GRACE CHURCH - ESTABLISHMENTS a
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ne"D " City of Salem, Massachusetts
Board of Health
a 120 Washington Street, 4th Floor, Salem, MA 01970
e o Tel. (978) 741-1800 fax. (978) 745-0343 P11b1�CHPAlth
health@salem.Com Prevent. Promote.Protect.
Kimberley Driscoll Larry Ramdin, MPH, RENS, CHO
Mayor Health Agent
FOOD ESTABLISHMENT PERMIT
(must be posted on the Premises of the Food Establishment)
2017
Permit Number: FM-16-627
Permit Type: Food Establishment nonprofit
Goods& Services: Food Service: Non-Profit
Name of License Holder: Grace Church Rev. Deborah Phillips
Name of Food Establishment Grace Church
Address of Food Establishment 385 Essex Street Salem, MA 01970
Restrictions: Church Kitchen
This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on
12/31/2017 unless sooner suspended or revoked.
Permit Fee: $0.00
Effective: 12/21/2016
Larry Ramdin, MPH, REHS, CHO
Health Agent
CITY OF SALEM, lu
MASSACHUSETTS > toHeaub
BOARD or HEALTH
120 WASHINGTON STREET,411'FLOOR
KIMBERLEY DRISCOLL TET...(978)741-1800 FAX(978)745-0343 LARRY RAMDIN,RS/RL'HS,CHO,CP-FS
MAYOR healdi@salem.com 5 '�
y® HEAL TI-I AGENT
Food Establishment Peup)ittiV'Olication
(Application must be submitted at least 30 days before ftcanned opening date)
O HH
1) Establishment Name: �j.,y�� '�V . �a�� v
2) Establishment Address:
3) Establishment Mailing Address(if different): ''JJ
4) Establishment Telephone No: Q7 8 -70 2-7g4,
5) Applicant Name&Title: '7U G — D
6) Applicant Address:
7) Applicant Telephone No: 24'Hour Emergency No: Email:
8) Owner Name&Title(if different from applicant):
9) Owner Address(if different from applicant):
10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of
officers or partner.
An association Name Title Home Address
A corporation
An individual
A partnership
Other legal entity
12 Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor,Manager,etc.
Name&Title:
Address:
Telephone No: Fax: Email:
Emergency Telephone No:
13) District or Regional Supervisor(if applicable)
Name&Title:
Address:
Telephone No: Fax: Email:
Check#: _ Date: Amount:
` Food Establishment Information
14) Water Source: 15) Sewage Disposal:
DEP Public Water Supply No: ( if applicable)
16) Days and Hours of Operation: 17) No. of Food Employees:
18) Name of Person in Charge Certified in Food Protection Management:
Required as of 101112001 in accordance with 105 CMR 590.003(A)
19) Person Trained in Anti-Choking Procedures(if 25 seats or more): ❑ Yes No
20) Location: 22) Establishment Type(check all that apply)
(check one) 0 Retail( Sq. Ft) O Caterer
Permanent Structure O Food Service-( Seats) O Frozen Dessert Manufacturer
Mobile 0 Food Service-Takeout 0 Residential Kitchen for Retail Sale
0 Food Service-'Institution 0 Residential Kitchen for Bed and
( Meals/Day) Breakfast Home
0 Food Delivery 0 Residential Kitchen for tied and
21) Length Of Permit: ..............................................................................Breakfast Establishments--------.............
(check one) RETAIL STORE RESTAURANT
Annual 0 Less than 1000sq.ft. $70 0 Less than 25 seats $140
Seasonal/Dates: 0 1000.10,000sq.ft., $280 0 Residential Kitchens $140
0 More than 10,000sq.ft. $420 0 25-99 seats $280
0 More than 99 seats $420
Temporary/Dates/Time: ................. ............
0 Bed&Breakfast/Childcare Services/Nursing Home $100
........................................................................................................................................
ADDITIONAL PERMITS
0 MAKE ICE CREAM,YOGURT/SOFT SERVE $25
❑ PASTURIZATION
ALL NON-PROFIT' $25
nc/udin , church kitchens, state funded chilbsam&advate club
23) Food Operations: Definitions: PHF-potentially hazardous food(timeHemperature controls required)
Non-PHFs—non-potentially hazardous food(no time/temperature controls required)
(check all that apply): RTE—rea -to-eat foods Ex.sandwiches,salads, muffins which need no further processing
Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held
Pre-packaged Non-PHFs for More Than a Single Meal Service
Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly
Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility
Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill
Prepared by Consumer
Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance
Processed Foods for and/or HACCP Plan(including bare hand
Service Within 4 hours contact alternative,time as public health
control.
Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of
Non-PHF and Non- Retail Sale Animal Origin
Perishable Foods Only -
Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered
Retail Sale I 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 TK. /Pot_ J lam( /Zi
�-
Pursuant to MGL Ch. 62C,sec.49A, I certify under the penalties of perjury that I,to my best knowledge and belief,
Have filed all state tax returns and paid state taxes required under law.
25) Social Security Number or Federal ID:
26) Signature of Individual or Corporate Name:
tl
QUESTIONAIRE - GREASE TRAPS 2013I,,
1. NAME OF ESTABLISHMENT:� U "\
2. ADDRESS OF ESTABLISHMENT:
3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP?
4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT HAVE?
CAPACITY IN GALLONS
5. HOW IS THE GREASE TRAP MAINTAINED? ON A DAILY BASIS? BY AN IN-HOUSE PERSON OR
BY AN OUTSIDE CLEANING SERVICE?
6. WHAT IS THE FREQUENCY THAT THE GREASE IS REMOVED FROM THE TRAP?
7. WHAT IS THE NAME OF THE FIRM WHO REMOVES AND/OR PICKS UP THE GREASE FROM
YOUR ESTABLISHMENT?
8. WHAT IS THE DATE OF YOUR LAST INVOICE FROM THE REMOVAL FIRM?
1
The Commonwealth of Massachusetts
V
Department oflndustrial Accidents
Offwe'of Investigations
I Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Comp`ensation Insurance Affidavit: General Businesses
Applicant Information I Please Print Leeibly
Business/Organization Name: ( ro,r
Address: > 25sle k r
City/State/Zip: j j e w MR OR-10 Phone#: q`t �; '1 'i 4 27 q 6
Are you an employer?Check the appropriate box: Business Type(required):
L❑ I am a employer with employees(full and/ 5. ❑Retail
orpart-time).* 6. ❑Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7, ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers'comp.insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152, §1(4), and we have 10.❑Manufacturing
no employees. [No workers'comp.insurance required]** 11. Health Care
4�We are a non-profit organization,staffed by volunteers, P Q
with no employees. [No workers'comp. insurance req.] 12. Other e k�c t C�
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
lam an employer that is providing workers'compensation insurance for my employees Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic.# Expiration Date:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify,under the pains and penalties ofperjury that the information provided above is true and correct
Signature: Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
1
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply your insurance company's name,address and phone number along with a certificate of insurance.
Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members
or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy
is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers'compensation policy,please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number.In addition,an applicant that
must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this
affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. #617-727-4904 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
www.mass.gov/dia
Fmm Revised 7/2010
City of Salem, Massachusetts
Board of Health
�r9 120 Washington Street, 4th Floor, Salem, MA 01970
Tel. (978)741-1800 Fax. (978) 745-0343 PablicHea ith.
health@salem.com Pre"ent. Promote. Protect.
Kimberley Driscoll Larry Ramdin, MPH, REHS, CHO
Mayor Health Agent
FOOD ESTABLISHMENT PERMIT
(must be posted on the Premises of the Food Establishment)
2016
Permit Number: FM-16-595 -
Permit Type: Temporary Food Non-Profit
Goods &Services: Food Service: Non-Profit
Name of License Holder: Ste Anne Church - Rev. John Kiley
Name of Food Establishment Mia's House of Sweets
Address of Food Establishment
Restrictions:. Mia's House of Sweets
Event-Paul Madore Chorale
12/18/16
Prepackaged Baked goods, cookies brownies and more.
This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on
12/18/2016 unless sooner suspended or revoked. /}
Permit Fee: '125.00
Effective: 12/18/2016
Larry Ramdin, MPH, REHS, CHO
Health Agent
r2= CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
�Vdgy�
120 WASHINGTON STREET,4T FLOOR
KIMBERLEY DRISCOLL TEL. (978) 741-1800
FAx(978) 745-0343
MAYOR lramdin&salem com
LARRY RAbIDIN,RS/RFHS,CHO,CP-FS
HEALTH AGENT
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 x600=THE AMOUNT DUE (EXAMPLE: 14 DAYS DIVIDED BY 7=2 X 600=$1200
APPLICATION FOR A TEMPORARY FOOD SERVICE PERMIT
M�A� '
NAME OF EVENT-P401 I AkYlli ? ('i�101q 1 - OT N"'H '�'f LOCATIONC /<Q. h0n4C 6i ( -
DATE(S)OF EVENT /b 010/0
NAME OF APPLICANT Yyu P"/ Ik-o e / hp wt le TELEPHONE# 97ff-a/9- �l3/04i
ADDRESS F/4? efdInc dj4y- & ,Aj � 104 D/9D7 '/
NAME OF BUSINESS Al le O mt 0-LrweG4f TELEPHONE#off/.T- /0/Pi- lk41 _
ADDRESS 114 Aoet C�, M)q 011/j /�
CERTIFIED FOOD MANAGERS NAME: f1T1A j�� /✓N�-i�/o CERTIFICATION#: /%?/749"
*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 MANAGERS 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:
T � ,ADDRESS
FOODS TO BE SERVED INCLUDING INGREDIENTS AND METHOD OF PREPARATION: I �Od./J iv7Glcrd/HA
IhOkWJ, P4wh,GJ ,-e- - �M 1 �yLW4kCivly
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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.
PURSUANT TO MGL C62C,S49A,I CERTIFY UNDER THE PENALTIES OF PERJURY THAT I,TO MY BEST KNOWLEDGE AND BELIEF,HAVE FILED ALL STATE TAX
RETURNS AND PAID ALL STATE TAXES REQUIRED
UNDER LAW.
SIGNATURE DATE SOCIAL SECURITY OR FEDERAL ID#
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------
CiHECK#: DATE AMOUMPAIQ:
APPROVED BY: DATE:
TFUPAPPI IO-1t nnr.ijpnATFORH9/71
0
R CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET,4T"FLOOR
KIMBERLEY DRISCOLL TEL. (978) 741-1800
MAYOR FAX(978) 745-0343
lramdin@salem.com
LARRY RAMDIN,RS/REHS,CHO,CP-FS
HEALTH AGENT
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 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.
Alo(e
Permit Hold r Date
TrUPAPPI 1n-11 nnn 11Pr)ATr:n A/19/11
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CERTIFICATION
MIA D'AGOSTINO
for successfully completing the standards set forth for the Se"Safe®Food Protection Manager Certificat on Examination,
which is accredited by the American National Standards Institute(ANSI)Conference for Food Protection(CFP).
170824 10470
C6 T,,IFIC UMBER EXAM FORM NUMBER
1/26 6 `, 1/26/2021
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DATE OF E "'KAINATION DATE OF EXPIRATION
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COMMONWEALTH OF MASSACHUSETTS Permit 0: FM-16-138
CITY OF BEVERLY µ
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a Fee:
Board of Health - Date Nsued: 2/16/2016
G �3yr." .Et..
MIA'S HOUSE OF SWEETS
Name. ' w
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Address
IS tHEREBY GRANTED RESIDENTIAL KITCHEN_L'4CE'NSE
This,License is granted in conformity with the statutes, Regulations and ordinarices gelating thereto,and expires on.
K 12/31/2016 unless sooner suspended or revoked. .,
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Board of Health
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. °pN➢IT'yd City of Salem, Massachusetts
� 6 affi
Board of Health lu
a 120 Washington Street, 4th Floor, Salem, MA 01970
SAP Tel. (978) 741-1800 Fax. (978) 745-0343 PlnblicHealth
N ➢ Prevent. Promote. Protect.
Iramdin@salem.com
Kimberley Driscoll Larry Ramdin, MPH, REHS, CHO
Mayor Health Agent
\ FOOD ESTABLISHMENT PERMIT
(must be posted on the Premises of the Food Establishment)
2016
Permit Number: FM-16-171
Permit Type: Food Establishment nonprofit
Goods&Services: Food Service: Non-Profit
Name of License Holder: Grace Church Rev. Deborah Phillips
Name of Food Establishment Grace Church
Address of Food Establishment , 385 Essex Street Salem, MA 01970
Restrictions: Church Kitchen
This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and.expires on
12/31/2016 unless sooner suspended or revoked.
Permit Fee: $25.00
Effective: 1/1/2016
CITY OF SALEM,
MASSACHUSETTS
»bucxeatrh
BOARD or Hi ne_❑t .m..�omn ,. ' ..,.
120 WAsrnNG]'ON Sind r,4T°FL00R
KIMBERLEY DRISCOLL Tea..(978)741-1800 FAx(978)745-0343 LARRY RAMDIN,RS/REHS,(1110,CP-FS
MAYOR Iramdin@salem.com HL',AI,ii AGIi;NP
Food Establishment Permit Application
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name: 4f q C8
2) Establishment Address:
3) Establishment Mailing Address(if different):
4) Establishment Telephone No: 01+7$ ^ �7 4�--.Z7
5) Applicant Name&Title: 1 ECi yi -Pro e IPS
6) Applicant Address: sa—W^� '77L)
/r, /!
7) Applicant Telephone No: '170'/ 6"L3JV24 Hour Emergency No: /7Q6/� �t0Email;6,CLS _ W ;Z9r)'I Ot
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
1
12 Person Directly Res onsible For Daily Operations Owner,/Person in Charge, Supervisor,Manager,etc.
Name&Title: 64 0✓""
Address: O �/' t.%ek
Telephone No: C Grt�) � - ->Z '6Faax: Email:a
Emergency Telephone No: / — 3®� 0 (3 /
13) District or Regional Supervisor(if applicable)
Name&Title:
Address:
Telephone No: Fax: Email:
Check#: 6_U_ _ __ Date: �� ��� Amount:
Food Establishment Information
14) Water Source: C�" 15) Sewage Disposal:
DEP Public Water Supply No: ( if applicable) O
16) Days and Hours of Operation: [ f�' 7�S 012 17) No. of Food Employees:
18) Name of Person in Charge Certified in Food Protection Management: Q
Required as of 101112001 in accordance with 105 CMR 590.003(A) few t
19) Person Trained in Anti-Choking Procedures(if 25 seats or more): ❑ Yes )C No
20) Location: 22) Establishment Type(check all that apply)
/ (check one) ❑)Retail t ❑Caterer
r Permanent Structure INFood Service-(� __ yro t ❑ Frozen Dessert Manufacturer
fMotrthe,t 0 Food Service-Takeout ❑ Residential Kitchen for Retail Sale
❑ Food Service-Institution ❑ Residential Kitchen for Bed and
( Meals/Day) Breakfast Home
❑ Food Delivery ❑ Residential Kitchen for Bed and
21) Length Of Permit: ------------------ Breakfast Establishments__.__._.--.,•___..__-,
(check one) RETAIL STORE RESTAURANT
Annual ❑ Less than 1000sq.ft. $70 ❑ Less than 25 seats $140
Saasnnal/Dates: ❑ 1000-10,000sq.ft. $280 ❑ Residential Kitchens $140
❑More than 10,000sq.ft. $420 ,Q 25-99 seats $280
❑ More than 99 seats $420
Temporary/Dates/Time: - ---- --- --- ---- ---- ---- -- --Se" - ------hN' -- ------------ ------------------------- --------- ------------ .....
❑ Bed& BreakfastlChildcare Services/Nursing Home $100
--------------------------- ----------. --------------------------------- -------_-_-.----------------
ADDITIONAL PERMITS
❑MAKE ICE CREAM,YOGURT/SOFT SERVE $25
❑ PASTURIZATION
ALL NON-PROFIT' $25
*Including, church kitchens, state funded childca private club
23) Food Operations: Definitions: PHF-potentially hazardous food(time/temperature controls required)
Non-PHFs-non-potentially hazardous food(no time(temperature controls required)
(check all that apply): RTE-read -to-eat foods Ex.sandwiches,salads, muffins which need no further processing
Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held
Pre-packaged Non-PHFs for More Than a Single Meal Service
Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly
Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility
Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill
Prepared by Consumer
Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance
Processed Foods for and/or HACCP Plan(including bare hand
Service Within 4 hours contact alternative,time as public health
control.
Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of
Non-PHF and Non- Retail Sale Animal Origin
Perishable Foods Only
Preparation of Non-PHFs Juice Manufactured and Packaged for �repares Food/Single Meals for Catered
Retail Sale Events or Institutional Food Service
Offers RTE PHF in Bulk Quantities
To be completed by the Board of Health
Retail Sale of Salvage,Out of Date
or Reconditioned Food Total Permit Fee:
Payment is due with application
I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will
comply with 105 CMR 590.000 and all other applic 2 ve 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: I^1 G W NPS'
Pursuant to MGL Ch. 62C, sec. 49A,I certify under the pe alties of perjury that I,to my best knowledge and belief,
Have filed all state tax returns and paid state taxes required under law. >w 2
25) Social Security Number or Federal ID: 1 2'2! 1
/,
26) Signature of Individual or Corporate Name: vl�
Nn'T'� City of Salem, Massachusetts
Board of Health
a 120 Washington Street, 4th Floor, Salem, MA 01970
A Tel. (978) 741-1800 Fax. (978) 745-0343 PlubliCHea ith
.Prevent, Promote. Protect.
Iramdin@salem.com
Kimberley Driscoll Larry Ramdin, MPH, REHS,CHO
Mayor Health Agent
FOOD ESTABLISHMENT PERMIT
(must be posted on the Premises of the Food Establishment)
2015
Permit Number: FM-15-253
Permit Type: Food Establishment nonprofit
Goods &Services: Food Service: Non-Profit
Name of License Holder: Grace Church Rev. Deborah Phillips
Name of Food Establishment Grace Church
Address of Food Establishment 385 Essex Street Salem, MA 01970
Restrictions: Church Kitchen
This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on
12/31/2015 unless sooner suspended or revoked.
Permit Fee: $25.00
Issued: 1/1/2015
- 1�' CITY OF SALEM, Q
MASSACHUSETTS
BOARD OF HL',ETI-1
120 WA51-QNG'rON S'mT.C'r,4"'FLOOR -
KIMBERLEY DRISCOLL TiiL.(978)741-1800 FAX(978)745-0343 ,1
LARRY R.\bIDM,RS/RF ,I5,CMO,CI'-I.g
MAYOR Immdin�,salem com
14EAL,n-i AGF,NP
Food Establishment Permit Application
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name:
2)- Establishment Address: St.. zU e q 7
3) .Establishment Mailing Address(if different):
4). Establishment Telephone No / '-a2 7 TC
5) Applicant Name&Title: r
6) Applicant Address: Q
7) Applicant Telephone No: r_ 4 Hour Emergency No: Email: 126.m
n Y1 t-
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 /(bH`pre X
,Ol(e)(3)
12 Person Directly Responsible For Daily Operations(Owner, Person in Charge,Supervisor,Manager,
Name&Title: — - —_Rev,
t. ---
Address:" Shoe
Telephone No: y QdJ Fax: Email:
Emergency Telephone No:
13) District or Regional Supervisor(if applicable)
Name&Titie: AJ 6t;
Address: DEC I014
YG ,c rt-EM
Telephone No: Fax: "AD OF•HEALTH
Check M-47 5 Date:__'�y� � Amount Vl, J
/U�/� — /Udh-Malt -
Food Establis' it 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 10/112001 in accordance with 105 CMR 590.003(A)
19) Person Trained in Anti-Choking Procedures(if 25 seats or more): ❑ Yes No
20) Location: 22) Establishment Type(check all that apply)
(check one) ❑ Retail( Sq. Ft) ❑Caterer
Permanent Structure ❑ Food Service-( ISeats) ❑ Frozen Dessert Manufacturer
Mobile ❑ Food Service-Takeout ❑ Residential Kitchen for Retail Sale
❑ Food Service-Institution ❑ Residential Kitchen for Bed and
( Meals/Day) Breakfast Home
❑ Food Delivery ❑ Residential Kitchen for Bed and
21) Length Of Permit: .. . . Breakfast Establishments,,,
(check one) RETAIL STORE RESTAURANT
Annual ❑ Less than 1000sq.ft. $70 ❑Less than 25 seats $140
seasonal/Dates: 0 1000-10,000sq.ft. ' $280 ❑Residential Kitchens $140
❑More than 10,000sq.fL$420 ❑25.99 seats $280
❑More than 99 seats $420
Temporary/Dates/rime: --------------------------------------- -------------------------------------------
----------..............................................
❑ Bed&Breakfast/Childcare Services/Nursing Home $100
ADDITIONAL PERMITS
-------------------------------
❑MAKE ICE CREAM,YOGURTISOFT SERVE $25
❑ PASTURIZATION $25
❑ALL NON-PROFIT" $25
'Including, church kitchens, state funded childcare 8 private club
23) Food Operations: Definitions: PHF-potentially hazardous food(t/me/temperature controls required)
Non-PHFs-non-potentially hazardous food(no time/temperature controls required)
(check all that apply): RTE-read -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 I for More Than a Single Meal Service
Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly
Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility
Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill
Prepared by Consumer
Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance
Processed Foods for and/or HACCP Plan(including bare hand
Service Within 4 hours contact alternative,time as public health
control.
Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of
Non-PHF-and Non-- Retail Sale Animal Origin
Perishable Foods Only
Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered
Retail Sale Events or Institutional Food Service
Offers RTE PHF in Bulk Quantities
To be completed by the Board of Health
Retail Sale of Salvage,Out of Date
or Reconditioned Food Total Permit Fee:
Payment Is due with application
I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will
comply with 105 CMR 590.000 and all other applicable I I.have en instructed by the Board of Health on how to obtain copies of 105 CMR
590.000 and the Federal Food Code.
r
24) Signature of Applicant:
Pursuant to MGL Ch.62C, sec.49A,I certify under the penalti of perjury that 1,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: a�(-�2�.I
26) Signature of Individual or Corporate Name: i^Y f`P Cr1f[✓"C 67 - �a �Evn
r
Massachusetts Department of Public Health Salem Board of Health
Division of Food and Drugs 120 Washington Street,4"'Floor
Salem, MA 01970-3523
Tel. (978)741-1 Boo Fax (978) 745-0343
City/Town of Address:
FOOD ESTABLISHMENT INSPECTION REPORT Tel.
Name Da Type of Operation(s) Type of Inspection
Food Service [Routine
-Address _. - - isk ❑ Retail "' r]Re-inspection
Telephone Level El Residential Kitchen Previous Inspection
_ ❑ Mobile Date:
OwnerHACCP YIN ❑ Temporary _ ElPre-operation
E(Z Ic- ❑ Caterer ❑Suspect Illness
Person-in-Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint
HACCIP
Inspector - 0 �.(� Permit No. ❑.Other
Each violation checked requires ane planation 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_(Red
Items) - Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑
q Allergen Awareness 590.009(G) ❑
corrective action as determined by the Board of Health.
FOOD PROTECTION MANAGEMENT I ❑12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
EMPLOYEE HEALTH 4 "` El 13. Handwash Facilities
- 'PROTECTIONFROM"CHEMICALS - _ �" '
❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ` - I'll, -`
E] 3., Personnel with Infections Restricted/Excluded
- .._x... - _, E F115.Toxic Chemicals -
"FOOD:FROM-APPROVED SOURCE, .. _. _
F14. Food and.Water from Approved Source 'jimErrEMPERATURE"CONTROLS(P.Ce-rtt liy Mazarttous Foodti)-
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy.of Ingredient Statements ❑ 17. Reheating
7. Conformance with Approved Procedures/HACCP Plans [118. Cooling
,PROTECTION FROM CONTAMINATION_ "', ��.rq ❑ 19. Hot and Cold Holding -
❑ 8.Separation/Segregation/Protection ❑20.Time as a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY4USCEPTiBLE=POPULATIONS-,(HSP)`
❑ 10. Proper Adequate Handwashing [121. Food and Food Preparation for HSP
❑ 11. Good Hygienic Practices ;CONSUMERADVISORY �
❑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. Noncritical (N)violations must be corrected Official Order for Correction:Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health.
C 590.000/federal Food Code.This report,when signed below
23. Management and Personnel (Fc-2X59o.0o3) 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
25. Equipment and Utensils (Fc-axsso.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)(59o.om) establishment operations. If aggrieved by this order,you
27. Physical Facility (FC-6X590.007) have a right to a hearing.Your request must be in writing
28. Poisonous or Toxic Materials (FcaX590.008) 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:
s: a+aaoo
Inspector's Signature: Prin :
PICsSignature: Print: I u Page oPages
i
Violations Related to Foodborne Illness
interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION
g Cross-contamination
FOOD PROTECTION MANAGEMENT 3-302.1.1(A)(]) Raw Animal Foods Separated from
1 590.003(.0) Asci-timent of Responsthihty* Cooked and RTE Foods*
590.003(B) Demonstration of Ktwwledge" Contamination from Raw Ingredients
2-_103.21 Pct son in charge�-dutnes 3-302.1.1(.4)(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 3-30211(.0) Food Prdtectiun*
require reporting by food employees and 3-30215 Washu) Fmits and Ve*etables
a pliemrts°' 3-304.11 Faxi Contact with Equipment and
590.003(F) Responsibility Of A,Ford Employee Or An Utensils*
Applicant To ReportTonic Person In Contamination from the Consumer
Char _* 3-306.14(A)("B) Returned Food and Resetsice of Food*
590.(N13(G) Re otn b`Persnn in Charge* Disposition of Adulterated or Contaminated
3 590.003(D) Exclusions and Restrictions* Food
590.003(E) Removal of Exclusions and'Restrictions 3-701.1'[ Discarding or Reconditioning Unsafe
Fotxia`
FOOD FROM APPROVED SOURCE
4 1 Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-Bl Compliance with Focal law`" � 4-501,111. Manual Warewashing-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 Warewashinp Hot Water
3-202.13 Shell Eggs* Sanitization Tem eratures*
3-202.14 E s and Milk Products.Pasteurized" 4-501.114 Chemical Sanitization-temp.,pH,
3-202.16 Ice Made From Potable Drinking*Water* concentration and hardness. *
5-101.11 Drinking Water from an Approved System* 4-60 L.f1(A) - Equipment Food Contact Surfaces and
Utensils Clean*
590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food-
590.006(B) Water Meets Standards in 310 CM0*
R 22.
Contact Surfaces and Utensils*
Shells 17 and Fish From an Approved Source
4-702.11 Frequency rpt Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan Fond Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and
3-201.15 MolluscanShellhsh from',NSSP casted Chemical* -
Sources* 10 Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by 2-'301.11 Clean Condition-Hands and Arms*
Regulatory Authority
3-202.18 Sliellstock 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 2401.11 Eating,Drinking or Usin Tobacco* .
3-202.11 PHFs Received at Proper Tciu ramres* 2401.1.2 Discharges From the Eyes,Nose and
3-202.15 Package hrtegrit * Mouth*
3-101.11. Food Safe aid Unadulterated* 3-301.'12 Preventing Contamination When Tasting*
fi TagalRecords:Shelistock 12 Prevention of Contamination from Hands
_3-202.18 Shellstock Identification" 590.004(E) Preventing Contamination from
3-203.1.2 ShellstockIdentification Maintained*" - Employees*
Tags/Records: 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(1) Labeling of Ingredients" 5-204.1'1 Lavation and Placement*
q Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance
/HACCP Plans Supplied with Soap and Hand Drying
3-502.11. Specialized Processing Methods* Devices
3-502.12 Reduced ox eftackavjng,criteria* 6-301.11 Handwashing Cleanser,Availability
8403.12 Conformance with Approved Procedures* L6-30 12 Hand Dr h*Provision
*Denotes critical item in the Weral 1999 FNA Code or 105 CMR 590.0(H).
CITY OF SALEM
BOARD OF HEALTH
Establishment Name:—CS0 CC—' iz_ 'A "i Date: Page: of
Rem code C-Critical Rem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Daft
No. Re}enmoe R-Red Item VerlRed
PLEASE PRRiT LEARLY
o -
�I 1 E f
vL ✓
d o
Gv
_ . /
J A-llO e'j Joarc
Z
2�
�Y tVJ
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 o voluntary Compliance ❑ Employee Restriction/
inspection, to observe all conditions as described, and to Exclusion
violations before the next ins
p O Re-inspection Scheduled Cl 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. '/ p
❑ Voluntary Disposal ❑ Other:
Violations Related to Foodborne Illness Interventions and Risk 3-501.15 Cooling Methods for PHFs
. Factors(Items 1-22) (Cont.)
19 PHF Hot and Cold Holding
PROTECTION FROM CHEMICALS
3-501.16(13) Cold PHFs Maintained at or below
14 Food or Color Additives 590.004(F) 410/450 F*
3-202.12 Additives* 3-501.16(A) Hot PHFs Maintained at or above
3-302.14 Protection from Unapproved Additives* 1400p *
15 Poisonous or Toxic Substances 3-501.16(A) Roasts Held at or above 130°F.
7-101.11 Identifying Information-Original
-,I 20 Time as a Public Health Control
Tt Containers*
3-501.19 Time as a Public Health Control*
:t 7-102.11 Common Name-Working Containers* 590.004(14) Variance Requirement
7-201.11 Separation-Storage*
7-202.11 Restriction-Presence and Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
u 7-202.12 Conditions of Use* POPULATIONS HSP
t. 7-203.11 Toxic Containers-Prohibitions* 21 3-801.1](A) Unpasteurized Pre-packaged Juices and
7-204.11 Sanitizers,Criteria-Chemicals* Beverages with Warnin•Labels*
7-204.12 Chemicals forWashing Produce,Criteria*
3-801.11 B Use of Pasteurized Eggs*
`I 7-204.14 Drying A encs,Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food and
7-205.11 Incidental Food Contact,Lubricants* Raw Seed Sprouts Not Served *
7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(C) Unopened Food Package Not Re-served.
7-206.12 Rodent Bait Stations*
7-206.13 Tracking Powders,Pest Control and CONSUMER ADVISORY
Monitoring* 22 3-603.11 1 Consumer Advisory Posted for Consumption of
! 1 Animal Foods That are Raw,Undercooked or
TIME/TEMPERATURE CONTROLS Not Otherwise Processed to Eliminate
16 Proper Cooking Temperatures for Patho•ens.*E"*".m1206"
PHFs 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell Eggs*
3-401.1 IA(I)(2) Eggs- 155°F 15 Sec.
Eggs-himiediate Service 1450FI Ssec* SPECIAL REQUIREMENTS
3-401.11(A)(2) Comminuted Fish,Meats&Game 590.009(A)-(D) Violations of Section 590.009(A)-(D) m
Animals- 155°F15 sec. * catering,mobile food, temporary and
3-401.11(6)(1)(2) Pork and Beef Roast- 130°I' 121 min* residential kitchen operations should be
3-401.1 I(A)(2) Ratites,In
jected Meats- 155°F 15 sec. debited under the appropriate sections
*
3-401.11(A)(3) Poultry,Wild Game,Stuffed PRFs,
above if related to foodborne illness
o
Stuffing Containing Fish,Meal, interventions and risk factors. Other
I Poult or Ratites-165°F 15 sec. * 590.009 violations relating to good retail
'r 3-401.11(C)(3) Whole-muscle,Intacl Beef Steaks practices should be debited under 429-
y� 145°F* Special Requirements.
R 3-401.12 Raw Animal Foods Cooked in a
Microwave IGS°F* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-401.11(A)(1)(b) All Other PHFs- 145°F 15 sec.* (Items 23-311)
�l 17 Reheating for Hot Holding Critical and non-critical violations, which do not relate to the
3-403.1](A)&(])) PHFs 165°F 15 sec. * foodborne illness interventions and risk./boors listed above, can be
! found in the following sections ojdte Food Code and 105 CMR
3-403.1 1(13) Microwave- 165°F 2 Minute Standing 590.000.
•,� Time* Item Good Retail Practices FC 590.000
3-403.1 1(C) Commercially Processed RTE Food- 23. Management and Personnel FC-2 .003
140°F* 24. Food and Food Protection FC-3 .004
r ,
I 3-4(13.1 I(L') Remaining Unsliced Portions of Beef 25. Equipment and Utensils FC-4 .005
A Roasts, 26. , Water,Plumbing and Waste FC-5 .006
18 Proper Cooling of PHFs 27. Physical Facility FC-6 .007
28. Poisonous or Toxic Materials FC-7 .008
3-501.14(A) Cooling Cooked PHFs from 140°F to 29. Special Requirements .009
• 70°F Within 2 Hours and From 70°F to 30. Other
�`- 41°F/45°1, Within 4 Hours.* zea
S
3-501.14(6) Cooling PHFs Made From Ambient
.' "temperature Ingredients to 41 0F/450F
Within 4 Hours*
�t 3-501.14(C) PHFs Received at Temperatures
According to Law Cooled to
41°F/45°F Within 4 Hours.
F
"Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
F
CITY OF SALEM
BOARD OF HEALTH p
Establishment Name: C iJ Date: G7 4ti� Page: of_
Rom Code C-Critical Rom DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Dere
No, Reference R-Red Item Verified
PLEASE PRINT CLEARLY
62
S L '
I
Discussion With Person in Charge: Corrective Action Required: ❑ No a Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction 1
inspection, to observe all conditions as described, and to
Exclusion
violations before the next ins
p E3 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 o Embargo ❑ Emergency Closure
your food permit.
13 Voluntary Disposal 0 Other:
r
I Violations Related to Foodborne Illness Interventions and Risk 3-501.15 Cooling Methods for PHI's
Factors(Items 1-22) (Cont.)
19 PHF Hot and Cold Holding
I PROTECTION FROM CHEMICALS
� 3-501.16(B) Cold PI-[Fs Maintained at or below
> 14 Food or Color Additives 590.004(F) 410/45017*
3-202.12 Additives* 3-501.16(A) Hol PHFs Maintained at or above
3-302.14 Protection from Unapproved Additives* 140°F.*
;+ 15 Poisonous or Toxic Substances 3-501.16(A) Roasts Held at or above 130°F.
;# 7-101.11 Identifying Information-Original 20 Time as a Public Health Control
S Containers* 3-501.19 Time as a Public Health Control*
7-102.11 Common Name-Working Containers* 590.004(H) Variance Requirement
iS 7-201.11 Separation-Storae*
7-202.11 Restriction-Presence and Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
t 7-202.12 Conditions of Use* POPULATIONS HSP
7-203.11 'Toxic Containers-Prohibitions*
21 3-801.11(A) Unpasteurized Pre-packaged Juices and
7-204.11 Sanitizers,Criteria-Chemicals* Bevera es with Warning Labels*
A 7-204.12 Chemicals for Washing Produce,Criteria* 3-901.11(B) Use of Pasteurized Eggs*
7-204.14 Drying A rents,Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food and
'1 7-205.11 Incidental Food Contact, Lubricants* Raw Seed Sprouts Not Served.
7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(C) I Unopened Food Package Not Re-served.
7-206.12 Rodent Bait Stations*
7-206.13 Tracking Powders,Pest Control and CONSUMER ADVISORY
Monitoring* 22 3-603.11 Consumer Advisory Posted for Consumption of
I Animal Foods That are Raw,Undercooked or
TIME/TEMPERATURE CONTROLS Not Otherwise Processed to Eliminate
16 Proper Cooking Temperatures for Pathogens.*'""'
PHFs 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs*
3-401.11A(I)(2) _ Eggs- 155°F 15 Sec.
Eggs-Immediate Service 145°1715sec* SPECIAL REQUIREMENTS
3-401.11(A)(2) Comminuted Fish,Meats&Game 590.009(A)-(D) Violations of Section 590.009(A)-(D) in
Animals- 155°F 15 s sec. * catering,mobile food, temporary and
3-401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 min* residential kitchen operations should be
3-401.11(A)(2) Ratites, Injected Meats-155°F 15 sec. debited under the appropriate sections
1
3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, above if related to foodborne illness
t Stuffing Containing Fish,Meat, interventions and risk factors. Other
S
Poultry or Ratites-165°F 15 sec * 590.009 violations relating to good retail
"1 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks practices should be debited under 29-
3 145°F* Special Requirements.
r 3-01.12 Raw Animal Foods Cooked in a
Microwave 165°F* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-401.11(A)(1)(b) All Other PRFs- 145°I' 15 sec. * (Items 23-30)
= 17 Reheating for Hot Holding Criricnl and non-critical violations,which do nor relate io the
foodborne illness iniervenrions and riskjacrors listed above. car be
r 3-403.11(A)&(D) PI-I}s 165°F I S sec. found in rhe following sections of the rood Code and/05 Ck1X
3-40.3.11(13) Microwave- 165°F 2 Minute Standing 590.000.
S ,tune* Item Good Retail Practices FC 590.000
3-403.11(C) Commercially Processed RTE Food- 23. Management and Personnel FC-2 .003
140°F* 24. Food and Food Protection FC-3 .004
3-403.11(,) Remaining Unsliced Portions of Beef 25. E ui ment and Utensils FC-4 .005
i
Roasts* 26. Water,Plumbingand Waste FC-5 .006
27. Physical FacilityFC-6 .007
18 Proper Cooling of PHFs 26. Poisonous or Toxic Materials FC-7 .006
3-501.14(A) Cooling Cooked PHFs from 140°F to 29. Special Requirements .009
70°F Within 2 Hours and Front 70°F to 30. Other
,* 41°F/45°F Within 4 Hours.* s.3wft b"Cx 2ea
' 3-501.14(13) Cooling PRFs Made From Ambient
Temperature Ingredients to 41 0F/450F
4 Within 4 Hour's*
3-501.14(C) PHFs Received at Temperatures
According to Law Cooled to
41°F/45°F Within 4 hours.
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Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000,
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-BoardofHealth r I4mberleyDnscoil• ,.
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DATE PRINTED t� 01/03/2013 � � '
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ESTABLISHMENT NAME_ �< "�� Grace Church m Salem Y
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2��File Number BHF 2004 00 t46 -,s' X385 Ess"eyx'Stree6t
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SaleI[1 ...e ' � `� s �'`"$ MA(01970 i. �
LOCATED AT ;
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`SALEM, MA 01970 ' ,
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* Permit Type-
"j
ype " s Permit No,:. Perms[Issued Permit Expires Fee Restnchons/Notes
FOOD SERVICES <x BHP 20t3 0345 Jan 1,2013 ,;Dec 31,2013 $25 00 -- ,'*#5
ESTABLISHMENTi , vt
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IN, f�Total Fees <'' $25;00-'
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PERMIT EXPIRES; December 31 2013
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This Permit is not transferable and must be reissued upon change of ownership or.location The permit must be posted
m a prominent locationin the Establishment 4 0 n ' u
In accordance with the State Sanitary Code,beofre any revonahons, improvements,or equipment Changes,are made, x
all plans for such must be submitted to and approved by the Salem Board of Health Page t
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>• CITY OF SALEM,.
MASSACHUSETTS
reuttcxeatta
BOARD or H[ ::AIr1-i ..�......,_.,...,,.,.
120 WASHINGTON Sntliaa'r,4'11'FLOOR -
KIMBERLEY DRISCOLL Tci-(978)741-1800 FAX(978)745-0343 LARRY RAVDIN,RS/REI-IS,C'1 10,CP-FS
MAYOR tramdina salem.com HiALTI-1 AGENT
Food Establishment Permit Application
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name: L J rUAL -,Uy-
2)
,2) Establishment Address:' Z$rj 'Esse-si
3) Establishment Mailing Address(if different):
4) Establishment Telephone No: C(`( '6 -7q4 12,196
5) Applicant Name&Title: V-V" cts e
6) Applicant Address:
7) Applicant Telephone No: 24 Hour Emergency No: '7yf-% Email:
8) Owner Name&Title(if different from applicant):
9) Owner Address(if different from applicant):
10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of
officers or partner.
An association Name Title Home Address
A corporation
An individual
A partnership
Other legal entity
l
12 Person Directly Res onsible For Daily Operations lowner, Person in Charge, Supervisor,Manager,etc.
Name&Title: JS ei
Address:
Telephone No: Fax: Email:
Emergency Telephone No:
13) District or Regional Supervisor(if applicable)
Name&Title:
Address:
Telephone No: 1 Fax: Email:
Check#: Date: Amount:
Food Establishment Informations
4
14) Water Source: 15) Sewage Disposal:
DEP Public Water Supply No: ( if applicable) ('x`171
16) Days and Hours of Operation: SwA'.','z 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 0 Food•Service-( Seats) El Frozen Dessert Manufacturer
Mobile D Food Service-Takeout 0 Residential Kitchen for Retail Sale
0 Food Service-Institution D Residential Kitchen for Bed and
( Meals/Day) Breakfast Home
D Food Delivery 0 Residential Kitchen for Bed and
21) Length Of Permit: Breakfast Establishments_
(chgck one) RETAIL STORE RESTAURANT
Annual ✓ D Less than 1000sq.ft. $70 ❑ Less than 25 seats $140
Seasonal/Dates: D 1000-10,OOOsq.ft. $280 D Residential Kitchens $140
D More than 10,000sq-ft. $420 D 25-99 seats $280
D More than 99 seats $420
Temporary/Dates/Time: -- ----------------------------------------- ---
❑ Bed 8 Breakfast/Childcare Services/Nursing Home $100
---------------------------------- ------------------------------------------
ADDITIONAL PERMITS
D MAKE ICE CREAM, YOGURT/SOFT SERVE $25
D PASTURIZATION $25
D TOBACCO VENDOR
4LL NON-PROFIT $25
(Including, church kitchens, state funded chi hate clubs)
23) Food Operations: Definitions: PHF-potentially hazardous food(timeRemperature 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 V for More Than a Single Meal Service
Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly
Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility
Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill
Prepared by Consumer
Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance
Processed Foods for and/or HACCP Plan(including bare hand
Service Within 4 hours contact alternative,time as public health
control.
Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of
Non-PHF and Non- Retail Sale Animal Origin
Perishable Foods Only
Preparation of Nan-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered
Retail Sale Events or Institutional Food Service
Offers RTE PHF in Bulk Quantities
To be completed by the Board of Health
Retail Sale of Salvage,Out of Date
or Reconditioned Food Total Permit Fee:
Payment is due with application
I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will
comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on howto obtain copies of 105 CMR
590.000 and the Federal Food Code.
24) Signature of Applicant: w
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.
alb � �25) Social Security Number or Federal ID: �
26) Signature of Individual or Corporate Name:
+� Commonwealth of Massachusetts
* City'of Salem
Board of health Kimberley Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 12/14/2011
ESTABLISHMENT NAME: Grace Church in Salem
File Number:.BHF-2004-000146 385 Fssex Street .
Salem MA 01970
LOCATED AT:
SALEM, MA 01970 .
Permit Type Permit No Permit Issued Permit Expires Fee Restrictions i Notes
1700D SERVICE BHP-2012-0039 Jan 1;2012- Dec 31,2012 $25.00
ESTABLISHMENT
Total Fees: $25.00:,
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PERMIT EXPIRE Decem e , 2012
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted
in a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,
an plans for-such must be submitted to and approved by the Salem Board of Health. Page 1
CITY OF SALEM, MASSACHUSETTS
B YARD OF HEALTH
- � - 120 WASHINGTON STREET' 4"`FI:,00R
To-(978) 741-1800
KINIBERt EY DRISC:OI L FAX(978) 745-0343
R�3YOR Lmmdint snieni.corri
DEC 14 ?011
LAItRv RA nf171 N,ItS/RI:(its,rai0,CP-1:'i
H7S,v rllAo,'xi, 34 4 0r �0-7Ay�
�N
201_APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT p
NAME OF ESTABLISHMENT ^�/� L 1�1 S ( 0(�At -•- C_r_49TEL# q pa' /•� 4 tl -a� 1 6
ADDRESS OF ESTABUSHMEW3, c SS Ek FAX#
MAI LINGADDRESS(if different) t
AIL-Business,: WET Website: WWW - G`r2!CP- C�uy-C I1 Salcm DY`Q
1x_'6712
� 130IZI4 ILR7,'g -� 44 -0"19 (,O*ftERS NAME {-1GV EL# �
ADDRESS '- i ( S S >~25' S A-1- F1,
STREET CITY STATE ZIP
CERTIFIED FOOD MANAGER'S NAME(S),::-- CERTIFICATE#(S) r
(Required in an establishment where potentially hazsrddus.food is prepared)
EMERGENCY RESPONSE PERSONTNO4{AS I UC�ti M� HOME TEL# ��"
PAYS OF OPERATION ( -Monday z Ttiesda W needs <-' <kThursda' j . :LrnuaY -Saturday z Sunday
HOURS OF OPERATION
Please write in tone of day. -
(For exam plellam-11 pm
TYPE OF ESTABLISHMENT TXkJghLck onl _____
—RETAIL STORE' YES NO less than 1000sq.ft. =$70
1000-10,000sq.ft. =$280
more than 10,004sq-ft- =$420
- - , ------------------
-----------
RESTAURANT .FS N0 1emss ih3n 25 seats =$140
(Outdoor'Stationary Food Cart 521.0) - 2 -9 seatS =$280
more than 99 seats =$420
--------------------Y- E $10000
BEDIBREAKFAST! ES. . NO. _
CHILDCARE SERVICES/NURSING HOME - ------------ -----•----- - ..........
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25
TOBACCO VENDOR Y S NO �$135
AU. NON-PROFIT(such as church kitchens) � NO
*_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 Chapte C,Section 49A;I certify under the pains and penalties of perjury that],to my best knowledge and belief,have filed all state tax
returns and\paid al!state t es equ'uad under the law. _
—ue Iro1wJ, ` i 1 y. 11 �I ► C y— �.— 1 - 3 4-
Signature Date Social Security or Federal identification Number
Updated 523/11 FOODAP201 i.admi Check#&Date- t__ ___- •I $!9D -