EMS - ESTABLISHMENTS S M EAD�
NaH1E�ON
UPC low
smudoom io VW*InUSA
® wru��emuaw
a
'010) 7� City of Salem, Massachusetts
Board of Health
a 120 Washington Street, 4th Floor, Salem, MA 01970
Tel. (978) 741-1800 Fax. (978) 745-0343 PablicHealth
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-15-110
Permit Type: RETAIL FOOD
Goods&Services: Retail Food: 1,000- 10,000 sq ft
Name of License Holder: Eastern Mountain Sports
Name of Food Establishment Eastern Mountain Sports
Address of Food Establishment 1 Vose Farm Road PETERBOROUGH NH 03458
Restrictions:
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: $280.00
Issued: 1/1/2015
Ir` CITY OF SALEM,
MASSACHUSETTS lwblicxeatth
BOARD of HEALTH ......,..,...,...,�.«.
120 WASHINGTON S REEr,4TH Fl.00n
KIMBERLEY DRISCOLL TEL.(978)741-1800 FAx(978)745-0343 LAItRY RAMDIN,RS/REI-IS,CI 10,CP-FS
MAYOR Immdin@salcm.com salem.com HE;\1.1'1-1 Ac&NT
Food Establishment Permit Application
(Application must be submitted at least 30 d''a,,..ys,, before the planned opening date)
1) Establishment Name:
2) Establishment Address: Pct�'q�i`�G �a S�,vn YN'tiq—
3) Establishment Mailing Address(if different): J(DC) Cnr p✓u (e-- (2QIUrF
4) Establishment Telephone No: 15toco
5) Applicant Name&Title:
B) Applicant Address:
7) Applicant Telephone No: 1 24 Hour Emergency No: Email: �IY1
8) Owner Name&Title(if different from applicant): L dJv-5-5 5 L
9) Owner Address(if different from applicant): CI
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
corporam
v ,
nWind'i al' C-G
A partnership
Other legal entity �� T
12 Person Direct) Responsible For Daily Operations Owner, Person in Charge,Supervisor,Manager,etc.
Name&Tide:
Address: 12�� '(Y)a' C> t Q O
Telephone No: qqg tj - l (p(P Fax: Email: ,°.0230 d�
Emergency Telephone No:
13) District or Regional Supervisor(if applicable)
Name&Title:
Address:
Telephone No: 3S3g Fax: Email: �( c
Check#:��_�(LL Date: Amount: `� v
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 1011/2001 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) stablishment Type(check all that apply)
(check one) 5rRetail( 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
( Meals/Day) Breakfast Home
❑ Food Delivery ❑Residential Kitchen for Bed and
21) Length Of Permit: Breakfast Establishments,,,„ ,,,,,,,,,,,,,,,,
(check one) RETAIL STORE RESTAURANT
Annual ❑ Less than 1000sq.ft. $70 ❑Less than 25 seats $140
Seasonal/Dates: E6000-10,000sq.ft. ❑Residential Kitchens $140
❑More than 10,000sq.ft. $420 ❑25.99 seats $280
❑More than 99 seats $420
Temporary/Dates/Time: - ------------6 -------- ------------ --- - - - --------------------------------------------------------------- ------
❑ Bed 8 BreakfastlChildcare 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 time(tempereture controls required)
(check all that apply): RTE—read -to-eatfoods 4 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 howto 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 or Federal ID: t 3'31
26) Signature of Individual or Corporate Name:
773, Rq
# 'N
"M I "K
-�U R�a Z
Z
IA_
A
Y A-
I-K
CW of Salem it
--arcof Realm
t�lumb6
dey-Ddiskdu
rI I
A
FoodfRetail Establlsliment ,i! MDATE PRINTED IP? M
T �_T
Ne
Ol/
t
N?Rr
1W I
SIV
�I-ESTABLISEIMENTWAME-;`
steir�.Mo"tiw,niportsM
Z
8
�p
Farm Koad-�
FileNumber BlIKU 1�-
000021 lk f, I,V ose
go.
r
�11 AM.
�_jw-jy.PETERBOROUGH
'V9 LA-',
aw 4
MW
M
5,
M Iff
WATER
hk 01
SALEMMA'
�Piriift:.T e SPS M ermJ6a.4;_!I"N_ ExiAres Fee
0296t
RETAILFOOD-1— i BHP-2014- z -bW3 1"20i,412't L
el,
.bpi sr- g, $280 00
a"tiL y€ y. T
'rN _2141aT
otfil Fees:,_�
7
w-W
a
FQLII�
u
V
A*
_A
45
V_
7
M
;yQt
pts ? -AW
4t,
101C
jg
PERMIT EXPHiES
ec
1' a - 49
R�
B6ard,6f Heall
e# ek4g
3-W
04 An
U",
K
V 71
_4� ti>
M.
P� —A
ye xfg-
F3, -W
S�
'iriiit is not transferable and Y'
This P oWd,,'
Imi t
Ek,
Restrictions
-
a
iii it prominent iiithe-jksi Establishment. _I
accordanceIn -R,im mcstate Sanit4taae,-.oeotre any ti W,or egwpment changes are made,
211.p'I-R"n's'forsu�c--h-must-b,,-esubinifted-to, 6&approved6 i'Salem Boardof Health
A
g
'.d
3,
ZIP
—A
M
MI RP t.,.
CITY OF SALEM, V
MASSACHUSETTS
BOARD OF HEALTH
120 WA9HiNGTON STREET,4" FLOOR
KIMBERLEY DRTSCOIL TEL.(978)741-1800 FAX(978)745-0343 LARRY RAMDIN,RS f REHS,CHO,CP-F5
MAYOR t,m 1 n air r rrnn HEAmii AGENT
Food Establishment Permit Application
(Application.must be submitted at least 34 days before the planned opening date) .
1) Establishment Name: tt r
2) Establishment Address: o Uo
3) Establishment Mailing Address(if different): p
4) Establishment Telephone No: 18-
5? Applicant Name&Title: o )
8) Applicant Address r t �vV
7) Applicant Telephone No: 24 Hour Emergency No: Email:
8) Owner Name&Tltle(If different from applicant):
8) 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=it_ty
12 Person Directly Res onslble For Daily Operations Owner,Person in Charge,su ervisor,Manager,eta
Name&Title:
Address:
Telephone No: Fax: Email:
Emergency Telephone No.•
13) District or Regional supervisor(if applicable)
Name&Title:
Address:
Tel No: Fax: Email:
Check#: P Date:—4 14
t14 Amount:�l
rooa tstapusnment 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 101/2001 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) 0 Retail( Sq.Ft) 0 Caterer
Permanent Structure 0 Food Service-( Seats) 0 Frozen Dessert Manufacturer
Mobile p Food Service-Takeout 0 Residential Kitchen for Retail Sale
0 Food Service-Institution 0 Residential Kitchen for Bed and
( Meals/Day) Breakfast Home
0 Food Delivery 0 Residential Kitchen for Bed and
21) Length Of Permit: ................. Breakfast Establishments
...........................
(check one) RKTAIL STORE RESTAURANT
Annual 0 Less than 1000sq.fL $70 0 Less than 25 seats $140
Seasonal/Dates: 01000-10,000sq.fL $280 0 Residential Kitchens $140
0 More than 10,000sq.ft. $420 0 25.99 seats $280
0 More than 99 seats $420
TemporarylDatesRme: - ----- --------- ------ -r, -----.... ..-... ......-..------------------------------------------- ---.......
D Bed&BreakfastlChlldcare Services(Nursing Home $100
........._------------------------........--------.._.--.........................------.......................------------.............
ADDITIONAL PERMITS
0 MAKE ICE CREAM,YOGURTISOFT SERVE $25
0 PASTURIZATION $25
0 ALL NON-PROFIT' $25
-Including,church kitchens,state funded childcare 8 whate club
23) Food Operations: Definhlons: PHF-potentially hazardous food(5malemperature controls required)
a I Non-PHFs-non-potentially hazardous food(no dam(femparature controls requlrso
(Check a9 that apply): RTE-ren to-eat foods .sondwkhes,salads,muffins which need no furtherprocessing, -
Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held
Pre-packaged Nam-PRFs for More Than a Single Mal Service
Sale of Commercially Preparation of PRFs 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 Gill
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 ofHealth
Retail Sale of Salvage,Out of Date
or Reconditioned Food Total Permit Fee:
Payment Is due with application
1,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 or Federal ID:
26) Signature of Individual or Corporate Name:
Jar. 2. 2014 1 : 331M No. 1292 P. 4
EASTERN MOUNTAIN SPORTS LLC
LISTING OF MEMBERS AND OFFICERS
Member Vestis Retail Group, LLC
Chief Executive Officer James Petry
Chief Financial Officer Garry Herdler
Vice President, Operations Scott Hampson
Vice President, Finance Daniel Bliss
Secretary Thomas Kennedy
Principal Agent Corporation Service Company
2711 Centerville Road,Suite 400
Wilmington, DE 19808
- )
+� Commonwealth of Massachusetts
m v City,of Salem r F
r+ Board off Health Klmbeiieq DriScoli
s
120 Washington Street,4 Floor Mayo
"SALEM,MA 01970
u ivr,
FDod/Betail Establishment Permit P _
DATE PRINTED:" '.12/19/201231
ESTABLISHMENT NAME: Eastern Mountain Sports. '
File Number BHF-2012-000021'.%' t laVOseFarm Road
ff
PETERBOROUGH # NH 03458 . -
:.LOCATED AT.
SALEM, MA- 01970
Permit Type Permit No.' Permit Issued Permit Expires:' Fee Restrictions/Notes ' V- '
RETAIL FOOD ,- BHP-2013-0258 Jan 1,2013 Dec 31,2013 $280.00
Total Fees{ $280 00"
n s
35
54
3_ Y�f
- m -
n a.
Yi
',PERMIT EXPIRE 16ecember 31,_2013;a
Board of Health
.d
a 5
f� _ iR01
'r•r _
y.
This Permit is not transferable and musi 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, 'Z
all plans for such must be submitted to and approved by the Salem Board of,Health. page 1, 41
a
a -
CITY OF SALEM, lu
MASSACHUSETTS
�tf�xeattn
BOARD OF FIF A1,11-1
120 WAST nNGTON S11tr..iaT,4O1 FLOOR
KIMBERLEY DRISCOLL Tiai-(978)741-1800 FAX(978)745-0343 LARRY RANIDIN,RS/REFIS,CFIO,(P-FS
MAYOR - lramdit g salerax Hi;AL;LI-I AG ENP
Food_Establishment Perm it_Application
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name: — �p
2) Establishment Address: q Pq� �, . mA G 0
3) Establishment Mailing Address(if different): ' 11 5
4) Establishment Telephone No: - :599 -
5) Applicant Name&Title: jILLQ-
i,
6) Applicant Address: i C)� fRA K) -;S4 59'
7) Applicant Telephone No:603-I'a,4- Ick i 24 Hour Emergency No:(a63- S�W6 Email:
8) Owner Name&Title(if different from applicant): Lc sVeT
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
�CA-corpora
al CL 1 i
A partnership
Other legal entity
12 Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor,Manager,etc.
Name&Title: C o ox fie. MckAmazE
^
Address: � 3 1f' q�S
Telephone No: -'7 4 5q Fax: Email:
Emergency Telephone No: - w - ,y5
13) District or Regional Supervisor(if applicable)
Name&Title: ,_TI ( n �j �St tC� (y
Address: Vasa }CIC m f Ul
Telephone No: J - L40 Fax: Email:
CheckS?Lb Date: �CT ��/ /� Amount:
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): 0 Yes No
20) Location: 22) Establishment Type(check all that apply)
check one $Retail( Sq. Ft) ❑ Caterer
ermanent Structur ❑ Food Service-( Seats) 13Frozen Dessert Manufacturer
o I e ❑ Food Service-Takeout ❑ Residential Kitchen for Retail Sale
❑ Food Service-Institution ❑ Residential Kitchen for Bed and
( Meals/Day) Breakfast Home
❑ Food Delivery ❑ Residential Kitchen for Bed and
21) Length Of Permit: Breakfast Establishments-----------------------
------------- -- -------
(check one) RETAIL STORE RESTAURANT
Annual 0 Less than 1000sq.ft. $70 D Less than 25 seats $140
Seasonal/Dates: 1000-10,000sq.ft. $280 ❑ Residential Kitchens $140
❑ More than 10,000sq.ft. $420 1125-99 seats $280
❑ More than 99 seats $420
Temporary/Dates/Time: ------------- -- __--"-- -- ---- --------------- ------in--------- -----------------
❑ Bed&Breakfast/Childcare Services/Nursing Home $100
-------------------
----------------------------------------. - --------------------------- -
ADDITIONAL PERMITS
❑ MAKE ICE CREAM,YOGURT/SOFT SERVE $25
❑ PASTURIZATION $25
❑TOBACCO VENDOR $135
11 ALL NON-PROFIT $25
(Including, church kitchens, state funded childcare&private clubs)
23) Food Operations: Definitions: PHF-potentially hazardous food(time/temperature controls required)
Non-PRFs-non-potentially hazardous food(no timeltemperature controls required)
check all that apply):- RTE-ready-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 V 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 a 00
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 howto 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 1,to my best knowledge and Belief,
Have filed all state tax returns and paid state taxes req�u�irredd under law..
25) Social Security Number or Federal ID: 13 - "J'1._VM3 0 5/�-t ` _ _ < _ _
26) Signature of Individual or Corporate Name: toSt�% V1`�'Io.tlhfAAJ 1 �!X�r�_S
I
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,0 Floor
Division of Food and Drugs Salem, MA 01970-3523
Tel. (978) 741-1800 Fax(978) 745-0343
City/Town of Address:
FOOD ESTAE)LISHMEfqf INSPECTION REPORT Tel.
Name Date Type ofOperation(s) Type of Inspection
❑ Fo ervice [4} ttine
Address Risk etail ❑ Re-inspection
Telephon Level ❑ Residential Kitchen Previous Inspection
❑ Mobile Date:
Owner aci [ITemporary ElPre-operationHACCP YIN_ ❑ Caterer ❑Suspect Illness
Person-in-Charg (PIC) Tim ,qr Li Mirr/eg' st LJ General Complaint
Inspector In:M SGS Permit Naf"' E]OtherCP
Out:
Each violat" checked requirean explanation on the narrative age(s)and a citation of specfflfic provision(s)violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors-(Red
Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑
Allergen Awareness 590.009(G) ❑
corrective action as determined by the Board of Health.
FOO D:PROTECTION MANAGEMENT' _ ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
.. a,. , ❑ 13. Handwash Facilities
EMPLOYEE HEALTH
PROTECTION FROWCHEMICALS
El _
❑ 2. Reporting of Diseases by Food Employee and PIC
14.Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded
-
FOOg ..OM APPROVEDSOURCE.. - _ _ a ❑ 15.Toxic Chemicals
rFR
❑ 4. Food and Water from Approved Source ,TIMErrEMPERATURE:CONTROLs(Potentially kaaardousFoodoI
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling
.PROTECTION FROM CONTAMINATION - _ _ _ " ❑ 19. Hot and Cold Holding
❑ 8. Separation/Segregation/Protection ❑20.Time as a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing rREQU1REMENT,S FOR HIGHLY-$USQEPTIBLE=POPULATIONSI(HSP)�
❑10. Proper Adequate Handwashing ❑21. Food and Food Preparation for HSP
El11.Good Hygienic Practices `CONSUMER ADVISORY -
El22. Posting of Consumer Advisories
Violations Related to Good Retail Practices-(Blue Number of Violated Provisions Related
Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22):
of Health. Noncritical(N)violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health.
C N 590.000/federal Food Code.This report,when signed below
23. Management and Personnel (FC-2X590.003) by a Board of Health member or its agent constitutes an
24. Food and Food Protection (Fc-3X590.004) order of the Board of Health. Failure to correct violations
25. Equipment and Utensils (FC-4X590.005) cited in this report may result in suspension or revocation of
the food establishment permit and cessation of food
26. Water, Plumbing and Waste (FC-5X590.006) establishment operations. If aggrieved by this order,you
27. Physical Facility (FC-6X590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7X590.008) and submitted to the Board of Health at the above address
29. Special Req ' ments (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION:
S flaoc
Inspector's Signatur Print: "
im
PICsSignature: Print: 2 ,a �,^ Page�ofges
,
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT 13 Crass-cimal Foodn
1 590.003(A) Asia memofResponsibility* 3-302.11 Raw Animal Foods Separated from
--�i e Cooked and RTE Foods*
590.003(6) Demonstration of Knowledge"
Contamination from Raw Ingredients
2-1.03.11 Person in change-duties 3-302.1l(,A)(2) Raw Animal Foods Separated from Each
Other*
EMPLOYEE HEALTH Contamination from the.Environment
2 590.003(C) Responsibility of the person in charge to 3-302.1.1(A) Food Protection*
require reporting by food employees and 3-'02 15 Washin Fruits and Vegetables
applicants* 3-304.11 Food Contact with Equipment and
590.003(F) Responsibility Of A Food Employee Or An Utensils*
Applicant To Report To The Person In Contamination from the Consumer
Charge* 3-306.14(A)(B) Returned Food and Reservice of Fuad*
590.003 13 Reporting by Person in Charge* Disposition ofAdufterated or Contaminated
3 59Q 003(D) Ez'elasion and Restrictions* Food
590,003(E) Removal of Exclusions and Restrictions 3-701.]t Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Food*
4 1 Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Compli:anee wnb Food Law* 4-501.111 Manual Warewashing-Hot Water
3-201.12 Food in a Hermetically Sealed Container* Sanitization TeLnEratureo,
3-20L 13 Fluid.Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water
3-202.13 Shell Eggs* - Sanitization Temperatures*.
3-202.14 �lk Products,Pasteurized* 750I.114 - Chemical Sanitization-temp.,pH,
3-202 MPotable 16 Ice Made From Drinking Water* concentration and hardness.*
5-101.11 Driukin Water from tm Approved System* 4-601.11(A) Equipment Food Contact Surfaces and
590.006(A) Bottled Dnnkm r Water' Utensils Clean*
4-60'_.1.1 Cleaning Frequency of Equipment Food
- 590.006,(B) Water Meets Standards in 31.0 CMR 22.0"` Contact Surfaces and Utensils*
Shellfish and Fish From, an Approved Source
4-702.11 Frequency of Sanitization of Utensils and
3-201.14 Fish and Ree eafianally CaupJ t Molluscan
Shellfish* Food Contact Surfaces of Equipment*
4-703.11 Methods of Sanitization-HotWaterand
3-201-15 Molluscan Shellfish from NSSP listed Chemical*
Sources* 10 Proper,Adequate Handwashing
Game and Authority
f4tsority oams Approved by 2-301.11 Clean Condition-Hands and Arms*
Re utafo Aufhcrity
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure*
590.004(C) Wild Mushrooms*- 2-301.14 When to Wash*
3-201.17 Game Animals* Il - Good Hygienic Practices
a Receiving/Condition 2-401..11 Eating,Drinking or Using Tobacco*
3-202.11 PHFs Received at Proper Tem ramres* 2-401.12 . Discharges.From the Eyes,Nose and
3-202.15 Package lute,it * - Mouth*
3-i0i'l l _ Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting*
6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination.from
3-203.1.2 Shellstock Identification Maintained* Em to es
Tags/Records:Fish Products 13 Handwash Facilities
3-402.1 t Parasite Destruction*
Conveniently Located and Accessible
3-402.12. Pkeccmds,Creation and Retention*
5-203.11 . Numbers and Capacities* -
590.004(l) Labeling of Ingredients* 5-204.11 Location and Placement*
5-205.11 Accessibility, ration and Maintenance
� Conformance with Approved Procedures -
1HACCP Plans Supplied with Soap and Hand Drying
3-502.11. Specialized Processing Methods* Devices
3-502.12 Reduced oxygen packagmj,criteria* --6-301.11 Handwashing Cleanser,Availability
8-103.12 Conformance with Approved Procedures* - 6-301.1.2 Hand Drying Provision
Denotes critical new in the federal 1999 Paid Code or 105 CMR 590.0W.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: Date: ID&& Page:_--f-,�- of
Item Code C—Critical Item UESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No, Reference R-Red Item -Verified
PLC: SEP INT CLEARLY
Wv
1440 LL�
i
Discussion With Person in Charge: Corrective Action Required: o o Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance Cl Employee Restriction
inspection, to observe all conditions as described, and to Exclusion
violations before the next ins
p ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty- ollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
(Q�j l2pt ❑ Voluntary Disposal ❑ Other:
i
r3-501.14(C) PHFs Received at Temperatuve,: -
�, Violations Related to Foodborne 111nesainterventions and Risk According to Lew Cooled to
Factors(items 1-22) fCont.) 41=Ft45`F Within 4 Homs.
3-501.15 CoobnE Methods for PHFs
PROTECTION FROM CHEMICALS 1g PHF Hot and Cold Holding
' 14 Foal or Color Additives
3-501.16(B) Cold PILPs Maintained at or below
3-202.12 Additives* 544.004{171 41°145`17*
3-342.24 Protection from Unapproved Additives* 590.004(F)
Hot PHFs Maintained at or above
} 15 Poisonous or Toxic Substances _ 1400P
7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 13WF.
Containers* 24 Time as a Public Health Contras
7-102.11, Comment Name-Working Containers* 3-501:19 - Time as a Public Health Control*
7-201.11 Se ation-Stora e* - 590.004(H) Variance Requirement
7-202:11 .Restriction-Presence and Use -
7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 'Toric Containers-Prohibitions* POPULATIONS MSP
7-204.11 Sanitiiem.Criteria-Chemicals* 21 3-801.i I(A) Unpasteurized Pre-packaged Iuices and
7-204.12 Chemicals for WashingProduce,Criteria* :Beverages with Warning Labels*
7-204.14 Drying Agents.Criteria'
3-801,11(B) Use of Pasteurize l Eras*
7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and
7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.°
7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served,
7-206.I3 Tracking Powders,Pest Control and
Monitorin *
CONSUMER ADVISORY
TIPAElE EMPERATURE CONTROLS 22 3-643.11 Consumer Advisory Posted for Consumption of
16
Proper Cooking Temperatures far Animal Foods That are Raw.Undercooked or
PNot Otherwise Processed to Eliminate
3-401.11A(1)(2) Eggs- 155`F 15 See.
patho ens.*mxs re yr zaor
! 3-302.13. Pasteurized Eggs Substitute for Raw Shell
,
E .Immediate Service 145o F15sec*
I' 3401.11(A)(2) r Comminuted Fish.Meats&Game Eggst
_
Animal's-155°F 15 see." SPECIAL REQUIREMENTS
3.44I.11(B)(I)(2) Pork and Beef Roast-130°F 121 min*
" 3 d4i.11(A)(2) Ratites,Injected Meats-155`17 IS 590'004(A)-(D) Violations of Section 594.009(A)-(D)in
see.* catering,mobile food,temporary and
3_401,11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be
Stuffing Containing Fish,bleat, debited under the appropriate sections
Poultry or Ratites-165017 15 sec.* above if related to foodborne illness
3401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
145°F* 590.009 violations relating to good retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited tender#129-
Microwave 165`F* Special Requirements.
3-401;11(A)(1)(b) All Other PHFs-145 F 15 sec.
i9 Reheating for Hot Holding VIOLA77ONS RELATED TO GOOD RETAIL PRAC77CE'S
3403.41(A)&(D) PRFs 165"F 15 see. * (Items 23-30)
3403.11(&) Microwave 165"F 2 Minute Standing Critical,and non-critical violations,which do we relate to the
Time* foodborne illness interventions and risk factors listed above, can be
3-403.11(C) Commercially Processed RTE Food- found in the follo»dng sections of the Food Code and 105 CMR
1400i x 59(1.000.
3403AHE) Remaining Unsliced Portions of Beef from j GoadRetail Practices
540.oatl
Roasts'; 23. 1 Manaaament and Personnel FC-2 .443
1=8Proper Cooling of PHFs 124. Foo!and Food Protection FC-3 .0 A
25. 1 Equipment and Utensils I FG-4 .465=
3-501.14(A) Cooling Cooked PHF%from140`Fto ! 26, -Water.Plumbin and Waste --_i FG-5 .M6
70°F Within 2 Hours and From 70°F 27. I Physical Facility
to 41`F/45°F Within 4 Hours.* 1 28. ' Poisonous or Toxic Materials ' FC 7 .048
I'F 3-501.14(6) Cooling PHFs Made From Ambient C 29. Special R uiremems ? -009
Temperature ingredients to 41`F/45`F ' I Oilier
Within 4 Hours* ss�csm :�zc:
Dmoce critical mai in the federal 1499 Feed Cale a'143 C-MR 594.004.
Commonwealth of Massachusetts
City of Salem
Board of Health Kimberley Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Foo"etail Establishment Permit
DATE PRINTED: 04/27/2012
ESTABLISHMENT NAME: Eastern Mountain Sports
File xuaber:BHF-2012-000021 I Voile Farm Road -. -
PETERBOROUGH NH 03458
LOCATED AT
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions 1 Notes
RETAIL FOOD BHP-2412-0437 Apr 27,2012 Dec 3:1,2012 $280.00
Total Fees: $280.00
PERMIT EXPIRES ecember 31, 2012
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 1
CITY OF SALEM10
,
MASSACHUSETTS
Public Health
BOARD OF HEALTH
120 WASHINGTON STREET,4-1 FLOOR
KIMBERLEY DRISCOLL TEL.(978)741-1800 FAX(978)745-0343 LARRY RAMDiN,RS/RENS,CHO,CP-FS
MAYOR Iramdirasalem.com HEALTHAGENT
Food Establishment Permit Application
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name: - f k-
2) EstablishmentAddress: QaXaAX'L'��d rnfy 1910 4z'-4-cl
3) Establishment Mailing Address(if different): P µ
4) Establishment Telephone No:
5) Applicant Name&Title: C }
6) Applicant Address: ` Tw \_ _ r u 1�5�
7) Applicant Telephone No: -9 7y 7 24 Hour Emergency No: 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.
sociation Name Title Home Address
co
An individual
rvidual i %-in-70rCEO t 0--' Fall
A partnership NC,,
Other legal entity
U UNCkoN
12 Person Directly Res onsible For Daily Operations Owner, Person in Charge,Supervisor, Manager,etc.
Name&Title: Q,
Address: o, ro,diSsz ,V`A tL%t - 4 aa.9
Telephone No: Fax: Email:
Emergency Telephone No: - '1459
13) District or Regional Supervisor(if applicable)
Name&Title: LAX
1 1 1
Address: Pd zcXCl
Telephone No: (OU Fax: Email:
� 73��
1
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 !St Retail( Sq. Ft) ❑ Caterer
ermanent Structure ❑ Food Service-( Seats) ❑ Frozen Dessert Manufacturer
Mobile ❑ Food Service-Takeout ❑ Residential Kitchen for Retail Sale
❑ Food Service-In'stitution ❑ Residential Kitchen for Bed and
( Meals/Day) Breakfast Home
❑ Food Delivery ❑ Residential Kitchen for Bed and
21) Length OfPermit: --------- ............ •--------•-----•--•-•-•--.................................Breakfast Establishments
' (check one) RETAIL•STORE RESTAURANT
Annual 13 ss than 1000sq.ft. $70 0 Less than 25 seats $140
Seasonal/Dates: V000-10,000sq.ft. $280 13 Residential Kitchens $140
0 More than 10,000sq.ft. $420 I 1325-99 seats $280
t 13 More than 99 seats $420
Temporary/Dates/Time: 0 Bed&Bebm6w&wcare Services 7Ng Hom
------------------------------------- ----------------------
ursine $100
ADDITIONAL PERMITS
0 MAKE ICE CREAM,YOGURT/SOFT SERVE• ' •$25-
El TOBACCO VENDOR $135
<' 13 ALL NON-PROFIT $25
(including,church kitchens, state funded childcare 8 private clubs
23) Food Operations: Definitions: PHF-potentially hazardous food(timettemperature controls required)
Non-PHFs-non-potentially hazardous food(no timeNemperature controls required)
check all that apply): RTE-ready-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 I 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
A 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 t .Animal.Origin
Perishable Foods Only
Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered
Retall'Sale Events or Institutional Food Service
Offers RTE PHF in Bulk Quantities
To be completed by the Board ofHea/th
Retail Sale of Salvage, Out of Date
or Reconditioned Food Total Permit Fee: of Qll).
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. n ' • _ - -
24) Signature of Applicant: �al LGCJiI�
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 or Federal ID: 3rr'__�__]``�,GQyt5� A 1�
26) Signature of Individual or Corporate Name: GC..&s n t 1 " I lx_V�L �1�