FIRST BAPTIST CHURCH - ESTABLISHMENTS (2) -�-t�5�` ",,�` � S� �+`lt�c.�t-t%� .._ �.j � Later-� -�-� C�2 �� r-eC,, �—
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Fust Baptist Church •_ � >:
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x'€. �x flle Number BHF 2009-000019 w ` �x -292 Lafayette Street -� �' 01,
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CITY OF SALEM, 1P
MASSACHUSETTS
BOARD or He:w:rj-i
1 FloOR
KIMBERLEY DRISCOLL T l0 978 741-1800 FAX(97811745 0343 DEC 1 7 pq It
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MAYOR 1mrndin@sa1em.com _ CITY �:i.,LEM HErlla'Fi AGHN'1'
BOARD ur HEALTH
Food Establishment Permit Application
(Application.must be submitted at least 30 days before the planned opening date)
1) Establishment Name: Ft res -r // /.5 T C/-&' C
2) Establishment Address: Z Z C , 2 S/4 c"7 j)G
3) Establishment Mailing Address(if different): e,gyh f
4) Establishment Telephone No: <? 7L -
5) Applicant Name&Title: L� ��iVL-' �S�G '�S�r e✓
6) Applicant Address: 7S d ev l we . &a t-1eWA-I FI 01115
wo,e,c
7) Applicant Telephone No: 7k-<26—&97 24 Hour Emergency Email: G✓iL(Mli
8) Owner Name&Title(if different from applicant):
9) Owner Address(if different from applicant):'
10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of
officers or partner.
An association Name Title Home Address. .....
A corporation
An individual
A partnership
Other legal entity Cj�7ZeL ki"
-
sible For Dail
Person Directs Res oncc Operations Owner, Person in-Cha e;-Su ervisor,Mana er,"etc.) -
Name&Tltie:
Address: Z�Z' Litl/ ; � L.7 `3✓� 5,a�rr�c .G�970
Telephone No: Fax: Email:
Emergency Telephone No: 49k-370Q
13) District or Regional Supervisor(if applicable)
Name&Title:
Address:
Telephone No: Fax: Email:
Check#:
Date: V! Amount ��/
Food Establishment Information
14) Water'Source: 15) Sewage Disposal:
DE?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) 0 Retail( Sq. Ft) 0 Caterer
Permanent Structure O Food Service-( Seats) 0 Frozen Dessert Manufacturer
Mobile 0 Food Service-Takeout 0 Residential Kitchen for Retail Sale
O Food Service-Institution O Residential Kitchen for Bed and
( Meals/Day) Breakfast Home
O Food Delivery 0 Residential Kitchen for Bed and
21) Length Of Permit: Breakfast Establishments---------------------
(check one) RETAIL STORE RESTAURANT
Annual O Less than 1000sq.ft. $70 O Less than 25 seats $140
Seasonal/Dates: 0.1000-10,000sq.ft. $280 17 Residential Kitchens $140
0 More than 10,000sq.ft. $420 0 25-99 seats $280
0 More than 99 seats $420
Temporary/Dates/Time: -
0 Bed&Breakfast/Chiidcare Seryices/Nursing Home $100
.................................-----------------------------------..................................... -----.....................
---
ADDITIONAL PERMITS
0 MAKE ICE CREAM,YOGURT/SOFT SERVE $25
E!/ASTURIZATION $25
Iff ALL NON-PROFIT' $25
Mncludin , church kitchens, state funded childcare B private club
23) Food Operations: Definitions: PHF-potentially hazardous food(dmeAemperature controls required)
Non-PRFs-non-potentially hazardous food(no dmeltemperature controls required)
(check all that apply): RTE-read -to-eat foods Ex.sandwiches,salad;mu/fins 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 FoodiSingle Meals for Catered
Retail Sale Events or Institutional Food Service
Offers RTE PHF in Bulk Quantities
To be completed by the Board of Health
Retail Sale of Salvage,Out of Date
or Reconditioned Food Total Permit Fee:
Payment is due with application
I,the undersigned,attest to the accuracy of the information provided In this application and I affirm that the food establishment operation will
comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR
590.000 and the Federal Food Code.
24) Signature of Applicant:
Pursuant to MGL Ch.62C, sec.49A,1 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:
�`� �x= � `Commonwealth of Massachusetts ` �� y ,l z
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BoardofaHealth M yl3f
� .. �120tWaslington Street,4th Flop. � `
5A)EM;MA 01970#
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�A
Temporary Foo Permt#
D`ATEPRINTED _ O8%b7/2013 "x
ESTABLISHMENTAAME =; Eust Bap str t Chu cr h, , ` k y
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Pxrmit Typg ��Yerout No P-- rmit,Iss-u _ermWEib
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!TEMPORARY FOOD. j3HP 2013-0,532 �„ _Aug:�10 2013 Aug`116f� . �EV�IVT Essex Street Fav
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¢ CIlY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET 4"FLOOR PT1b1iCHC8Ith
Prevent.Promote.Protect
TEL. (978) 741-1800 FAx(978) 745-0343
KIMBERLEY DRISCOLL Iramdin(as9em.com
LARRY ILvML)IN,RS/RF,HS,CI-Ip,CV-PS
MAYOR HEAL:ITI AG1iwr
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:'I4 DAYS DIVIDED BY 7=2 X 6OO=$1200)
APPLICATION FOR A TEMPORARY FOOD SERVICE PERMIT
NAME OF EVENTj6w 6ingk (Z/ LOCATION
DATE(S)OF EVENT Axa 10 V- ( S
NAME OF APPLICANT TELEPHONE(-q-?-C-q4#?, 3:� -
UO 6f- Wkn
ADDRESS La 61A
^y,p, /
NAME OF BUSINESSeimB /` sr ITIELEPHONE# 1?r I �/
ADDRESS 9 A777v (03.3t 4(J
CERTIFIED FOOD MANAGER'S NAME:- I 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 ESTABLISHMENT'S 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
FOODS TO BE SERVED INCLUDING INGREDIENTS AND METHOD OF PREPARATION: (06
i�'firw
svetAA U9A.C&A.,o C I&OTTLOD
I HAVE READ THE BOARD OF HEALTH,"REQUIREMENTS FOR TEMPORARY FOOD ESTABLISHMENTS."I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS REGARDING
THOSE REQUIREMENTS. I UNDERSTAND THEM,AGREE TO ABIDE BY THEM AND UNDERSTAND THAT FAILURE TO DO SO WILL RESULT IN REVOCATION OF MY
TEMPORARY FOOD ESTABLISHMENT PERMIT.
PURSU4SIGNgATUR
49A,I CERTIFY UNDER THE PENALTIES OF PERJURY THAT 1,TO MY BEST KNOWLEDGE AND BELIEF,HAVE FILED ALLSTATE TAX
RETURNTAX UIRED �j�
UNDER —
DATE SOCIAL SECURITY OR FEDERAL ID#
CHECK#: nnDAM /� L Amo PND:
APPRWEDBY.. C N /l.. DAZE: O
Guidelines for Temporary Food Vendors
T=RADADDI 1P_14 m..r nonATDn Rn m11
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: 1-:1
• Your Certified Food Manager certificate, temporary food and propane permits (if applicable) must be
conspicuously displayed on site.
• Only the foods stipulated on your temporary food permit may be sold.
• Foods must be obtained from an approved commercial source. Proof of source such as boxes, receipts etc. must be
on site.
• All potentially hazardous foods such as hot dogs, commercially pre-cooked sausages, hamburgers, prepared
vegetables, must be maintained either above 140°F or below 41'F.
• Only mechanical refrigeration or crushed / cubed ice is allowed as a cooling medium. Foods shall not come in
contact with water or undrained ice. Packaged foods may not be stored directly in ice if it is subject to the entry of
water.
• Cooking temperatures are as follows:
§ Commercially pre-cooked products-140°F
• All foods, drinks and condiments shall be handled and stored in a manner that prevents contamination such as using
clean covered containers, storing equipment and food up off the ground etc. Trash bags are not to be used for food
storage.
• Running water with liquid soap and disposable paper towels for hand washing must be available.and set-up prior to
food preparation. Bottled water with a pull out spout is acceptable. Check with the Health Department for other
acceptable methods.
• All food handlers shall wash their hands after' utilizing the toilet facilities, smoking, eating, changing tasks, and
changing gloves or when hands become contaminated. All wrist jewelry and adornments must be removed.
• Bare hands may not contact ready-to-eat foods. Suitable utensils shall be used'such as deli tissue, spatulas, tongs,
single-use non-latex gloves etc. Bare-hand contact shall be minimized with foods that are not ready-to-eat.
• All equipment, utensils, containers etc. shall be in clean, sanitary condition. Where there are no warewashing
facilities obtainable, a spare set of work utensils shall be available.
• All carts must be thoroughly pre-cleaned before set-up at the event.
• People handling the food shall wear clean outer garments,hair restraints, and utilize good hygienic practices.
• Vendors licensed to sell scooped ice cream must store scoops individually in each tub of ice cream or provide
dipper well with running water
• Smoking is prohibited within 10 feet of a cart or food storage area. Employee must wash their hands thoroughly
with soap before returning to work.
• Garbage and refuse shall be disposed of in a satisfactory manner. The premises shall be kept clean.
• A stem type of thermometer that has been properly calibrated must be available for testing potentially hazardous
foods on site. The thermometer must be cleaned and sanitized before and after use in a manner approved by the
Health Department. Refrigerated units must have thermometers
• A labeled spray bottle of sanitizer prepared at proper concentration must be on site and used on all food contact
surfaces, utensils etc. Proper concentrations should be determined with pH papers. Concentrations are as follows:
§ Chlorine sanitizer: 50— 100 PPM § Quaternary sanitizer: 200 PPM
If any of these conditions are not set-up and maintained, your temporary food permit will be immediately
revoked and you will be ordered to stop serving food.
If you have any questions regarding the above conditions, call the Salem Board of Health at 978-741-1800 prior
to the event.
I have read understood and agree to adhere to the above conditions.
Permit Hold I
Date
_ I