14 NEW DERBY STREET - GARCON SUPERSLICE PIZZA PIE PARLOR (FORMERLY FLIP THE BIRD) - REMODEL PLAN REVIEW ����„EIVED
CITY OF SALEM, MASSAC S
r BOARD OF HEALTH SEP 0 5 2023
98 WASHINGTON STREET 3RD FLOOR
> Public Health
SALEM,MA 01970 CITY OF SALEM Prevent.Promote.Protect.
TEL. (978) 741-1800 BOARD OF HEALTH
ROBERT MCCARTHY health.,r_salem.com DAVID GREENBAUM,RS,CHO
ACTING MAYOR HEALTH AGENT
REMODELING PLAN REVIEW APPLICATION FOR CURRENTLY
LICENSED ESTABLISHMENTS
(Application must be submitted at least 30 days before construction begins)
REMODEL CONVERSION /NEW OWNER (NO FEE) Application fee: $90.00
Date
Category: Restaurant ✓ , Institution , Daycare , Retail Market , Other
Name of
Establishment: C'��4RGul'y� ��p6 �Ll Lb \ ' � F1 ,6 AN Q_L_b 1
Address: JT
Phone, email if available: ��1� Y�1�' �.�' 7C�(VW LVY"
Name of Owner: T e-M A VAN M ,U �,
Mailing Address: j6)7/ '1� � 2, '''` � 0 v
Telephone: I-$ r +,1101P I �
Applicant's Name: V,6-6w-A"lj "N � 5
Title (owner, manager, architect, etc.):
Mailing Address: ---
Telephone/email:___ _
I have submitted plans/applications to the following authorities on the following dates:
Plumbing____ -- Building Fire -_ _ Planning - Electrical
Conservation Engineering _-_ - _Licensing _ -- Historical Commission_
City Clerk Public Services _ _ Water Assessors
Hours of Operation: Sun (t,J I U Mon _`_ l 1 _ Tues �l p Wed _'!\f I b
Thurs 1 H tD FRI (M I' Sat l� 0C)
Number of Seats: _ _ 0 Number of Staff: , 7s (Maximum per shift)
Maximum Meals to be served: (approximate number): Breakfast Lunch 10 6 Dinner `�0-0Type of Se+ ce: (check all that apply): Sit Down Meals V _ _ Other _ _4% Take Out
Caterer V Mobile Vendor
Project Start date: _ _ _ Completion date:
Please enclose the following documents:
Application Fee $90.00 (Check or Money Order made out to "City of Salem" )
Proposed Menu (including seasonal, off-site and banquet menus)
Manufacturer Specification sheets for each piece of equipment shown on the plan
Site plan showing location of business in building; location of building on site including alleys, streets;
and location of any outside equipment (dumpsters, well, septic system - if applicable)
Plan drawn to scale of food establishment showing location of equipment, plumbing, electrical services
and mechanical ventilation (color coded)
Equipment schedule
FOR OFFICIAL USE ONLY
DATE RECEIVED: FEE AMOUNT:$
RECEIVED BY:
APPROVED BY. DATE APPROVED-