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GABLES SETTLEMENT PRESCHOOL - ESTABLISHMENTS GABLES SETTLEMENT (PRE SCHOOL) 114 DERBY STREET e A€z, Commonwealth of Massachusetts ' .may •f i ,. • ""sn' es- c _ ? '€x m x e;A�#�� u. City of Salem x>"`r S, '»' sy X x's q+i ,�`^ ``x'�-`v"9 '� - �r7W � � €r IGMDeney Dnseoll f s Board of Health _ x 3 Mayor, �w � t " s 120 Weshmgton Street,4th Floor E i ' a �* SAL.E:M,MA '6197a0F,: ,� rr ,."''. , - :meg ..l s y, '�` '�c�3-.§s "e', w"fd} d, -L i. `"` tv e ` 1Food%Retail Establishment Permlt DATE PRINTED 12120/2013 -51 Uk Gym,[+- "¢, F�,.+ „,�s'-,�' ?'' #� ,�T"OW .. �� 2'S� N �^-�"m e "3"'i .�,"' 'y��. .Ye' f 3.. �%m� xv` ESTABLISHMENT NAME Genetr+al Nutrition Center,#5310 - j ,semi A 4.3' s uYj �s» .,> ` . s s-•k- ?' `' w ' 300 6th Avenue,R1 OPS A sr 016 Number BHF 20M000143� " a + r Pittsburgh ° �SPA15222 # 4 a.y,x : y$»'r v.::� '" „�', a .rS . .�R 5 Y `N+'«`' '' "'Ti y.''a `y ''.' h�k s✓=+ ` 'aw. .. {Ty� - r LOCATED AT 511 t Permlt Type Permit No Per inif Issued Permit Expires Fee Restrichons/Notes , . Wll`lRETAIL FOOD BHP 20'14-0202 Jan i 2014-;,Q,Dec 31;2014` $280 00 ra ^ Total Fees r gp X5280 00 4 y. --- '*.a.X ,�.+ ,w 'r•$°a's^ :.,4. t.i `Z N � ..: �• r �'-�s -3w "e'�,,""` t3 ^"G i ,.r�s'.r h ��z ITT f f s`. [2 Av _ ,�4va ` Y ^-h" 3""b 5�. '- 4 x, - e Say 3 x 3 az x s yr ,- " '!�a"fxi . `-' } _ Z »' -`.:., 'e3" s a a "*3 "a''E 'rram s al, j :. � z*' a'�" '-€ tt�. 4, t , �.'T i 1 Zia c.vr z �` S✓ * Y kms"'£ Fes` ' OW`i c Fxa. .r w`E fiF � �'r .' °' � ,:=s x'45 a -_ '� '"6 � + '�3 � � � 2'.ci�- ri�',,L �,� � �•»••3.�.�' x s `G.'� �£�x � y � 411 PERMIT EXPIRES f� ecember 31,:2014 zr r , 1`Ks ." f° .. +' r �. A$oar(]of Health 7 � ... `yY �y � +,"'� �'°�,* � �xGX"s£r v, ,��"sFF3�� ✓:�`T't?'s�'.4isis F `� �� x��s#a w+u " � .s,a This Permit is not trsasferable and must be'reissued poo change of ownership or 1oca6on The pewit must be`po d a 1 xr x in a prominent locadoi in the Establishment . ' xi v Iu accordance with the State Sanitary Code',beofre sny revonations,improvements or egwpment changes are made, such must-be submitted to and approved by the SalemBoard of -II plans for Health , ; page t EE sl„ z°sr n-+: •r _ N w� '� yr2' _ te' y is x� ''`' ` ' r4'a4`3E-3• �'if t,-€"�i"' "z':✓ t t e" g W' 1 ' CITY OF SALEM, 1P MASSACHUSETTS � PebticHealFh BOARD or HI ,�:riI .,...,,...,m.,....o•..,. 120 WASHINGTON S1111.0 ',411'FLOOR KIMBERLEY DRISCOLL Tr]'.(978)741-1800 FAX(978)745-0343 LARRY"R1bIDIN,RS/R1,LIS,CHO,CP-FS MAYOR 1mmdinQsa1em.com HEAL.i'H A(iI'dN'r Food Establishment Permit Application (Application.must be submitted at leaastt 30 days before the planned opening date) 1) Establishment Name: i5 Al2 I-RpAZ- & ; l W O4Y/ p�/V 7Zla/fne105 ,531c:> 2) Establishment Address: ri y/ I�(Sj� D Ski' 7� /4 �+ 0I1 �70 3) Establishment Mailing Address(if different): .500 p �/ 4) Establishment Telephone No: /// g- "41- 24�� 5) Applicant Name&Title: 51! 441A G �tgQ�Nf} LlG s 6) Applicant Address: sAA41 yft3 c� 7) Applicant Telephone No:412•21f9'4&4' 24 Hour Emergency No: J-Mo-/�/7B Email:AN�44NpE-F7.461 8) Owner Name&Title(if different from applicant): 66-416AI, NOWPOAl e0A0 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 corporation Inrvi ua E cGOSCJ A partnership Other legal entity 12 Person Directly Res onsible For Daily Operations Owner, Person in Charge,Supervisor,Manager,etc. Name&Title: A-490A) Address: Telephone No: 1l' /nn .sry ,j1 Fax:4/Z"338-If 919 Email: *Oil•G'Om Emergency Telephone No: 13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: Fax: Email: Check#: Date: Amount: e Food Establishment Information or )4) Water Source: P(I gG iG 15) Sewage Disposal: teUeL-/c, DEP Public Water Suppl No: (if applicable) 16) Days and Hours ofOperation: 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 Proced as(if 25 seats or more): ❑ Yes No 20) Location: 22 tablishment Type(check all that apply) (check one) / eta ( 1151W Sq. Ft) 0 Caterer Permanent Structure!/ O Food Service-( Seats) O Frozen Dessert Manufacturer Mobile Cl Food Service-Takeout O Residential Kitchen for Retail Sale ❑ Food Service-Institution 13 Residential Kitchen for Bed and ( Meals/Day) Breakfast Home O Food Delivery ❑Residential Kitchen for Bed and 21) Length Of Permit: _ _Breakfast Establishments...................... -.................................... (che one) RETAIL STORE RESTAURANT Annual P Lthan 1000sq.ft. $70 / ❑Less than 25 seats $140 Seasonal/Dates: 000-10,OOOsq.1 ❑Residential Kitchens $140 O More than 10,OOOsq.ft. $420 ❑25-99 seats $280 ❑More than 99 seats $420 Temporary/DatesRme: ------ - --- ------------- ------------------- 0 Bed&BreakfastlChildcare Services(Nursing Home $100 ADDITIONAL PERMITS ❑MAKE ICE CREAM,YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 0 ALL NON-PROFIT` $25 "Including, church kitchens, state funded childcare 8 private club 23) Food Operations: Definitions: PHF-potentially hazardous food(timekemperaturecontrols required) Non-PHFs—non-potentially hazardous food(no time/temperature controls required) (check all that apply): - RTE—ready-to-est foods Ex.sandwiches,salads,muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control. Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application I,the undersigned,aftest 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. i 24) Signature of Applicant: r� L� Pursuant to MGL Ch.62C, sec.49A, I certify under the penalties of perjury that I,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: ;05- 112- 26) 5- 1112-26) Signature of Individual or Corporate Name: 1' GENERAL NUTRITION CORPORATION 300 Sixth Avenue Pittsburgh,PA 15222 7/15/63 PA TAX IDENTIFICATION NO. 25-1124574 (412)2SS-4662 --------------------------------------------------------------------------- Joe Fortunato,President&CEO 300 Sixth Avenue Pittsburgh, PA 15222 Michael Nuzzo,Executive Vice President &CFO 300 Sixth Avenue Pittsburgh, PA 15222 Gerald J. Stubenhofer,Jr., Sr. Vice President&Secretary 300 Sixth Avenue Pittsburgh, PA 15222 Arthur W. McSorley,Vice President 300 Sixth Avenue Pittsburgh, PA 15222 David J. Sullivan,Assistant Secretary 300 Sixth Avenue Pittsburgh, PA 15222 The Conznxonwealth ofMassachitsetts ( Depat entofbxdustrialAceidents Duke 01111uesU931hMS 600 YYashinglon Street, 7`h Floor Boston Mass. 02111 Workers'Corn))ensauon Insurance Affidavit-General Businesses name: 46,N6941, 'V U /,7 /7Q/0N C lOR address: 30o � 4 city P►rr-S3 u 1C 07' state: PA zp/: f, 2/2_0 hones .412 2) 8 9 �4^ 66 work site location(full adrtressl: &l!AIz A D l S t �A SA(. 5! 1, f/�YT Q/ 9 70 ❑ I am a sole proprietor and have no one Business Type: etail (j RestaurantfBar/Eatmg Establishment ark ng in any capac) y. 1j ❑ Office❑Sal (including Real Estate,Autos etc) I am an einplo erwath 47 employees(full&�uttune) ❑Otlter r am an employ e�rrp^'roviding workeprs,r�compensati�on/for,may.-er,,,nploy_,ee�s/wor�kijng on�tnhrs�lo/b�- ,,p ctr¢iiany name:- Ca ���/�z'1�� "N� / /�- s✓ '/ _/ (,��1/ ES:X.'!�/, a-�. adii�es5r :j3"�o/�� ,'��- .✓�'" 1y ^'� �+ �j / — city: �" 1'(;- I3V !". C.P 4, rrT �"..Jt� 4/��ZJf pylons insurance co / .'_T� •FN� -.(iVSC.� I am a sole proprietor and have hired the independent contractors listed below who have the following workers' compensation polices: uhone#..r 1n5uranCCCn Po"11cV# u4�ra..Oh.."_'e.�'2° camps fly natl'ICt address. city, phone#, ulsu rant Failure to secure coverage as required ander Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$IDDM a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify and the pains and penalties foe ury hat the information provided above is true Jand correct. signature ,'j� iAt-Q 2.� � (.�� Date t )2� �y� �y Print nameQ�A fie- t '^i tt 'Y?CL _Phone# 4(Z !Gg g- ,: *_.:.M : f official use Duty do not write in this area to be completed by city or town official SCe city or town: perm t/license#_, OBuitding Department Qliceusing Board til check if immediate response is required ❑Selectmen's Office {]Health Department n contact person: ._ phone u; DOtber s (ro.iscd SIL 2003) CERTIFICATE OF LIABILITY INSURANCE DATEOlMlIM13 !) OI NIDON THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the poliry(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the A certificate holder in lieu of such endarsementis)- � CONTACT PRODUCER NAME. Aon Risk Services Centrdl, ZRt. o (866) 283-7122 (FA (847) 953-5390 m Pittsburgh PA Office (Ar—No.EMi: AIC,NP.: y Dominion Tower, 10th Floor E-MAIL . 625 Liberty Avenue AUDA i Pittsburgh PA 15222-3i10 USA INSURER(S)AFFORDING COVERAGE NAIG4 INSUREO INSURERA: Liberty Insurance Corporation 42404 GNC Corporation MKR8: 300 6th Avenue 11th Floor Pittsburgh PA 15222-2514 USA INSURERC; , INSURER D: INSURFRE WNREIt F: ' COVERAGES CERTIFICATE NUMBER:570048953373 REVISION NUMBER: THIS IS TO CERTIFYTHAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD' INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.OMITS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAIMS. Limits shown are as requested INSR LTR TYPE OFIN6UPANCE III VIVO POLICYNUMBER I MIXTKVYYYYI MM LIMBS GENERILLIABILITY EACH OCCURRENCE COMMERCIAL GENERAL LIABILITY MISUISES Ea Aavnanm ctXws U0E []OCCUR MED EXP VM maperaAAJ PERSONAL&ADV UUURY GENERALAGGREf TE GE AGGREGATELIMRAPPIIESPER: PRODUCTS-COMP/OP AGG POLICY 'A Lac A AUTOMOBILE LIABILITY AS7-631-509783-053 01/31/2013 01/31/2014 COMBINED31WLEUMIT $2,000,000 a¢Mm X ANY AUTO 60DILYINJURY(Perpersw0 0 A"' SCHEDULED BODIUYINJURY(Pc..c N) AUT 8 19REDAUT03 NON.OVMEO PROPERtt DPAIAGE N AUTOS �'aA Y 0 UMHNEILA LIAB Occu EACHCCCURRENCE U EXCESS UAe CLAIM1ttMADE AGGREGATE DED ENnON AMP R RWMPr ATWNAND Y/N ADS D50978 033 01/31/2013 01/31/1014 X LAWLTYroW USITAATS OTH ANY PROPRfl:TORIPARTNERIIXECIITN6 ER EL EACH ACCIDENT 51,DOO,ODO A OFFIcfJVL®NBFrt EXQIIDeDT N N/A wC7631509783023 01/31/201301/31/2014 IMaMamry In NFD OR &wI 41,000,000 IIye 4eamTauMx DE6CRpnON OF OPERAnONSbMmv EL DISEASE-POLICY LIMIT 51,000,000__ DESCRIPTION OF.OPERATIONS 1 LOCATIONS VEHICLES WbcN ArAPo 101,A&4llmui RamaMs SCNGWe,amaa space Is repuln4l EVIDENCE OF COVERAGE NA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF SHE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE r TI EMRATION DATE TNEREOP,NOTICE YALL BE DELIVERED IN ACCORDANCE WITH THE POl1CY PROVI610N3. GNC Corporation .300 6th Avenue nth Floor AUTHORIZEDREPRESENTATIVE Pittsburgh Pp 15212-2514 Lisa �:/�rGkJkrwoA-a L�iaa ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(201 DIOS) The ACORD name and logo are registered marks of ACORD rrae > 0114 DERBY STREET House of the Seven Gables Settlement Pre-School City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ J Item Status Violation Critical Urgency (Telephone: Violations Related to Good Retail Practices (Blue Items) 1745-5909 - Equipment and Utensils FAIL Non-Critical BLUE Owner: Comment:Microwave requires general cleaning. .The House of the Seven Ga Physical Facility FAIL Non-Critical BLUE IPIC: I Cathy Diffin Comment:Water stained ceiling tiles in men's room.Investigate source of leak&replace ceiling tiles. t Inspector: 1I,Elizabeth Salandrea Date Inspected:Correct By: 3/3/2008 Risk Level r Permit Number: I BHP-2008-0162 Status: SIGNED OFF #of Critical Violations: 0 yTime IN: Time OUT: i ,Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical f Violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately 1 or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 05,2008 ) Page 1 oft t� > Item Status Violation Critical Urgency ;RED: — Violations Related to !Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) l City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMSO 2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 05,2008 ) Page 2 oft 0114 DERBY STREET House of the Seven Gables Settlement Pre-School City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 745-5909 Physical Facility - FAIL Non-Critical BLUE Owner: Comment: 2 lights in dry storage in the basement need covers. The House of the Seven Ga PIC: 3 tiles in the hallway to the bathroom have stains on them-replace stained tiles. Cathy Diffin Inspector: Elizabeth Salandrea Date Inspected:Correct By: 9/26/2008 r Risk Level: Permit Number: BHP-2008-0162 'Status: ' SIGNED OFF t#of Critical Violations: '0 Time 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®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 26,2008 ) Page I 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®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 26,2008 ) Page 2 oft s �6 r The House of the Seven Gables Settlement Association f 54 Turner Street f • Salem,MA 01970-5698 f Tel.:(978)-744-099 1,x119 Fax: (978)741-4350 www.7 abl�es.org E-mail:H7GOlson@aol.com David-A.Olson Museum Director