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°o DI City of Salem, Massachusetts
Board of Health
a 120 Washington Street, 4th Floor, Salem, MA 01970
Tel. (978)741-1800 fax. (978) 745-0343 Pt>tb1lCHealth
health@salem.com !Prevent..Promote.Protect.
Kimberley Driscoll Larry Ramdin, MPH, REHS, CHO
Mayor Health Agent
FOOD ESTABLISHMENT PERMIT
r
(must be posted on the Premises of the Food Establishment)
2017
Permit Number: FM-16-691
Permit Type: Food Establishment< 25 seats
Goods &Services: Residential Kitchen: B&B
Name of License Holder: Coach House Inn- Patricia Kessler
Name of Food Establishment Coach House Inn
Address of Food Establishment 284 Lafayette Street Salem MA 01970
Restrictions: Bed & Breakfast
This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on
12/31/2017 unless sooner suspended or revoked.
Permit Fee: $0.00
Effective: 12/29/2016
Larry Ramdin, MPH, REHS, CHO
Health Agent
CITY OF SALEM, '
MASSACHUSETTS
BOARD OIHLALT - •,"•` �"" """`�.
' H
120 WASHINGTON SIY EE r,411'FLOOR
KIMBERLEY DRISCOLL TEL.(978)741-1800 FAX(978)745-0343 LARRY RAMDIN,RS/RENS,CHO,CP-FS
MAYOR healtb@salem.com
HEALTH AG ENT
Food Establishment Permit Application
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name: C US Lf/ fD q va
2) Establishment Address: 7'7'j- Sy-
3) Establishment Mailing Address(if different):—
4) Establishment Telephone No: J'7y - p Z
5) Applicant Name&Title: T2,C��} SCS OWN'EI!-
6) Applicant Address: 2—,?Il )iAAyCM,Sr
77 %� �fly/y�igKESSLFrL Q
7) Applicant Telephone No: V,09A4HourEmergencyNo: 7,?-30-3606 Email:
8) Owner Name&Title(if different from applicant):
9) Owner Address(if different from applicant): --
10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of
officers or partner.
An association Name Title Home Address
A corporation
An individual
A partnership
Other legal entity
12 Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor,Manager,etc.
Name&Title: G
Address: �936v-i—�
Telephone No: Fax: Email: S47n£,4f oe�a
Emergency Telephone No: q7d 3,U-' `o`
13) District or Regional Supervisor(if applicable)
Name&Title:
Address:
Telephone No: Fax: Email:
Check#: �/d Date: Amount: SAV,00
Food Establishment Information
14) Water Source: 15) Sewage Disposal:
DEP Public Water Supply No: ( if applicable)
16) Days and Hours of Operation: 17) No. of Food Employees:
18) Name of Person in Charge Certified in Food Protection Management:
Required as of 101112001 in accordance with 105 CMR 590.003(A)
19) Person Trained in Anti-Choking Procedures(if 25 seats or more): ❑ Yes No
20) Location: 22) Establishment Type(check all that apply)
(check one) O Retail( Sq. Ft) 0 Caterer
Permanent Structure 0 Food Service-( Seats) 0 Frozen Dessert Manufacturer
Mobile 0 Food Service-Takeout O Residential Kitchen for Retail Sale
0 Food Service-Institution FiResidential Kitchen for Bed and
Meals/Da Breakfast Home
0 Food Delivery �y Ipy OrResidential Kitchen for Bed and
21) Length Of Permit: .............................................. ....... .Breakfast .....................
(check one) RETAIL STORE g 9A RESTAURANT
Annual 0 Less than 1000sq.ft. $70 0 Less than 25 seats $140
Seasonal/Dates: 0 1000-10,OOOsq.ft. $280 0 Residential Kitchens $140
0 More than 10,000sq.ft. $420 0 25.99 seats $280
0 More than 99 seats $420
Temporary/Datesmme:
Bed 8 Breakfast/Childcare Seryices/Nursing Home $100
ADDITIONAL PERMITS
0 MAKE ICE CREAM,YOGURTISOFT SERVE $25
0 PASTURIZATION $25
❑ALL NON-PROFIT` $25
*Including, church kitchens, state funded childcare&private club
23) Food Operations: Definitions: PHF-potentially hazardous food(time/temperature controls required)
Non-PHFs-non-potentially hazardous food(no timeltemperature controls required)
(check all that apply): RTE-rea to-eat foods Ex.sandwiches,salads,muffins which need no further processing
Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held
Pre-packaged Non-PHFs for More Than a Single Meal Service
Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly
Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility
Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill
Prepared by Consumer
Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance
Processed Foods for and/or HACCP Plan(including bare hand
Service Within 4 hours contact alternative,time as public health
control.
Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of
Non-PHF and Non- Retail Sale Animal Origin
Perishable Foods Only
Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered
Retail Sale Events or Institutional Food Service
Offers RTE PHF in Bulk Quantities
To be completed by the Board of Health
Retail Sale of Salvage,Out of Date
or Reconditioned Food Total Permit Fee:
Payment is due with application
I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will
comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR
590.000 and the Federal Food Code.
��J
24) 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 filed all state tax returns and paid state taxes required under law.
25) Social Security Number o(Feder . o7 - 2ig 7 16
26) Signature of Individual or Corporate Name:��
A
QUESTIONAIRE - GREASE TRAPS 2013
1. NAME OF ESTABLISHMENT:
2. ADDRESS OF ESTABLISHMENT:
3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP?
4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT HAVE?
CAPACITY IN GALLONS
5. HOW IS THE GREASE TRAP MAINTAINED? ON A DAILY BASIS? BY AN IN-HOUSE PERSON OR
BY AN OUTSIDE CLEANING SERVICE?
6. WHAT IS THE FREQUENCY THAT THE GREASE IS REMOVED FROM THE TRAP?
7. WHAT IS THE NAME OF THE FIRM WHO REMOVES AND/OR PICKS UP THE GREASE FROM
YOUR ESTABLISHMENT?
8. WHAT IS THE DATE OF YOUR LAST INVOICE FROM THE REMOVAL FIRM?
" WORKERS COMPENSATION AND EMPLOYERS' LIABILTY
INSURANCE POLICY ----INFORMATION PAGE
INSURER: POLICY NO: WE157372A
NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY
222 AMES STREET RENEWAL
DEDHAM, MA 02026 NCCI Company No: 21059
Account No:
FEIN: 04-2692161
i
ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS:
PATRICIA KESSLER DSA COACH HOUSE INN NUMBER ONE INS AGCY, INC
284 LAFAYETTE STREET C/O SOUCY INSURANCE
SALEM MA 01970 AGENCY INC.
PO 4467, 85 LAFAYETTE
STREET
SALEM, MA 01970
AGENT NO.: 20001SOU
LEGAL ENTITY: INDIVIDUAL
OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classification Schedule)
ITEM 2. POLICY PERIOD: From: 04/29/2016 To: 04/29/2017
Effective 12:01 A.M. Standard Time at the Insured's mailing address.
ITEM 3. COVERAGE:
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the
states listed here:
MA
B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits
of liability under Part Two are:
Bodily Injury by Accident: $ 100, 000 each accident
Bodily Injury by Disease: $ 500, 000 policy limit
Bodily Injury by Disease: $ 100, 000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
SEE ENDORSEMENT WC 20 03 06 B
D. This Policy includes these Endorsements and Schedules:
See Schedule of Forms and Endorsements.
ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and
Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to
verification and change by audit.
Total Estimated
Minimum Premium: $ 234 Annual Premium: $ 508
Audit Period: ANNUAL Additional / Return Premium:
Comments :
Issued At:
i Date: 03/21/2016 Countersigned by
WC 00 00 01 A Copyright 1987 National Council on Compensation Insurance
INSURED COPY
''1 The Commonwealth of Massachusetts
Department oflndustrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston,MA 02114-2017
www.massgov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information // Please Print Legibly
Business/Organization Name: (f 6 A-C f{ )V vu 5 F. j,'A1 l
Address: 2- t-`: ST,
City/State/Zip: 1;'1,- Phone#: 7f`�7V 'y0 _,_
Are you an employer? Check the appropriate box: Business Type(required):
1.1J f am�er with employees(full and 5. ❑Retail
or 'art-time 6. ❑Restaurant/Bar/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]* 1LE]Health Care
4.❑ We are a non-profit organization,staffed by volunteers, /7 q p
with no employees. [No workers'comp. insurance req.] 2O
12. ther Olj 9 />�£gAs7-
'My applicant that checks box#1 must also Edi 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'copmpensadon insurance for my employees. Below is the policy information.
Insurance Company Name: ��_>�gr'/9t.��+7" p .U,Lu<r.( .tJ.J/,•+.a— ' �
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic.# Z- Expiration Date: 1
Attach a copy of the workers'coniPeusatio-policydeclaration page(showing the policy number and expiration
ration 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 cern ,under the pains an�d/penalties ofperjury that the information provided above is true and correct.
Siana Date:
Phone#: Z
Oficial 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#:
www.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 budding 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,MGI,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 licensers 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 permidicense 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:
The Commonwealth of Massachusetts
Department of industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
TeL #617-727-4900 ext 406 or 1-877-NIASSAFE
Fax#617-727-7749
www,mass.gov/dia
Form Revised 7(2010
SALEM FIRE DEPARTMENT
°0 a 48 LAFAYETTE ST
e� SALEM, MA 01970
ai (978) 744-1235
tRF,ll°
June 3, 2015
The Coach House Inn
284 Lafayette ST
Salem, MA 01970
Congratulations, an inspection of your facility on Jun 3, 2015 revealed no
violations.
Inspection Note No sprinkler system
01367 (Lt.)Peter Schaeublin Patricia kessler
Inspector
e dCCNDiT��� City of Salem, Massachusetts
. -q °�. lu
Board of Health
a 120 Washington Street, 4th Floor, Salem, MA 01970
Tel. (978) 741-1800 Fax. (978) 745-0343 PubliCHealth
Iramdin@Salem.Com Prevent. Promote. Protect.
Kimberley Driscoll Larry Ramdin RS/REHS, CHO, CP-FS
Mayor Health Agent
FOOD ESTABLISHMENT PERMIT
(must be posted on the Premises of the Food Establishment)
2015
Permit Number: FM-15-219
Permit Type: Food Establishment< 25 seats
Goods&Services: Residential Kitchen: B&B
Name of License Holder: Coach House Inn- Patricia Kessler
Name of Food Establishment Coach House Inn
Address of Food Establishment 284 Lafayette Street Salem MA 01970
Restrictions: Bed & Breakfast
This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on
12/31/2015 unless sooner suspended or revoked.
Permit Fee: $100.00
Issued: 1/1/2015
r�g�
• CITY OF SALEM,
MASSACHUSETTS PublicHealth
BOARD of HEALTH >....,...am....,...,.
120.WASHINGTON S'iimmt',4TH Fr.00R
KIMBERLEY DRISCOLL Tim.(978)741-1800 F,�x(978)745-0343 LARRY RAbMIN,RS/R1--IIS,CIIO,CP-FS
MAYOR - ImrndinQsalem.com H1 Al.;n-I AGENT
Food Establishment Permit Application
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name:
2) Establishment Address: 2' � / � E- T
3) Establishment Mailing Address(if different):
?�j
4) Establishment Telephone No:
s) Applicant Name&Title: jG%ff r ElSL G Ur1V-£f-
6) Applicant Address:
7) Applicant Telephone No: �)AS&e4l4r24 Hour Emergency No:/ 06
8) Owner Name&Title(if different from applicant): ---
_ J'
g) Owner Address(if different from applicant):
10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of
officers or partner.
An association Name Title Home Address
A corporation
indiv-
A-partnership
Other legal entity
12 Person Directly Res onsible For Daily Operations Owner, Person in Charge,Supervisor,Manager,etc.
Name&Title:
Address:
Telephone No: Fax: Email:
Emergency Telephone No:
13) District or Regional Supervisor(if applicable)
Name&Title:
Address:
Telephone No: Fax: Email:
Check#:_ Date: Amount: �C� ��
7
Food Establishment Information
14) Water Source: 15) Sewage Disposal:
DEP.Public Water Supply No: (if applicable)
16) Days and Hours of Operation: 17) No.of Food Employees:
18) Name of Person in Charge Certified in Food Protection Management:
Required as of 101112001 in accordance with 105 CMR 590.003(A)
19) Person Trained in Anti-Choking Procedures(if 25 seats or more): ❑ Yes No.
20) Location: 22) Establishment Type(check all that apply)
(check one) ❑ Retail( Sq. Ft) ❑Caterer
Permanent Structure ❑ Food Service—( Seats) ❑ Frozen Dessert Manufacturer
Mobile ❑ Food Service—Takeout ❑ Residential Kitchen for Retail Sale
❑ Food Service—Institution ❑ Residential Kitchen for Bed and
( MealslDay) Breakfast Home
❑ Food Delivery ❑Residential Kitchen for Bed and
21) Length Of Permit: URABreakfast Establishments
RETAIL STORE ---RESTANT...••••--------------
(check one) E3 Less than 1000sq.ft. $70 13 Less than 25 seats $140
Annual 131000.10,000sq.ft. $280 ❑ Residential Kitchens $140
Seasonal/Dates: ❑More than 10,OOOsq.ft. $420 ❑25-99 seats $280
❑More than 99 seats $420
Temporary/DatesMme: . -------------- -------- --- ------ -- --- ---- ------...---------------------------------------------
Rr Bed&Breakfast/Childcare Services/Nursing Home $100
-------------- ....................................------------_------------------ _--------------- ------ ---__---
ADDITIONAL PERMITS
❑MAKE ICE CREAM,YOGURT/SOFT SERVE $25
❑ PASTURIZATION $25
❑ALL NON-PROFIT' $25
'Including, church kitchens, state funded childcare&private club
23) Food Operations: Definitions: PHF-potentially hazardous food(time/temperature controls required)
Non-PHFs-non-potentially hazardous food(no timeRemperature controls required)
(check all that apply): RTE-read -to-est foods Ex.sandwiches,salads,muffins which need no further processing
Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held
Pre-packaged Non-PHFs for More Than a Single Meal Service
Sale of Commercially Preparation of PHFs For Hot And. PHF and RTE Foods Prepared For Highly
Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility
Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill
Prepared by Consumer
Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance
Processed Foods for and/or HACCP Plan(including bare hand
Service Within 4 hours contact alternative,time as public health
control.
Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of
Non-PHF and Non- Retail Sale Animal Origin
Perishable Foods Only
Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered
Retail Sale Events or Institutional,Food Service
Offers RTE PHF in Bulk Quantities
To be completed by the Board of Health
Retail Sale of Salvage,Out of Date
or Reconditioned Food Total Permit Fee:
Payment is due with application
I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will
comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR
590.000 and the Federal Food Code.-,.--> _
24) 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 filed all state tax returns and paid state taxes required under law.
25) Social Security Number r Federal ID �2 fo
26) Signature of Individual or Corporate
Commonwealth oi"Massachusetts
f : City of Salem
Board of Health I tnberley Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 12/1812008
ESTABLISHMENT NAME: Coach House Inn
File Number:BHF-2004.000103 284 Lafayette Street
Salem MA 01970
LOCATED AT: 0284 LAFAYETTE STREET
SALEM,MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions I Notes
FOOD SERVICE BHP-2009-0005 Dee 18,2005 Dec 31,2009 $100:00
ESTABLISHMENT
Total Fees: $100.00
i
PERMIT EXPIRES December 31,2009
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any ievonations,improvements,or equipment changes are made,all
plans for such must be submitted to and approved by the Salem Board of Health. Page 1
L
r-
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET,4:mFLOOR
FLOOR
TEL. (978) 741-1800
KIMBERLEY DRISCOLL FAX(978) 745-0343
MAYOR IDIONNEna sALeni.COM
JANET DIONNE,
ACTING HEALTH AGENT
2009 APPLICATION FOR/ PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT ( :0zl-WW1 !TD 21�'E_ TEL# / 2dP__��
ADDRESS OF ESTABLISHMENT FAX
MAILING ADDRESS
(if different)
EMAIL- Business':( F//9Cff/�OUS�/NN/��L�J/JiC/�ST, / /site: �!J/9CG>`ffOVS� S�Lr✓ 7 i% rl
OWNER'S NAME ?21"1, r1 F SS_G/Ci2. —TEL#
ADDRESS
STKEET CITY STATE ZIP
CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S)
(Required in an establishment where potentially hazardous food is prepared)
J;
`t
EMERGENCY RESPONSE PERSON HOME TEL#
DAYS OF..OPERATION,. L ',;Monda �= Tuesda Wednesda . 1's1t Thursda :,;>. ... 'Edda Saturda .' .
Sunda a:
HOURS OF OPERATION
Please write in time of day. -
For example l l am-1 l pm -
TYPE OF ESTABLISHMENT FEE (check only)
RETAIL STORE YES NO less than 1000sq.ft. =$ 70
1000-10,000sq.ft. =$280
more than 10,000sq.ft. =$420
RESTAURANT YES NO ------------- --------Iess,than 25 seats -------=$140
(Outdoor Stationary Food Cart$210) 25-99 seats =$280
_ more than 99 seats =$420
BEDBREAKFA YES NO $100
------ - - - -----
Ee - SERVICES
ADDITIONAL PERMITS -
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25
TOBACCO VENDOR YES NO $135
ALL NON-PROFIT(such as church kitchens) YES NO $25
*Please pay total with one check payable to the City of Salem.
This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted ina prominent-location
in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for
such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax
returns qn9-pai all s e taxes wired unde the law.
/ //hz e /13 930 Y/ 9�
�4ig5a_ Date —
— Socia Sec it or Federal Identification Number
----—------'---------- -A------ -- —
------- ------------ 2
Revised 424/07 FOODAP2008.adm Check#&Date A 0 f yr,&
0284 LAFAYETTE STREET Coach House Inn
City of Salem
Mass Housing (Health) - Inspection
( Rev. May 14,2008 )
Area To Ins)ect:: - ;y Item: Status: Nature of problem or correction:
Entire Preis
mes, Owners Responsibility to Maintain Struc Not Done
!Ck to Issue Certificate Windows,floors, doors, ceilings, roof in FAIL The left bay window in room 27 has broken sash cords. Repair broken sash
NO good condition (410.500) cords.
Building Layout The Same?: .i The left window in room 28 has broken sash cords. Repair broken sash cords.
IYe3: r The window to the fire escape in room 34 does not open. Repair window to
Inspector: open and close freely.
David Greenbaum
Date&Time Requested:
at
Date of Inspection:
aWednesday, May 14, 2008 ;
!Reinspect By::
Certificate Number:
e
Certificate Expires On:
!Status:
OPEN
Notes:
All other rooms had no c
LCLicen
' - ring.Fire Prevention s a
120 Washington Street,4th Floor*SALEM,MA*Phone:(978)741-1800*Fax:(978)745-0343
GeoTMS®2008 Des Lauriers Municipal Solutio Page I of I
z Y t
Commonwealth of Massachusetts '
e r City of Salem
Board of Health IGmbefley Drisooll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 01/03/2008
ESTABLISHMENT NAME: Coach House Inn
File Number.BHF-2004-000103 284 Lafayette Street
Salem MA 01970
LOCATED AT: 0284 LAFAYETTE STREET
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
FOOD SERVICE BHP-2008-0164 Jan 3,2008- Dec 31,2008 $100.00
ESTABLISHMENT
Total Fees: $100.00
PERMIT EXPIRES December 31, 2008
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any revonations,improvements;or equipment changes are made,all
plans for such must be submitted to and approved by the Salem Board of Health: ; _ Page 3 of 9
y
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
'�tym 120 WASHINGTON STREET,4T"FLOOR
TEL.(978) 741-1800 Ewa
KIMBERLEY DRISCOLL FAX(978) 745-0343 �I VED
MAYOR. _ ., - ISOOTTna SALEM.COM
NOV 2 71001
JOANNE SCOTT, CITY OF SALE
HEALTHAGENT AGENT BOARI) OF HEALTH
2008 APPLICATION FOR /PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT COI�C,17 / /r'yS� Z TEL# �1!Y �yr `yU 9-Z
ADDRESS OFESTABUSHMENT —O Y 77 FAX#
MAILING ADDRESS(if different) S'Aynf? ,
Cy/�r. �•9� ruuu� w�T
EMAIL-Business': ffG-cl�Sf.I.NN>'�:• Website: ��iRGfL/�UdJ£S,,5i-Gd/y/.-c.C>,�
OWNER'S NAME �/�7p n/-LGi� �£SSGG�2 TEL# 117c'- 7 t/ Y-)a�O P 2
ADDRESS 0 7 ��/41�ET1T S6jLlTm /'��//A /PTD
STREET - CITY STATE . ZIP
CERTIFIED FOOD MANAGER'S NAMES) CERTIFICATE#(S)
(Required in an establishment wherepotentially hazardous food,is prepared)
n,, �.
EMERGENCY RESPONSE-PERSOM - - -'`''HOME TEL#
DAYS:OF OPERATION Monday •Tuesda _. Wednesday -1 Thursday, Friday Saturday Sunda
HOURS OF OPERATION.
Please write in time of day. j
(For example 11 am-11 pm)
TYPE OF ESTABLISHMENT FEE (check only)
RETAIL STORE YES NO less than 1000sq.ft. =$70
1000-10,000sq.ft. =$280
more than 10,000sq.ft. =$420
- -- --------------------------- - --------------------------------------------------------- ---- ------- --------...---"---'------
RESTAURANT YES NO less than 25 seats =$140
(Outdoor Stationary Food Cart$210) 25-99 seats =$280
more than 99 seats =$420
BEDIBREAKFASTINO $100
CHILDCARE SERVICES---
ADDITIONAL PERMITS-----------
-----------------------------------------.....------------------------------------------------------------
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25
TOBACCO VENDOR YES NO $135
ALL NON-PROFIT(such as church kitchens) YES NO $25
'Please pay total with one check payable to the City of Salem.
This.Permit,is!not transferable and must be reissued upon change of ownership.The Permit must be posted in prominent.location
-- _-_-
in the Establishment __.. _ _._ _ _ _ --- . --_, --_-- .. ,_ --- ,-- __-- _ -__--i
"In-accordance withthe State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for
,such must be:submitted to and approved by the Salem,Board of Health. -
Pursuant to MGL Chapter 62C,Section 49A,.I certify under thepains and penalties of perjury-that I,to my best knowledgeand belief,have filed all state tax
retur d paid all state taxes gwred under the law. - ---. .- - - -
i ure Date Social Security or Federal Identification Number
-----'---------- ------- j--. ------ - ----------------------
Revised 4/24/07 FOODAP2008.adm Checkd&Date Q,_�(t/9471 $ - -
,f
CITY OF SALEM, MASSACHUSETTS
HEALTH AGENT
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
KIMBERLEY DRISCOLL JSCOTT@SALEM.COM
MAYOR
JOANNE SCOTT
HEALTH AGENT
September 4, 2007
Patricia Kessler
284 Lafayette Street
Salem, MA 01970
Dear Sir/Madam:
In accordance with Chapter III, Sections 127A and 127B of the Massachusetts General Laws, 105
CMR 400.00; State Sanitary Code, Chapter 1: General Administrative Procedures and 105 CMR
410.00: State Sanitary Code, Chapter 11: Minimum Standards of Fitness for Human Habitation, an
inspection was conducted of the property at 284 Lafayette Street (Coach House Inn) conducted
by David Greenbaum,Sanitarian, on Wednesday, August 29, 2007.
Notice: if this rental unit is occupied by a child or children under the age of 6 years, it is the property
owner's responsibility to notify tenants of lead related reports and tests, and to ensure that this unit
complies fully with 105 CMR 460:000: Regulations for Lead Poisoning Prevention and Control. For
further information or to request an inspection, contact the Salem Board of Health at 978-741-1800.
You are hereby ORDERED to make a good-faith effort to correct the violations listed on the
enclosed inspection report.
Failure on your part to comply within the time specified on the enclosed inspection report will result
in a complaint being sought against you in Salem District Court. Time for compliance begins with
receipt of this Order.
Should you be aggrieved by this Order, you have the right to request a hearing before the Board of
Health. A request for said hearing must be received in writing in the office of the Board of Health
within 7 days of receipt of this Order. At said hearing, you will be given an opportunity to be heard
and to present witness and documentary evidence as to why this Order should be modified or.
withdrawn. An attorney may represent you. Please also be informed that you have the right to
inspect and obtain copies of all relevant inspection in investigation reports, orders and other
documentary information in the possession of this Board, and that any adverse party has the right
to be present at the hearing.
Please be advised that the conditions noted may enable the occupant(s)to use one or more of the
statutory remedies available to them as outlined in the enclosed inspection report form.
For the Board of ealth Reply to:
2ne Scott David Greenbaum
Health Agent Sanitarian
cc:Building Inspector,Licensing&Fire Prevention
JS/I-II.
0284 LAFAYETTE STREET ] Coach House Inn
PatriciaKessler City of Salem
284 LAfafayette Street IJ
Salem, MA 01970
Mass Housing (Health) - Inspection
( Rev. Aug 31,2007 )
Area To Inspect:: Item: Status: Nature of problem or correction:
Entire Premises Owners Responsibility to Maintain Struc Not Done
Ok to Issue Certificate ?: Windows,floors, doors, ceilings, roof in FAIL Room 11 has water stains on the walls above the beds. Owner states this is the
NO good condition (410.500) result of a leaking roof that has been repaired and the wall paper will be replaced.
Building Layout The Same ?:
Yes
Inspector:
David Greenbaum
Date &Time Requested:
at
Date of Inspection:
Wednesday,August 29, 2007
Reinspect By::
Certificate Number:
Certificate Expires On:
Status:
OPEN
Notes:
Rooms 10, 12, 29, 31 and 32
had no violations.
Rooms 25, 26, 28, 33 and 34
were occupied.
Cc: Licensing Building Fire
Prevention
120 Washington Street,4th Floor*SALEM,MA*Phone:(978)741-1800• Faz:(978)745-0343
GeoTMS®2007 Des Lauriers Municipal Solutio Page 1 of 1
SALEM FIRE DEPARTMENT Inspec. ate: 1.0 1 /
Insp.Number INSPECTION AND VIOLATION REPORT Relnsp.Date:
. Occupancy Name ��4 Occupancy Type IAAOI t 1.00&�
Address /• ,.a CIA 1 1 u� Bldg. #'s Ye- No❑ Floor/Section onle"L
Inspector Name ( V� 1 Cor�Erany Notifications
/' ❑Health ❑Bldg. ❑Electrical ❑Police
in
1. Exterior 6. Heating Systems ❑ N/A
fire escapes/decks Pass ❑ Fail ❑Warn ❑ N/A combustibles Pass ❑ Fail ❑Warn ❑ N/A
proper storage Pass ❑ Fail ❑Warn ❑ N/A within 5 feet
proper access Pass ❑ Fail ❑Warn ❑ N/A defective chimney Pass ❑ Fail ❑Warn ❑ N/A
KNOX BOX Pass ❑ Fail ❑Warn ❑ N/A defective system Pass ❑ Fail ❑Warn ❑ N/A
other Pass ❑ Fail ❑Warn ❑ N/A
2. Exits
open properlyPass ❑ Fail ❑Warn ❑ N/A 7. Electrical
exit blocked Pass ❑ Fail ❑Warn ❑ N/A defective wiring q\Pass ❑ Fail 13 Warn ❑ N/A
exit signs working Pass ❑ Fail ❑Warn ❑ N/A panels accessible qPass ❑ Fail ❑Warn ❑ N/A
adequate lighting Pass ❑ Fail 11 Warn ID N/A extension cords: II
door(s) locked Pass ❑ Fail ❑Warn ❑ N/A proper use Pass ❑ Fail ❑Warn ❑ N/A
signs needed Pass ❑Fail ❑Warn ❑ N/A cover plate missing Pass ❑ Fail ❑ Warn ❑ N/A
in need of repair Pass ❑ Fail ❑Warn ❑ N/A proper fusing Pass ❑ Fail ❑Warn ❑ N/A
emergency lights Pass ❑ Fail ❑Warn ❑ N/A Cher Pass ❑ Fail ❑Warn ❑ N/A
other ❑ Pass ❑ Fail ❑Warn ❑ N/A
3. Fire Alarm System ❑ N/A Ya Fire Extinguishers ❑ N/A
signs needed Pass ❑ Fail ❑Warn ❑ N/A
operative ] Pass ❑ Fail ❑ Warn ❑ N/A properly mounted Pass ❑ Fail )KWarn ❑ N/A
properly labeledLl{ Pass ❑Fail ❑Warn ❑ N/A proper type Pass ❑ Fail ❑Warn ❑ N/A
accessible Pass ❑ Fail ❑Warn ❑ N/A obstructed ] Pass ❑ Fail ❑ Warn ❑ N/A
-trouble indication Pass ❑ Fail ❑Warn ❑ N/A need recharging Pass ❑ Fail ❑Warn ❑ N/A
defective devices Pass ❑ Fail ❑Warn ❑ N/A other Pass ❑ Fail ❑Warn ❑ N/A
missing devices dd Pass ❑ Fail ❑Warn ❑ N/A
other 11 Pass ❑Fail ❑Warn ❑ N/A 9. Sprinkler&Standpipe System
4. Kitchens N/Avalves tabled ❑ Pass ❑ Fail ❑Warn ❑ N/A
10 Ib.ABC extinguisher ❑ Pass ❑ Fail ❑Warn ❑ N/A valves accessible ❑ Pass ❑ Fail ❑Warn ❑ N/A
at hazard pressure reading ❑ Pass ❑ Fail ❑Warn ❑ N/A
ext.system operat. ❑ Pass ❑ Fail ❑Warn N/A FDC clear/capped ❑ Pass ❑ Fail ❑Warn ❑ N/A
roof collect.clean ❑ Pass ❑ Fail ❑Warn N/A Valves open ❑ Pass ❑ Fail ❑ Warn ❑ N/A
system inspected ❑ Pass' ❑ Fail ❑Warn N/A valves secured ❑ Pass ❑ Fail ❑Warn ❑ N/Ae.❑
-'other
clean ❑PassFail ❑Warn N/A spare head avail. ❑ Pass ❑ Fail ❑Warn ❑ N/A
other ❑ Pass., ❑-Fail ❑Warn ❑ N/A heads obstructed ❑ Pass ❑ Fail ❑Warn ❑ N/A
�i p Q IIQ 1 dOD{Z5. Storage other ❑ Pass ❑ Fail ❑ Warn ❑ N/A
proper labeling Pass ❑ Fail ❑Warn ❑ N/A
proper storage Pass ❑ Fail �Warn ❑ N/A PTN Form #84-Completed Yes❑ No❑
legal storage XPass 13Fail Warn ❑ N/A
other ❑ Pass ❑ Fail ❑Warn ❑ N/A Form #58- Filed Yes❑ No❑
10. Violations Found
l<
t� t
Form 7x16-(Rev.11/93) Copies: White-Fire Prevention Yellow-Inspecting Company Pink-Building Owner/Manager
or l
CITY OF SALEM, MASSACHUSETTS RECEIVED BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970 DEG - 4 2006
TEL. 978.741-1800
FAX 978-745-0343 CITY OF SALEM
Kimberley Driscoll WWW.SALEM.COM BOARD OF HEALTH
Mayor JOANNE SCOTT, MPH, RS, CHO
HEALTH AGENT
2007 APPLICATION FOR PERMIT TO OPERATE A FOOD�ESTABLISHMENT
NAME OF ESTABLISHMENT- 75�/ ">'v' t1 TEL#_/`�J�`
ADDRESS OF ESTABLISHMENT Z ' � J FAX,#
MAILING ADDRESS(if different)
EIAAIL--Business': i / i/�_' /SG Q _Owner's:
OWNER'S NAME.. /!t aL TELAt J�'Z0-7V)lY- 109'_
1'/7�7c rr oft-, S?7g-33S 3Ga6-c cct
ADDRESS ZX y L./!i 24C_/7SGS9.
STREET CITY r STATE -1R --
CERTIFIED FOOD MANAGER'S NAMES} �— CERTIFICATE#(S)
(Required in an establishment where potentially hazardous food is prepared) -
EMERGENCY RESPONSE PERSON l r9-J'!! E do ;O& ;2: HOME TEL#
_DAYS OFOPERATION Monday Tuesday Wednesday Thursday Friday _t Saturday Sunday
ROURSOFOPERATION
Please write In note of day.
(For example Ilam-110m) _I
TYPE OF ESTABLISHMENT FEE (check only)
RETAIL STORE YES less than 1000sq.ft. =$ 50
1040-10,000sq-ft. =$100
more than 10,000sq.ft. =$250
RESTAURANT---:.- _
. ._-.YES ... ... ... .... ----- --- ----
----less- - - -25...- - .seats.. =$----. =$-- -_100---
NO than_
25-99 seats =$150
more than 99 seats =$200
_..... - - . - -.._... - - ----- --- -- .. .... ----- ------ -----------
BEDIBREAKFAST YE_ _NO _ $104 ,
..._....._.-.._--------------_--- . - .. -- .........._.-.......- . ------
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES N $5
TOBACCO VENDOR YES $50
ALL NON-PROFIT(such as church kitchens) YES $25
"Please pay total with one check payable to the City of Salem.
This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a
prominent location in the Establishment.
In,accordance with the State Sanitary Code,before any renovations, improvements, or equipment changes are
made, all plans for such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 6 C, Section 49A, I certify underthepains and penalties of perjury that I,to my best knowledge and belief,
hav all e tax relur and p' all state taxe reed under the law
y/ 'z-9 e .
4 ' 039 -30 -- 5°/¢7
gnature Date Social Security or Federal Identification Number
-------------- ----- -------------------------------- - -- ---------------------------- ---------.------- ---------------------
Revised 111131013,FOOt3AP2C07.adm `Check#&Dale
Commonwealth of Massathasetts
?F • -. • C '� k a 'ti 4 4 k K-Y a
��`�hj£ '.'.ra .:; Fa_'",. �Mi.i P'. �yeax ..::"ate' ,+ '",`•�-.� '�srt m:. �.i ��'"i0 HA2' .:.-�i'�`�;d,�M'�Or ,.��`°�r"C'*� s T
SALEM,MA 01974, � .a
Food/Retail Establishment Permit
DATE PRINTED: 12/20/2006
ESTABLISHMENT NAME: Coach House Inn
File Number:BHF-2004-000103 284 Lafayette Street
Salem MA 01970
LOCATED AT: 0284 LAFAYETTE STREET
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
FOOD SERVICE BHP-2007-0128 Dec 20,2006 Dec 31,2007 $100.00
ESTABLISHMENT
Total Fees: $100.00
PERMIT EXPIRES December 31, 2007
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any revonations, improvements,or equipment changes are made,all
plans for such must be submitted to and approved by the Salem Board of Health. Page 2 of 8
ae.,b/Y, w nYM<h 'TYY `M�+rV4w'WWv.' M ^si War wM Y HwWN e F fr�t wb'FA+4 +M+'b +W't,�f'K+V
aty�, 4`m w{Sp-,� 'm �. "'r1 �54"Y. .Ns+ ea<'Y.u� *?Mn f a y ,�+� �'�.`.'ms,•r-'asY3tiM1C
°""'rrr.,"'• ,,"6'.w^xa'rtkH tf um `- gg�k'L" •�ys' i�aw ,„�� aG31E�t"^ i¢"`'i�wt`t '4�*r+ yx:
rr•'p`t't .+- Ir §- m�W 'fi7ka ' 'Y'1,q[�'' ' 3F"T'�'Y`+•i'Av�2' �S^ i2�H�'��.
4 ka k ...Commonwealth of Massachusetts 'S }� ,, ;w z " ' .
A.
Board of Health ' ' s 4�
120 Washington Street,4th Floor
p SALEM,MA 01970
-1 Food/Retail Establishment Permit
DATE PRINTE 01/03/2006
WHO'S PLACE OF BUSINESS IS: Coach House Inn
File Number:BHF-2004-0103 284 Lafayette Street
Salem MA 01970
LOCATED AT: 0284 LAFAYETTE STREET
SALEM,MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
FOOD SERVICE BHP-2006-0081 Jan 3,2006 Dec 31,2006 $100.00
ESTABLISHMENT
Total Fees: $100.00
PERMIT EXPIRES December 31 2006
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all
plans for such must be submitted to and approved by the Salem Board of Health. Page 4 of 23
CITY OF SALEM, MASSACHUSETTS
,�. BOARD OF HEALTH
s 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
STANLEY J. 11SOVICZ, JR. FAx 978-745-0343
MAYOR W W W.SALEM.COM
JOANNE SCOTT, MPH, RS, CHO
HEALTH AGENT
2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT v
NAME OF ESTABLISHMENT C0 A(J/ J7D OS C- -Z;VV TEL# �;T-;7
ADDRESS OF ESTABLISHMENT 7 /�I/ �Yt✓TTT✓" �7�
MAILING ADDRESS (if different)
OWNER'S NAME //.G/� SSS TEL#�2d-27'Y410-,9,>'
ADDRESS
CITY_ ,47-E,o _ STATE �� ZIP Dz -2d
CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s)
(required in an establishment where potentially hazardous food is prepared.)
EMERGENCY RESPONSE PERSON -. HOME TEL# -
HOURS OF OPERATION`. Man: - ` Tue '-"-Wed:AThu. - Fri.: Sun.:'. -'
TYPE OF'ESTABLISHMENT," FEE.(check only) -
RETAIL-STORE".,/9 -YES. NO .J_; s ; less than 1000sq ft =$,50
1000-10,000sq.ft. =$100 `'
- more than 10,000sq.ft. =$250
---------------------------------.................... . -- ------............ . . -----------............
RESTAURANT YES NO / less than 25 seats =$100
2 `7 �l ( 25-99 seats =$150
v�`t (� more than 99 seats =$200
-----------------------------------------------------------------------------------$10-- -------------------
BED/BREAKFAST YE NO 0
----------------------------------------------..... ...... ....------....... ....... .
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5
TOBACCO VENDOR YES NO $50
ALL NON-PROFIT(such as church kitchens) YES NO $25
*Please pay total with one check payable to the City of Salem .
This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted
in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes
are made, all plans for such must be submitted to and approved by the Salem Board of Health.
Pursuant to.MGL Chapter•62C, Section 49A, I certify under the pains and penalties,of perjury.that I, to my best
-knowledge and belief:have.,filed all state tax returns and paid all state taxes required under tfte law.
SignatuDatlee °r SocialQ Secur=ity 3o_rP_F_ede�a�l
Identification Number
--------------------
- --------------- ------ - -
Revi d
11/03/05 FOODAP2.adm Check#&Date Ae4AA� /;2 /1' A '
jaa
i
w <
SJ
CITY OF SALEM, MASSACHUSETTS
g BOARD OF HEALTH
� A
9, 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA O 1970
TEL. 978-741-1800
FAX 978-745-0343
STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR - HEALTH AGENT
June 30, 2005
Patricia Kessler
284 Lafayette Street
Salem, MA 01970
Dear Sir/Madam:
In accordance with Chapter III, Sections 127A and 127B of the Massachusetts General Laws, 105
CMR 400.00; State Sanitary Code, Chapter 1: General Administrative Procedures and 105 CMR
410.00: State Sanitary Code, Chapter 11: Minimum Standards of Fitness for Human Habitation,
an inspection was conducted of the property 284 Lafayette Street occupied by(Lodging House)
conducted by David Greenbaum, Sanitarians on Tuesday, June 28, 2005.
Notice: if this rental unit is occupied by a child or children under the age of 6 years, it is the
property owner's responsibility to notify tenants of lead related reports and tests, and to ensure
that this unit complies fully with 105 CMR 460:000: Regulations for Lead Poisoning Prevention
and Control. For further information or to request an inspection, contact the Salem Board of
Health at 978-741-1800.
You are hereby ORDERED to make a good-faith effort to correct the violations listed on the
enclosed inspection report.
Failure on your part to comply within the time specified on the enclosed inspection report will
result in a complaint being sought against you in Salem District Court. Time for compliance
begins with receipt of this Order.
Should you be aggrieved by this Order, you have the right to request a hearing before the Board
of Health. A request for said hearing must be received in writing in the office of the Board of
Health within 7 days of receipt of this Order. At said hearing, you will be given an opportunity to
be heard and to present witness and documentary evidence as to why this Order should be
modified or withdrawn. You may be represented by an attorney. Please also be informed that
you have the right to inspect and obtain copies of all relevant inspection in investigation reports,
orders and other documentary information in the possession of this Board, and that any adverse
party has the right to be present at the hearing.
Please be advised that the conditions noted may enable the occupant(s) to use one or more of
the statutory remedies available to them as outlined in the enclosed inspection report form.
T�_o the Board`of Health Reply to:
- ' 61a/MR1'YC
Janne Scott L-' David Greenbaum
/Health Agent Sanitarians
cc: Licensing Building Inspector Fire Prevention . .
0284 LAFAYETTE STREET Coach House Inn
Patricia Kessler City of Salem Lodging House
284 Lafayette Street
Salem, MA 01970 Mass Housing (Health) - Inspection
( Rev. Jun 28,2005 )
Area To Inspect:: Item: Status: Nature of problem or correction:
Entire Premises Installation of Screens Not Done
Ok to Issue Certificate?: April 1 st to October 30 both inclusive, In FAIL Screens for all windows must be installed from April 1st-October 31 st inclusive
NO , each year (410.553) each year.
Building Layout The Same?: Locks Not Done
Yes Every operable exterior window contains FAIL The front window in Room 10 the lock screws need to be resecured.
Inspector: locking device (410.480(E))
David Greenbaum
Date&Time Requested: Screens for Windows Not Done
at Cover part of window designed to be FAIL Many windows are missing screens. Owner must provide screens for all
Date of Inspection: open (410.551(1)) windows.
Tuesday, June 28, 2005
Reinspect By::
Certificate Number:
Certificate Expires On:
Status:
OPEN a
Notes:
There is a question of proper
numbering of rooms.
Licensing will verify with the
Fire Department that current
numbering is satisfactory.
Rooms 6& 8 were occupied.
Cc: Licensing, Building, Fire Prevention
-'
GeoTMS®2005 Des Lauriers Municipal Soluti Parc I of I_
rt '
A�,
•• � a. A - .. .. w a s
CITY OF SALEM9 MASSACHUSETTS
BOARD OF HEALTH
• e
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MAO 1970
TEL. 978.741-1800
FAX 978-745-0343
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter 94,
Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food
Establishment in the City of Salem is hereby granted to:'
Type of Establishment: Bed and Breakfast
Name of Establishment: Coach House Inn
Address of Establishment: 284 Lafayette Street
Owner's Name: Patricia Kessler
Restrictions:
Application Date: 1/13/2004
Permit for Food Establishment 253-04
Frozen Desserts/Ice Cream
Permit for the Sale of Tobacco Products
These Permits Expire December 31, 2004
This permit is not transferable and must be reissued upon change of
ownership or location. The permit must be posted in a prominent location
in the Establishment,
In accordance with the State Sanitary Code, before any renovations,
improvements, or equipment changes are made, all plans for such must be
submitted to and approved by the Salem Board of Health.
HEALTH AGENT
r _
u CITY OF SALEM, MASSACHUSETTS �.
BOARD OF HEALTH ��I'1ggq((( �\t
• • 120 WASHINGTON STREET, 4TH FLOOR �I\
9 SALEM, MA 01970 VVV
e
TEL. 978-741-1800 DEC 2 -2003
FAX 978-745-0343 / ^
STANLEY LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO I„IT-Y CI SALEM
MAYOR HEALTH AGENT BOARD OF HEALTH
2004 APPLICATION FOR PERMIT TO/// e— ZOPERATE AFOOD ESTABLISHMENT
L1/17
NAME OF ESTABLISHMENT ( Gf/. #0 USIAI TEL#
ADDRESS OF ESTABLISHMENT
MAILING ADDRESS (if different)
OWNER'S NAMEp�/ TEL#
�j�/L/�" �C£SSC£!L
ADDRESS ZD / I� Y-6;077 �T
CITY S ftzJ,. r STATE ,, 7A- ZIP _-
CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) _
(required in an establishment where potentially,hazardous food is prepared.)
EMERGENCY RESPONSE PERSON HOME TEL#
HOURS OF OPERATION: Mon. Tue. Wed. Thu. Fri. Sat. Sun.
TYPE OF ESTABLISHMENT FEE check only
RETAIL STORE YES NO 63-5 less than 1000sq.ft. =$ 50
G( 1000-10,000sq.ft. =$100
more than 10,000sq.ft, =$250 .
RESTAURANT YESNO less than 25 seats =$100
25-99 seats =$150
more than 99 seats =$200
BED/BREAKFAST ES NO $100
ADDITIONAL PERMITS
MAKE (notjust serve) ICE CREAM, YOGURT, SOFT SERVE YES O $5
TOBACCO VENDOR YES $50
ALL NON-PROFIT(such as church kitchens) YES $25
Please pay total with one check
payable to the City of Salem
This Permit is not transferable and must be reissued upon change of ownership. The Permit must
be posted in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment
changes are made all plans for such must be submitted to and approved b the Salem Board of
9 � P PP Y
Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my
b wledge a elief, have fled allstate ax returns and paid all state taxes required under the law.
Dap '.
Signature Date Social Security or Federal Identification Number
-------------------------------------------------------------------------------------------------------------------------------------
Revised 11/03/03 FOODAP2.adm Check#&Date 1,3W— it-2-4-off
. °i'k"se. T` ,m � i {Y s _N'• v, -k"`# + i w1T •Y �. .bAiic�r. ' ,re
-} { ` y'-5}µ7w.'� � .i e9x�.t 100 S:Y
aw , '.dmt^a' a ., t! A- ,' ,w,�- -•v,
f''�k re+'14ekh �1+�:r Y3 n,ys+M.0°a. �,u„ ��-•"v ma tt .,G 'yda. ;{ dat�Xdi+••w.tYaH:
CITYOFtSALEM� MASSACHUSETTS s t� Y � , iso
. . BOARD HEALTH
_ OF x°
#-f 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA O 1970 -
- TEL. 978-741-1800
FAX 978-745-0343
STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO ,.
MAYOR - HEALTH AGENT -
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter 94,
Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food
Establishment in the City of Salemis hereby granted to:
'Type of Establishment: Bed and Breakfast
Name of Establishment:"Coach House Inn
Address of Establishment: 284 Lafayette Street
Owner's Name: Patricia Kessler
Restrictions:
Application Date: 12/6/2004
Permit for Food Establishment 192-05
Frozen Desserts/Ice Cream
Permit for the Sale of Tobacco Products
These Permits Expire December 31, 2005
This permit is not transferable and must be reissued upon change of
ownership or location. The permit must be posted in a prominent location
in the Establishment,
In accordance with the State Sanitary Code, before any renovations,
improvements, or equipment changes are made, all plans for such must be
submitted to and approved by the Salem Board of Health.
�HEACTH AGENT
i CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH _
+ 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800 -
FAX 978-745-0343
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
2005 APPLICATION FOR PERMIT
/T/O OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT C�D/�iL/" i/S�. �itl/1/ TEL
A# /7f'Z
. ADDRESS OF ESTABLISHMENT
MAILING ADDRESS (if different) J �y
OWNER'S NAME i/!1i/f1 /C£SSCC'e— —TEL# ��yy�y(79Zi
ADDRESS c C 17
CITY _ i9�L4rt STATE ZVA ZIP D) 1` 7
CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s)
(required in an establishment where potentially hazardous food is prepared.) p
EMERGENCY RESPONSE PERSON !�61A� Ctq� HOME TEL# / f-�2 KX-fIo1�
HOURS OF OPERATION: Mon. �Tue. —Wed. Thu. --Fri. ;__Sat. Sun.
TYPE OF ESTABLISHMENT FEE check only
RETAIL STORE YES N - less than 1000sq.ft. =$ 50
1000-10,000sq.ft. =$100
more than 10,000sq.ft. =$250
RESTAURANT YES1 less than 25 seats =$100
O 25-99 seats =$150
more than 99 seats =$200
BED/BREAKFAST /YES NO $100
ADDITIONAL PERMITS/
MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES $5
TOBACCO VENDOR YES dS19 $50
ALL .NON-PROFIT(such as church kitchens) YES $25
Please pay total with one check
payable to the City of Salem
This Permit is not transferable and must be reissued upon change of ownership. The Permit must
be posted in a prominent location in the Establishment.
in accordance with the State Sanitary Code, before any renovations, improvements, or equipment
changes are made, all plans for such must be submitted to and approved by the Salem Board of
Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my
��knowledge a belief have filed all stat tax returns and paid all state taxes required under the law.
��� — i �o� 039- estate 17
Signa Date Social Security or Federal Identification Number
----------------------------------------------- r1 ------------ -- - -----------------------------------
Revised 11/03/03 FOODAP2.adm Check#&Date / eY
l�
SENDER;,COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Received by(Please Print Clearly) B. Date of Delivery
(em 4 if Restricted Delivery is desired. _Q
■ Print your name and address on the reverse
so that we can return the card to you. C,Signatu
■ Attach this card to the back of the mailpiece, j� =— ' - ,.� El Agent
or on the front if space permits. / r - _ - - El Addressee
D. Is delivery address different from item 1?
1. Article Addressed to: If YES,enter delivery address below: ❑ No
COACH HOUSE INN
C/O PATRICIA KESSLER
284 P Y TTE STTR{�EET +'
SAL
3. Service Type
Certified Mail ❑ Express Mail
JAN12 '2004 El Registered ❑ Return Receipt for Merohandise
❑ Insured Mail ❑C.O.D.
C MP 4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article N""e !Fe 1 r I
i H, i ;ii .'t i
PS Form 3811,July.1999 Domestic Return Receipt 102595-00-M-0952
UNITED STATES POSTAL SERVIC J P S.` s
.,USPS
r, Permit No.G1,0.
• Sender: Please primPyot n e, address,-and ZIP+4 in'this bo)OO"
City of Salem
j Board of Health
120 Washington Street—4th Floor
Salem, MA 01970
o '
U.S. Postal Service
CERTIFIED MAIL RECEIPT
(Domestic Mail Only;No Insurance Coverage Provided)
Postage $
S
Certified Fee
. Postmark
117,� Return Receipt Fee - Here
O- (Endorsement Required) -
Restricted Delivery Fee
C3 (Endorsement Required)
C3
..Total Postage&fees
M" ame Please Print clearly)ryf(to be completed by mailer) p:
a— Straet,-Apt No.:or-P-0 Box No............................_--------_........-----------
ir
r
QN.State,ZIP.4 ---_......................
i
Certified Mail Provides:
■ A mailing receipt
■ A unique identifier for your mailpiece
■ A signature upon delivery
■ A record of delivery kept by the Postal Service for two years
Important Reminders:
■ Certified Mail may ONLY be combined with First-Class Mail or Priority Mail.
■ Certified Mail is not available for any class of international mail.
■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mall. For
valuables,please consider Insured or Registered Mail.
■ For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse mailpiece 'Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt, a USPS postmark on your Certified Mail receipt is
required.
■ For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted Delivery".
■ If a postmark on the Certified Mail receipt is desired,please present th,arti-
cle at the post office for postmarking. If a postmark on the Certified Nlail
receipt is not needed,detach and affix label with postage and mail.,
IMPORTANT:Save this receipt and present it when making aminquiry.
PS Form 3800,July 1999(Reverse) 102595-99-M-2087
f_ CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
e 120 WASHINGTON STREET, 4TH FLOOR
3
SALEM, MA 01970 ti
TEL. 978-741-1800
FAX 978-745-0343
STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
December 22, 2003
Coach House Inn
C/o Patricia Kessler
284 Lafayette Street
Salem, MA 01970
« Dear Ms. Kessler:
Please sign the enclosed check for your 2004 Food Permit. I tried calling you but I only got the answering
machine and had no otlier number to reach you.
If you have any questions, please call my',office.
Very truly yours,
F
Joanne Scott
Health Agent
JS/mfp '
CERTIFIED MAIL 7099 3400 0009 4078 9720 '
53-7055/2113.. .1341
PATRICIA KESSLER0880039615
DBA COACH HOUSE INN
284 LAFAYETTE ST. _ DATE
SALEM, MA 01970-5462
C J
:.
`# PAY ORDER THE / � !ice //2 $/
ORDER IJV �.
p OF
ft �� 'e w-22 .s
DOLLARS -... -
SalemF ve�
210 Ei Sheer,Salem,MA 01970 `
M
MEMO -- — —
v: 2Li3405581: 08800396LS"s L3Ill i
IM1U.S.Postal Service
CERTIFIED MAIL RECEIPT
(Domestic Mail Only; No Insurance Covera ge Provide
r
F I E
M Postage $
M
17, Certified Fee
Retum Receipt Fee Postmark
O
O (Endorsement Required) Hera
O Restricted Delivery Fee
p (Endorsement Required)
O Total Postage®Fees
7
rR Sent ro
rl
...................................--------.....--------------------------------..._---__..__..
Street Apt.No.;
r3 or Po Box No.
N C/ty,Stafe,ZIPS d
L
:11 11
Certified Mail Provides:
■A mailing receipt
■A unique identifier for your mailpiece
■A signature upon delivery
■A record of delivery kept by the Postal Service for two years
Importarrt Reminders:
■Certified Mall may ONLY be combined with First-Class Mail or Priority Mail.
■Certified Mail is not-available for any class of international mail.
■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mal.
■For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please completeand attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waver for
a duplicate return receipt,a USPS postmark on your Certified Mal receipt is
required.
■For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted Defivery'.
■If a postmark on the Certified Mail recelpt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt Is not needed,detach and affix label with postage and mail.
IMPORTANT:Save this receipt and present it when making an Inquiry.
PS Form 3800,January 2001 (Reverse) 102595-01-M•1829
CITY OF SALEM, MASSACHUSETTS
s�M` •�yQ' '� BOARD OF HEALTH
sF. 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
m
TEL 978-74 1-1 BOO
9�C/,gryg
FAX 978-745-0343
STANLEY USOVICZ, JR. ,JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
r April 30, 2002
Patricia Kessler
Coach House Inn
284 Lafayette Street
Salem, Me. 01970
Dear Mrs. Kessler:
In accordance with Chapter II, Sections 127A and 127B of the Massachusetts General Laws, 105 CMR 400.00, State
Sanitary Code, Chapter I: General Administrative Procedures and 105 CMR 410.00: State Sanitary Code, Chapter II:
Minimum Standards of Fitness for Human Habitation, an inspection was conducted of the property at 284 Lafayette St.
conducted by Virginia Moustakis, Sanitarian on Tuesday,April 30, 2002 at 9:30 AM
Notice: If this rental unit is occupied by a child or children under the age of 6 years, it is the property owner's responsibility
to notify tenants of lead related reports and tests, and to ensure that this unit complies fully with 105 CMR 460.000:
Regulations for Lead Poisoning Prevention and Control. For further information or to request an inspection, contact the
Salem Health Department at 741-1800.
You are hereby ORDERED to make a good-faith effort to correct the violations listed on the enclosed inspection report.
Failure on your part to comply within the time specified on the enclosed inspection report will result in a complaint being
sought against you in Salem District Court. Time for compliance begins with receipt of this Order.
Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for
said hearing must be received in writing in the office of the Board of Health within 7 days of receipt of this Order. At said
hearing, you will be given an opportunity to be heard and to present witness and documentary evidence as to why this
Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have
the right to inspect and obtain copies of all relevant inspection or investigation reports, orders and other documentary
information in the possession of this Board, and that any adverse party has the right to be present at the hearing.
)
Please be advised that the conditions noted may enable the occupant(s) to use one or more of the statutory remedies
available to them as outlined in the enclosed inspection report form.
For the Board of Health: Reply to:
lan"ne Scott Virginia Moustakis
Health Agent Sanitarian
cc: Councillor Regina Flynn,Licensing Board, Fire Prevention, & Building Inspector
JS1 vm c-n-violet Certified Mail #7001 1140 0000 6733 7547
' i
i
EI
;i
CITY OF SALEM HEALTH DEPARTMENT
' 120 WASHINGTON STREET 4TH FLOOR ,
Salem, Massacnusetts 01970 Page 1 of
State SanitaryCode; Chapter II 105•CMR 410.000 . tt
Minimum Standards of Fitness for:Human.Habitation _.
r kv, ,
» 5
Occupant "6vny/Z&se 7,✓;y - �� v�fasf Phone
Address: �gy ��Faue•//e_�S'f Apt.# i/``"Pm3 Floor i-a-
Owner: P4hQ)C/R K.tc/FR Address.
Inspection Date: .,/-3e-oa L }. Time:-
Conducted
ime Conducted By: Li'�a57 ifris Accompanied By: ,cwsbva
Anticipated Reinspection Date:
/,3vilc�i.v5 /eticPtz�•N. !-eRrtk.Di/9aaGa
Specified Time Reg.#410.. Violation(s)
(' - #.1.'.}' rte,. .r_ZYi-'r•_�. .. :. , Y F ,��-t/� y It
(°. Q
r
Occupa.+xc.y .: -P ,y
I �..'��,. ». .� r -�" "xs.rf� r+ ' ...?•r ;` l':=.F,�f'..x :;:art•Q%z 4 i;:�e }� s .A. T x � k e �. n .7� "'y., I�.` ,�'�t ^•a,�
p IZ x." •,:4.i '
i r kr
J
epi&C01si/vq
One or more of the above violations may endanger matenally.impairhther,health t �1�Q�A--- - I TV
safety, and well being of the occupant(s)
ant(s) s •' a��l��gJe�O�
l y 9 P
Code Enforcement Inspector
Este es documento legal importante. Puede que afecte sus derech6s
x I tit., w
Piip.dP ndauirir una traducaon,de'esta forma sies necesario llamaral teI fono 741,,1800. a `'
Y
.,+`^^d te4a <r., it °
Appendix II (14)
Legal Remed esTor-Tena49 of Residential Holzsing
The following is a brief summary of some of the legal remedies tenants,may use in order to get
housing code violations corrected
1. Rent Withholding(Massachusetts.General Laws, Chapter 239,section 8A): If Code Violations Are Not
Being Corrected you may be entitled to hold back your rent payments. You can do this without being evicted if:
You can prove that your dwelling unit or common areas contain code violations which are serious
enough to endanger or materially impair your health of safety and that your landlord knew about the
violations before you were behind in your rent.
x the violations and they can be repaired while you continue to live in the
Y
You did not cause r
buildin
f g. M ,a
'
You are prepared to pay any portion of the rent into court if a judge orders you to pay it. (For this,
it is best to put the rent money aside in a safe place)
2. Repair and Deduct(Massachusetts General Laws, Chapter III,section 127L): The law sometimes allows
you to use your rent money to make,the repairs yourself. If your local code enforcement agency certifies that
there are code violations which may endanger or'materially impair your health, safety, orwell-being, and
your landlord has received written notice of the violations,you>may-be able.to use this.remedy. If the owner
fails to begin.necessary repairs (or to enter into a written contract to have them made)within five days after
the notice or to complete repairs within 14 days after notice,you`can use up to four months rent m any year
to make repatis : `...t %:.' 4, a! 4;?k i• -' a•{ r n:. -.; '. ., w,:F_ ,.s,'v+
3. Retaliatory Rent Increases or Evictions Prohiliifed(Massachusetts General Laws;Chapter 186,'section
18,and Chapter 239, Section 2A): The owner may not increase your rent or evict you in retaliation for
making a complaint to"your local:code'enforcement'aggncy`aliout d6&violations If the owner raises"your
rent to try to evict mithin:siz months afteryou hayermade the complaint,he or sh64ill have to show agood
' reason for the increase'or eviction which is unrelated to your complaint. Youmay lie. ba le to sue the landlord
for damages or if he or she tries this. -
4. Rent Receivership (Massachusetts GeneiafLaws Chapter II,section 127 C-H):,The occupants and/or the.
Board of Health may petition the District or Superior Court to allow rent to be paid into court rather than to
the owner. The court may then appoint a"receiver"who may spend'as much of the-rent money as is needed
to correctthe'violation.The'receiver is'not subject to a spending limitation of four nouths'rent.
5. Breach.of.Warranty of Habitability: You.may be entitled to sue,your landlord to have all or some of your
rent returned if your dwelling unit does not meet minimum standards of habitability.
3 . - .... 3, r y „.
6. Unfair& Deceptive Practices(Massachusetts General`Laws, Chapter'93A) Renting an apartment with
code violations is a violation of the consumer'protection act and regulatioris, for which you may sue an
owner.
The information presented above is only a summary of the law. Before you decide to withhold rent or,take any
other legal action;itis advisable that you consult an attorney. If you can not afford to consult anattomey, you
should contact thenearest legal serviceseoffrce;+whrch,is- .?
Neighborhood Legal Services
37 Friend Street xrY _
Lynn,MA. 01902
(781)-599-7730 :, ".
*M 'i"k::z<
.s _;:+ _ a.. ..m_:__., z,� .e . .., . _.» ., . . _sem.' Ew-L• ....
CITY OF SALEM HEALTH DEPARTMENT
120 WASHINGTON STREET 4TH FLOOR
Salem,Massachusetts 01970 Page Of o2
/� p Date:
Name: (2''7 / / ctcP moi✓ o% Address:
Specified Time Reg.#410.. VIOIat10f1(S)
' �y sr0 wr j n 6ef r asd Bed �-
9- G e
t ° 30
x/c,
A. s P ti e .n • eLp /v
r
R
t
r i
l y
Y
Page —of—
Date-.—
Name:
fDate-.Name:
Address:
4 , , iii
Specified Time Reg.#410.. Violation(s)
i
y
ii
j
}
�SEN. DELIVERY
■ Complete items 1,2,and 3.Also complete A. Received by(Please Print Clearly) B. Date of Delivery
item 4 if Restricted Delivery is desired.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece, ❑Agent
or on the front if space permits. ❑Addressee
D. Is delivery address different from item 1? ❑Yes
1. Article Addressed to:��/� If YES,enter delivery address below: ❑ No
s�-
so�
3. ice Type
rCertified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑C.O.D.
V4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number(Copy from service label)
gaol i(yo o.eao,,,, ;733,. 7 rN7... ... .
-
PS Form 3811July 1999' .. .toe� Domestic Return Receipt 102595-o0-M-0952
I I I 1 11 1 ,1161M i 11111 i 111 11
UNITED STATES POSTAL SE ast S�I
`; - -� -First-"CMt—
/� .�.t-.a...,,,_ ..Postage`&Fees-Paid
USPS-No-43-
P_eynit•NNoaC�1.0_
• Sender: PleaseY crar s
Pname addre�yandz v
�o (1�45* Tf
I Ilf Health
IVIS Scott, anne, Health Agent
MAY 13 200220 Washington Street—4th Floor
Salem, MA 01970-3523
I I Y U C,/, alvi
BOARD OF HEALTH
,I„L„Iil,,,,,IL„Id,,,Ll„If,l,1„Ltill It II
rA
=' ' o CITY OF SALEM, MASSACHUSETTS
3. - BOARD OF HEALTH
� s 120 WASHINGTON STREET, 4TH FLOOR
S SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
STANLEY USOVICZ, JR. .JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
If
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter
94 , Section 305A and Chapter III , Section 5 of the General Laws, to operate
a Food Establishment in the City of Salem is hereby granted to:
Owner' s Name: Patricia Kessler
Name of Establishment : Coach House Inn
Address of Establishment : 284 Lafayette Street
Type of Establishment : Bed & Breakfast
Application Date : 12/10/2002
Restrictions:
Permit for Food Establishment 57-03
Frozen Desserts/Ice Cream
Permit for the Sale of Tobacco . Products
These Permits Expire December 31, 2003
This permit is not transferable and must be reissued upon change of
ownership or location. The permit must be posted in a prominent location
in the Establishment.
In accordance with the State Sanitary Code, .before any renovations,
improvements, or equipment changes are made, all plans for such must be
submitted to and approved by the Salem Board of Health.
HEALTH AGENT
ti ,:
r �
• CITY OF SALEM, MASSACHUSETTS -
�ONUIT�
BOARD OF HEALTH
5
120 WA51-WASHINGTONSTRf_ET. 4TH FLOOR DEC 0 2007
SALEM. MA 01970
rr_� I ;
sell � 97a-7a1-leoo SALEM
°'rnne�
FAx 978-745-0343 -BOARD C,v HEAL-Y f-I
STANLEY USOVICZ, JR. JOANNE SCOTF. MPH. RS. CHO
MAYOR HEALTH AGENT
2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT `/
NAME OF ESTABLISHMENTL'f/ d//S� yNN� TEL# / 7� ;�I"�7 09 Z--
ADDRESS OF ESTABLISHMENT
MAILING ADDRESS (if different)
OWNER'S NAME� �/C//✓����-OSG�� TEL# 9��`7� �Y®�Z
ADDRESS ��m� /�S /Tls�✓�
CITY STATE____ ZIP._,,____ __
CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s)
(required in an establishment where potentially hazardous food is prepared.)
EMERGENCY RESPONSE PERSON HOME TEL#
HOURS OF OPERATION: Mon. Tue. Wed. Thu. Fri. Sat. Sun.
TYPE OF ESTABLISHMENT FEE check only
RETAIL STORE YES NO less than 1000sq.ft. =$ 50
1000-10,000sq.ft. =$100
more than 10,000sq.ft. =$250
tr a
RESTAURANT YES NO less than 25 seats =$100
25-99 seats =$150
more than 99 seats =$200
BED/BREAKFAST YE NO $100
ADDITIONAL PERMITS
MAKE ICE CREAM, YOGURT, SOFT SERVE YES NO $5
TOBACCO VENDOR YES NO $50
ALL NON-PROFIT(such as church kitchens) YES NO $25
Please pay total with one check
payable to the City of Salem
This Permit is not transferable and must be reissued upon change of ownership. The Permit must
be posted in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment
changes are made, all plans for such must be submitted to and approved by the Salem Board of
Health.
f �
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my
•best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law.
Si nat -D a Social Security or ecieral Identification Number
9� = -----------------/__ -------------0_3YY —?'-a-=-YlP-7-------------------------
Revised 11/25/02 FOODAP2.adm Check#&DateZ-
10-09-1998 5:S1PM FROM ELECTRIC-DEPT- 978 745 4638 P- 2
CITY OF SALEM, MASSACHUSETTS
IsELECTRIC DEPARTMENT
44 LAFAYETTE STREET
SALEM, MA 01970
TEL. (978) 745.6300
FAX (978) 745-4638
STANLEY J. USOVICZ, JR. MARK.ROCHON, WIRE INSPECTOR
MAYOR
r '
NOVEMBER 20, 2003
CERTIFIED MAIL: 7002 2030 0004 6711 0306 NOV 192003
TO: PATRICIA KESSLER CITY OF SALEM
COACHMAN HOUSE BOARD OF HEALTH
284 LAFAYETTE ST.
SALEM,MA 01970
SUBJECT` 284 LAFAYETTE ST.
3''° FLOOR BATH EXHAUST FAN
THE SALEM FIRE DEPARTMENT AND MARK ROCHON, WIRE INSPECTOR,
WERE SENT TO 284 LAFAYETTE ST. TO INSPECT AN ELECTRICAL SMOKE
SMELL ON OCTOBER 23, 2003. THE 31D FLOOR BATH EXHAUST FAN WAS
REMOVED. THIS OFFICE HAS NOT RECEIVED A PERMIT OR AN INSPECTION
REQUEST FOR THE REPAIR OF THIS EXHAUST FAN,
PLEASE,TAKE TI{E NECESSARY STEPS TO CORRECT T141S ELECTRICAL
HAZARD.
THIS WORK SHALL BE DONE BY A LICENSED ELECTRICIAN WITH A PERMI I'
FROM THIS OFFICE-
IF YOU HAVE ANY QUESTIONS PLEASE CONTACT ME AT MY OFFICE.
XOURS T DULY,
MARK ROCHON, WIRE INSPECTOR
CC
FIRE PREVENTION: FAX: 978.745-9402
BUILDING DEPT: FAX: 978-740-9402
HEALTH.DEPT: FAX: 978-745-0343
U.S. Postal Service
(Domestic Mail Only;No Insurance Coverage larovi,�Fd)
- .
CERTIFIED MAIL RECEIPT ,
N w1flraA c
nl Postage $
Caddied Fee
Postmark
Return Receipt Fee ; Here
.(Endorsement Required)
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ORestrictetl Delivery Fee
M,
(Endorsement Required)
C3 Total Postage&Fees
Na lease Print Clevlyl(too cyympleted by mailer)
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Cevtified Mail Provides:
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Important Reminders:
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IMPORTANT:Save this receipt and present it when making an inquiry.
PS Form 3800,July 1999(Reverse) 102595-99-M-2087
l ♦.
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CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970-3928
JOANNE SCOTT, MPH, RS,CHO NINE NORTH STREET
HEALTH AGENT Tel:(978)741-1800
Fax: (978)740-9705
April 26, 2001
Patricia C. Kessler
284 Lafayette Street
Salem, MA 01970
Dear Ms. Kessler:
In accordance with Chapter III, Sections 127A and 1278 of the Massachusetts General Laws, 105 CMR 400.00, State
Sanitary Code, Chapter I: General Administrative Procedures and 105 CMR 410.00: State Sanitary Code, Chapter 11
Minimum Standards of Fitness for Human Habitation, an inspection was conducted of the property 284 Lafayette Street
occupied by(Bed & Breakfast) conducted Virginia Moustakis, Sanitarian on Wednesday,April 25, 2001 at 9:30 A.M..
Notice: If this rental unit is occupied by a child or children under the age of 6 years, it is the property owner's responsibility
to notify tenants of lead related reports and tests, and to ensure that this unit complies fully with 105 CMR 460.000
Regulations for Lead Poisoning Prevention and Control. For further information or to request an inspection, contact the
Salem Health Department at 741-1800.
( You are hereby ORDERED to make a good-faith effort to correct the violations listed on the enclosed inspection report.
Failure on your part to comply within the time specified on the enclosed inspection report will result in a complaint being
sought against you in Salem District Court. Time for compliance begins with receipt of this Order.
Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for
said hearing must be received in writing in the office of the Board of Health within 7 days of receipt of this Order. At said
hearing, you will be given an opportunity to be heard and to present witness and documentary evidence as to why this
Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have
the right to inspect and obtain copies of all relevant inspection or investigation reports, orders and other documentary
information in the possession of this Board, and that any adverse party has the right to be present at the hearing.
Please be advised that the conditions noted may enable the occupant(s) to use one or more of the statutory remedies
available to them as outlined in the enclosed inspection report form.
For the Board of Health: Reply to:
I
t Joanne Scott Virginia Moustakis
Health Agent / � Sanitarian
cc: Licensing Board,Board, Fire Pre✓vention, Building Inspector, & Councillo✓r Kimberly Driscoll
Certified Mail#7099 3400 0009 4093 2362
,JS/sjk c-h-violet
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CITY OF SALEM HEALTH DEPARTMENT
Nine North Street
• Salem, Massachusetts 01970 Page 1 of /
State Sanitary Code, Chapter II: 105 CMR 410.000
Minimum Standards of Fitness for Human Habitation
Occupant : &,ol, SeLz-a C as7- Phone: 7-1y-"o :7i
Address: o 8a zz r—,Y cl Apt.W // Floor ,
Owner: Address: aFy Lac.,lve//z' Lcf
S/i�e�n, �d o�990
Inspection Date: 4(a-6--aooTime: �o
Conducted By: LA� t-6t 0s Accompanied By:l-ic N f
Anticipated Reinspection Date: •sR '� � f �j��„�1!/�PQ
Specified Time Reg.#410.. Violation(S)
N aX
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V4 0S �- 6 .flo 6110 ,5
s--O/ -4-,3 4ea6 CWCA1 -
d, e
Ng L?WW'ef &L14YzAe /hr
4 L!9&
One or more of the above violations may endanger or materially impair the health
rear esv�vrfr�
safety, and well being of the occupant(s) 6oltd/^9 J7e-/°1-
Code Enforcement Inspector /. G' yC�oti�c�c �
k Dai'5 e�t�
Este es documento legal importante. Puede que afecte sus derechos.
Puede adquirir una traduccion de esta forma sies necesario Ilamar al telefono 741-1800.
J
Appendix II (14)
Legal Remedies for Tenants of Residential Housing
The following is a brief summary of some of the legal remedies tenants may use in order to get
housing code violations corrected :
1. Rent Withholding(Massachusetts General Laws, Chapter 239, section 8A): If Code Violations Are Not
Being Corrected you may be entitled to hold back your rent payments. You can do this without being evicted if:
You can prove that your dwelling unit or common areas contain code violations which are serious
enough to endanger or materially impair your health of safety and that your landlord knew about the
violations before you were behind in your rent.
You did not cause the violations and they can be repaired while you continue to live in the
building.
You are prepared to pay,any portion of the rent into court if a judge orders you to pay it. (For this,
it is best to put the rent money aside in a safe place)
2. Repair and Deduct(Massachusetts General Laws, Chapter III, section 127L): The law sometimes allows
you to use your rent money to make the repairs yourself. If your local code enforcement agency certifies that
there are code violations which may endanger or materially impair your health, safety, or well-being, and
your landlord has received written notice of the violations,you may be able to use this remedy. If the owner
fails to begin necessary.repairs(or to enter-into a written contract to have them made)within five days after
the notice or to complete repairs within 14 days after notice,you can use up to four months rent in any year..
to make repairs.
3. Retaliatory Rent Increases or Evictions Prohibited(Massachusetts General Laws,Chapter 186,section
18,and Chapter 239,.Section 2A): The owner may not increase your rent or evict you in retaliation for
making a complaint to your local code enforcement agency about code violations. If the owner raises your
rent to try to evict within six months after you have made the complaint, he or she will have to show a good
reason for the increase or eviction which is unrelated to your complaint. You may be able to sue the landlord
for damages or if he or she tries this.
4. Rent Receivership(Massachusetts General Laws Chapter II, section 127 C-H): The occupants and/or the
Board of Health may petition the District or Superior Court to allow rent to be paid into court rather than to
the owner. The court may then appoint a"receiver"who may spend as much of the rent money as is needed
to correct the violation. The receiver is not subject to a spending limitation of four months'rent.
5. Breach of Warranty of Habitability: You may be entitled to sue your landlord to have all or some of your
rent returned if your dwelling unit does not meet minimum standards of habitability.
6. Unfair& Deceptive Practices (Massachusetts General Laws, Chapter 93A) : Renting an apartment with
code violations is a violation of the consumer protection act and regulations, for which you may sue an
owner.
The information presented above is only a summary of the law. Before you decide to withhold rent or take any
other legal action, it is advisable that you consult an attorney. If you can not afford to consult an attorney, you
should contact the nearest legal services office, which is
Neighborhood Legal Services
37 Friend Street
Lynn, MA. 01902
(781)-599-7730
I�
UNITED STATES POSTAL SERVICE First-Class Mail
•* Postage R Fees.Paid
Permit No. G-10
• Sender: Please print your name, address, and ZIP+4 in this box
WOARD OF HEALTH
ALEM, MA 01370
em Health DepartnlPnt
MAY 2 — 2001 9 North St.
Salem, Mass. 01970 -39L0
CITY OF SALEM
HEALTH DEPT.
I
I
SENDER: COMPLETE THIS iSECTION
Complete items 1,2,and 3.Also complete ed by(Pleas Print early) B. Dat of livery
item 4 if Restricted Delivery is desired., �� 0
Print your name and address on the reverse
so that we can return the card to you. C. Signa ure
Attach this card to the back of the mailpiece, X ❑Agent
or on the front if space permits. EI Addressee
D. Is de rverya ress different from item l? ❑ Yes
1. Article Addressed to: If YES,enter delivery address below: .❑ No
Patricia C. Kessler
284 Lafayette Street
Salem, MA 01970
3. Service Type
XM Certified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑C.O.D.
(284 Lafayette Street BSB) VM 4. Restricted Delivery?(Extra Fee) El Yes
. Article Number(Copy from service label)
7099 3400 0009 4093 2362
IPS Form 381.1,ally 1999 Domestic Return Receipt 102595-00-M-0952
°Sl 'F1�' ) L'
.'k; � x f .Cea*.y'1 1 k. •"4 •t
CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970-3928
JOANNE SCOTT,MPH, RS,CHO NINE NORTH STREET
HEALTH AGENT Tel:(978j 741-1800
Fax:(978)740-9705
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE.'A FOOD ESTABLISHMENT
In accordance with regulations .promulgated under authority of Chapter '
94, Section 305A and Chapter III, Section 5 of the General Laws, to operate
a Food Establishment in the City of Salemishereby granted to:
Owner' s Name: PatriciaKessler
Name of Establishment: Coach House, inn
Address of Establishment : 284, ''Lafayette Street
Type of Establishment: Bed & Breakfast "
Application Date lOf2?f2000 `
Restrictions:
Permit for Food Establishment �. 1-01
Frozen DessertsfIce Cream,
Permit for..the 'Sale of Tobacco.`Products « ` x
These Permits Expire December 31, '2000
..
This permit is not transferable and must be reissued upon change of
ownership or location. In .accordance with the State Sanitary`Code,. all .. '
plans of renovations, improvements, equipment changes must be Approved, y :.
the. Health Department.,,, -
y
qVL
tr HEALTH AGENT
:,
Y -
WED -a'
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CISEMTY
DE T. rn�
CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970-3928
JOANNE SCOTT, MPH, RS, CHC NINE NORTH STREET
HEALTH AGENT ,} Tel'.(978)741.1800
'J[,J Fait:(978)740.9705
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT /9C {�h`�USS �.,//r� TEL# ���� S1a19 2
ADDRESS OF ESTABLISHMENT
MAILING ADDRESS (i€differo,'It) ---.—
OWNER'S NAME ?CG/F¢�� { SG TEL# 2��0 �
ADDRESS R r'' 7 j�66t
CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s)
(required in an establishment where potentially hazardous food is prepared.)
EMERGENCY RESPONSE PERSON_ TEL#
ESTABLISHMENT'S DAYS & HOURS OF OPERATION
TYPE OF ESTABLISHMENT [ { FEE check only
RETAIL STORE YES NO $40
RESTAURANT YES NO #seats_ #nonsmoking_ $40
/3s0 Y-eaE'9,e'Y ' *1910
ADDITIONAL PERMITS
MAKE FROZEN DESSERTS YES NO $5
TOBACCO VENDOR YES NO $10
I{ Please pay total with one check payable to the City of Salem
This permit is not transferable and must be reissued upon change of ownership.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment
changes are made, all plans for such must be submitted to and approved by the Salem Board of
Health.
Pursuant to MGL Chapter 52C, Section 49A, I certify under the pains and penalties of perjury that 1, to my
b> owledge and belief, have filed all state tax returns and paid all state taxes required under the law.
r �D ZZ Qy'2-69�/r j
Signature Date Social Security or Federal identification Number
--------- -------- --- ------– ------ -- - ---- –
Revised;10/20/98 foodap2.adm [' ..,,Check#&Date
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CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970-3928
JOANNE SCOTT, MPH, RS,CHO NINE NORTH STREET
HEALTH AGENT Tei:(978) 741-1800
Fax:(978) 740-9705
October 3, 2000
Stephen & Patricia Kessler
284 Lafayette Street
Salem, MA 01970
Dear Sir/Madam:
In accordance with Chapter 11 of the State Sanitary Code, 105 CMR 410.000, Minimum
Standards of Fitness for Human Habitation, a recent reinspection was conducted of
your property located at 284 Lafayette Street (Bed/Breakfast) conducted by.Virginia
Moustakis, Sanitarian of the Salem Board of Health on September 27, 2000 @ 11:00
am.
The violations noted in the last report have been corrected.
Thank you for your cooperation in this matter.
For the Board of Health Reply to:
Joanne Scott, Virginia Moustakis,
alth Agent Sanitarian
JSlmfp
cc: Licensing Department Fire Prevention Building Department
Councillor Kimberely Driscoll
I =_
.y 4
CITY OF SALEM HEALTH DEPARTMENT
Nine North Street Pae 1 of
Salem, Massachusetts 01970 g
State Sanitary Code, Chapter II: 105 CMR 410.000
Minimum Standards of Fitness for Human Habitation
Occupant : &C4. a Phone: 7yd- yo 9a.
Address: age /A6cwe7*_ S7_ Apt.# 1 16mYns Floor i_a
Owner:,st��„F/� �bne,�lg he<s/ Address:
Inspection Date: 9-A 7-oD Time: or) g7�n
Conducted By: V eatA4ct _kL Accompanied By: \�qdzv 10CLIj
Anticipated Reinspection Date: Ivo , - a-l` dLs 7„r �EVP^'nayt �Ft/cz
Specified Time Reg.#410.. Violation(s)
A / lV_ NC VArtl4tn 4Zd2f, /S
v v
c
tiv " .Z 4,oee a)e.<e 1W v c
0 N d
N'
One or more of the above violations may endanger or materially impair the health
safety, and well being of the occupant(s)
Ins
Code Enforcement Inspector
p • .
Este es documento legal importante. Puede que afecte sus derechos.
Puede adquirir una traduccion de esta forma sies necesario Ilamar al telefono 741-1800:
IMPORTANT MESSA
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MADE IN U.S.A.
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FORM 4009
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NOTES.;
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COURT DOCKET NO. Q CITATION NO.
CITY OF SALEM p,2 7 3 7
VIOLATION NOTICE
NAME(LAST,FIRST,INITIAL)
Kessce,e f c'1,9,
STREETADDRESS CITYr-OWN STATE ZIP
asy 1"5ee CV-
LICENSE NO. LIC.EXP.DATE DATE OF BIRTH
OWNER'S NAME(LAST,FIRST,INITIAL)
P./2 le7el G
S REETADDRESS CITYr-OWN STATE ZIP
a J 777a, p! o
REGISTRATION NO. STATE EXFF.DATE MAKID7YPE YEAR COLOR
DATE O%IOIffy TIME DATE CITATION WRITTEN ves50rvAL
/ CCYY''�� AM INJURY
❑ M �� ❑VES
P
�o2caOi ❑NO
LOCQTION_OFyIOL/yTION E RCI G EPL
OFFENSE CHAP. SECT. FINES
A '0=414v¢e Trp o4fzLrl/ d
q Roo/ Fea —1'711'
B
leu—rime 5-9
C
OFFICER I.D.NO. TOTAL Qp
FINE
' (,f DUE �W
O FICER CERTIFIES COPY GIVEN TO VIOLATOR
❑J�f HANo
X ���✓� LIJ� BY MAIL
DO WIT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY
ORDER OR BY CHECK MADE PAYABLE TO:
CITY CLERK
CITY HALL
93 WASHINGTON STREET
SALEM,MA 01970
TEL.(508)745-9595 X 251
1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON
REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE
PAYMENT IN THE AMOUNT OF
$ CASE H
SIGNATURE
SEE OTHER SIDE FOR FURTHER INFORMATION
ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL
kPjRT DOCKET NO. CITATION NO. .
CITY OF SALEM A�}
VIOLATION NOTICE A2737
1
NAME(LAST,FIRST,INITIAL)
,
STREETADDRESS OTY/TOWN STATE ZIP
' rS PYYC�.J �/l77
LICENSE NO. LIC.EXP.DATE DATE OF BIRTH
OWNER'S NAME(LAST,FIRST,INITIAL)
s.l' L? /�9�/C�/
STREETADDRESS CITY/TOWN STATE ZIP
REGISTRATION NO. / STATE EXP DATE MAKE/TYPE YEAR COLOR
DATGOFfV.QL�TLpf7 TIME � DATE CITATION WRITTEN iwua NAL
I/A9d/17P7 AM �g YES
E3 PM /— -D;PJOJ LINO
LOCk�,ION'O�FI/Or/�Si✓.rL �N E B CXPE OC
abx cam Q/srCJt, �&a/,n i/��6rP
OFFTX/L&W 4 _Z . f� CHAP. SECT FINES
A f�f /1J�
B Sf'A YG JSf,,
C
OFFICER IyD.NO. TOTAL
FINE s &V -9
V //- uSra,'�IS DUE
OFFICER CERTIFIES COPY GIVEN TO VIOLATOR
❑ HAND
X �/Yi BY MA14.
DO NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY 7,
ORDER OR BY CHECK MADE PAYABLE TO:
CITY CLERK
CITY HALL
93 WASHINGTON STREET -
SALEM,MA 01970
TEL.(508)745-9595 X 251
1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON
REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE
PAYMENT IN THE AMOUNT OF
$ CASE#
SIGNATURE
SEE OTHER SIDE FOR FURTHER INFORMATION
ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL
'fib .l y =�''� d � i& _ tr7 . r � - �'e- ,•
ciry_OF SALEM;MASSACHUSETTS
;BOAR D,OF*+HEALTH .- 5
.a 120 WASHINGTON STREET, 4TH FLOOR �e
SALEM, MA 01970 ,
_ TEL. 978-741-1800 w .
FAX 978-745-0343
STANLEY USOVICZ, JR. JOANNE SCOTT, 'MPH, RS, CHO
MAYOR - - HEALTHAGENT
A
. . ti
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter
94 ;, Section 305A 'and Chapter,III, Section 5.• of the General- Laws, to >operate
a Food Establishment. in the City. of Salem'-is , hereby granted to: ^
Owner' s Name: Patricia Kessler
Name of Establishment'S 'Coach House Inn
Address of Establishment 284> Lafayette` Street
Type of Establishment r Bed & Breakfast
Application Date: 12/11/20011
Restrictions:
Permit4for Food -Establishment' r .x 1'83 02f
z
Frozen Desserts/Ice Cream ,
Permit for the Saleof 'Tobacco Products
These Permits Expire Decemberi,31, 2002:.`
This permit is not transferable and must be reissued upon change of
ownership or location. :The permit must be posted in a prominent location
in the Establishment:.
In accordance with the .State Sanitary Code, before any renovations,
improvements, or equipment changes are -made; allplans forasuch must be
submitted to and approved by the Salem Board of Health.
cz ,
HEALTH AGENT
o CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH '
.f 2 • 120 WASHINGTON STREET, 4TH FLOOR ry(q
8 SALEM, MA 01970 ® ; If \11L
TEL. 978-741-1800 6$
FAX 978-745-0343
STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR' + - { - HEALTH AGENT
r, q> IT(OF SALEM
HEALTH D T.
2002 APPLICATION FOR PER//MIT,, TO OPERATE A FOOD ESTABLISHMENT
/ G
NAME OF ESTABLISHMEN1f�0A /T�S� �irwt TEL#
ADDRESS OF ESTABLISHMENT
MAILING ADDRESS if different)
OWNER'S NAME �/� / /L(C%f{ � TEL# 97f
ADDRESS
CITY f17 a?in STATE,-Al,-,91' ZIP
CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s)
(required in an establishment where potentially hazardous food is prepared.)
EMERGENCY RESPONSE PERSON7/IT/Z/G/ SS« HOME TEL
DAYS/HOURS OF OPERATION: Mone. •!tlVed. Thu. c_Fri.=Sat. 4-Sun.
TYPE OF ESTABLISHMENT FEE check only
RETAIL STORE YES NO Q3 -0�} $40
RESTAURANT YES NO U $40
BED & BREAKFAST NO $40r/`
ADDITIONAL PERMITS
MAKE ICE CREAM, YOGURT
SOFT SERVE YES (0 $5
TOBACCO VENDOR YES (�N 10
NO CHARGE FOR NON-PROFIT(such as church kitchens) PLEASE INCLUDE COPY OF TAX
EXEMPT FORM
Please pay total with one check
payable to the City of Salem
This Permit is not transferable and must be reissued upon change of ownership. The Permit must
be posted in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment
changes are made, all plans for such must be submitted to and approved by the Salem Board of
Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my
best kn leda and b i f, have filed all state tax returns and paid all state taxes required under the law.
ignature Date Social Security or Federal Identification number
-- --- - — ---- ------------ -- --- --- - - --- ---------
Revised 11/1/01 foodapZadm Check#&Date "SO - /a%7-D/
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SENDER: COMPLETE THIS SECTION
■ Complete items 1,2,and 3.Also complete A e ived by(Please Wase CI rl) B. Da of very
item 4 if Restricted Delivery is desired. g. ,� J C
■ Print your name and address on the reverse
so that we can return the card to you. C. Signal e f,
■ Attach this card to the back of the mailpiece, X 0.Addre
or on the front if space permits. ❑Adressee
[. Is delivery address different from item 1? ❑Yes
1. Article Addressed to: If YES,enter delivery address below: ❑ No
Stephen & Patricia Kessler
284 Lafayette Street
Salem„ MA 01970
3. Service Type
®Certified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
VIII - 4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number(Copy from service label)
Z 447 277 911
PS Form 3811 July 1999, I i Domestic Return Receipt 10259500-M-0952
UNITED STATES POSTAL SERVICE First-Class Mail
Postage&Fees Paid
USPS
Permit No. G-10
• Sender: Please print your name, address, and ZIP+4 in this box
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BOARD OF. HEALTH
OCT 3 " 2000 §;alerri, MA 91970-3 9a 9
CITY OF SALEM
HEALTHDEPT.
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rIMP®RTANT MESSAGE
FOR f
DATE 02- 5�- O 6 TIME
PHONE -7 7 _ 7lz�l / P-
AREA COOE NUMBER EXTENSION
D FAX
❑ MOBILE
AREA CODE NUMBER TIME TO CALL
( TELEPHONED PLEASE CALL
CAME TO SEE YOU WILL CALL AGAIN
WANTS TO SEE YOU RUSH
RETURNED YOUR CALL WILL FAX TO YOU
MESSAGE &WZd
SIGNED! 00
Wops. MADEI4009 O
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IMPORTANT MESSAGE
FOR
DATE 1, TIME •� .M.
PHONE
AREA CODE NUMBER EXTENSION
❑ FAX
❑ MOBILE
AREA CODE N BER TIME TO CALL
TELEPHONED 'PLEASE CALL
CAME TO SEE YOU WILL CALL AGAIN
WANTS TO SEE YOU RUSH
RETURNED YOUR CA WILL FAX TO YOU -
MESSAGE f
SIGNED
VFWFORM 40
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CITY OF SALEWBOARD OF HEALTH
Salem, Massachusetts 01970-3928
JOANNE SCOTT, MPH,RS,CHO - - NINE NORTHSTREET
HEALTH AGENT Tel:(678)741,1800
Fax:(978)740-9705
June 21, 2000
Stephen & Patricia Kessler
284 Lafayette Street
Salem, MA 01970
F
Dear Owner/Manager:
The Board of Health, Building and Fire Departments are
l: scheduling yearly:.inspection of all establishments
licensed as rooming houses. The Salem Licensing Board
will review inspection and reinspection reports in
accordance with its license renewal procedures..
The inspection will include dwelling units, and common
areas, therefore each tenant must ,be present or he/she .
must sign the enclo§ed'release 'form which will allow the
inspectors to enter' the` unit .
Your establishment 'at 284 Lafayette Street has been
scheduled to be inspected on 'Wednesday July 12, 2000 at
10:00 am.
Thank you for. your anticipated cooperation.
Sincerely,
For the Board of Health
oanne Scott
Health Agent
cc: Frank DiPaolo, Inspector of Buildings
Charles Latulippe, Fire. Prevention
..Harold Blake, Chairman, Salem Licensing Board
F C
9 ;4 � �, �R- � Nt�� 3su�:_ ,�r�h� E j-: ,ice l.•.k�r,. � �'s - -
CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970-3928
JOANNE SCOTT, MPH, RS,CHO NINE NORTH STREET
HEALTH AGENT + Tel:(978)741-1800
Fax: (978)740-9705
MEMORANDUM
To: Stephen & Patricia Kessler
From: Joanne Scott, Health Agent
Date: July 12, 2000
Re: Rooming House Inspection for Coach House Inn
CC: . Frank DiPaolo, Inspector of Buildings, Charles Latulippe, Fire Prevention,
Harold Blake, Chairman, Salem Licensing Board
The rooming house inspection for 284 Lafayette Street on July 12, 2000 at 10:00
a.m. has been rescheduled to September 27,2000 at 10 00 am.
� Y
CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970-3928
JOANNE SCOTT, MPH, RS, CHO NINE NORTH STREET
HEALTH AGENT Tei:(978) 741-1800
Fax:(978)740-9705
MEMORANDUM
To: Stephen & Patricia Kessler
From: Joanne Scott, Health Agent
Date: August 7, 2000
Re: Rooming House Inspection
CC: Frank DiPaolo, Inspector of Buildings, Charles Latulippe, Fire Prevention,
Harold Blake, Chairman, Salem Licensing Board
The rooming house inspection for 284 Lafayette-Street_on Septe_ mber,27, 2000 at
10:00 am has been rescheduled to�S te_mber V, 2000 at 11:00 am per your
request.
i '