J MODE & FIDDLEHEAD - TEMPORARY FOOD PERMIT From: David Shea
Sent: Thursday, September 27, 2007 8:19 AM
To: Joanne Scott
Cc: Barbara Sirois
Subject: RE: Licensing Question
Yes, she will need a one day license. The process is very simple and when she has the
license she is protecting herself from possible liabilities.
Have her call Barb for an application. If the date of the event is soon, we can process a
voice vote over the telephone.
Thanks
David
-----Original Message-----
From: Joanne Scott [mailto:]Scott@Salem.com]
Sent: Wednesday, September 26, 2007 1:32 PM
To: David Shea
Subject: Licensing Question
Dear David:
J. Mode, a woman's clothing store on Front Street, has advertised a clothing show.with
wine and cheese (she may have already done thgis before too). She definitely needs a
food permit from us. Does she need a license from the Licensing Board? She says that
she doesn't need one because she is giving it away. These events are open to the
public.
Thank you,
Joanne
CITY OF SALEM
BOARD OF HEALTH
Name of Establishments: J. Mode & Fiddleheads
Addresses: Front Street
Owners: Janet Barsanti & Jacqueline Albanese
Phone: 'q-7s- -7vy- -70o7; 47&- -75z5- 0008
Date: September 26, 2007
Ms. Barsanti owns a clothing store and Ms. Albanese owns a florist store.
Several times per year, these establishments serve alcohol and cheese to
patrons during special events.
A Temporary Food Establishment Permit will be issued allowing limited food
service.
The Board of Health must be notified (by telephone of all events.)
FOOD SERVICE
The food consists of cubed cheese and crackers.
Since cheese is a Potentially Hazardous Food it may not be held at room
temperature more than 4 hours, in total including preparation time.
All ready-to-eat foods must be handled with tongs, tissues, or gloves.
SANITIZER
A commercially prepared sanitizer must be on hand to clean any tables whetre
food is displayed. The sanitizer must have an EPA Registration number on its
label.
All other requirements of the food code are waived at this time.
INSPECTIONS
A food establishment inspection may be conducted anytime food is being served.
anne ScottDate
Health Agent
an6t Barsa ti to
c
ejKe Albanese Date
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
• - 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
JOANNE SCOTT, MPH, RS,.CHO
Kimberley Driscoll HEALTH AGENT
Mayor
APPLICATION FOR A TEMPORARY FOOD SERVICE PERMIT
FEE: 1-3 DAYS= $200 p,0P-ot'a� 'fid
4-7 DAYS= $300
MORE THAN 7 DAYS= $400.
'�,,L CHECK PAYABLE TO THE CITY OFF SALEM. CASH �+/
NAME OF EVENT .` / GlI7�r vr'/GJ lrt�� _ / LOCATION GY 7' �'tQR (Y.
DATE{S}OF EVENS f/(e re'6 iQ u ('A?4. 2 7"'.?zZ 7
NAME OF APPLICANT )A / p.rte^ p.
,� 14,c/a"/"�_LjC�/ 9"e6 --TELEPHONE# / 7 o ' J�S• eco �+
ADDRESS Otey/Ydi7 T LAY` ._�:/� " 0/9 ;PC)+ '
NAMEOFBUSINESS_ '/'-^�7ai�/i� �CCA16f� TELEPHONE# Q '-, VS- ec)ep
ADDRESS �T �'"G�n �7. Cr? A A�* 1174? elO Pn
CERTIFIED FOOD MANAGER'S NAME CERTIFICATION# -
A PLAN OF THE ESTABLISHMENT IS: ENCLOSED DRAWN ON THE BACK
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: cheese 7K-
� /c3�C2-
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.
PERSUANT 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.
SIGNATURE DATE SOCIAL SECURITY OR FEDERAL ID#
--- -
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CITY OF SALEM; MASSACHUSETTS
BOARD OF HEALTH - - -
• - - • --. 120 WASHINGTON STREET, 4TH'FLOOR - -
SALEM, MA 01970
TEL.,978-74 1-1800 _ '-
. FAX 978-745-0343
_ - - JOANNE SCOTT, MPH., RS, CHO
Kimberley Driscoll HEALTH AGENT
Mayor
APPLICATION FOR ATEMPORARY FOODSERVICE PERMIT
O
�J,, /— FEE: 1-3 DAYS= $200
np �ro� fi '�d
�� /r -V OwG(, ✓( MDAYS= $300
MORE THAN 7 DAYS= $400
�
' CHECK PAYABLE TO THE CITY OF SALEM,NO CASH
NAME OF EVENT i y_upp�� //[^^1- ) L/L-1� LOCATION
DATE(S) OF EVENT ? �0
NAME OF APPLICANT J Ce VhPT Etc � C a y��-1 �J. � TELEPHONE#
ADDRESS <~ (V'I-('P Vc S b �4 w t G , /
NAME OFBUSINESS J /"I[J `P TELEPHONE# /2 YY /-V -
ADDRESS 17
CERTIFIED FOOD MANAGERS NAME � 1 /G SCCA1 CM CERTIFICATION#
A PLAN OF THE ESTABLISHMENT 15 ENCLOSED DRAWN ON THE BACK
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�I �.V(�-L VI L� Vl ir'✓�
FOODS TOO BE SERVED INCLUDING INGREDIENTS AND METHOD OF PREPARATION: :CFC�, 0 CXr
ro bx A nj ��D
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.
PERSUANT 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. X` J
SI ATURE DATE SOCIAL SECURITY OR FEDERAL ID#
TEMP"PL RE" E011425102 PE ITp CHECO&DATE