Vacedure at,
9M WWW"S M4
Mai IM,- iolj�'
M,ah enyrign, MA 01062
ismoM
f-wedloWirlp,
Move %Quont ger"m
RIMMAO'd (3"L Rnpall
g,,,qoq1 Pop ANIM-
AlliIl!',
rusulmu TWIM"
DINO jvuun-(
% A Dig
Baker Commodities Inc.
134 Rear Billerica Ave.
N. Billerica Ma. 01862
(978)-454-8811 Fax (978)-654-7788
GREASE TRAP CONTROL LOG
BUSINESS NAME:
DATE
GALLONS
TECH SIGNATURE
COMMENTS
�3u 1 11
1u
�u L- ��� 2�
Good