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City of Salem ; .
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wBoard of Health
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120 Washington Street,4th Floor K4x
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Temporary Food Permit YTT
DATE PRINTED: 08/01/2012
ESTABLISHMENT NAME Classy Chassis-Cart#1
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File Number BHF-2004-000100 Kevin Kafalas „
a - 5 Malm2Avenue
SALEM k _ MA= 0]970
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a s }µSALEM, MA-01970 q _
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Permit Type Permit No.' Permit Issued Permit Expires Fee Restrictions/Notes
TEMPORARY FOOD BHP-2012-0558 Aug 3,2012 Aug 4,2012'- $300.00�EVENT: Salem Maritime:Festival •,
LOCATION: In front of the
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PERMIT EXPIRES ugust 4,2012 E
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r ° CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET,4°i FLOOR
TEL. (978) 741-1800
KIMBERLEY DRISCOLL FAx(978) 745-0343
KwOR
Iramdin@salem.com
salem.com
LARRY R,%NIDIN,RS/RN.1-I,,,CIIO,cP-FS
HEAL I'I-I AGi:N'I'
CHECK PAYABLE TO THE CITY OF SALEM,NO CASH Fri
FEE: NON-PROFIT=$25 1-3 DAYS=$300 4-7 DAYS=$600 J
OVER 7 DAYS =>7 DIVIDED BY 7 x600=THE AMOUNT DUE (EXAMPLE: 14 DAYS DIVIDED BY 7=2x 600=$1200)
APPLICATION FOR ATEMPORARY FOOD SERVICE PERMIT
NAME OF EVENT ` I ( LOCATION LC`A Le� /r/�,104 �j-(N(�j
DATE(S)OF EVENT LA ^ 1v - q
NAME OF APPLICANT QLA C. `1 1 p \��_ n. s TELEPHONE#
ADDRESS cn on �"') \} ( \\ �Cn.I,� ✓Y, �� lT I /� ZO G
NAME OF BUSINESS ( ' I ASC �C IC���(1��['CM1.R✓1 TE•LEPHONTE# / �- 9(� QCT
ADDRESS nr, fY�
CERTIFIED FOOD MANAGER'S NAME: CERTIFICATION#: U Yl >,Gc
*A PLAN OF THE ESTABLISHMENT FOR THE EVENT MUST BE ATTACHED TO COMPLETE THIS APPLICATION*
FOR ESTABLISHEMNTS OUTSIDE OF SALEM,MA:
I
*A COPY OF THE CERTIFIED FOOD MANAGERS CEV#ICATE AND ESTABLISHMENT'S PERMIT MUST BE ATTACHED TO COMPLETE THIS APPLICATION.*
TYPE OF REFRIGERATION: _GAS ICEDRY ICE OTHER
METHOD FOR COOKING/HOT HOLDING: ��GAS _OTHER
✓
METHOD FOR SANITIZING: ^! ` 1 CHEM1CCAL OTHER
SOURCE OF FOOD: NAME: \ Ty r, ( ^!•-CT C1\ '. ADDRESS J\ , M. G,
FOODS TO BE SERVED INCLUDING INGREDIENTS AND METHOD OF PREPARATION:
�Q
I HAVE READ THE BOARD OF HEALTH,"REQUIREMENTS FOR TEMPORARY FOOD ESTABLISHMENTS."I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS REGARDING
THOSE REQUIREMENTS. I UNDERSTAND THEM,AGREE TO ABIDE BY THEM AND UNDERSTAND THAT FAILURE TO DO SO WILL RESULT IN REVOCATION OF MY
TEMPORARY FOOD ESTABLISHMENT PERMIT.
PURSUANT TO M C62C,S49A,I CERTIFY UNDER THE PENALTIES OF PERJURY THAT 1,TO MY BEST KNOWLEDGE AND BELIEF,HAVE FILED ALL STATE TAX
RETURNS AN PAID L STATE TAXES QUI ED D
UNDER LAW. to - (iA.(.
SIGNATURE DATE SOCIAL SECURITY OR FEDERAL ID#
---------- _____- __ ---------_-_-______-__�---------------___---__- ____---______--------------_ _
CI�LKP V yb DATE I� AMWNTPND:_
APPROVED BY: DATE:
TFRIDADDI 111_11 n,,I IDn ATPn RH9/11
Guidelines for Temporary Food Vendors
In order to ensure that safe and sanitary foods are served to the public, your temporary food permit is issued
based on the following conditions:
• Your Certified Food Manager certificate, temporary food and propane permits (if applicable) must be
conspicuously displayed on site.
• Only the foods stipulated on your temporary food permit may be sold.
• Foods must be obtained from an approved commercial source. Proof of source such as boxes, receipts etc. must be
on site.
• All potentially hazardous foods such as hot dogs, commercially pre-cooked sausages, hamburgers, prepared
vegetables, must be maintained either above 140°F or below 41°F.
• Only mechanical refrigeration or crushed / cubed ice is allowed as a cooling medium. Foods shall not come in
contact with water or undrained ice. Packaged foods may not be stored directly in ice if it is subject to the entry of
water.
• Cooking temperatures are as follows:
§ Commercially pre-cooked products -140°F
• All foods, drinks and condiments shall be handled and stored in a manner that prevents contamination such as using
clean covered containers, storing equipment and food up off the ground etc. Trash bags are not to be used for food
storage.
• Running water with liquid soap and disposable paper towels for hand washing must be available and set-up prior to
food preparation. Bottled water with a pull out spout is acceptable. Check with the Health Department for other
acceptable methods.
• All food handlers shall wash their hands after utilizing the toilet facilities, smoking, eating, changing tasks, and
changing gloves or when hands become contaminated. All wrist jewelry and adornments must be removed.
• Bare hands may not contact ready-to-eat foods. Suitable utensils shall be used such as deli tissue, spatulas, tongs,
single-use non-latex gloves etc. Bare-hand contact shall be minimized with foods that are not ready-to-eat.
• All equipment, utensils, containers etc. shall be in clean, sanitary condition. Where there are no warewashing
facilities obtainable, a spare set of work utensils shall be available.
• All carts must be thoroughly pre-cleaned before set-up at the event.
• People handling the food shall wear clean outer garments, hair restraints, and utilize good hygienic practices.
• Vendors licensed to sell scooped ice cream must store scoops individually in each tub of ice cream or provide
dipper well with running water
• Smoking is prohibited within 10 feet of a cart or food storage area. Employee must wash their hands thoroughly
with soap before returning to work.
• Garbage and refuse shall be disposed of in a satisfactory manner. The premises shall be kept clean.
• A stem type of thermometer that has been properly calibrated must be available for testing potentially hazardous
foods on site. The thermometer must be cleaned and sanitized before and after use in a manner approved by the
Health Department. Refrigerated units must have thermometers
• A labeled spray bottle of sanitizer prepared at proper concentration must be on site and used on all food contact
surfaces, utensils etc. Proper concentrations should be determined with pH papers. Concentrations are as follows:
§ Chlorine sanitizer: 50— 100 PPM § Quaternary sanitizer: 200 PPM
If any of these conditions are not set-up and maintained, your temporary food permit will be immediately
revoked and you will be ordered to stop serving food.
If you have any questions regarding the above conditions, call the Salem Board of Health at 978-741-1800 prior
to the event.
I have read understood and agre a' here to the above conditions.
Permit Hol Date `
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f ' CITY OF SALEM, MASSACHUSETTS
BOARD or HEALriki
120 WASHING'T'ON STREET,4' FLOOR
TEL.(978)741-1800
KIMBERLEY DRISCOLL FAX(978)745.0343 A
MAYOR hamdin(&aler11V0M
JUL
LARRY RAMDIN,RS/KERS,CRO,CP-['S
2 ti 'cu i
HEALTH AGENT CITY OF SALEM
BOARD OF HEALTH
APPLICATION FOR A MOBILE FOOD SERVICE PERMIT
Fe $ 10 payable to The City of Salem, No Cash
Name of Applicant�T►r�i� S Telephone# R _ %�IsB'(may
Address y rn ZI-'V rye, DID CA i,e40n,:� nn Cl
Certified Food Manager 3o Sie—RV-) Certtiificate# _ '�"jm 9-
Name of Business (',l{��,. N e.Y�c,��1 S S�vTelep onh e# �- Rig- C3c�el'11
Address
Manufacture Frozen Desserts? Yes No_
Type of Vehicle &) 4Registration#e
'! Location of O eratior y / f
Name & Address of Licenseffood Service Establishment Servi gas Base of
0 7077
Operation ULe�(' (' .� Telephone# - L
Location of Toilet & Hand washing Facilities On C'v.. Ti7wv
Menu &!Ajsagj w,-) b ,P i e, -9—bAe' I (g"es
Type of refrigeration: Ice Dry Ice G Other
Method for Cooking and/or Hot Holding: �Gas� Other
Method for Sanitizing: Chemical t/ Hot Water (170 F)
I have read and agree to abide by The Salem Board of Health Regulations regarding "Mobile Food Units &
Pushcarts" and will notify the Salem Board of Health of any changes in this application.
Pursuant to MGL C62C, S49A, 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.
�Z6 "gnature
Social Security#or Federal ID# Date
--------------- --------------
Revised: 5/23/11 Pemtit# Check#&Date
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EXAM FORM NO. 4624
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CERTIFICATE NO. 7800884
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ServSafeil' Certification
to JOSEPH CATINO
for successfully completing the standards set forth for the ServSafee Food Protection Manager Certification Examination,
which is accredited by the American National Standards Institute iAN59-Conference for Food Protection ICFP). t�
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5/4/2011
DATE OF EXAMINATION
5/4/2016
DATE OF EXPIRATION ,
heal lewaeppty.Check with your local tepulalmy agency tot moerufigtion mquimmaras
NATIONAL
RESTAURANT
ASSOCIATION® m
Paul Ninentart
/x955 Executive Director,National Restaurant Association Solutions 19
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Date of Expiration: 06/03/2016
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