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A L PRIME ENERGY - ESTABLISHMENTS A.L. Prime Energy 175 Lafayette Street } r n n I I l I 4 i E� • � Commonwealth of Massachusetts City of Salem Kimberley Driscoll Board of Health Mayor 120 Washington Street,4th Floor SALEM,MA 91970 Food/Retail Establishment Permit DATE PRINTED: 01/11/2010 ESTABLISHMENT NAME: A.L. Prime Energy File Number:BHF-2004-000115 319 Salem Street Wakefield MA 01880 - LOCATED AT: 0175 LAFAYETTE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2010-0222 Jan 4,2010 Dec 31,2010 $70.00 TOBACCO VENDOR BHP-2010-0223 Jan 4,2010 Dec 31,2010 $135.00 Total Fees: $205.00 PERMIT EXPIRES December 31,—2010-- Board 010Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS • BOARD OF HEALTH .r %% 120 WASHINGTON STREET,4"FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 �FC -MAYOR DGREENBAUtvI&ALEM.COM L eo, •_ 9 DAVID GREENBAUM, ACTING HEALTH AGENT hE 9CT/y 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT t NAME OF ESTABLISHMENT A , L, PtQ�M [ 50ee a TEL# ADDRESS OF ESTABLISHMENT 115 LAFA yG—_ TTE T2-51d—S _- FAX#_; �I2-51d-6— 9 9 41 -� MAILING ADDRESS(if different) � 19 SAL-,4--/4AS T, 6,JA ('CLF/ELd MA a I W h0 EMAIL- Business': Website: A L PA IM G , C UM OWNER'S NAMEA,L. PRIME ENcfGy CU/t/ft)t_%AAi7 (STEL# X 2-u2 ADDRESS 3 19 S A LEM S T. CUA V C--F/cL0 MA g )- STREET CITY STATE ZIP CERTIFIED FOOD,MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) // 1 EMERGENCY RESPONSE PERSON BASIL ZA ZA HOME TEL# �DAYS�OF O,PERATfONs ,`„ Morwday;�, , "" „z Tuesday,; �Wetlesday"�I'�„Thursdaya,�w�lFnday";�ai,;. =zSaturday ,;��`r]( 3�Sunday, HOURS OF OPERATION Please write in time of day, 6,00 A•M For example 11 am-11 pm j —\u;�• /� TYPE OF ESTABLISHMENTFEE (check only) RETAIL STORE YES NO less than 1000sq.ft. 1000-10,000sq.ft. =$280 morethan 10,000sq.ft. =$420 --------------------------------- ---- -- ------------------------------------------------------------------------------------------ RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 - ------------------------------------------------------------ --- --- ------------------------------------------------------------------------------------------ BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES/NURSING HOME------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE Y NO TOBACCO VENDOR YES $135 ALL 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 er 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returnsan aid all st a xes required under the law. Z 2- 2 4-1 9 aq-3U24Y Sign Date Social Security or Federal Identification Number. ------ ------------ — --— -- ----.7-- ---—-- Revised 424/07 FOODAP2008.adm Check#&Date $ to IL Commonwealth of Massachusetts ` s City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/23/2008 ESTABLISHMENT NAME: A.L. Prime Energy File Number:BHF-2004-000115 319 Salem Street Wakefield MA 01880 LOCATED AT: 0175 LAFAYETTE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2009-0141 Dec 23,2008 Dec 31,2009 $70.00 TOBACCO VENDOR BHP-2009-0142 Dec 23,2008 Dec 31,2009 $135.00 Total Fees: $205.00 PERMIT EXPIRES December 31, 2009 --� Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 IMPORTANT MESSAGE FDR a, �AA M. DATE /d /a'nJ�rT TIME M OL OF -/V L PL i^-C PHONE ? � a b1"Z�'3 / AREA ODE NUMBER EXTENSION ❑ FAX O MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH. RETURNED YOUR CALL WILL FAX TO YOU MESSAGE SIGNED FOR 4009 V MAO IN U.S.A. NOTES • CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4"'F 0' )R^, E TEL. (978) 741-1800 "�•d d'`�',-�„ KIMBF.RLFY DRISCOLLz e ~T FAY(978)745-0343 MAYOR IDIONNI. sALEM.COM NQ c/ X25?� JANET DIONNE, ao C F � Og ACTING HEALTH AGENT O OF/yT k, 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT A , L, PAIML- ENMGY TEL# (9+�) _-y0 — 9 + 1 ADDRESS OF ESTABLISHMENT 1--�5 L FA "L: 7--FC- TO, ST FAX# MAILING ADDRESS(if different) 319 SALEM S7, Alk KrAAA U I EEO EMAIL- Business': Website: OWNER'S NAME A . L , PR IM L— f/tl60a'Y C oNIUL—TAu7 !,U(TEL#_ LTV71)2`/d—e Zo 1 X za Z ADDRESS_319 SA661A ST (Ll/kKC—G/EL/> /vV} oly" STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON RA S IL z_A Z A HOME TEL# C6 IT)2-(2--3 S-S ,,DAY.SOF,OIERATII - ` ' ` Mdnda " I ', T esda Wednesda Thursda ':1- ; 'Friday,' Saturday 1 Sunda HOURS OF OPERATION ! Please write in time of day. to P f!. _ G�- [ 4 AST -T 11A/1 (For example Ilam-11 pm) ! TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. _$70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 ------------------------------------------ ------ RESTAURANT YES O less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 BED/BREAKFAST/ YES O $100 CHILDCARE SERVICES -------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES �O $25 TOBACCO VENDOR <YES NO $135 ALL NON-PROFIT(such as church kitchens) YES— $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MG ap 2C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns and par ll state I at required under the law. Signature Date Social Security or Federal Identification Number Revised 424/07 FOODAP2008.adm Check#&Date Commonwealth of Massachusetts - City of Salem s • Board of Health 120 Washington Street,4th Floor Kimberley Driscoll Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2008 ESTABLISHMENT NAME: A.L. Prime Energy File Number:BHF-2004-000115 319 Salem Street Wakefield MA 01880 LOCATED AT: 0175 LAFAYETTE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2008-0016 Jan 3,2008 Dec 31,2008 $70.00 TOBACCO VENDOR BHP-2006-0043 Jan 3,2008 Dec 31,2008 $135.00 Total Fees: $205.00 PERMIT EXPIRES December 31, 2008 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be postedin a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 3 of 28 1 0 QTY OF SALEM, MASSACHUSEM BOARD OF IUALTH �am�su l 120 WASHINGTON STREET,,4" FLOOR TEL.(978)741-1800 KIMBERLEY DRISCOLL FAx(978)745-0343 MAYOR ISCO7Taa SALEM COM JOANNE SCOTT, HEALTH AGENT 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT A ,1, PR IM F 5.0 a(y TEL# (1-9) -*'/o — 9 1-1 F ADDRESS OF ESTABLISHMENT_ I TS , LAFA YC-7Tr- S7. FAX# 01) 7-'/6--991 MAILING ADDRESS(if different) 319 SAC EM S T. I /i KC-G/Eta MA o 1880 EMAIL-Business': Website: OWNER'S NAMEA__L_P/21ME c<1 LY CoNtu2T4NT /✓C_ TEL# 6:1I) 2c/d-o"i X20L ADDRESS 319 SACEM JT. AAA of &Fo STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON BA Sit ZA Z A HOME TEL# DAYS OF OPERATION Monday Tuesday Wednesday Thursday Friday Saturday Sunda HOURS OF OPERATION Please write in 6me of day. 6 — )p (1— )� 6.—�� 4 _7„ _ (� ( c (For example 11am-11pm) I V o 9 TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. = 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 -- - - - - -- - -------------------------- ------ - ...-.....-n 2 se ___ RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 BED REAAST/--------------------YES--- NO ---------------------.....-------------------------------- $.1.0..0....... CHILDCARE SERVICES ---------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR rY S NO 135 ALL NON-PROFIT(such as church kitchens) YES NO $25 `Please pay total with one check payable to the City of Salem. This Permit is.not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns and paid all s es required under the law. Signature -Date kt Z 31J/ ua-� Social Security or Federal Identification Number - --- ------ - -- -- - n_ Revised 4/24/07 FOODAP2008 adm Check#&Date�i�� (�j In 7 S 2m✓J I* CITY OF SALEM, MASSACHUSETTS BOARD OfHERECEIVED� 120 WASHINGTON STREETT,, 4 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 DEC 42008 FAX 978-745-0343 KimberleyDriscoll www.sALEM,COM CITY OF SALEM Mayor JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT A . ( ?A(M C 6145f 6 Y -TEL#-, (91Et) +VO — 9 I ADDRESS OF ESTABLISHMENT 1 5 LA FA VG !'TG—' S l FAX# l3-F(1 2 W— P 9 MAILING ADDRESS(if different) 3 1 9 `;A L EM ST, _ IyA0 �.4,,,.-e► � �a EMAIL--Business': Owner's t OWNER'S NAME 1Z - TEL# 0:8(�2— _pyo l ADDRESS STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) Ll /A CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON L A S(L L A 7-A HOME TEL# t 2-12-— 2-175- DAYS Of OPERATION Monday Tuesday^ Wednesday Thursday Friday Saturday A Sunday NDDDS OF OPERATION C Please wNtelndmeaiday. (far examole 11am-11mal J TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE Y�S NO (less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES NO less than 25 seats $100 25-99 seats =$150 more than 99 seats =$200 ........ ..... .......... ............. .......... ..... ....._..... ......... -------- -------------- ........ BED/BREAKFAST YES 1Q $100 ----------------------- .._....... ............. ..... ..... ...... I................. _.... ..... ............ ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE Y S NO $5 TOBACCO VENDOR YES O $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 `Please pay total with one check payable to the City of Salem. This Permit is riot transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. S_ignatur Date Social Security or Federal Identification Number - ------- - f,� - - -- - — -mjiji?-�ub -----. .------_---- _- ------ ----------- --------------- ------------------- -------------- Revised 11113/06 0KAP2007.adm Check#8 Date__ 9 i _,_/ o o $ —Wa200 $ - '�",�>,: ..LY Y„- b} r } � Y3i h i xr. "S + t+f:..y r..r+4.w,+r "�cM y y § 4W�4 �.y -• K Y � NIC. M t/h. tlp" S94�iw+1°f �. C�omwmwowniw+.e�aeltth�eof M4a'sgsachusettsl ,�y �,, '#S�" ��i* �1.. ��' i :T�. Fc w*?yWY*fP�1¢'ryysa•�p�" #�i Y 1� q,�`r('F �Y'� [ {}- .�'+� rN� M��a 'F`..q � ,".'a �. la"+&;';�.5si *• r,ir',`,.§lhxil�a . s • ��,r} L¢ 43xr h'" �1� _B08rd of He8lth ' ',y.,, 6v, ° �? -120 Washington Street,4th Floor :° , r apo-'a,A iIGmbe�leY � � Dnscoll SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/19/2006 ESTABLISHMENT NAME: A.L. Prime Energy File Number:BHF-2004-000115 319 Salem Street Wakefield MA 01880 LOCATED AT: 0175 LAFAYETTE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2007-0060 Dec 19,2006 Dec 31,2007 $50.00 TOBACCO VENDOR BHP-2007-0083 Dec 19,2006 Dec 31,2007 $50.00 Total Fees: $100.00 PERMIT EXPIRES Weember 31, 2007 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 of 24 ' \.at+9 t`C?M° �" {^^,"s*i�r,1^h`t'Y�c W'7^w r, .� .�o$.rsq•.mxi'�� N`•.r-:, rr».r. rrAd.s hi.�-• 't`*' n ,"'� -4� `�} , Wy,,'�+ s.a •},.. 7r`:«'� v "+' ✓fY.rF+'4+k�,a. 4.. : r6m-sriroA1'F�+ .atc+tih``��••°-rx..N. ,.,,,+„9 {._ve�s'Ma`-4+.ntwvc +rd..r:ro' ,k y+6i4:'kiiMlb` i' �Yau7ts} +sv 7..7^.r^r{ra^�•. -w^ww...t;�ra.:�AIeVW'F/t� ?M1�s Commonwealth of Massachusetts City of Salem, s : Board of Health 120 Washington Street,4th Floor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/05/2006 WHO'S PLACE OF BUSINESS IS: A.L. Prime Energy File Number:BHF-2004-0115 319 Salem Street _ Wakefield MA 01880 LOCATED AT: 0175 LAFAYETTE STREET SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2006-0005 Jan 1,2006 Dec 31,2006 $50.00 TOBACCO VENDOR BHP-2006-0006 Jan 1,2006 Dec 31,2006 $50.00 Total Fees: $100.00 PERMIT EXPIRES IDecember3l, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.Tire permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 2 of 18 CITY OF SALEM, MASSACHUSETTS IIS BOARD OF HEALTH {� DEC 0 52005 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 CITY OF SALEM TEL. 978-741-1800 BOARD OF HEALTH STANLEY J. USOVICZ, JR. FAX 978-745-0343 MAYOR wW W.SALEM.COM JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT R - L . P/t IM C 61-16�e(Y TEL#—b}g) -}yo - 9 '4 IF ADDRESS OF ESTABLISHMENT 1_�S LA FA YET-TE R D. MAILING ADDRESS (if different) 319 SAt EM I7. (,/A ITC-iiEu) MA d I %; Q OWNER'SNAMEA L PRIAr EWbeGY (-d,✓/o(7A Jr /n/C TEL# { TI) 2y6-atut XLaL ADDRESS 319 SALEM J7. STATE M 4 ZIP 0( 9&u CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON BASIL 7—A Z A HOME TEL# 61-4 z 11 -1 -f HOURS OF OPERATION: Mon.6-�� Tue. -iiA Wed. 4-I -Thu. (_,• Fri. t Ia Sat. -rQ Sun. Z-r TYPE OF ESTABLISH FEE checkonl r C•RETAIL.STORE) YES NO I less than 1000sq.ft. 50 1000-10,000sq.ft. =$ more than 10,000sq.ft. =$250 ---------------------- --------------- ---------- ------------------------------------------------ -- ----------------- -----------_---............------- RESTAURANT YES NO less than 25 seats $100 25-99 seats =$150 more than 99 seats =$200 ---------YES--------N----O-----------------------------------......----------------------------- $100--------------- BED/BREAKFAST -- - ............. -------------------------------------------------------------- *----------------------- *-------------------------------------- ADDITIONAL PERMITS MAKE_(notjust serve) ICE CREAM, YOG4RT, S_gFT SERVE Y NO (TOBACCO_VENDOR) 0QG� ES NO $50 ALL NON-PROFIT(such as church kitchens) YES 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 hapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledg n beli , have filed all state tax returns and paid all state taxes required under the law. oy-711,7,q Y9 Signature Date Social Security or Federal Identification Number ------------------------------------------------------------- ---� ----- --------------------------------------------------- Revised 11/03/05 FOODAP2.adm Check#&Date ' 9_Q44 � 4 M1.� CITY OF SALEM, MASSACHUSETTS • ; BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 vJ STANLEY J. USOVICZ, JR. FAX 978-745-0343 MAYOR W W W.SALEM.COM JOANNE SCOTT, MPH, RS, CHO September 21,2005 HEALTH AGENT A. L. Prime 175 Lafayette Street Salem, MA 01970 Dear Owner: On Tuesday August 23,2005 personnel from the Tobacco Control Program conducted a compliance check to determine if your permitted establishment would sell a tobacco product to a minor. A 17-year-old female purchased cigarettes from a clerk in your store. Documentation is now on file at the Board of Health regarding that sale. A. L. Prime is in violation of Section IIIA)of the Salem Board of Health Regulation Affecting the Purchasing of Tobacco Products. According to this section,the sale of cigarettes, chewing tobacco, snuff,or any tobacco in any of its forms to any person under the age of eighteen shall be punished by a fine of(Three Hundred Dollar fine)for the Third offense. FOLLOWING THE THIRD (3RD)OFFENSE,THE BOARD MAY CONSIDER POSSIBLE REVOCATION OR SUSPENSION OF THE PERMIT. The North Shore Tobacco Control Program and the Salem Board of Health have worked with you and your employees to demonstrate methods to ensure compliance with this regulation. Therefore,you are ordered to pay a fine of$300.00 for the violation stated above. A check or money order payable to the City of Salem must be at the Board of Health office, 120 Washington Street,4th floor,within ten days of receipt of this notice. Should you be aggrieved by this Order,you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven (7) days of receipt of this Order. At said hearing,you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports,orders, and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. If you have any questions regarding this notification please call me at 741-1800. Sincerely yours, io— Scott Health Agent JS/mfp CERTIFIED MAIL: 7003 3110 0005 1992 1967 cc: North Shore Tobacco Control Program Christina Harrington, Board of Health Chairman and Members AL PRIME ENERGY CONSULTANT, INC. © Banknorth 57532 319 SALEM STREET mass chums WAKEFIELD,MA 01880 53-7054/2113 9/28/2005 _ s PAY TO THE C ITY OF SALEM ORDER OF "`300.00 Three Hundred and 00/100""•""*"«««,.«««,.«.«......,..«««_«««.....,.,«..««........,«««.......««.««««.....««.........., DOLLARS € C ITY OF SALEM Board of Health 120 Washington St. Salem , MA. 01970 MEMO: 175 Lafayette St 3Rd Tobaccoo fine '05753211• 1: 21L3705451: 824320355611• CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 3i 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 .� TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: A.L. Prime Energy Address of Establishment: 175 Lafayette Street Owner's Name: A.L. Prime Energy Consulant Inc. Restrictions: Application Date: 11/16/04 Permit for Food Establishment 010-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 004-05 These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT CITY OF SALEM, MAL` ;ril�SEf: BOARD OF HEALT,, l/ 120 WASHINGTON STREET, 4TH .LOOR NOV 16 2004 r e - SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 CITY OF SALEM STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH MAYOR HEALTH AGENT 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT A . ( . PR IME L:wm6, TEL#193:g) }yo.- 9 418 ADDRESS OF ESTABLISHMENT Ill LA FAYc T7l- R d . MAILING ADDRESS (if different) 319 SAIL-M I7 &/A KP NIA of 880 OWNER'SNAME A -L PlZiMC- EN6PLy Co,✓lui7.4A1t INC TEL# (340ZY6--OZpl X20 L. ADDRESS ?19 S Al EMl J T. CITY tVAI,E/-iEll_� STATE MA ZIP Alir CERTIFIED FOOD iv"IANAGER'S NAME(S) CERTIFICATE#(G)_ (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON f2 A f+L ZAZA HOME TEL# (61l) 21 t HOURS OF OPERATION: Mon. 6-I6 Tue.4-1% Wed. -Io,Thu. -14, Fri. (-Iu Sat. }-1 Sun. TYPE OF ESTABLISHMENT—s FEE check only RETAIL STORE YES O less than 1000sq.ft. _$ 50 1000-10,000sq.ft. =$100 / more than 10,000sq.ft. =$250 RESTAURANT YES NO r y j less than 25 seats =$100 j�� 7 25-99 seats =$150 vv 7 more than 99 seats =$200 BED/BREAKFAST YES NO /� 6pX, $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR <IES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MG ter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowl ge nd b 'ef, have filed all state tax returns and paid all state taxes required under the law. Iv v U -.Tb?}Y Signatur V Date Social Security or Federal Identification Number -------------------------------------------------------------m ------------ -----------------//-f-]]- ------------------------------------ Revised 11/03/03 FOODAP2.adCheck#& DatG. �7 i CITY OF SALEM, MASSACHUSETTS ' BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-74 1-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: A.L. Prime Energy Address of Establishment: 175 Lafayette Street Owner's Name: A.L. Prime Energy Consulant Inc. Restrictions: Application Date: 11/14/2003 Permit for Food Establishment Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 008-04 These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT �� ati�t� �� ,�.�'�= 'r � � �� '-��'` �_-____ G CITY OF SALEM, MASSACHUSETTS J, BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: A.L. Prime Energy Address of Establishment: 175 Lafayette Street Owner's Name: A.L. Prime Energy Consulant Inc. Restrictions: Application Date: 11/14/2003 Permit for Food Establishment 21-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 008-04 These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT CITY OF SALEM, MASSACHUSETTS (tom t .% BOARD OF HEALTH 3 120 WASHINGTON STREET, 4TH FLOOR �p SALEM, MA 01 970 NOV 13 2003 TEL. 978-741-1800 CC FAX 978-745-0343 VpI (❑❑�r1''}}OF HEALTH STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO 80p R[) `�' MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT 'A . L . PRIMc &16e r TEL# (9 '-E) 4-vu - 9 4A ADDRESS OF ESTABLISHMENT ITS S L A FAYc!i TE Si, W&I M . 01 y4-3 MAILING ADDRESS (if different) 3 19 S AL&/A S-1, 6VAKC-G%EL/J MA al 'kto OWNER'SNAME h • L.PRIME 646?Ly Cu,1J'UlTA/V7 WC TEL# W 7-16-oZut ADDRESS C!TY STATE 71P CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON RA 91L 2-AZA HOME TEL# 7 12-jlJj HOURS OF OPERATION: Mon.6-%q Tue.6-%� Wed.(-kms Thu. 6-Im Fri.-JL%-*-Sat. -w Sun. €'- f TYPE OF ESTABLISHMENT, FEE check only RETAIL STORE ES NO ✓less than 1000sq.ft. =$50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS i MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 Gip y TOBACCO VENDOR ES NO $50 /1 0 ALL NON-PROFIT(such as church kitchens) = NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to pter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best kno edg and lief, have filed all state tax returns and paid all state taxes required under the law. .-? u Signat Date Social Security or Federal Identification Number = ------------------------ ----�-�---------------------------------------------------------- Revised 11/03/03 FOODAP2.adm Check#&Date I ' Massachusetts Department of Public Health Salem Board of rS Health 120 Washington'Street, 4th Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 NameA Dat T of 0-aration(s) T e of inspection /�. ictAr / r] Food Service outine Addressf /h Risk Detail E] Re-inspection 11 Telephone Level El Residential Kitchen Previous Inspection 7 qb / L ❑ Mobile Date: OwnerHACCP YM [I Temporary ❑ Pre-operation fk L ® m' �rER Gvf+Sv FIG ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In: Ll HACCP Inspector �IF�1t 6 M Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provisions)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties EMPLOYEE HEALTH El13. Handwash Facilities --. ... .- ' .-, .. _ PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC - •� = .t;, El3. Personnel with Infections Restricted/Excluded El 14.Approved Food or Color Additives FOOD FROM APPROVED SOURCE . El 15.Toxic Chemicals_ ��" _' ❑ 4. Food and Water from Approved Source TIMErrEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures - ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION"" ' ' "` `"'' ❑ 19. Hot and Cold Holding [_18. Separation/Segregation/Protection E]20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizingii REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)„li El 10. Proper Adequate Handwashing ❑ 21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices ';' CONSUMER ADVISORY'- ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below tr � ; p 9 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-a)(sso.00s) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S:5901nepe Foci 40.Cop �j Inspector's Signat i :. Print: ,j � ,7 / / �c(C Rga 'I (fi PIC's Signature: ///� f � / Print: Page_of�Pages 641t-_�� Wolations Related to Foodborne Illness Interventions and Risk Factors(ftems 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT fi 1 Cross-contamination 1 590.003(A) Assignment of Res onsibilit Y. 3-302.1.1(A)(]) Raw Animal Foods Separated from 590.003(B) Demonstration ofKnowled e" Cooked and RTE Foods* 2-103.11 Person in charge-duties Contamination from Raw Ingredients 3-302A I(A)(2) Raw Anhnal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by foal employees and 3-302.1.t(A) Food Protection* applicants'* 3-30215 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report'ro The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) Reporting t Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclnsiona and Restrictions Food 3-70LII Discarding of Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* d Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004{A-B) Compliance with Foal Law" 4-501..111 Manual Warewashing-HotWater Sanitization Temperatures* 3-201.12 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashin.--Hot Water 3-202.13 Shell E*trs* Sanitization Temperatures* 3-202.1.4 Eggs and Milk Products.Pasteurized* 4-501..11.4 Chemical.Sanitization-temp.,pH, concentration and hardness. * 3202.16 Ice Made From Potable Drinking Water* 4-601.11(A) Equipment Food Contact Surfaces and 5-101,11 Drinking Water from an Approved System, Utensils Clean* 590.006(A) Bottled Drinkin Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0` Contact Surfaces and Utensils" Shelifieft and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equi ment* Shellfish* 4-703.11 Methods of Sanitization=Hot Wit er and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301.11. Clean Condition-Hands and Arms* Re uiato Authorit 3-202.18 Shellstock Identification Present* 2-301.12 Cleanlm,Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201..17 Game Animals* 1.1 Good Hygienic Practices y Receiving/Condition 2 401.11 Eatin=,Dr nkin�or Usrntr Toba co* 3202.11. PI-fFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes, Nose and 3-202.15 Package Inte it Mouth* 3-101.11. Food Safe and Unadulterated* 3-301..12 Preventin Contamination When 1'astin 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12Shellstock Identification Maintained* Employees* Tags/Records:Fish Products 13 Handwash Facilities 3402.11 Parasite Destruction* Conveniently Located and Accessible -402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities* 3 _ e Labeling of Ingredients* 5-204.11 location and Placement* 510.004(7) 9 9 -2 .11 Accessibilit Operation and Maintenance 55 0 7 Conformance with Approved Procedures ' /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 S ecialized Processin Methods* Devices 3-502.12 Reduced ox en packaging,criteria* 6-301.11 Handwashing n Cleanser, Availabilit 8-103.12 Conformance with Approved Procedures* 6-301.1.2 Hand Dr in Provision *Denotes critical item in the federal 1999 Foal Cade or 105 CMR 590,000. , CITY OF SALEM BOARD OF HEALTH. �� Establishment Name: /� L �r�r«�( . c£ I�ttrr�� Date: //!J�7/ ©!1 Page: 7i of 1i Rem Code C-Critical Item No. OF VIOLATION/PLAN OF CORRECTION bate No.. Reference R-Red Item Verified - PLEASE PRINT CLEARLY Nn tt�ot�AT��+-►f C d- r .K6-' 4 Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five/dollars br suspension/revocation of ❑ Embargo ❑ Emergency Closure syour food permit. '� / �/✓ �f/7/ ❑ Voluntary Disposal ❑ Other: v/ i 3-501.14(C') PHFs Received at Temperatures Violations Related to Foodborne fitness Interventions and Risk According to Law Cooled to Factors(items 1-22) (Cont.) 41"F/45"F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501,16(B) Cold PflFs Maintained at or below 590.00-4(F) 41%45°F* 1.5 Poisonous or Toxicxic Substances 3-302.14 Poisonfront am t roved Additives* 3-501,16(A) Hot PHFs Maintained at or above 140°F.* 7-101.11 Identifying Information-Otiginal 3-501.16(A) Roasts Held at or above 130'F. Containers* 7-102.11 Conanon Natne-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Stora e* 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and tJse* 590.004(H) Variance Re uirement 7-202.12 Conditions of Use* 7-203.11 'Toxic Containers-Prohibitions, REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers,Criteria-Chemicals* POPULATIONS(HSP) 7-204.12 Chemicals for Washing Produce,Criteria" 21 3-80'1_11(A) Unpasteurized Pre-packaged Juices and Beverages with Warnin Labels* 7-204.14 Dryingants.Criteria* 3-801.11(B) Use of Pasteurized Egos* 7-205.11 Incidental Food Contact. Lubricants* 7-206.1 I. Restricted Use Pesticides.Criteria* 3-801.11(1)) Raw or Partially Cooked Animal Food and 7-20G.12 Rodent Bait Stations'" Raw Seed Sprouts Not Served. * 7-206.13 Tracking Powders,Pest Control and 3-801.11(C) Uno ened Food P teka>e Not Re-served Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw,Undercooked or 16 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate PHFs EaR�s�e,.nno� 3-401.11A(1)(2) Eggs- 155'F15 See. Pathogens.m Las-Immediate Service 145'Fl5sec* 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish,Meats&Game E s* Animals- 155'F 15 sec. 3-401.11(B)(1)(2) Pork and Beef Roast-130'F 121 min* SPECIAL REQUIREMENTS 3-40L I l(A)(2) Ratites,Injected Meats- 155'P 1.5 590.009(A)-(D) Violations of Section 590.009(A)-(D) in sec.* catering, mobile food,temporary and 3-401_11(A)(3) Poultry,Wild Game, Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish, Meat, debited under the appropriate sections Poultry or Ratites-165°F 15,sec. * above if related to foodborne illness 3-401A 1(C)(3) Whole-musele,'Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#'29- Microwave 165'F* Special Requirements. 3-401.1 l(A)(1)(b) All(hher PHFs-- 145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PF1Fs 165°.F 15 sec. * (.items 23-30) 3-403.11(B) Microwave-165°F 2 Minute Standing Critical and non-critical violations, which do net relate to the Times` foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Comrne,rcially Processed I2TE Food- found in the fallowing sections of the Food Code and 105 CMR 140'F* .590.000. 3-403.11(E) Remaining Unsliced Portions of BeefItem Good Retail Practices _ FC 590.000 - ---- - Roasts* 23. Mena anent and Personnel FC-2 .003 1g Proper Cooling of PHFs 24. Food and Food Protection FC-3 004 25. Equipment and Utensils FC-4 .005 3-501.W(A) Cooling Cooked PHFs from 140'F 10 26. Water,Plumbin and W rite FC 5 006 _. 70°P Within 2 FIours and From 70°F 27. Ph deal Fadlitv ___ _ FC-6 .007 1. to 41.°F/45°F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(13) Cooling PHFs Made Froin Ambient 29. S ectal Re uirements _ .009 Temperature Ingredients to 41°F/45'F _50. _Oi„her ___--_,_,-__ Within 4 Hours:x .1 11W-4'66-2 d« *Denotes critical itwn in ax federal 1999 Food Code or 105 CMR 590000. ONWT ell, Ci' -Y OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR i s SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT.,MPH, R8, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94 , Section 305A and Chapter III , Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to : Owner ' s Name : A.L. Prime Energy Consulant Inc . Name of Establishment : A. L. Prime Energy Address of Establishment : 175 Lafayette Street Type of Establishment : RETAIL FOOD Application Date : 01/15/2003 Restrictions : Permit for Food Establishment Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 60-03 These Permits Expire December 31, 2003 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem BoardofHealth. ((// HEALTH AGENT J 1 15 03 12: 29p A. L. Prime Ener gy inc. 7812469971 P. 2 ire -Ian 09 03 04:56p Joanne Scott Salem DO" 976 745 0 ii i yr� d f: r CITY OF SALEM, 1"{Ar25ACNUSIETTS JAN 15 2�E33 -1 BOARD OF HrALTH 120 WA$WiNnTpN STnCCT, AT,, FLeoR a ?fffi�s rt SnLCiw. MA 01970 GI a _ZM Y r��. 97e:,A,.,�oO BOAFG toF HEALTH �-_`� FAR W10e 745 0343 .J,1nNNC Scor, MPu. RS, CRO NlAvpn HFrLTN AGCN, 2003 APPLICATION FOR PERMIT TO OPERATF A FOOD ESTABLISHMENT N/0-4F OF ESTABLISHMENT TEL 4-0 _311 AOURESSOFESTA3LISHMENT I + L..ArCAYC- (Tc , 5T. MAILING ADDRESS(ifdillerent) 319 SA1 M ST- LU i1c��[_ .aAM okeQ O'WNER'S NAME A..-L , (JA 1M r: r4Y CUri,�faM� lac, TEL a 90 ZY6--o2ut ADDRESS � j 9 S At FM 17% CITY CjAKEI';W- STATE MA ZIP Ol1^'Zro CERTIFIED FOOD MANAGER'S NAMES) CERTIFICATEB(s) (required in an establishment where potentially hazardous food is prepared-) tMtKGENCY RCSPONSE PERSON B,4 S f L ?Az 4 NOME TEL#f4L'12 Z I L -2-f S3 HOURS OF OPERATION:Mon,6- 9 Tue,6 4� Wed.i-A Thu. (,- 7 Frl (-� Sat, }_ 2 Sun. 8-F TYPE OF ESTABLISHMENT � FEE check only RETAIL STORE _ k0� less than 1000sq.ft. =$50 1000-10,000sq-tt. -$100 more than 10.000sq.ft. =$250 RESTAURAN i YES NO less than 25 sesta -$100 25.99 seats =$150 more than 99 seats =$200 BEDIBREAKI-A5l YES NO $100 ADDITIONAL PERMITS YtAKE.ICE CRLAM,YOGURT,SOFT SERVE, Y6,. NO $5 TOBACCO VENDOR ( ES? NO(.V-Q-3 $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 Please pay total with onecheck payable to the City of Salem This Permit is not transterable 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 ter 62C.Section 09A, i certify under the pains and penalties of perjury that 1,to my best k ledge and b let,have(ileo all slate tax relun5 and paid all stale taxes required under the law. tLjd1 tly-.l!/l'�'y9 _ 5ignw4 -! -" pale Social Security or Federal Identification Number •-----..-._ . __.....------------------------------ ------------------ _..__••-.`-__ Revised 11125102 FOODAP2.ad. Cnecht B Date A, 25 03 12:29p R. L. Prime Energy Inc. 7822469971 p. 2 �Ener9Y _ TO : CC-I j-..o... ......... ?.AsS FAX # : Rr.7E�..-. 74.5:.-..U3.�i 3 _ Gam: f3.M... -..X13«.se/......?�.t��................ _ DATE: ..�r. ...�Z. ...ai-G'�.,�................. wl JAN 15 2003 _ FROM: BOARD OF HEALTH _ DEPT. .�� !C.t*S.L..�.O.I�J•...... Number of pages including cover sheet: .........� ........ _ SUBJECT: ..................�n�.�c Lz �....�� .l c).Y..... a�.r?(�.t.t`.� �L�,�, ... .......................................... ...... ._ ................................................................. ...... ...... ._..... .......... ....... ..........._....... _ ........... ............................ ..................................... ...... ............ ................I...........I.......... ._ ..... ... 319 Salem Street Wakefield , MA 01880 Tel : 781-246-0201 . Fax : 781-246-9971 Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4°i Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date Type of Operation(s) Tvoe of Inspection 4•L AX IM rs IC96% / L -i Fz Ll Food Service outine Address IRisk etail ❑ Re-inspection A P Lev I El Residential Kitchen Previous Inspection l7 Telephone C- El Mobile Date: �- 6� OwnerHACCP YM ElTemporary ElPre-operation A. L • g-11< &<Z ❑ Caterer ❑ Suspect Illness Person in Charge(PIC)8/f51e Time ElBed&Breakfast ElGeneral Complaint In: [I HACCP InspectorQ p Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT _ s L] 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS - ❑ 2. Reporting of Diseases by Food Employee and PIC [:114.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM.APPROVED SOURCE ❑ 4. Food and Water from Approved Source TIME/rEMPERATURECONTROLS(Potentially Haiardous Foods) ❑ 5. Receiving/Condition [:116. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION. ❑ 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 HIGHLY SUSCEPTIBLE POPULATIONS(HSP) F1 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR ofdN�th. eal590.000/federal Food Code. This report, when signed below 23. Management and Personnel (Fc-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils cited in this report may result in suspension or revocation of (Fc-a)(sso.00s) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other /// DATE OF RE-INSPECTION: 5:5001 Vs IFOr -M dw / J Inspe oy' g PIC's Signature: " j /� Print: Pagel of Pages ' 0 Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) _PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Cross-contamination I 590003(A) Assignment of Responsibility* 3-302.11(A)(1) Raw Animal Foods Separated from 590.003( Demonstration of Knowledge* Cooked and I2TE Foods* 2 103.11 Persoa in charge-duties Contamination from Raw Ingrodlents 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Foot!Protection* applicants,* _ 3-302.15 WashineFruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or Air 3-304.1 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge'k Contamination from the Consumer 590.003(0,) Reporting by Person in Charge.* 3-306.14(A)(13) Returned Food and Reservice of Food* 3 590,003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated )90.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food" 4 _ Food and Water From Regulated Sources 9 Food Contact Surfaces 590-004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-20L12 Food in a Hermetically Scaled Container* Sanitfzationlem.erasures* 3-201.1.3 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell E-,s* Sanitization Te� 3-202.1.4 Eggs and Milk Products.Pasteurized" 4-501.114 Chemical Sanitization-temp.,pH, concentration and hardness. 3-202.16 ice Made FroinPotable DrinkingWater" 4-601.11(A) Equipment FooContact Surfaces and 5-101.11 Drinking Water from an Approved System* Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Clearing Frequency ofEquipment Food- 590.006(,13) Water Meets Standards in 310 CMR 22.W Contact Surfaces and Utensils" Sheitlish and Fish From an Approved Source 4-702.11 Frequency of Sanitization o1Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Ec ui menY'" Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* LO Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301.11 Clean Condition-Hands and Arms" 3-202.18 Shellstock Identification Present* 2-301.12 Clearing Procedure* 590.004(0) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Came Animals* 11 Good Hygienic Practices S Receiving/Condition 2-401-11 .,,,. F;at'ing,Driirk'in or CJsing Tobacco* 3-202.11 PHF%Received at Proper Temperatures* 2401.12 Discharges From the Eyes.Nose and 3-202.15 _ Package lntegriL y* Month* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing.Contamination When Tastin=°` fi Tags/Records:Shellstock L12 Prevention of Contamination from Hands 3-202.13 Shellstock Ident'iflcation* 590.004(E) Preventing Contamination from 3-203.12 Shel'tstock Identification Maintained* Em !ogees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 PaasiteDestructon'° Conveniently Located and Accessible 3-402.12 Records.Creation:md Retention* 5-203.1.1 Numbers and Ca acities* 590.004(7) Labeling of Ingredients' S-204.1 t Location and Placement'! 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging,criteria* 6-301..11 llandwashinaCleanse:.Availability 8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drying Provision -� '"Denote,critical item in the federal 1999 Food Code or 105 CMR.90.000. CITY OF SALEM BOARD OF HEALTH Establishment Name:4• Z_ C4vErL0,' 4 Date: 12/ 22/03 Page: 2 of Item Code C-Critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference. R Red Item Verified - PLEASE PRINT CLEARLY L LLQ .4 Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes r ; I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion ❑ 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 dors-or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. .tA4 �//� ��. ' ❑ Voluntary Disposal ❑ Other: _ `t � 3-501.14(0 PHFS Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According fi Law Cooled to Factors(items 1-22) (Cont.) _ 41'F/45°F Within 4 Hours. PROTECTION FROM 3-50115 Cooling Methods'forPHFs - Food or Color Additives 19 PHF Hot and Cold Holding I4 3-501.16(13) Cold PRFs Maintained at or below 3-20212 Additives* 590.004(F) 41'/45°F'0 3-302.14 Protection from Unao roved Additives'K Poisonous or Toxic Substances 3-501.15(A) Hot PHFS Maintained at or above Is 14u°F. 7-101.11 Identifying Information-Original 3-50t.16(A) Roasts Held at or above 1307 Containers" 7-102.11 Common Name-Working Containers'' 20 Time as a Public Health Control 7-3.01.11 Separation-Sl'oage* 3-501.19 Time asaPublic Health Control* 7-202.11 Restriction-Presence and Use" 590.004(H) VarianceRe'cuirement 7-202.12 Conditions of Use' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.'11 Toxic Containers-Prohibitions* POPULATIONS(HSP) 7-204.11 Sanitizers,Criteria-Chemicals* - 7-204.12 Chemicals for Washing=Produce,Criteria* 21 3-80111(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drying Agents.Criteria* Beveraees with Warning Labels* 7-205.11 htcidental Food Contact,Lubricant's* 3-801.11(B) Use of Pasteurlred E--s* 7-206.11 Restricted Use Pesticides,Criteria* 3-1301.11(D) Raw or Partially Cooked t ved. *Pood and _ 7-206.12 Rodent'Bait Stations* Raw pend Sprouts Not Served. 7-206.13 Tracking Powders,Pest Control and 3-80 L 1 I(C) Unopened Food Package Not Re-served. Monitoring' CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal F'o&That are Raw.Undercooked or PHFS Not Otherwise Processed to Eliminate 3-401.11A(()(2) 1"Etis In5'F].SSee, Pathogens r. :e""0" 0" t-°s-Immediate Service 145°Fl5soc* 3-302-1.3 1 pasteurized Eggs Substitute for Raw Shell ER rS* 3-401.11(A)(2) Comminuted Fish.Meats&Crane Animals- Ii5°F 15 sec. "' SPECIAL REQUIREMENTS _ 3-401.11(13)(1)(2) Potk and Beef Roast-1.30°F 121 min* 3-401.11(A)(2) Raotes, InjeUt.d Meats-155'F 15 590.009(A){m I Violations of Section 590.009(A)-('D)in sec x catering,mobile Pood, temporary and 3-401.11(A)(3) Poultry,Wild Game.Stuffed PHFS, residential kitchen operations should be 9tuffinL Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-I65'F 15 sec. * above if related to foodborne illness 3-401.'11(C)(3) Whole-muscle, Intact Beef Steaks interventions and risk factors. Other 145'F* 590.009 violations relating to good retail . 3-401..12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFS-- 145°F'15 sea 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403-'11(A)&(D) PLIFs 165'F 15 sec. * (Items 23-30) _3-403.11(13) Microwave- 165°P 2 Minute Standing Critical and non-critical vrotations, which do not relate to the Time* foodborne itleess interventions and risk factory listed above, can be - 3-40311(C) Commercially Processed RTE Food- found in the folheving sections or the Foot!Code and 105 Cti1K 140°F* 590.000. 3-403.1 I(E) Remaining Unsticed Portions of Beef Item 1 Good Retail Practices FC ' 590-000 Roasts* 23. _Mana ement and Personnel ! FC-2 .003 ` -- ---0- Ig Proper Cooling of PHFS 24._- Food and Food Protection _ ! FC- 3 004_ 251lHqwpment and Utensils FC-4 .005 ..... 3-501A4(A) Cooling Cooked YHPs From 140°F to 26. W atel Plumbingand W aste FC-5 .006 70'F Within 2 Hours and From 70°F 27. 1 Physical Facility __IFC-6 .007 1 to 41'F/451"Within 4 Hours * 28. 1 Poisonous or Toxic Materials IFC-7 .008 I' 3-501.14(B) Cooling PHFS Made From Ambient 29. 1Speclai Hegulrernents _009 Temperature Ingredients to 41'F/45'F 3o, I Other __----.---- ,._ .._-_------.. _ - Within 4 Hours* *Denotes critical iters in the federal 1999 Food Code or 105 CR4R 590.000. HP Fax Series 900 Fax History Report for Plain Paper Fax/Copier Joanne Scott Salem BOH 978 745 0343 Jan 15 2003 9:5 lam ALast Fax Time TTpg Identification Duration P= Etauh Jan 15 9:50am Sent 917812469971 0:39 2 OK Result: OK - black and white fax w oxw CYTY OF SALEM, MASSACHUSETTS BOARD OF HEALTH * 120 WASHINGTON STREET, 4TH FLOOR + SALEM, MA 01970 a x . TEL. 978-741-1800 p' FAX 978-745-0343 STANLEY IJSOVICZ, JR. -JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT Facsimile Transmittal To: i� Fax RE: Date : J/lS/�.3 Page(s): including this cover# Message: Board of Health News ----------------------------------------------------------------For Your Information Office Hours: Effective September 3, 2002 through June 27, 2003 ; Monday, Tuesday, & Wednesday 8:00 AM to 4:00 PM Thursday 8:00 AM to 7:00 PM Friday 8:00 AM to 4:00 PM Do Salem Residents Know ? — Applications for a permit to remove exterior paint are required by the Salem Board of Health. No fee for permit and electric sanding is not permitted. Regulations for home owners and painting contractors are available. CITY OF SALEM, MASSACI IIJSETTS v j H f T. BOARD OF HEALTH - s 120 WAS H I NGTON STREET, 4TH, FLOOR SALEM, MA 01970 t TEL. 978-741-1800 FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONAIEALTH OF MASSACHUSETTS PERMIT TO OPERATE A: FOOD ESTABLISHMENT In `accordance with regulations promulgated under authority of Chapter 94., Section 305A and Chapteri'III,' Section 5 of the General Laws, to operate a Food Establisfin1- - in the '0 6 'f'Salem is hereby granted to: Owner' s Name : A.L. Prime Ene.rgy.Consulant Inc . Name of Establishment : A.L. Prime Energy Address of Establishment : 175 Lafayette Street ,Type ofFEstablishment :• RETAIL, FOOD Application Dabe: li/26/2001 Restrictions. :' .< r .• a.-f", M: , Foodb shmen22-02Permit.�for. Estali g..Frozen Desserts./=IceCream Permit for the ;Sale of Tobacco, Products 9-02 These Permits Expire December= 31;, '2002 This permit is not transferable and must•be. reissued upon change of ownership 'or location. The-•permit '=xmst 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. `//}/'/J/I'%') HEALTH AGENT a CITY OF SALEM, MASSACHUSETTS • BOARD OF HEALTH e r 120 WASHINGTON STREET, 4TH FLOOR � SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 I;liU V 2 L 200' STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT CITY OT SALEM HEALTH DEPT. 2002 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT A . L . PRIME c U1RG Y TEL# (91Q 4 yu - 9 4 t B ADDRESS OF ESTABLISHMENT 1 }5 LA F/a Yf %T S7, MAILING ADDRESS (if different) 3 19 B SA L EM S7, (,(JA KEhIEGD MA •0I S Xd OWNER'S NAME AA .fPI/AC CWZ'2,)e' CUNfU[TAA/T INC. TEL# $ ( 2y6—oLdl ADDRESS 3190 SAC EM S CITY bJA Kc F/c"t-O STATE M A ZIP o t no CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON BASIL z A 7-A HOME TEL# (61 1) 2 12.-3 5 2 3 DAYS/HOURS OF OPERATION: Mon. __,�,Tue. ✓Wed. ✓Thu. ✓Fri. ✓ Sat. ✓Sun. TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO $40 RESTAURANT YES0�_ a2 $40 BED & BREAKFAST YES ® $40 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT SOFT SERVE YES NO $5 ( TOBACCO VENDOR ES NO q-6a- NO CHARGE FOR NON-PROFI (such as church kitchens) PLEASE INCLUDE COPY OF TAX EXEMPT FORM 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 Mer 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowle ge d bell , have filed all state tax returns and paid all state taxes required under the law. J,, ItIat-/w U tq- 311.? 7 Y9 Signature Date Social Security or Federal Identification number ------------------------------------------------------------------------------------------------ Revised ll/1/01 foodap2.adm Check#&Date oa Y THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 120 Washington Street, 4th Floor BOARD OF HEALTH Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 745-0343 Name �✓J / J e y-- Date J Type of Operation(s) Tyne of Inspection /T• f� . +Ql/Pr El Food Service 4outine Address / ys- /lam C P is U'Retail ❑ Re-inspection ❑ Residential Kitchen Previous Inspection Telephone .7 c`B.- C / L ❑ Mobile Date: Owner A• n HACCP YIN ❑ Temporary ❑ Pre-operation El Caterer El Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In: ❑ HACCP Inspector ' Out: Permit No. ❑ Other ZT e . Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/ Knowledgeable/ Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH El2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS El3. Personnel with Infections Restricted/ Excluded El 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE EJ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) El 16. Cooking Temperatures El 5. Receiving/Condition El6. Tags/Records/Accuracy of Ingredient Statements El 17. Reheating ❑ 7. Conformance with Approved Procedures/ HACCP Plans El 18. Cooling El 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20. Time as a Public Health Control ❑ 8. Separation/Segregation/ Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 10. Proper Adequate Handwashing ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related Items) Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/Federal Food Code.This report, when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.006) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: Inspector's Signature: �:/ IPrint: PIC's Signature Print: Pag/ or'2 Pages !: FORM 734A HOBBS&W%RR(EN ISOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 590.003(A) Assi nment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11 Person in Charpe-Duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment ;2.' 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) Food Protection* require reporting by Food Employees and 3-302.15 Washing Fruits and Vegetables Applicants 3.304.11 Food Contact with Equipment and 590.003(F) Responsibility of a Food Employee or an Utensils* Applicant to Report to the Person in Charge* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE 9 Food Contact Surfaces Food and Water From Regulated Sources 4-501.111 Manual Warewashing-Hot Water 590.004(A-B) Compliance with Food Law* Sanitization Temperatures* 3-201.12 Food in a Hermetically Sealed Container* 4-501.112 Mechanical Warewashing-Hot Water 3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures* 3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.14 Eggs and Milk Products,Pasteurized* Concentration and Hardness* 3-202.16 Ice Made from Potable Drinking Water* 4-601.11(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved System* Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3.201.14 Fish and Recreationally caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization- Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* ;10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* 11 Good Hygienic Practices 3-201.17 Game Animals* 2-401.11 Eating,Drinking or Using Tobacco* 5 Receiving/Condition 2-401.12 Discharges From the Eyes,Nose and 3-202.11 PHFs Received at Proper Temperatures* Mouth* 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-101.11 Food Safe and Unadulterated* ""12` Prevention of Contamination from Hands 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from 3-202.18 Shellstock Identification* Employees* 3-203.12 Shellstock Identification Maintained* 13 Handwash Facilities Tags/Records: Fish Products Conveniently Located and Accessible 3-402.11 Parasite Destruction* 5-203.11 Numbers and Capacities* 3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement* 590.004(J) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance 7; Conformance with Approved Procedures Supplied with Soap and Hand Drying =w /HACCP Plans Devices 3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability 3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision 7103.12 Conformance with Approved Procedures* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. t I CITY OF SALEM 1 i BOARD OF HEALTH I, Establishment Name: , e 46.p4V I/ Date: Page: 1z of Z Item Code C,—Critical Item ' w DESGRtPl'lON OFMIOLATIONI/ PLAN OF CORRECTION - Date ' �' Verified ` i No. Reference R—Red Item s Y PLEASE PRINT CLEAflLV �k 4j t d 4 3 t Discussion With Person in Charge: Corrective ActionRequired: ❑ No O Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to comply Exclusion with all mandates of the Mass/Federal Food Code. I understand that noncompliance may ❑ Re-inspection Scheduled ❑ Emergency Suspension [ result in daily fines of twenty-five dollars or suspension/revocation of your food permit. ❑ Embargo ❑ Emergency Closure ( , ❑ Voluntary Disposal ❑ Other Ifo FORM 734B HOBBS & WARREN - BOSTON g Violations Related to Foodborne Illness Interventions and Risk 3-501.14(C) PHFs Received at Temperatures Factors(Red Items 1-22) (Cont.) According to Law Cooled to 41°F/45°F Within 4 Hours.* PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives ...19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below 3-202.14 Protection from Unapproved Additives* 590.004(F) 41°F/45°F* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original 140°F.* Containers* 3-501.16(A) Roasts Held at or above 130°F.* 7-102.11 Common Name-Working Containers* '--'.20 Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS(HSP) 7-204.11 Sanitizers,Criteria-Chemicals* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204,12 Chemicals for Washing Produce,Criteria* ;'y, Beverages with Warning Labels* 7-204.14 Drying Agents,Criteria* 3-801.1l(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact,Lubricants* 3-801.1 I(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.* 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.* 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of TIME/TEMPERATURE CONTROLS Animal Foods that are Raw,Undercooked or 16 Proper Cooking Temperatures for not Otherwise Processed to Eliminate _ PHFs Pathogens.* Effective 11112001 3-401.1IA(1)(2) Eggs- 155°F 15 Sec. 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* Eggs-Immediate Service 145°F 15 Sec.* 3-401.1l(A)(2) Comminuted Fish,Meats&Game SPECIAL REQUIREMENTS Animals- 155*F Sec.* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 Min.* catering, mobile food,temporary and 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 Sec.* residential kitchen operations should be 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, debited under the appropriate sections Stuffing Containing Fish,Meat, above if related to foodborne illness Poultry or Ratites- 165°F 15 Sec.* interventions and risk factors. Other 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 590.009 violations relating to good retail 145°F* practices should be debited under#29- 3-401.12 Raw Animal Foods Cooked in a Special Requirements. Microwave 165°F* 3-401.11(A)(1)(b) All Other PHFs- 145°F 15 Sec.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES YT. Reheating for Hot Holding (Blue Items 23-30) 3-403.11(A)&(D) PHFs 165°F 15 Sec.* Critical and non-critical violations, which do not relate to the 3-403.11(B) Microwave- 165°F 2 Minute Standing foodbome illness interventions and risk factors listed above, can be Time* found in the following sections of the Food Code and 105 CMR 3-403.11(C) Commercially Processed RTE Food- 590.00. 140°F* Item Good Retail Practices FC 590.00 3-403.11(E) Remaining Unsliced Portions of Beef 23. Management and Personnel FC-2 .003 Roasts* 24. Food and Food Protection FC-3 .004 Proper Cooling of PHFs 25. Equipment and Utensils FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140°F to 26. water, Plumbing and Waste FC-5 .006 70°F Within 2 Hours and from 70*F 27. Physical Facility FC-6 .007 to 41°F/45°F Within 4 Hours.* 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Sp ecial Requirements .009 Temperature Ingredients to 41°F/45°F F30. Other Within 4 Hours* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. s - 11488 AL PRIME ENERGY CONSULTANT, INC. 314 SALEM STREET 5-7515/0110 WAKEFIELD,MA 01880-4942 /+ OATS L PAYTO ORDEE F DOLLARS 8 = n'O L L4B8ii' I:O L 10751501: 699000 2 L7961,• i w o CITY OF SALEM, MASSACHUSETTS ef� BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR a SALEM, MA 01970 9gW, TEL. 978-741-1800 FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT April 30, 2002 A.L.Prime Energy 175 Lafayette Street YM Salem,MA 01970 t c n Dear Owner, On April 19, 2001,personnel from the Tobacco Control Program conducted a compliance check to determine if your permitted establishment would sell a tobacco product to a minor. A 16-year-old female purchased cigarettes from a clerk in your store. Documentation is now on file at the Board of Health regarding that sale. A.L.Prime Energy is in violation of Section III(A)of the Salem Board of Health Regulation Affecting the Purchasing of Tobacco Products. According to this section,the sale of cigarettes,chewing tobacco, snufl; or any tobacco in any of its forms to any person under the age of eighteen shall be punished by a fine of three hundred dollars($200)for the SECOND offense. The North Shore Tobacco Control Program and the Salem Board of Health have worked with you and your employees to demonstrate methods to ensure compliance with this regulation. Therefore,you are ordered to pay a fine of$200.00 for the violation stated above. A check or money order payable to the City of Salem must be at the Board of Health office, 120 Washington Street,4u' floor within ten days of receipt of this notice. Should you be aggrieved by this Order,you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven (7)days of receipt of this Order. At said hearing,you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports, orders, and other documentary information in the possession of this Board,and that any adverse party has the right to be present at the hearing. if you have any questions regarding this notification please call me at 741-1800. Sincerely yours, L �C�dW('— Scott Health Agent Cc: North Shore Tobacco Control Program Martin Fair,Acting Board of Health Chairman CERTIFIED MAIL 7001 1140 0000 6733 7592 U.S. Po I Service "CEFTIFIED MAIL RECEIPT 1�nrcstic Mail Only; No insurance Coverage Provided) rLn C} F F IC 11A M Postage $ M l` Certified Fee 1] Postmark E3ReFee Here 0 (Endorsement Reqq Hem C7 Restricted Delivery Fee O (Endorsement Required) C3 Total Postage 8 Fees S r9 ent riC. L r P r3 Apt.N O or or PC PO Bos Na. --------------------------------------------------------_..--.....-----..--_--............. M1 Clfy,State,ZIPS 4 Certified Mail Provides: ■A mailing receipt ■A unique identifier for your mailpiece ■A signature upon delivery ■A record of delivery kept by the Postal Service for two years Important Reminders: ■Certified Mail may ONLY be combined with First-Class Mail or Priority Mall. ■Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS postmark on your Certified Mail receipt is required. ■For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". ■ If a postmark on the Certified Mail receipt is desired,please present the ard- jcl at the post office for postmarking. If a postmark on the Certified Mail eipt is not needed,detach and affix label with postage and mail. IMPOWNT Save this receipt and present it when making an inquiry. PS Form 3808,January 2001 (Reverse) 102595-01-e1-1829 UNITED STATES POSTAL SERA E C SSF First Clasp Mil— I USP6 a&Fees Paid Perinit No. G-10 • Sender: Please " me, address, and ZIP+4 in this box /g�"k ty of Salem gym and of Health F 0 Washington Street-4th Floor �P 17 2001 Salem, MA 01970 ITY OF SALEM EALTH DEPT. I JILr4�n111ri4Jn41114��nIL,LI44J4LdLr414111rnlnirf COMPLETE •N COMPLETE THIS SECTIONON DELIVERY ■ Complete Item<1,2,and 3.Also complete A. Received by(Please Print Clearly) B. Date of Delivery item 4 if Restricted Delivery is desired. ■ Print your name and address on the reverse AIA I so that the can return the card to you. C. Signatur ■ Attach this card to the back of the mailpiece, ( ❑Agent or on the front if space permits. / ❑Addressee D. Is delivery address different from item 1? 13 Yes 1. Article Addressed to: If YES,enter delivery address below: ❑ No A.L. Prime Energy 175 Lafayette Street Salem, MA 01970 3. SeType Certified Mail ❑ Express Mail n ❑ Registered ❑ Return Receipt for Merchandise ❑ Insured Mail ❑ C.O.D. mp 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number(Copy from service label) 7099 34 PS Form 3811,July 1999 Domestic Return Receipt 102595-00-M-0952 ' CITY OF SALEM, MASSACHUSETTS corm BOARD OF HEALTH is i' 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT April 30, 2002 A.L.Prime Energy 175 Lafayette Street S�'7-U Salem,MA 01970 Dear Owner, On April 19, 2001,personnel from the Tobacco Control Program conducted a compliance check to determine if your permitted establishment would sell a tobacco product to a minor. A 16-year-old female purchased cigarettes from a clerk in your store. Documentation is now on file at the Board of Health regarding that sale. A.1..Prime Energy is in violation of Section ID(A)of the Salem Board of Health Regulation Affecting the Purchasing of Tobacco Products. According to this section,the sale of cigarettes,chewing tobacco,snuff or any tobacco in any of its forms to any person under the age of eighteen shall be punished by a fine of three hundred dollars($200)for the SECOND offense. The North Shore Tobacco Control Program and the Salem Board of Health have worked with you and your employees to demonstrate methods to ensure compliance with this regulation. Therefore,you are ordered to pay a fine of$200.00 for the violation stated above. A check or money order payable to the City of Salem roust be at the Board of Health once, 120 Washington Street,4f° floor within ten days of receipt of this notice. Should you be aggrieved by this Order,you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven (7)days of receipt of this Order. At said hearing,you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports,orders, and other documentary information in the possession of this Board,and that any adverse parry has the right to be present at the hearing. if you have arry questions regarding this notification please call me at 741-1800. Sincerely yours, 4f) a Scott Health Agent Cc: North Shore Tobacco Control Program Martin Fair, Acting Board of Health Chairman CERTIFIED MAIL 7001 1140 0000 6733 7592 i 11488 AL PRIME ENERGY CONSULTANT, INC. 319 SALEM STREET 5-7515/0110 WAKEFIELD,MA 018804942 DATE S - PAY ORDS F 7R2REOF viii L�I�t� DOLLARS SlovereignI n�0 i 1488ii' r:0 i 1075 i 50r: 699000 2 17 96116 l ' �coxurr n s� C/Mlrye CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH, RS,CHO 120 Washington Street 4th Floor HEALTH AGENT August 27, 2001 Tel: (978)741-1800 9 Fax:,�(978)745-0343,✓ A.L. Prime Energy 175 Lafayette Street Salem, MA 01970 U Dear Owner: ( U i On August7, 2001, personnel from the Tobacco Control Program conducted a compliance check to determine if your permitted establishment would sell a tobacco product to a minor. A 16-year- old female purchased cigarettes from a clerk in your store. Documentation is now on file at the Board of Health regarding that sale. A.L. Prime Energy is in violation of Section III(A)of the Salem Board of Health Regulation Affecting the Purchasing of Tobacco Products. According to this section, the sale of cigarettes, chewing tobacco, snuff, or any tobacco in any of its forms to any person under the age of eighteen shall be punished by a fine of one hundred dollars ($100)for the first offense. The North Shore Tobacco Control Program and the Salem Board of Health have worked with you and your employees to demonstrate methods to ensure compliance with this regulation: Therefore, you are ordered to pay a fine of$100.00 for the violation stated above. A check or money order payable to the City of Salem must be at the Board of Healthoffice, 9 North Street within ten days of receipt of this notice. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven (7)days of receipt of this Order. At said hearing, you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports, orders, and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. If you have any questions regarding this notification please call me at (978)741-1800. Sincerely yours, oanne Scott Health Agent cc: North Shore Tobacco Control Program Leonard Milaszewski, Board of Health Chairman CERTIFIED MAIL 7099 3400 0008 9438 6464 N2 2135 City of Salem - Board of Health Violation Notice - Tobacco Sale to Minors This notice is to inform you that during a tobacco sales compliance check,your establishment violated the Salem Board of Health regulation#24 prohibiting the sale of tobacco products to persons under 18 years of age. 4 . L. KfxIMc LN ka/ Name of establishment (-?! &,4 F✓} Address Date of sale Time of sale Minor's ftge/gender Minor's ID# r f / /A--iM Adult supervisors Narrative report of incident and description of seller by adult supervisor who will testify at the Salem Board of Health meeting including a description of the seller: I affirm, under the pains a d penalties of perjury, that the above report is true to the best of my knowledge and be Adult supeVisor(Signature) Adult supervisor (Print name) VENDOR STATEM T: I acknowledge I received this Violation Notice on at _ AM nd I am being given a carbon copy of this notice. I also acknowledge that I have been told that a letter regarding Board of Health follow-up to this violation will be mailed to me at the above address. �- Owner/Manager/Clerk(Signatu lY i16� Owner/Manager/Cle k(Print name) If vendor refuses this Notice or if Adult Supervisor feels unsafe in delivering it,an explanation must be written on a note attached hereto. Mailing of this Notice is thus required. For further information, contact the North Shore Tobacco Control Program at 978/741-5646. Board of Health-white/NSTCP-yellow/Establishment-pink Section X: -�tsta�'itisttmcut Survey Participants Nun t p Nnme of Furchasu: 44 `7 or[Dtl Addrrsr Age: 14 Sex: ❑Matecmalc .. City: Zip Code: Name of Butt escortiData Collator. Sample Area Of smaller than city or town ptcasc identify): Time of Chock: am❑ pm l9---" Type of Fsublishmeat Chant ❑ ladepeadent ❑ Not Known Date of Check er Style of FAUbiisbment(Check Only One): ❑ vea too Store ❑ phatntacy/Drug Store ❑ Gas Miai-Mart Gas Station Only ❑ Grocery Store ❑ Ltgwr Storo ❑ Dunt Store ❑ Bar ❑ Ptivato Club(VFW,[.e&a.eta) ❑ Rrxtaratat(Ow Arc&) ❑ Itcstaurant(OtherArca) ❑ Odha(bowiingalley.golfctub.e(a) ' Section 2: Did liteyoutk cater the premises aatd attempt to purchase a tobacco product? Yes No ❑ if res,please continue onto the nest quesdom IINo.please skip this rection and go to rection J. u/was tobacco sold? EX Over-the-counter by youth asking the clerk for the product. ❑ Ove-rho-oountaby youth selecting product Crorn aself-service display. , ❑ From a rrnQatg machine with a lockout device. ❑ From avcadiag machine without a lockout devim rt i Was the Pardtaser•askod Cor ID? Yes ❑ No 0 Was Me Patdtasm asked for hWher age? Yes 11 No r Sexofcalc 'Male Ferate ❑ Approximate age of ff7 Did the perk say anything to you when the purchase was made? ... Type of tabaoeo asked for.fU cigarettes ❑ Chewmip ❑ Cigars ❑/rOther Please specify Was the sale-made? Ycs,D No❑ (if Yes,how much did the product cost: S Section 3: If the youth did not eater the premises or did not attempt to purchase tobacco producti please check here: ❑ and iadicate why:- ❑ dosod roc the day ❑ couldn't locate business ❑ buyer knows clo Wmudunt (3admission charge ❑ dosod Cor the reason ❑ no longer in business ❑ establishment inappropriate for youth [I admission ❑ closed to are public Eldoesn't sett tobacco ❑ unsafe rsubtishmcnt - — ❑ denied admission at door ❑ vending machine broken ❑ unsafe area ,— Please call the MTCP Evaluation Director at(617)624-5906 it you have any questions. i= r 10791 AL PRIME ENERGY CONSULTANT, INC. 319SALEMSTREET 5-7515/0110 WAKEFIELD,MA 01880-4942 EO � PAY onrE TOTNE t ��U ORDER OF ' DOLLARS Sovereign FOR .. _ 1140;10,79,11!4 1:0 i I0TSa SO.i: 699000 2 1 79 AP CO M Postage $ 7 Er Certified Fee Postmark rO Return Receipt Fee Here M (Endorsement Required) O Q Restricted Delivery Fee (Endorsement Required) 0 O Total Postage 8 Fees M N6rtre(Please Pdnt Clearly)(to be completed by mailer) 17- Street,Apt.Na;or PO Box No.Er _ O .....Ciy,..... ............................... C3 State,ZIP+4 Certified Mail Provides: ■ A mailing receipt ■ A unique identifier for your mailpiece ■ A signature upon delivery ■ A record of delivery kept by the Postal Service for two years Important Reminders. ■ Certified Mail may ONLY be combined with First-Class Mail or Priority Mail. k ■ Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For j valuables,please consider Insured or Registered Mail. f ■ For an additional fee,a Retum Receipt may be requested to provide proof of J delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3911)to the article and add applicable postage to cover the fee.Endorse mailpiece 'Return Receipt Requested".To receive a fee waiver for a duplicate return receipt, a USPS postmark on your Certified Mail receipt is required. M For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the I endorsement"Restricted Delivery". I If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail -.: receipt is not needed,detach and affix label with postage and mail. r PORTANT:Save this receipt and present it when making an inquiry. Form 3800,July 1999(Reverse) 102595-99-M-2087