The URL can be used to link to this page

FIRST BAPTIST CHURCH - ESTABLISHMENTS First Baptist Church 4 (56 Federal Street) . �lll a'`s 'a UPC 10230 No. Hl§,3 HASTINGS,MN a 7y�"- TTPf:i,t/ a- � i + 1. k a ''••,�, ca ` ° '.am*2'" #' _�,' ` ria r? - 3. r° „ es� ' a A, Commonwealth of MassachusettsQm e � CUy of Salem` � � , 3 imbe y Dnscol Board of Healthy Al - � * Mayor Washington Street;4th Floor , k rr w71- �z s �SALEIVI;MA"01970} x'y'<"�j2-'"i- .[ �`m' ..,�, ems" � �� Ftiod/Retail Estabhslith tON Permit _ P-OA EPRINTED � 12/13/20121 # a � � 24 j `xzti,.�'` i e"`s'- -g " TM r`�' x W1u — 0E E ,-:- ' F►rA BaP ttst Church k MENTNAESTABLISH 292 Lafayette Streeter �-0 .-* , File Number BHF 2009 000019 s p p. . � -s �, s _ r e 3 MA 01970 SbA =.M t 3 K ,� "rT rk SALEM, MA 01970 � i? g� " �,;Pernut No. Permit Issued x Permit Ezp�res Fee3Restnctions 6:Notes� d A�fi �.PermltT p_e r 3= b BHP 2013 0177 Jan 1,2013 >Dec 31;201-, � � r FOOD SERVICEtg ESTABLISIBvIENT N as $2500 � r,. oFees tal pixx lea fi " 3{"v g ,``, y# m xi,`' �" � a z tea, 3 s a r '•�`'-'z ,.5i � J�v mp }a _'3' E k' au .�.g w• y Tgr`,.,, yT ^n".m,�" at, L or pt Mi Wo T ' a s sus �m$*t`el, a"+ =` '` PERMTT EXPIRES D&6iiber 31;2013 t 77 V Board d Health � •. e� a ' v @F 410 � IW 6+., a ""n" °"r S g ^,� r'.^v" '� T y .dA'%. x8._Gs;r r' * This Permit is not transferable and must be reissued upon chap a of ownership or location The perirut must be posted-W s m a prominent Location in the Establishment , n = ment chan es aKA Rre madA; In accordance with the State 6amtary�Code, eoov d b the Salem Boa Pd of Health o mpA�� 9Page t r a►►plans for such must be submitted tond aper Y Ts �� o - ° 'sn �� 4� �`�' t?a5 '�•� � fl��a� '��f .,Ty �- Cty My�y^ vi. ' � � :: � '"K'.{ � ,b i^ �i -.1Tfi'�tfi`� � "e� ^ n^ CITY OF SALEM, MASSACHUSETTSrHeaft, BOARD OF HVAJ rH - -. - 120 WnstIlNGroN Mui--in"4"�FI, Rf IIS,CI IO,(:1'-1''S a AIiRY.IL\RIDIN,Rti KIiIBERLEY'DRISCOLL - TI:l,.(978)741-1800 FAx(978)745 MAYOR` - lcaindin salem.com' / HI,flL771 AG I,N'1' _ DEC 2112012 _. Food Establishment Perm•i &ation (Application must be submitted at least 30 daysAi.QQF -Wanned opening date)., 1) Establishment Name: AA � 2) Establishment Address: � 1,2 7 . - LP�LC_ /w/� G`j70 3) Establishment Mailing Address(if different): 4) Establishment Telephone No: 790 5) Applicant Name&Title: I/-o e¢5 Uee� 6) Applicant Address: /'1, ed Ale rl 7) Applicant Telephone No ,Z- , .24 Hour Emergency No: ,qM t' Email: c 8) Owner Name&Title(if different from applicant): 9) Owner Address(if different from applicant): , 1b) 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 tjA corporation //`�'� '' // ,� / _ / J C An individual IV A)IC l_Uil9, a �d e-rx&- 00 0 n '4'c' & �1 A partnership E oGh n/ �/+51�/�2 75 /�/e• 0 Other legal entity 12 Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor,Manager,etc. Name&Title: ezl), P m P L41S Address: J r vG p✓ -6 G✓O!"l &A Telephone No: i7 fl '7 -3.7.-ASO Fax: Email: Emergency Telephone No: G-2) 33- S2-S' 13) District or Regional Supervisor(if applicable) Name&Tiiie: Address: 'Telephone No: Fax: Email: Check#:y 7y Date: 7 /O 2/9<li Amount: �zS:GO AR 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) PersortTrained 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) D 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 0 Less than 1000sq.ft. $ 70 ❑ Less than 25 seats $140 Seasonal/Dates: 13 1000-10,OOOsq.ft. $280 ❑ Residential Kitchens $140 „ ❑ More than 10,000sn.$.. $420 . .� _ 4 25-99-seats - $280'. ❑ More than 99 seats $420 --- --- - -- ------ ----- --- -- ---- -- ------ ----- ------- -- - - --- Temporary/Dates/Time: - -- --- - - -- - ❑ Bed&BreakfasUChildcare Seryices/Nursing Home $100 ----------------------------------------------------------I------------------------------------------------------------------------ ADDITIONAL PERMITS ❑MAKE ICE CREAM, YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 ❑TOBACCO VENDOR $135 ❑ALL NON-PROFIT $25 (Including, church kitchens, state funded childcare 8 private clubs 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-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 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- fcetaii 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 foodestablishment operation,will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how toobtaincopies of 105 CMR 590.000 and the Federal Food Code. - 24) Signature of Applicant: �.a+ / ti •- Pursuant to MGL Ch. 62C, sec.49A, I certify under the penaltie f perjury that 1,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law.fi \ 25) Social Security Number or Federal ID: lJ�FZ - -S�3 �l LX � A)to) 26) Signature of Individual or Corporate Name: A? K114�_N1101z, �A ilth4Maisicfiu tti ko 41-iX.,7 W ��Cofdlflonwe S-alemlw-j,—�ii- e '-BW ard of Health 4, Of K %*120-WAshingtoft Strect.".. q V 10- 197 g, k�:, 'Si P ,Temporary F66dT6rfiiit YI 37lK Nu DATE PRINTED-.' 0W10/2612y �, ,% R v N't �4M 4 --u L L First,Baptist.Cliuirch— ESTABLISHMENT NAME:- File Nijjrba.��BHF-2009-000619W..� 292 Lafayette Street r, W'. A k, v X R -4 MA �01970' W I �Pl I -4q,5- �� LOCATED AT -Lill ilk ?SALE 1, 01,970 4 M, MA" U4�� X, t PermitE FoCRestricti6ini blN6tes Notes p TEMPORARY FOODAu0582'�'- §Aug-11;2012,z Ae. ug 12 2012� $0.00 E-VENT:,Essrx&re'et Fair - ' if 't LUL;A1-1U1N:Essex -Street FOOD A A� --*1 ON 'X-f TO'SD'Fi"Piavr r ESERVE M Soda ad t— Sull ;-water " Notal at 0 00- Al wozw RK k, UN 4v q� �1, W '10 -P- tn ju STS IVtM,V, 4--,ek -7, m4 iV!F4 `a xIV 4, fl— 4. V� W re— IN 0 V'� •NIV 'Z g, 4 lz�- PERM+T—,EXPIRFS7tv, K cl, NW Board Of R61tVN- x 4-A OWL- k- f F OM� z" -IM f-I t lot A 3t _WV X� Z-0 s W�f V14 'YsT 0 11 C, g, ms`s 'OW sM i,Y p A, F W O a t5 r N Church Weekly Activities- Church School-Sunday at 9:00 a.m. n v o 0 W .� m Morning Worship- 10:30 a.m. i ^n 1 _ (September thru June) Summer Worship- 10:00 a.m. , (Mid June to second week in September) i Bible Study-Wednesday at 6:30 p.m. ° CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4"'FLOOR TEL. (978) 741-1800 KIbII3ERLEY llRISCOLL FAX(978) 745-0343 MAYOR Iramdin o salem.com LARRY RANIDIN,RS/RHI-IS,CI[0,CP-ISS HEAL:ITE I AGNT CHECK PAYABLE TO THE CITY OF SALEM.NO CASH FEE: NON-PROFIT=$25 1-3 DAYS=$300 4-7 DAYS=$600 OVER 7 DAYS=>7 DIVIDED BY 7 X 600=THE AMOUNT DUE (EXAMPLE: 14 DAYS DIVIDED BY 7=2 X 600=$1200 APPLICATIONFOR A TEMPORARY FOOD SERVICE PERMIT NAME OF EVENT LOCATION�CJFJJ CTf DATES)OF EVENT Oy NAME OF APPLICANT '� TELEPHONE# '��'X ' T7"/-�7Q( ) ADDRESS mc, NAME OF BUSINESS ��'fl t^�� TELEPHONE# ADDRESS CERTIFIED FOOD MANAGERS NAME: .CERTIFICATION#: *A PLAN OF THE ESTABLISHMENT FOR THE EVENT MUST BE ATTACHED TO COMPLETE THIS APPLICATION* FOR ESTABLISHEMNTS OUTSIDE OF SALEM.MA: `A COPY OF THE CERTIFIED FOOD MANAGER'S CERTIFICATE AND ESTABLISHMENTS PERMIT MUST BE ATTACHED TO COMPLETE THIS APPLICATION TYPE OF REFRIGERATION: GAS ICE' DRY ICE _OTHER METHOD FOR COOKING/HOT HOLDING: - GAS OTHER METHOD FOR SANITIZING: CHEMICAL 'OTHER SOURCE OF FOOD: NAME: ADDRESS FO TO BE SERVED INCLUDING INGREDIENTS AND METHOD OF PREPARATION: .. I H E READ T E BOARD OF H LTH,"REQUIREMENTS FOR TEMPORARY FOOD ESTABLISHMENTS."I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS REGARDING THOSE REQUIREMENTS. I UNDERSTAND THEM,AGREE TO ABIDE BY THEM AND UNDERSTAND THAT FAILURE TO DO SO WILL RESULT IN REVOCATION OF MY TEMPORARY FOOD ESTABLISHMENT PERMIT. - PURSUANT TO MGL C62c,S49A,I CERTIFY UNDER THE PENALTIES OF PERJURY THAT 1,TO MY BEST KNOWLEDGE AND BELIEF,HAVE FILED ALL STATE TAX RETURNS AND PAID ALL STATE TAXES REQUIRED UNDER LAW. SIGN T E /) D E SOCIAL SECURITY E ERA �j , =Lc5WDS = - -= - ' •• CIti=CKp: DATE AMOUNT PAD: APPROVED BY: DATE: TFI.IDAD01 1!1_1 i nnn I IDn ATCn A/1 x/11 Guidelines for Temporary Food Vendors In order to ensure that safe and sanitary foods are served to the public, your temporary food permit is issued based on the following conditions: • Your Certified Food Manager certificate, temporary food and propane permits (if applicable) must be conspicuously displayed on site. • Only the foods stipulated on your temporary food permit may be sold. • Foods must be obtained from an approved commercial source. Proof of source such as boxes, receipts etc. must be on site. • All potentially hazardous foods such as hot dogs, commercially pre-cooked sausages, hamburgers, prepared vegetables, must be maintained either above 140°F or below 417. • Only mechanical refrigeration or crushed / cubed ice is allowed as a cooling medium. Foods shall not come in contact with water or undrained ice. Packaged foods may not be stored directly in ice if it is subject to the entry of water. • Cooking temperatures are as follows: § Commercially pre-cooked products -140°F • All foods, drinks and condiments shall be handled and stored in a manner that prevents contamination such as using clean covered containers, storing equipment and food up off the ground etc. Trash bags are not to be used for food storage. • Running water with liquid soap and disposable paper towels for hand washing must be available and set-up prior to food preparation. Bottled water with a pull out spout is acceptable. Check with the Health Department for other acceptable methods. • All food handlers shall wash their hands after utilizing the toilet facilities, smoking, eating, changing tasks, and changing gloves or when hands become contaminated. All wrist jewelry and adornments must be removed. • Bare hands may not contact ready-to-eat foods. Suitable utensils shall be used such as deli tissue, spatulas, tongs, single-use non-latex gloves etc. Bare-hand contact shall be minimized with foods that are not ready-to-eat. • All equipment, utensils, containers etc. shall be in clean, sanitary condition. Where there are no warewashing facilities obtainable, a spare set of work utensils shall be available. • All carts must be thoroughly pre-cleaned before set-up at the event. • People handling the food shall wear clean outer garments, hair restraints, and utilize good hygienic practices. • Vendors licensed to sell scooped ice cream must store scoops individually in each tub of ice cream or provide dipper well with running water • Smoking is prohibited within 10 feet of a cart or food storage area. Employee must wash their hands thoroughly with soap before returning to work. • Garbage and refuse shall be disposed of in a satisfactory manner. The premises shall be kept clean. • A stem type of thermometer that has been properly calibrated must be available for testing potentially hazardous foods on site. The thermometer must be cleaned and sanitized before and after use in a manner approved by the Health Department. Refrigerated units must have thermometers I ` • A labeled spray bottle of sanitizer prepared at proper concentration must be on site and used on all food contact surfaces, utensils etc. Proper concentrations should be determined with pH papers. Concentrations are as follows: § Chlorine sanitizer: 50— 100 PPM § Quaternary sanitizer: 200 PPM If any of these conditions are not set-up and maintained, your temporary food permit will be immediately revoked and you will be ordered to stop serving food. If you have any questions regarding the above conditions, call the Salem Board of Health at 978-741-1800 prior to the event. I ve read understood ltnd agree to adhere to the above conditions. Z Permit Holder bate 'Jill CHAMBER of COMMERCE 26 Essex Sftet Salem,MA 01970 9711-794-000-4 August 1, 2012 Dear Vendor Thunk you for participating in the Chamber's annual Essex Street Fair to be held on Saturday, August 11;and-Sunday;--August 12,-2812. _. Please observe the following: • Please plan to arrive at the Fair between 8:00am-10:00am to,set up your 10' space.(We ask that you refrain from hanging items from your tent cover.) • Chamber employees will be available on-site to assist you in locating your space. The Chamber registration table will be set up in front of the entrance to the Peabody Essex Museum. You may drive your car Saturday onto Essex Street between 8:00am and 10:00am for set up. Please note that the breakdown time is 6:00 pm on both days. In order to avoid traffic congestion on Essex Street,we ask that you find your space assignment, unload your vehicle, and park immediately. Please DO NOT set up with your car on Essex Street.We have over 50 vendors assigned and we need your cooperation with this in order to open the Fair by 10:00am. • Please note you may want to bring a trash bag for removal of your trash items. There is no trash removal for vendor trash, and we are not allowed to throw empty boxes or oversized items in the street barrels. Attached you will find a map of the entire downtown area, and a space assignment for your table or tent www Your space assignment is: Please note that the Chamber reserves the right to change space assignments. We recommend all-day parking available at the Museum Place Garage on New liberty Street(off Church St)or the Church Street lot. If you have any questions or concerns, please call the Chamber at(978)744.0004. We look forward to seeing you on the 11 Sincerely, iThe Salem Chamber of Comm ff" Twig i www salem-chamb+�ro r I i . I1} k it; x �f�li..ifl Y'. r 'i r 4 1 �1 e'� Rrtr ul .f l J c Va.S 8n t c r 1� d p4 N:a'h: r,.; xa gti'1 n 4 ,:`' r / d F Y` w r r+, q f y"^ r ty!'-e ru M1 1 u �F >i op; ' A t: ! f is �, '. 3 1 � � .�i'.dr Y I'':f�4 JV✓ x,.ta . �i'E � Y �i.!' l � f {., r ) ,• , �1( f ,'�.1s i �t / ev.e Y �' . . r f n➢ .rt�,y rsr�lr ye w'�a! I 1 'Sn + S "� r t r la f'"'tr4t 4 i ..`yl rev v tti t�r , + E1'y, + tr _a + le NA>vl• r { 4 l % 4 We / 4\'�`'r�+4Y t� J ` YP i //,r yi�' x Y♦ri` rZ et tf i-j12,r P t , it yi` }Ih � u k h' i i'r#k, k•J � r "i F '� t � 2r w' ' i � � � r � l � �� v. i •d�L �'} r J'Sb b .�A rl j"� > � r � � P"'y� '� it yT PopJ,t t Y cadfMp.e 'J y VSs J ` 1 v r r' m, 1 1 r , '�vmimBneae.e a s n. B e� � dw 9tai I z , � as .,<" tt4�'�' f e p � t v q + iF �'uytl CPn ♦ h i 1 + ` %�.�J �Y.l na a i7. Dpol �+ `t9BMW10Q' l Yah j13rtp�a Soma w rovrtl�'equ.re r ,.BgeNvkro e ` ti r w :SAu6&A.4'' W�L '. -,oi,J, i rli� wM. 1 I ,* I .{ 2 ({ _�JI r Yf lid h r r 1 P /' K 1• yisI I 11 L 1 V y, :jf•F b: 4 Raefalodu'rfi w , w Y i: 4 i F ,J 41 41 $, ii { < fi' r I l yr l+4 / r °-1,Tly f H Y? sf 1 r' f 'f' A AI Halloween Vendor Booths f H �F I t A - i Vndxrom,rl/Bm..oeo1th ys ® CITY OF SALEM ,ra F r r oot3,. ....,.::ii vii m 56 Federal Street First Baptist Church City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: IPROTECTION FROM CONTAMINATION 744-3780 Handwash Facilities FAIL Critical RED Owner: Comment:There is no hot water at the left hand sink in the ladies room.Restore hot water at a minimum temperature of 110°F at First Baptist Church this hand wash sink. Right side sink has hot water. PIC: Violations Related to Good Retail Practices (Blue Items) Miriam Baez Equipment and Utensils FAIL Non-Critical BLUE Inspector: Comment:The Frigidaire refrigerator/freezer in the kitchen needs a thorough cleaning. t David Greenbaum Date Inspected:Correct By: The Hotpoint refrigerator/freezer in the hall needs a thorough cleaning. 2/28/2007 Physical Facility FAIL Non-Critical BLUE Risk Level: Comment:There are water stains on the ceiling of the ladies room. Investigate the source of the leak and repair. Repair and repaint the ceiling. Permit Number: BHP-2007-0106 Status: SIGNED OFF '#of Critical Violations: 1 lTime IN: Time OUT: 'Urgency Description(s): 'BLUE: ,Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 28,2007 ) Page 1 oft :} Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 28,2007 ) Page 2 oft CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH � p^� 120 WASHINGTON STREET, 4TH FLOOR RECEIVED SALEM, MA 01970 TEL. 978-741-1800 DEC 13 2006 FAx 978-745-0343 CITY OF SALEM Kimberley Driscoll WWWSALEM.COM BOARD OF HEALTH Mayor JOANNE SCOTT, MPH, RS,CHO HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT a ro{t of SoleM TEL#- -3'I tY� ADDRESS OF ESTABLISHMENT e 4 e re 1 S t D/ 9?d FAX# 9Z 7 7 300,5/--i_j '7 MAILING ADDRESS(if different) EMAIL--Ed ss': Owner's: _ OWNER'S 1AME TEL# DRESS STREET CITY STATE ZIP CERTI IED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Req red in an establishment where potentially hazardous food is prepared) ` EM RGENCY RESPONSE PERSON HOME TEL# _OAYSOFOPIE THIN Monday Tuesday Wednesdav Thursday Friday Saturday Sunday HOURS OF OPERATION Piease write in time of nay. ` l lror exampie iiam-iivmi TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,009sgft =$100 more than 10,000sq.ft. =$250 ....... ------- ...° ...--------0---- -.-- --- ------- -- ---- -- _....-- --.--- le --- -a-- --- ... - - - RESTAURANT YES NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 -- - -- ... _.... ......... . ....._..._.....__...---------.--..... .$,10- 0- ,10. ............ .......... ..... ....BEDlBREAKFAST YES NO $100 ---..._------............... _........ - .._------ -- --------------_- ......... --------- -- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR IYES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief, have filed all state lax returns and paid all stale taxes required under the law. Sign e DaI Social Security or Fe era�I fico Number . t_. t oc . - ----------------- - Q - -------- 1.�----- ----- ----------------------- Rcvised 11113106 FOODAP2007.adm ✓Check#&pale_,'Z.if fpm, n I j S 2..5,n p ;� l,ommonw'ealth of Massachusetts' } '*,;+ � x ' ' 'k&,F, • • 4,� ,�`}; "' 4'„$ BOa�C1l�galtll �'t'ap, +llt � s trs �"k4,�3+ y4 t ,r ' ,�vYr 9FK x.... 4 `£ yh tPti sdtl rp/'-L:Fb4 x"iC'r.? y £ ' - '� � '. r. ✓ G �s``-'�q'��4'.#�{ t��e ��,;mac ',YL” Rfl .,� ��mbetiey Onseoil ... ;�.,_ .ic-., 'r n `.�"S:•. �"`J:°!.xi.^` $.. ..'w,Y Yl`i :M^-,. .- yA.�,x'�''�` ...�L,..:,May()r l 1hw�,s` m^ SALEM,MA` 01970. Food/Retail Establishment Permit DATE PRINTED: 12/20/2006 ESTABLISHMENT NAME: First Baptist Church File Number:BHF-2004-000139 56 Federal Street Salem MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2007-0106 Dec 20,2006 Dec 31,2007 $25.00 ESTABLISHMENT Total Fees: $25.00 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 23 �+x� ' '^Commonwealth of Massachusetts ' +�;-wh �' i Board of Health ^. 120 Washington Street,4th 4 Floor t b SALEM,M,MA 01970 , Food/Retail Establishment Permit DATE PRINTED: 01/03/2006 WHO'S PLACE OF BUSINESS IS: First Baptist Church File Number:BHF-2004-0139 56 Federal Street i Salem MA 01970 LOCATED AT: SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2006-0092 Jan 3,2006 Dec 31,2006 $25.00 ESTABLISHMENT Total Fees: $25.00 1 PERMIT EXPIRES December 31, 2006 Board of Health -ro96el 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. r 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 14 of 23 , / CITY,OF SALEM9 MASSACHUSETTS BOARD OF HEALTH s 120 WASHINGTON STREET, 4TH FLOOR .,.. SALEM, MA 0 o � T, o TEL. 978 1-100 u o STANLEY J. UsOylcz, JR. FAX 978-745-0745-08343 MAYOR WWW.SALEM.COM DEC 0 5 2005 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT CITY OF SALEM BOARD OF HEALTH 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT F rs IL-*f d C-.L" o� SUR-e.MTEL# 97 u 7 y tf. 37 K C3 ADDRESS OF ESTABLISHMENT 's It, MAILING ADDRESS (if different) _ OWNER'S NAME TEL# ADDRESS CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON b t c-k HOME TEL# -79. -7-7*. all HOURS OF OPERATION: Mon. Tue. Wed. Thu. Fri.—Sat.—Sun.- TYPE ri. 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 YES NO less than 25 seats =$100 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 NO $5 TOBACCO VENDOR YES NO $511- ACL NON"F OFIT(such as church kitchens) ES 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 filled all state tax returns and paid all state taxes required under the law. 1 -:-ZYUrU of ©q D., ` -3I �b Signature Date Social Security or Federal Identification Number --------- ------- ------ --------- ----- -- - - -- r 1— v Revised 11/03105 FOODAP2.adm Check#&Date-026;G i-r� b5 Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4th Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741,-1800 Fax (978) 745-0343 Name // / / Date / Type of 0 eration(s) / TV oe of Inspection fi 7 I- r, cr"1n I lil-IrIMsi.� 1/ Lkr Food Service CPrIP9 ❑ Routine Address Risk ❑ Retail TI /n ❑ Re-inspection }L L'_ c/f- x L C>< Level ❑ Residential Kitchen Previous Inspection Telephone / �� 37kO El Mobile Date: Ownerr 9 HACCP Y/N ❑ Temporary ❑ Pre-operation 4RP oa40-t ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) M//P/ H 2L Time ElBed&Breakfast [I General Complaint In: ❑ HACCP Inspector /I1DaSrrc/iiS Out: Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s) violated. A Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. , FOOD PROTECTI4N_MANpC,EMENT'� `;: ;' ","" Zi „ " : , El12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties 13. Handwash Facilities t EMPLOYEE HEALTH" z m "k ��`-�`„''r �hLa -'u y a �a r _ ,u.�'c�a_3r„�5„«wrLa 20, r,a„ h�`.PROTECTION FROM ❑ 2. Reporting of Diseases by Food Employee and PIC .. a �a �- �.m ., 3 r"a=1 _,ami d 4,L.�,MW [114.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15 Toxic Chemicals .acs.-�„ h FOOD FROM APPROVED SOURCE_ , ,,,, ,eu ,rm, � ,„- azoVP _. ❑ 4. Food and Water from Approved Source ewTIME7TEMPERATURE CONTROLS(Potentlally Hazardous Foods)" }i2 .a.. ❑ 5. Receiving/Condition [116.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP_Plans ❑ 18.Cooling iPROYECTION FROM CONTA9NINATION l ," x rye ,! . ,� `'°'_ ❑ 19. Hot and Cold Holding „Aw' ❑ " .�.. .F„ '= 20 Time As a Public Health Control ❑ Ey 9.S. Separation/Segregation/Protection 9. Food Contact Surfaces Cleaning and Sanitizing g REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULAT(ONS(HSP}'=",°t ❑21. Food and Food Preparation for HSP [110. Proper Adequate Handwashing MUCH El 11. Good Hygienic Practices --- ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(items 1-22): of Health. Non-critical (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 ofCHe7W,;. 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of,Health member or its agent constitutes an 24. Food and Food Protection (Fc-3)(590.004),-_ order of the Board of Health. Failure to correct violations V 25. Equipment and Utensils (Fc-4)(590.005) 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-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other - DATE OF RE-INSPECTION: 5:5Mnsp dFoi 14.0 c Inspector's Signature: Print: PIC's Signature: iJ ��,.`.� �. Print: m'2 ,, p�y Page of Pages �[.w U Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT K Cross-contamination 1 590.003(x) Assignment of Responsibility* 3-302.1.1(A)(]) Ravi Annual Foods Separated from 590.003(B) Demonstration of Knowledge" Cooked and RTE Foods* 2-103.11 Person in charge-duties Contamination from Raw Ingredients - 3-3021,1(A)(2) Raw Annual Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* applicants* 3-302.15 WashingFouts and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-30411 Foal Contact with Equipment and Applicant To Report To The Person In Utensils* Char e* Contamination from the Consumer 590.003(G) Reportingb.Person in Change* 3-306.14(A)(B) Returned Food and Reservice of flood* 3 590.003(D) ExcluslonsandRestrictions* Disposition ofAdulterated orContaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCEFord* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food.Law* 4-501..111. Mannas Warewashine-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashinb Hot Water Sanitization Temperatures* 3-202.13 Shell E-s* 450 3-202.14 Ego and Milk Products.Pasteurized* 1.114 Chemical Sanitization-temp.,pH, concentration and hardness.3-202.16 Ice Made From Potable Drinking Water* 5-101_1.1 DrinkingWater from an Approved System* 4-fi01.11(A) Equipment Ct Foal Contact Surfaces and 590.006(A) Bottled DrinkingCleaning Utensils 4-602.1T Cleaaning Frequency of Equipment Food- 590.006(B) Water Meets Standards m310 CMR 22.0* Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.1 1. Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Fold Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-HotWaterand 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-202.1.9 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201..17 Game Animals* 11 Good Hygienic Practices 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.1.2 Discharges From the Eyes, Nose and - 3-202.1.5 Packa e tette ity* - Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tastin 6 Tags/Records:Shelistock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.1.2 Shellstock Identification Maintained* Ent to•ees* TagelRecords:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-203.11. Numbers and Capacities* 590.004(7) Labeling of Ingredients" 5-204.1.1 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 S ecialized Processing Methods* Devices 3-502.12 Reduced ox•gen racka hg.criteria* 6-301.11 Handwashin Cleanser, Availability 8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drvin�Provision *Denotes critical item in the federal 1999 Foci Cate or 105 CMR 590,000. CITY OF SALEM /n1 / BOARD OF HEALTH & Establishment Name: Fi/'s7 0f/ST,- !/.,zc/ fcfie Date: 3- c2l (/(n Page: of Rem CodeC-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION "` Date No. Reference 'R=Red Item Verified. } ' PLEASE PRINT CLEARLY ` Z-2 I 1 iJG 1 9 COS _ C- t �G -) Le PZeq, CA,, } � °� o°F �e s �v eor,/v • '/ P IOP V,14rA / i.vo r' I P cCll�QfE /X09 VIP r=R s / e f 7 Q iti ive f �� OofO� 8e 1 3 9 I e Fle 'V minas t a/-, o Ile- a /v Peje A/ oso t" .td.P g• 7i7iiv�'/..� a �P/c�� ec w,o i asfR �. c SFr>� " /,usP -c7'1'�_n a� 3 Gvdies dam Io YeS Al 4SZW, s Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes t I have read this report, have had the portunity to ask questions and agree to correct all ❑ volunta y Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion L3 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-five dollars or suspension/revocation of ❑. Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: 'r �l 3-501.14(( PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Lain Cooled to Factors(items 1.22) (Cont.) 1 41°F/45'F Within 4 Hours. PROTECTION FROM CHEMICALS 3-SOL75 Conlin"Methods for PHFs Food or Calor Additives 14 PHF Hot and Cold Holding 14 3-501.16($) Cold PHFs Maintained at or below 3-202.12 Additives'" 590.004(F) 4P/45° F` 3-302.14 Protection or T Una z n'oaed Additives' 4-501 16(A) Hot PHFs Maintained at or above I$ Poisonous or Toxic Substances - 140'1. 7-101.11 identifying,Information-Ori!nal Containers* 3-501,16(A) Roasts Held at or above 130°P. 20 Time as a Public Health Control 7-102.11 Common Name-Working Containers` 7-201.11 Se oration-strata cN, 3-501-19 Time asaPublic Health<`anhvl" -- 590.004(8) Variance Re niremenC 7-202.11 Restriction-Presence and Use* 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Pmhemic ls- POPULATIONS(HSP) 7-204.1 I. Sanitizea�s,Criteria-Chemicals` 7-204.12 Chemicals for W tshine Produce,Criteria" 21 3-801.11(A) Unpasteurized Prc-packaged Juices and 7-204.14 D�m�A eats.Cnteua* - �BeveaaIev with 1&a intnal abels* 3-801.11(B) Use of Paa-teunzed Eyes* 7-205.11 Incidental Food Contact,Lubneari 3-801.11(77) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides. Criteria* Raw Seed Sprouts Not Served. 7-206.12 1 FraRodentBait Stations* 3-801.11(C) Unopened vend Food Package Not Re served. 7-206.13 'Tracking Powders,Pest Control and Monitoring CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Conking Temperatures for Animal Foods Mar are Raw,Undercooked ar PHFs Not Otherwise Processed to Eliminate 3-401.1 JA(1)(2) Pbgs- t55F15Sec. Pathogens. Er>s-Imm�ediateSery ice 145`FlSsee* 3-302.13 Pasteurized Eggs 5nbstitute'farRaw Shell 3-401.,11(A)(2) Comminuted Fish,Meats-&G.une E ass" Animals- 155'F 15 sec. SPECIAL REQUIREMENTS 3-401.11(B)(1)(2) Pork and Beef Roast - 130'F 121 min* 3-401.11(A)(2) Ratites, Injected Meats 155`F 15 590-009(A)-(D) Violations of Section 590.0O9(A}(D)in sec * catering, mobile food,temporary and 3-401..1 I(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should he Stuffing Containing Fish, Meat, debited under the appropriate sections Poultry or Ratites-165'F'15 sec.x above if related to foodborne illness 3-401.1 I(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 under#29- Microwave 165°F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs-1.45°F t5 sea I7 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(L)) PHFs 165F 15 sec.* ((tents 23-30) 3-403.11(&) Microwave-165°F 2 Minute Standine, Ciidcal and non-critical violalions, which do not relate to the Time" .foodborne illness interventions and riskfactors tislerd abore, can be ;-403.1 I(C) Commercially Proce*sed R'PE Foal- found in the fntlotmirrg sections oJ'tfte Food Code mu!105 CMR '140°F* 590.000. - 3-403.t1(E) Remaining Uusliced Portions of Beef Item Good RetailPractrces FC 580000 Roasts* 23. Mara ement and Personnel. _FC-2 .003 18 Proper Cooling of PHFs 24. Food and Food Protection _- _.._- -FC - 3 .004 25. _ Equipment and Utensils __FC 4 -I .005 3-50114(A} Coalite Cooked PFll�s from 140°F to 26Water, PlumbM and W asie FC-5 1 .006 70°P Within 2lours and From 70°F 27. Physical Facility FC-6 I, .007_ to 4l'F/45°F Within 4 Hours.* 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(1) Cooling PHFs Made From Ambient 29. S eeial R- uiremants _ j .009 Temperature Ingredients to 41"F145°F 30. Other Within 4 Hours* ex ommn,ts-z.:a Denotae critical item in Ole Federal 1999 Food Code or 105 CMP 590000. CITY OF SALEM // ABOARD OF HEALTH Establishment Name: �h�ft &0 s7` �'` AsDate: Page: -'sof --3 t7` Item Code C-Critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTIONDate No. Reference R Red Item -' - - - - - _ Verified PLEASE PRINT CLEARLY No ,5e ! aow'e Q di upas Ailcq A z /ces e Leap 4 Air/,t/er/ qzesfdC/F F uree%Lv ✓f LoRj Ale- /� ea C .mese- & AM-t- 76,S PE,4'I' Av2027 Y t Y `E Discussion With Person in Charge: Corrective Action Required: ❑, No. ❑ Yes have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that . 'y noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure x° your food permit. n ❑ Voluntary Disposal ❑ Other: e 3-501.14(C)� PHFs Received at Temperatures Violations Related to Foodborne illness Interventions and Risk According to law Cooled to Factors(items 1-22) (Cont.) i 4 FF/45'F Within 4 Homs- PROTECTION FROM CHEMICALS 3-5O1.75 Coolim�Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Additives'* 590-004(F) 41`145°F* 3-302.14 Protection from Una roved Additives* 3-501,16(A) Hot PHFc Maintained at or above 1g Poisonous or Toxic Substances MO°F.* 7-10L11 lden(ifytinglnfantation-Original 3-Sffl.1.6(A) RnastsHeld atorabove 130°F Container'" 7-1.02,11 Common Name-Workinm C<unainerg* '20Time as a Public Health Control 7-201.11. Se aration-Storage* 3-501.19 Time as a Public Healih Conh'nl* 590.004(H) Variance Re-uirement 7-202.'11 Restriction-Presence and Use* - - 7-202.12 Conditions of ers REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Porte-Co,Crites a-Chemibi cAs- POPULATIONS(HSP) 7-204.11. Sarntizers,Criteria 7-204.1.2 Chemicals for Washing Produce Criteria* 21 3-80'I A I(A) Unpasteurized Pte-packaged Juices and 7-204.14 Duma Agents.Cutetia" Beverages with tit a nine I nboN- 7-205.11 Incidental Food Contact.Lubrieants* 3-801.11(B) Use of Pasteurized E ns* 7-206.1.1. Restricted Use Pesticides,Criteria* 3-801 11(0) Raw or Partially Cooked Annual Paul and Raw Seed S routs Not Served. 7-206.12 Rodent Bait Stations* 3-90'1.11(C) Unopened Food Pscka�e Not Re-served, 7-206.13 Tracking Powders.Pest Control and Monitoiina CONSUMER ADVISORY TIMEtTEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foals That are Raw,Undercooked or E6 Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate Patho«ens.*errocr:e rrozoai 1-401.11 A(l)(2) Eggs- 155`17 15 Sec. Pasteurized Ef m 7s-Imediate Service 145"Fi51sec* 3-302.13 asteurized Eggs Substitute for Raw Shelf Eggs* 3-401.17.(A)(2) Comminuted Fish,Meals Sc Game - Animals- 155°F 15 sec. * ( )( ( SPECIAL REQUIREMENTS 3-401.11 B C) 2) Pork and Beef Roast-13U°F 721 mini* 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)413) Violations of Section 590.009(A){D)in sec. * catering, mobile food,temporary and 3-401..1.1(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec. "' above if related to foodborne illness 3-401.11(C)(3) Whole-muscle, Intact Beef Steaks interventions and risk factors. Other 145oF* 590.009 violations relating to good retail 3401.1.2 Raw Animal Fork Cooked in a practices should be debited under J#29- Microwave 165°F* Special Requirements. 1 401..11(A)(1)(b) All Other PHFs- 145°F 15 sec 19 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHf,s 165T 15 sea. * (Items 23-30) 3-403.11(B) Microwave- 1.65° F2 Minute-Standing Critical and non-critical violations, wkich do not relate.to the Time* foodborne illness iuterveniions and risl-faciors listed above, can be 3-403.11(C} Cammercia(lti Processed RTE Fund- ,found iu the fotlowhrg sections of the Food Cade and 105 CMR 140°F* 590.000. _ S90 OQt} 3-403.11(E) Remaining item 1 Good Retail Practices I FC Unsliced Portions of Beef - Roasts' 9-__-__-- FC I -2 .003 Roasts* 23. Management and Personae _ _ 18 Proper Coding of PHFs 24. Food and Foal Protection FC-3 A04 25, iz ui meat and Utensils F-- 4 .005 3-501.14(A) Cooling Cooked PHFs from Y4f} F to 2g- Water, Plumbing end M1taste FC-5 .006 - ----- . 70'F Within 2}-Iaur and From 70'F 27. Physical Facility. FC-6 .00707 to 41`F/45"F Within 4 Hotrs. * 1 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. S ecial R uirements .009 - Temperature Ingredients to 41`'171451r' 30. Other 1 _ Within 4 Hours* ssvoro,.�waa-za,� *D) notes critical iters in the Wet al 1999 Food Code or 105 CMR 590000. IMPORTANT MESSAGE FOR 111 DA 3 l ® TIMEe A. . OF PHONE AR .GOOF NUMBER EXTENSION ❑ FAX U MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TOSEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YDUR CALL WILL OAX TO YOU MESSAGE ((fix, UJ 0&uk-, 4:LLnU,.P, -e 1 d SIGNED FORM 4009- j_- ll�- MADE IN U.S.A. i !i i : _ 1 w z .,� s •-« 5` f �e myf•.�,�''.i,Y"" t. � �q +s'+a�-t^�� m..,.. -� ��"F v�� i'� ��"'r'i e4 -•+ +�+-'%`x ,a& 4 K3 t", r` «fie m 7-� "CITY OF'SALEM; MASSACHUSETTS �'.BOARD'OF HEALTH r -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 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: Church Kitchen Name of Establishment: First Baptist Church Address of Establishment: 56 Federal Street Owner's Name: First Baptist Church Restrictions: Application Date: 11/29/2004 Permit for Food Establishment 89-05 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. HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH D -120 WASHINGTON STREET, 4TH FLOOR o SALEM, MA 01970 ��1/l✓✓✓(((1� '°•^gid(,/ 1V/ O TEL. 678-741-1800 NOV FAX 978-745-0343 O 23 ZOO4 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 89p��OF' 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISRMLQd'Dr�Al NAME OF ESTABLISHMENT F1r5T ��ta� L' nµru(t v� Sr�2YBL# 4�$ • ��F�k, X780 H ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different) OWNER'S NAME TEL# ` ADDRESS 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# H.r I 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 I0,000sq.ft. =$250 RESTAURANT YES NO &C3 less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 I _ - ADDITIONAL PERMITS , MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR NO $SIL ALL NON-PROFIT(such as church kitchens) :ES 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 lit knowledge and b#li-ef, have filed all state tax turns and paid all state taxes required under the law. tom . 1t �( a4'` 0q_ _t, 1 - 53 _64 ,Signature. Date Social Security or Federal Identification Number ---- ---------- - - - --------------------------------------------------------------------- - ---------------------- Revised 11/03/03 FOODAP2.adm Check#&Date y 56 Federal Street First Baptist Church City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Telephone:'` -"""'"' Item Status Violation Critical Urgency Nature of problem or correction 7443780 , ;,-_ Non-compliance with: Done - Owner: Anti-Choking PASS ❑ First Baptist Church Tobacco PASS ❑ PIC:' Miriam Baez 4§ FOOD PROTECTION MANAGEMENT - Done Inspector: B s - PIC Assigned/Knowledgeable/Duties PASS ❑o RED :.::. Janet Dionne EMPLOYEE HEALTH Done Date Inspected Correct By, Reporting of Diseases by Food Employee and PIC PASS Q RED 3115/2005 Personnel with Infections Restricted/Excluded PASSd❑ RED Risk Level f _ 1'1 f} -'-�t ft•- FOOD FROM APPROVED SOURCE Done Food and Water from Approved Source PASS ❑d RED Permit Number BHP-2005-0165: _ A Receiving/Condition PASS ❑/ RED Status: s , 2= t - Tags/Records/Accuracy of Ingredient Statements PASS ❑d RED -. - - - - FULL'COMPLY cc x ' - - - - #Of CfIfIC81 Violations: - Conformance with Approved Procedures/HACCP PASS ❑d RED c ' Plans 1 LL= PROTECTION FROM CONTAMINATION Done Time IN: ' Time ,u Separation/Segregation/Protection PASS ❑�/ RED - s - b _ - Notes ... �„ Food Contact Surfaces Cleaning and Sanitizing PASS ❑d RED 244�- Proper Adequate Handwashing PASS RED Urgency Description(s) Good Hygienic Practices PASS ❑d RED BLUE Prevention of Contamination from Hands PASS ❑d RED Violations RelatedtoGood Retail Practices(Critical AxHandwash Facilities FAIL ❑d RED provide hand soap at handwash sink. in violations must be corrected pump type dispenser immediately or within 10 days)(Non-critical violations mens restroom-provide soap in wall hung _ ,. dispenser or in pump style dispenser. GeoTMSO2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Mar 17,2005 ) Paee I of 56 Federal Street First Baptist Church must be corrected immediately PROTECTION FROM CHEMICALS Done Or within 90 days) - Approved Food or Color Additives PASS ❑J RED _ RED : _ Toxic Chemicals PASS RED Violations Related to k-, Foodborne Illness Interventions TIMEITEMPERATURE CONTROLS(Potentially Haz Done and Risk Factors (Require ' >* Cooking Temperatures PASS RED immediate corrective'action)N Reheating PASS RED Cooling .. PASS RED Hot and Cold Holding PASS RED Time As a Public Health Control PASS RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Done Food and Food Preparation for HSP PASS 0 RED CONSUMER ADVISORY Done Posting of Consumer Advisories PASS RED GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Mar 17,2005 ) Page 2 of 56 Federal Street First Baptist Church Violations Related to Good Retail Practices (Blue Done Management and Personnel PASS ❑ BLUE Food and Food Protection PASS ❑ BLUE Equipment and Utensils FAIL ❑ BLUE Magic Chef freezer had temperature of 10°f.to be maintained at temperature of 0°f or below. Microwave near fridge units need general cleaning. Frigidaire freezer missing thermometer. Provide visible accurate thermometer maintained at 0'f or below as mandated. please obtain test strips to ensure proper testing and concentration of sanitizing solution .chlorine test strips.. Water, Plumbing and Waste PASS ❑ BLUE Physical Facility PASS ❑ BLUE Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements - PASS ❑ BLUE Other-See Notes PASS ❑ BLUE r GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Mar 17,2005 ) Page 3 of CITY OF SALEM9 MASSACHUSETTS ^ BOARD OF HEALTH g� 120 WASHINGTON STREET, 4TH FLOOR I �p SALEM, MA O 1970 TEL. 978-741-1800 FAX 978-745-0343. STANLEY J. USOVICZ, JR. - JOANNE SCOTT, MPH, RS, CHO MAYOR _ HEALTH AGENT i COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, I Section 305A and Chapter I II, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: Church Kitchen Name of Establishment: First Baptist Church Address of Establishment: 56 Federal Street Owner's Name: First Baptist Church Restrictions: 'I Application Date: 12/17/2003 Permit for Food Establishment . 211-04 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 I* CITY OF SALEM, MASSACHUSETTS ` BOARD OF HEALTH ILII '� s 120 WASHINGTON STREET; 4TH FLOOR IIjSV r�.^` VVV � SALEM, MA 01970 DEC 17 2003 .� TEL. 978-741-1800 9,q,� FAX 978-745-0343 CITY OF SALEM STANLEY LISOVICZ, JR. - JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT FIRST BAPTIST CHURCH SALEM TEL# 978-744-3780 ADDRESS OF ESTABLISHMENT 56 FFDFRAT, STREET 4AI,Fm MA 01970 MAILING ADDRESS (if different) OWNER'S NAME TEL# ADDRESS CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON DENNIS DUVAL HOME TEL# 978-922-1919 HOURS OF OPERATION: Mon. �Tue. t' Wed. �L Thu h 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 RESTAURANT YES NO less than 25 seats =$100 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 NO $5 TOBACCO VENDOR / YES NO ALL NON-PROFIT(such as church kitchens)p?1/ o T 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,eauipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pur ant to hapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best k wledge and eli , ave filed all IT Let)x retu�rqs and paid all state taxes required under the law. —�6-0 J b is 3 Signature Date Social Security or Federal Identification Number --------- -------- - ------ -- ----- -------- - ----- ---- - - ---- Revised 11/03/03 FCODA P2.adm Check#&Date Id -'�Z /.2—J `O a i � i i i Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 41h Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date / T ceof 0 eration s Tvoe of In T 11517, 7`/S7" a-as D T Food Service ❑ Routine AddressRisk Retail �� El ® ftsidei�tial Kt he `� ❑PrevioussInnspection pection Telephone ❑ Mobile Date:9. 2f 6r3 OwnerHACCP YM ElTemporary ❑ Pre-operation f/> r r „� Al� ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint O Permit No. Ll HACCP Inspector � �,7�a„�,_>=7 : l Out: ❑Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. i FOOD PROTECTION MANAGEMENT _ El 12. Prevention of Contamination from Hands L] 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities i EMPLOYEE HEALTH , : , PROTECTION FROM CHEMICALS e '.�- .. .�._..._..._,...._.. _ se.W�.. El2. Reponing of Diseases by Footl Employee and PIC -w - .-- .. ❑ 3. Personnel with Infections Restricted/Excluded El 14. Approved Food or Color Additives .FOOD FROM APPROVED SOURCE - ._ El 15.Toxic Chemicals .. a..F..r.�. e ?'TIME/TEMPERATURE CONTROLS P ❑ 4. Food and Water from Approved Source ( otentially Hazeidous Foods) F] 5. Receiving/Condition 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans , [118.Coaling PROTECTION FROM CONTAMINATION - r z' "" ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing P REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)' 10. Proper Adequate Handwashing El 21. Food and Food Preparation for HSP ❑ ❑ 11. Good Hygienic Practices )"CONSUMER ADVISORY,„ ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): v of Health. Non-critical (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. 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 5. E ui ment and Utensils cited in this report may result in suspension or revocation of q p (FC-4)(590.005) the food establishment permit and cessation of food 26. Water,Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (59b.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S,5Wns clFcrm 14d c i Ins" pr's Signat , � ,I / Print: PIC's Signafure: �.1 _? Print: `1'P M S ��L Page __of &Pages ` v Violations Related to Foodborne Illness interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT $ Crass-contamhraron '( 590.003(A} Aast oment of Respon<daility* 3-302.17(A){1� Raw Animal Fails Separated from 590.003($7 Demonstration of Knnwleder�_ _ Cooked and RTE Foods* L2-103.11 Person in charge-duties Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated frontEach EMPLOYEE HEALTH Other` 2 590.003(C) Responsibility of the person In charge to Conta.atination from the Environment require rcporti of by foot employees and 3-302.1 t(A) Food Protection* a plieantss` _ 3-302.15 Washin Fruits and ti'egetables 590.00:3(F) Responsibility Cb A Fool Employee Or An 3-304.11 Font Contact with Equipment and Applicant To ReportTo The Person In Utensils* Charas* Contamination from the Consumer 590.003(C3) Re Cortin b Person in Charee" 3-306.14(A)(B) Reim red Food and Reservicc,of PaxPs 3 590.003(0) Exclusions and Restrictions" Disposition atAdulteratedor Contaminated INILO-3(I )_j Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditimona Unsafe FOOD FROM APPROVED SOURCE Food' 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-8) Compitance,with Pood Lawx 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Seated Container" Sanirtzation'1-em eratures" 3-201.13 Fluid Milkand Milk Products* 4-501.112 Mechanical Warewashim-HotWater 3-202.13 Shell Ems* Sanitization Temtetatvres* 3-202 14 Fa�s and Milk Products.Pasteunzzd" 4-501.114 Chemical Sanitization-temp., pH, concentration and hardness r 3-202.I6 let Made Prom Potable Drinking*Water" 5'tOh i l llrinkin Water Fiat an Approved Svstem* 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 590.006(%) Bottled DrmkinL Water4-602.11 Gleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0" Contact Surfaces and Utensils* Shegfish and Fish From an Approved Source 4-70111 Frequency of 5anirizatron of Utensils and .3-201,74 Fish and Recreationally Caught Molluscan _ Pool Contact Surfaces ofE ui menti" Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201-15 Molluscan Shellfish from NSSP Listed ChernicaP° Sources* dg Proper,Adequate Handwashing Game and Wild Mushrooms App,ovedby 2-30,1.11 Clean Condition-Maids and Arms* Re Mato Authadt - 3=202.18 Shellstock Identification Present* 2-361.72 Cleanin�� Procedure* 590.004(C) Wild Mushrooms- 2-301.14 When to Wash- 3-201.17 Gam©Anrmals""" 1.1 Good Hygienic Practices 5 Receiving/Condition 2-401.11 Eatinsg Tobacco* ,Drinkinor Ush 3-202.11 PHB Received at Pro ter Tran,erasures* 2.40,L72 Discharges prom the Eves, ;Vose and 3-202.15 Pad:rt�e hueurit " Mouth* 3-101.11 Food Safe and Unadulterated r3-301.12 Preventing Contamination When TastinL* 6 TaoPecords:Shellstock 12 Prevention of Contamination from Hands 3-202.13 Shellstock identification* 59t).004(E) Preventing Contamination frons 3-203.12 Shellstock Identification Maintained* Ent ndwash Facilities ilovees" Tags/Records: Fish Products 11 Conveniently Loafed andAccessible 3-402.11 Parasite Destruction` Co - 3-402.12 Records.Creation and Retention* 5-203.11 Nunbersand Capacities* 590 0()4(7) Labeling of ingredients 5-204.11. Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility. Operation and'Maintenance fHACCP Plans Supplied with Soap and Nand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced ox en tacks he criteria* 6-301.11 Haridkvashiug Cleanser,AvailabiHt 8-103.12 Conformance with Approved Pmcedures,h 6-301.12 Hand Dryim*Provision '"Denotes MUCld Ruin in the tedeald 1999 Fond Code 01 l0i CMR 590.000. ,l CITY OF SALEM BOARD OF HEALTH Establishment Name: G a /gran f�� r or Date: ?- a t n/F Page: sQ of -Item Code C-Critical Item - DESCRIPTION OF VIOLATION/PLAN OF CORRECTION - Irate No. Reference R-.Red Item Verified PLEASE PRINT CLEARLY ' 3 IL t• -�?� A l .// n u _ 1 v x } i n F j le/— r-v ,z— &_l /.)v Lb V Li L,9/,/Y h Y4Llps 4z-) Al/,a ' Corrective Action Required: ❑ No _ LI Yes Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion 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-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: 3-501,l4oC) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(Items 1-22) (Cont.) 41'F/45'f Within 4 Hours. PROTECTION FROM CHEMICALS 3-501,15 Cooliniv Methods for PHFs Food or Color Additives 19 PHF Hot and Cold Holding DE 3-501.16(B) Cold PIIF- N'tairlained at or below 320312 !v.1dit-I ves;* 590.004(F) 4 1'145'F* -J'� !:Rp L�j Iona thijil Poisonous -t' 3-501.10(A) Hot PHFs Maintained at ks abokQ endue I r I:, - Poisonous or Toxic Substances 140"F, 7-101.11 Identifying Information-Original 3-501.16(A) Rokt',u; Held at or abiwe 13o`F. ContairiersIl -Time as a Public Health Control -7-10111 colnuto.it'Narno- Working�ContalnerR' 20 3-501.19 roue as a i,ubbc Healthcontror, 7-201.11 Sc arduou-- 7-202,11 Restriction-I and Us- r 590.004(]{I Valance Rec uirement Conditions of use' 7-203.1 I Foxic Containers-Prohibitions' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizeis.Criteria-ChemickiN,* POPULATIONS(HSP) -204,11 Chemicals lot �Vaihjng Produce 7 Criteria* 21 3-80111{A) Unpasteurized PrePackagedJoices and 1 , I - 7-204.14 _DrLmiI Agent��Cittena , flewerazes with Warning Labels'� 7-205.11 Incidental Food Contact, Lunt icants* 3-801.11(B) Use of Pasteurized ES�-sl 3-80 Ll I(D) Raw(it Partially Cooked Aninial Food and 7-200 1-1 Restricted Use Pesticides,Crneria� I R,,Seed Sproul,Not Served. 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package.Not Reserved. , 7-206.13 Tracking Powders, Pest Control and Monitoring' CONSUMER ADVISORY 22 3-603.11 Cori Advisory Posted for Consumption of lfi TIME)"FEMPERATURE CONTROLS Animal Foods That are Raw. Undcrrooked or Proper-cooking Temperatures for Not Otherwise Processed to Eliminate PHFs n-er 3-401.t JAll)(2) Eggs- 155`F 15 see. -- Pathoetals., F. s-Im ninth kit e Service i ce 14 5'F I fiscc 3-302,13 lik,sicurized E.-Is Substitute for Raw Slidt 3-401.1 I(A)(2) Comminuted Fish. Meats&I-G-amc -- E Auunak- iso'F 15 sec. 4 SPECIAL REQUIREMENTS 3-401.11($)(1)(2) Pork and Beef Roast- 130F 121 unin* 590.009(A) 1-40 1.11(A)(2) Ranter, 155F 15 -(D) Violations ofSecuon 590.009(A)-(I)) in Ikec' * catering, mobile lood, tempos try and 3-401.11(A)(3) Poultrv,Wild Gakw.Stuffed PFIF's, residential kitchen operations should be Stuffing Containin',Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sec. above if related to foodborne illness 3-441, I(C)(-,) Whole-muscle, Intact Beef Steaks interventions and risk factors. Other 145°F* --- 590.009 violations relating to good retail 3-401.12 Raw Aminal Foods Cooked in a practices should be debited under #29 - Microwave 165°F* Special Requirements. 3-401.1 I(A)(1)(b) All Other PHFs 145°F 15 sec, t7 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES .3-403.11(AWD) Pffs 165'F 1.5 sec. * (Items 23-30) 3-403.11(13) Microwave- 16TI72�Nfinute,�Standwtg Critical acrd non-criticalwoiations, thich do not relate to the Time* foodborne ilhiess intervenzionv and risk factors fisted above, can he 3-403.11(C) Commercially Processed R'rE Food- fimmi in thefollowhor sections of the Tood Code and 105 ChWR 140017* 590.000. 3-403.11(E) Remaining I-Aisliced Portions of Beef item Good Retail Practices FC 590.000 1: Roasts* _23.__ ManNerrient and Personnel FC-2 omIg - Proper Cooling of PHFs 24. Food and Food Protection FC-3 .004 25. Equipment and Utensils FC-4 005 3-50I14(A) Gaoling Cooked PI IFs front 140' ---------------- ----------- -- F t( 26. Water.�Plumbi and Waste FG-5 006 70"IF Within 2 HouriI and From 70^F _27 Phsicai Faciltt 1 FG-6 -007 to 41"1-145°F Within 4 Hours, 2B. Poisonous or Toxic Nisceria Is FC-7 008 3-501 14TB) Cooling PfFs Mull loom Ambient 29, Special Requirements 009 Temperature Ingi-cilients to 41'F/45-F 30. Other Deno tea critical item inthe tederal i999FuodCode oi IM CM2 590.000. a CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH '� • 120 WASHINGTON STREET. 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY 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 : Owner ' s Name : First Baptist Church Name of Establishment : First Baptist Church Address of Establishment : 56 Federal Street ! Type of Establishment : Church Kitchen Application Date : 01/02/2003 Restrictions : Permit for Food Establishment 195-03 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. qo.$L.� HEALTH AGENT CITY OF SALEM. MASSACHUSETTS a �cosolr,� .r BOARD OF HEALTH 120 WASHINGTON STREET. 4TH FLooF SALEM. MA 01970 DEC 2 6 2002 �s TEL. 978-741- I800 9�Cp/1N6 FAX 978-745-0343 �+! I ✓r' :3l1LLi� Sl'ANLEY USOVICZ. JR. BOARD OF HEALTH J OANNi- SCOTT. MPH, RS. CHO MAYOR HEALTH AGE,ir 2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT F 9N - Y�y-39Fe iR<f /�,gvr/sT �unycy TEL# ADDRESS OF ESTABLISHMENT �?6 fEI]Exo,44 Sr. MAILING ADDRESS (if different) OWNER'S NAME TEL# ADDRESS CITY STATE____ CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME TEL# 99f- 9.374 HOURS OF OPERATION: Mon. Tue. Wed. Thu. Fri.—Sat.—Sun.— TYPE ri. Sat. Sun.TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1000sq.ft. _$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES 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) ES 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 be_st knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. ,rte ! a i D a- O - Sig ature Date Social Security or Federal Identification Number ------------------------------------------------------------------------------------------------------------------------------------ Revised 11/25/02 FOODAP2.adm Check#&Date 1939x2 Z 1,21 n a.. � as� ..,..y,Nwi'-f_"^'�.-.•....it.N.Y}�a.i'�:},jvr'-6m.N7�("^4 �'t.:ia4sNf. .�..9^.Y'^sM•+�np�,.'..+� �T#iE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 120 Washington Street, 4th Floor BOARD OF HEALTH Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978)745-0343 Name7 - Date .Type of Operation(s) T f n ion S-� C (// / (,v XFood Service Routine Address Risk Retail ❑ Re-inspection c _ Level L ElResidential Kitchen Previous Inspection d Telephone p7 �� / - � m j�� EJMobile _ Date: Owner / 7 O /' h HACCP Y/N ❑ Temporary ❑ Pre-operation �( /�% 7��JS% °/✓/�'t ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) ^C / Time [:1 Bed&Breakfast L1 General Complaint I r .L_7� In: ❑ HACCP Inspector/ 14)"-7m ` //C/ /7/ f' Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(;) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/ Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH El2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS El3. Personnel with Infections Restricted/ Excluded El 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE El 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) El 16. Cooking Temperatures El 5. Receiving/Condition ❑ 6. Tags/ Records/Accuracy of Ingredient Statements El 17. Reheating El7. Conformance with Approved Procedures/ HACCP Plans El 18. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding El8. Separation/Segregation/ Protection El 20. Time as a Public Health Control El 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 10. Proper Adequate Handwashing ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. 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. Non-critical (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. 590.000/Federal Food Code.This report, when signed below C N I by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing 28.'Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: Inspector's Signature: Prink=�,_ f PIC';Signature:�f_ _ �-•� Print: I, Page!of Z Pages FORM 736A HOBBS&WARREN -BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION " Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 1,1 590.003(A) Assignment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11 Person in Charge-Duties 3-302.11(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 3-302.11(A) Food Protection* require reporting by Food Employees and 3-302.15 Washing 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 Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated ,3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE 0` Food Contact Surfaces 4 Food and Water From Regulated Sources 4-501.111 Manual Warewashing-Hot Water 590.004(A-B) Compliance with Food Law* Sanitization Temperatures* 3-201.12 Food in a Hermetically Sealed Container* 4-501.112 Mechanical Warewashing-Hot Water 3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures* 3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-tem H, P P 3-202.14 Eggs and Milk Products,Pasteurized* Concentration and Hardness* 3-202.16 lee Made from Potable Drinking Water* 4-601.11(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved System* Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 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 Recreationally caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization- Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* BYO ` Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* 11 Good Hygienic Practices 3-201.17 Game Animals* 2-401.11 Eating,Drinking or Using Tobacco* 5: Receiving/Condition 2-401.12 Discharges From the Eyes,Nose and 3-202.11 PHFs Received at Proper Temperatures* Mouth* 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-101.11 Food Safe and Unadulterated* 12.,.. Prevention of Contamination from Hands 6' Tags/Records:Shellstock 590.004(E) Preventing Contamination from 3-202.18 Shellstock Identification* Employees* 3-203.12 Shellstock Identification Maintained* 13 Handwash Facilities Tags/Records: Fish Products - Conveniently Located and Accessible 3-402.11 Parasite Destruction* 5-203.11 Numbers and Capacities* 3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement* 590.004(J) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance 7 Conformance with Approved Procedures Supplied with Soap and Hand Drying /HACCP Plans Devices 3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability 3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision 8-103.12 Conformance with Approved Procedures* •Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. , CITY OF SALEM BOARD OF HEALTH Establishment Name //��/ / / �/ S' / L ((U/CJ�? Date: Page. G� of z " Item Code ,C' Critical Item ', DESCRIPTION OF VIOLATION£/ PLAN OF CORRECTION Date 4 R No. Reference -Red Item i r '. &m•, PLEASE PRINT CLEARLY s:y ?' , Verified U U '€ f Discussion With Person in Charge: Corrective Action Required:, ❑No ❑Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to comply Exclusion with all mandates of the Mass/Federal Food Code. I understand that noncompliance may ❑ Re-inspection Scheduled ❑ Emergency Suspension result in daily fines of twenty-five dollars or suspension/revocation of your food permit. ❑ Embargo ❑ Emergency Closure 9 Y ❑ Voluntary Disposal ❑ Other FORM 734B HOBBS &WARREN • BOSTON - Violations Related to Foodborne Illness Interventions and Risk 3-501.14(C) PHFs Received at Temperatures : Factors(Red Items 1-22) (Cont) According to Law Cooled to 41°F/45*F Within 4 Hours.* PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below 3-202.14 Protection from Unapproved Additives* 590.004(F) 41°F/450F* Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original 140°F.* Containers* 3-501.16(A) Roasts Held at or above 130°F.* 7-102.11 Common Name-Working Containers* Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS (HSP) 7-204.11 Sanitizers,Criteria-Chemicals* 21'. 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* Beverages with Warning Labels* 7-204.14 Drying Agents,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact,Lubricants* 3-g01.11(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.* 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY V 22 3-603.11 Consumer Advisory Posted for Consumption of TIME(TEMPERATURE CONTROLS Animal Foods that are Raw,Undercooked or 16„ Proper Cooking Temperatures for not Otherwise Processed to Eliminate _ PHFs Z Pathogens.* Enecl,-11112001 3-401.11-A(I)(2) Eggs- 155°F 15 Sec. 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell Eggs* Eggs-Immediate Service 145°F 15 Sec.* 3-401.11(A)(2) Comminuted Fish,Meats&Game SPECIAL REQUIREMENTS Animals- 155*F Sec.* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 Min.* catering,mobile food,temporary and 3-401.11(A)(2) Ratites,Injected Meats- 155°F 15 Sec.* residential kitchen operations should be 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, debited under the appropriate sections Stuffing Containing Fish,Meat, above if related to foodborne illness Poultry or Ratites- 165°F 15 Sec.* interventions and risk factors. Other 3-401.11(C)(3) Whole-muscle, Intact Beef Steaks 590.009 violations relating to good retail 145°F* practices should be debited under#29- 3-401.12 Raw Animal Foods Cooked in a Special Requirements. Microwave 165°F* 3-401.1l(A)(1)(b) All Other PHFs- 145°F 15 Sec.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES -17>: Reheating for Hot Holding (Blue Items 23-30) 3-403.11(A)&(D) PHFs 165°F 15 Sec.* Critical and non-critical violations, which do not relate to the 3-403.1 l(B) Microwave- 165°F 2 Minute Standing foodborne illness interventions and risk factors listed above, can be Time* found in the following sections of the Food Code and 105 CMR 3-403.11(C) Commercially Processed RTE Food- 590.00. 140°F* Item Good Retail Practices FC 590.00 3-403.11(E) Remaining Unsliced Portions of Beef 23. Management and Personnel FC-2 .003 Roasts* 24. Food and Food Protection FC-3 .004 Proper Cooling of PHFs 25. Equipment and Utensils FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Water, Plumbing and Waste FC-5 .006 70°F Within 2 Hours and from 70°F 27. Physical Facility FC-6 .007 to 41*F/45°F Within 4 Hours.* 28, Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .009 Temperature Ingredients to 41°F/45°F 30. Other Within 4 Hours* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.