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AMELIA PAYSON GUEST HOUSE-BB - ESTABLISHMENTS AME!✓A PAY-Sow GusS7 l�c1sF W//VrEp, Sf- S ' 4� J Gls OF v11f /o;/S' SeRvtA-7 �maf�N� L &a k ras,,'� r .r I I SALEM FIRE DEPARTMENT w 48 LAFAYETTE ST { SALEM, MA 01970 � (978) 744-1235 a s ti k N} 11 June 3, 2015 Amelia Payson House 16 Winter ST Salem, MA 01970 r Congratulations,an inspection of your facility on Jun 3, 2015 revealed no violations. Inspection Note No sprinkler system 01367 (Lt.)Peter Schaeublin Ada M. Roberts Inspector r . 6 °N°`T" City of Salem, Massachusettslu { - i Board of Health "a 120 Washington Street, 4th Floor, Salem, MA 01970 Tel. (978) 741-1800 Fax. (978) 745-0343 PI1bI1CHCAlul Prevent. Promote. Protect. Iramdin@salem.com Kimberley Driscoll Larry Ramdin RS/REHS, CHO, CP-FS Mayor Health Agent FOOD ESTABLISHMENT PERMIT (must be posted on the Premises of the Food Establishment) 2015 Permit Number: FM-15-209 Permit Type: Food Establishment< 25 seats Goods&Services: Residential Kitchen: B&B Name of License Holder: Amelia Payson-Ada Roberts Name of Food Establishment Amelia Payson Guest House Address of Food Establishment 16 Winter Street Salem MA 01970 Restrictions: Bed and Breakfast Permit This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on 12/31/2015 unless sooner suspended or revoked. Permit Fee: 100.00 Issued: 1/1/2015 ✓ :' Nf SS C T I US I ITS 4�� LP Public Health '( 70 t rh il.. ilN fel— 1#07 LAlU Y > >MDI ,R M 1S <K),1-11-1;S CITY OF SALEM BOARD OF HEALTH Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: 2) Establishment Address: -}- 3) Establishment Mailing Address(if different): 4) Establishment Telephone No: 5) Applicant Name&Title: —A 6) Applicant Address: 9-s-alo — I `f bar xJL � ® 7) Applicant Telephone No: 5 24 Hour Emergency No: Email: 8) Owner Name&Title(if different from applicant): 9) Owner Address(if different from applicant): 10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers or partner. An association Name Title Home Address AA cor n individual artnership Other legal entity 12 Person Directly Responsible For Daily Operations (Owner,Person in Charge,Supervisor, Manager,etc.) Name&Title: p`. S L Address: Telephone No: -7cJ k3O7 Fax: Email: 6bov-)C.C,0" (0 /-1() Emergency Telephone No: — 13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: Fax: Email: Check#: " Dater Amount: �� I'✓d Food Establishment Information / 14) Water Source: Sr e�� 15) Sewage Disposal: l� d c 1 r DEP Public Water Supply N (if applicable) pp 16) Days and Hours of Operation: M — 0c;R. No.of Food Employees: 18) Name of Person in Charge Certified in Food Protection Management: p /� Requited as of 101112001 in accordance with 105 CMR 590.003(A) 19) Person Trained in Anti-Choking Procedures(if 25 seats or more): ❑ Yes No 20) Location: 22). Establishment Type(check all that apply) � (check one) ❑ Retail( Sq. Ft) ❑ Caterer t/ Permanent Structure ❑ Food Service-( -Seats) ❑ Frozen Dessert Manufacturer Mobile ❑ Food Service-Takeout ❑ Residential Kitchen for Retail Sale O Food Service-Institution ❑ Residential Kitchen for Bed and ( Meals/Day) BreakfastUorne ❑ Food Delivery Mllesidentiaf Kitchen for Bed and 21) Length Of Permit: Breakfast Establishments...................... check one) RETAIL STORE RESTAURANT 13Ann Less than 1000sq.ft. $70 13 Less than 25 seats $140 easonal/Dates: ❑ 1000-10,OOOsq.ft. $280 ❑ Residential Kitchens $140 ❑ More than I0,OOOsq.ft. $420 ❑25-99 seats $280 ❑ More than 99 seats $420 Temporary/Datesfrime: "Be-...�.. -...._e---- S ..............u --------- ._.... d 8: BreakfasUChildcarServices/Nrsing Home $100 --111...­........... ............................... ......­­............... ADDITIONAL PERMITS � ❑ MAKE ICE CREAM,YOGURT/SOFT SERVE $25 ❑ PASTURIZATION . $25 ❑ALL NON-PROFIT' $25 *Including, church kitchens,state funded childcare&private club 23) Food Operations: Defirudons: PHF-poten0allyhazardous food(bmeltemperature controls required) Non-PHFs-non-potendal/y hazardous food(no 6meltemperature controls regi¢red) (check all that apply): RTE- -to-eat foods .sandwiches,salads,muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only reparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will complywith 105 CMR 590.000 and all other applicable law. I have been instructed bythe Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. 24) Signature of Applicant Pursuant to MGL Ch.62C,sec.49A, I certify under the penalties of perjury that I,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: c) \ y — L4 _ y 1p L47 26) Signature of Individual or Corporate Name: ��� i � -. 0 0 Amelia Payson House November 4th, 2014 Heather Lyons Paul City Of Salem Board of Health 120 Washington Street 4th Floor Salem,MA 01970 Re: 2015 Food Establishment Permit Application Dear Heather, Enclosed is my application for our 2015 Food Establishment Permit along with a check, #3726 for$100.00. Should you have any questions,please call my cell: 978 210-9814. Once I see that my check is cashed, I know we will be all set. Thanks! Ada May Roberts Amelia Payson House 16 Winter Street Salem,Ma. 01970 978 744-8304 Cell: 978 210-9814 16 Winter Street Salem, Massachusetts 01970 (978) 744-8304 w ?d CITY OF SALEM, MASSACHUST_XI'S BOARD or. 1 JL ALTH 120 WASHINGTON STREET 4r'.FLOOR lth TFI.,. (978) 741-1800 FAR(978) 745-0343 KIMBERLEY DRISCOLL liat-ndin@saleiii.com L,ARRI"lUV%1DIN,RS/Rfa-IS,(if[0,CP-FS MAYOR f-11W,CFS Ac"FNP 4/27/2012 Amelia Payson House 16 Winter Street Salem MA 01970 16 Winter Street Dear Owner: The Salem Board of Health, Building and Fire Departments are scheduling yearly inspection of all establishments licensed as lodging houses. The Salem Licensing Board will review inspection and re-inspection reports in accordance with its license renewal procedures. The inspection will include dwelling units and common areas, therefore each tenant must be present or he/she must sign the enclosed release form which will allow the inspectors to enter the unit. Your Lodging House at 16 Winter Street has been scheduled to be inspected on Wednesday 6/6/2012 at 11:00:00 AM ' Thank your for your anticipated cooperation. Sincerely, Larry Ramdin Health Agent cc: Michael Lutrzykowski, Assistant Inspector of Buildings Lt. Erin Griffin, Fire Prevention Robert St. Pierre, Chairman, Salem Licensing Board i CITY OF SALEM, MASSACHUSEl-fS y BOARD OF HEALTH 120 WASHINGTON STREET,4"'FLOOR TEL. (978) 741-1800 KIMBERL:EY DRISCOLL FAx(978)745-0343 MAYOR DGRF.E R UUNJ I RNI cc>u DAVID GRF.ENBAUM,RS l ACTINGHIILTHAGENT 5/9/2011 Amelia Payson House 16 Winter Street Salem MA 01970 16 Winter Street Dear Owner: The Salem Board of Health, Building and Fire Departments are scheduling yearly inspection of all establishments licensed as lodging houses. The Salem Licensing Board will review inspection and re-inspection reports in accordance with its license renewal procedures. The inspection will include dwelling units and common areas, therefore each tenant must be present or he/she must sign the enclosed release form which will allow the inspectors to enter the unit. Your Lodging House at 16 Winter Street has been scheduled to be inspected on Wednesday 6/8/2011 at 11:00:00 AM Thank your for your anticipated cooperation. Sincerely, David Gre nba m, A ng Health Agent cc: Tom McGrath, Assistant Inspector of Buildings Erin Griffin, Fire Prevention Robert St. Pierre, Chairman, Salem Licensing Board CITY OF SALEM; MASSACHUSETTS + BOARD OF HEALTH 120 WASHINGTON STREET,4°{FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAx(978)745-0343 MAYOR uGur}rBaunaC�sn z: i.ca� DAVID GRGENBAURI ACTING 14FA1,TH.A{TENT I 4/27/2010 Amelia Payson House 16 Winter Street Salem MA 01970 16 Winter Street Dear Owner: The Salem Board of Health, Building and Fire Departments are scheduling yearly inspection of all establishments licensed as lodging houses. The Salem Licensing Board will review inspection and re-inspection reports in accordance with its license renewal procedures. The inspection will include dwelling units and common areas, therefore each tenant must be present or he/she must sign the enclosed release form which will allow the inspectors to enter the unit. Your Lodging House at 16 Winter Street has been scheduled to be inspected on Tuesday 6/29/2010 at 11:00:00 AM Thank your for your.anticipated cooperation. Sincerely, David Gr enbaum, A Ing Health Agent cc: Tom McGrath, Assistant Inspector of Buildings Erin Griffin, Fire Prevention Robert St. Pierre, Chairman, Salem Licensing Board 4 I. CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH - 120 WASHINGTON STREET,4'"FLOOR - TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAx(978)745-0343 MAYOR IMANCINIcar SAL FAi cOXI JANE%I'MANCINf ACENGHEAr;iHAGFINT - - 3125109 Amelia Payson House 16 Winter Street Salem MA 01970 16 Winter Street Dear Owner: The Salem Board of Health, Building and Fire Departments are scheduling yearly inspection of all establishments licensed as lodging houses. The Salem Licensing Board will review inspection and re-inspection reports in accordance with its license renewal procedures. The inspection will include dwelling units and common areas, therefore each tenant must be present or he/she must sign the enclosed release form which will allow the inspectors to enter the unit. Your Lodging House at 16 Winter Street has been scheduled to be inspected on Wednesday 4/22/2009 at 10:00:00 AM Thank your for your anticipated cooperation. Sincerely, I net Mancini, Acting Health Agent cc: Edgar Paquin, Assistant Inspector of Buildings Erin Griffin, Fire Prevention David Shea, Chairman, Salem Licensing Board , t. Commonwealth of Massachusetts s e City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/18/2008 ESTABLISHMENT NAME: Amelia Payson Guest House File Number:BHF-2004-000129 16 Winter Street Salem MA 01970 LOCATED AT: 0016 WINTER STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2009-0008 Dec 18,2008 Dec 31,2009 $100.00 ESTABLISHMENT Total Fees: $100.00 PERMIT EXPIRES Iecember 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 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH00 ��.: 120 WASHINGTON STREET,4r"FLOOR �(�, II TEL. (978) 741-1800 -/ n _ KvIBERLEY DRISCOLL FAZ(978) 745-0343 S ! I Gtj MAYOR IDIONNE&SALEM.COM �� JANET DIONNE, _ ,(� ACTING HEALTH AGENT 1 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT &- - IM a.10 - 9 �i`f NAME OF ESTABLISHMENT A MC . e,�� .; ua �6�SrTEL# 2LI ADDRESS OF ESTABLISHMENT 1 ( r_o }— FAX# MAILING ADDRESS(if different) //I EMAIL-Business': b" —mP SLe ® AOL • Cn!✓I Website: r; rn Q. ��=1 a V-%r `G)r� OWNER'S NAME ,X�_ ��, � It oL�TEL# �i`5n�y,�g� ADDRESS STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) ��Q� C�r_ 1n �EE�, CERTIFICATE#(S) '3 !t Lo lr `J (Required in an establishment where potentially hazardous food is prepar EMERGENCY RESPONSE PERSON , AJ-, HOME TEL# DAY.S,OF OPERATION-, "Mond k'l ! ':1Tuesda , "Wednesda ThuWdayf Fdde � ', t Saturday, i Sunda""x`i. HOURS OF OPERATIONn� .e.-1 Please write in time of day. &–r p U zci (For example Ilam-11pm) ✓�- I S� �_�– "�c –ro T(^yUl 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 NO less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 �;ES ---- ---------------------- ....................--- -----....................... ......) EA KFASTI j iJO. $100 CHILDCARE SERVICES ---- ---- ---- -------yE ---------------------------------------------------------- J ADDITIONAL PERMITS MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment a In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns and paid all state taxes required under the law. Signature Date Social Security or Federal Identification Number -----------—--- ---- ----$ �]J�-�— -$ ------- -------- Revised 424/07 FOODAP2008.adm Check#&Date 71 N/ Y )yl co CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR Iraq SALEM, MA 01970 TEL. 978-741-1800 FAX 978.748.0343 KIMBERLEY DRISCOLL JSCOTT@SALEM.COM MAYOR JOANNE SCOTT HEALTH AGENT - 4/9/08 Amelia Payson House 16 Winter Street Salem MA 01970 16 Winter Street Dear Owner: The Salem Board of Health, Building and Fire Departments are scheduling yearly inspection of all establishments licensed as rooming houses. The Salem Licensing Board will review inspection and re-inspection reports in accordance with its license renewal procedures. The inspection will include dwelling units and common areas, therefore each tenant must be present or he/she must sign the enclosed release form which will allow the inspectors to enter the unit. Your Rooming House at 16 Winter Street has been scheduled to be inspected on Wednesday 5/14/2008 at 11:00:00 AM Thank your for your anticipated cooperation. Sinc erely, Joanne Scott, Health Agent JS/HL cc: Edgar Paquin, Assistant Inspector of Buildings Erin Griffin, Fire Prevention David Shea, Chairman, Salem Licensing Board lu„°Fy, YY{ fis..:. + ,JM�•`A_.:�f' ,4T�E wis I 4+-.w.+=n x". b^�E'..,rn v-..!.rY.. Commonwealth of Massachusetts` F r w w City of Salem Board of Health IGmbedey Drisooll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2008 ESTABLISHMENT NAME: Amelia Payson Guest House File Number:BHF-2004-000129 16 Winter Street Salem MA 01970 LOCATED AT: 0016 WINTER STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2008-0170 Jan 3,2008 Dec 31,2008 $100.00 ESTABLISHMENT Total Fees: $100.00 PERMIT EXPIRES IDecember3l, 2008 Board of Health 04 01V 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 toandapproved by the Salem Board of Health. Page I of 9 'o 3 QTY OF SALEM, MASSAC HUSEM BOARD OF HEALTH �'Annva d�' 120 WASHINGTON STREET,4"m FLOOR 'ISL. (978) 741-1800 KIMBERLEY DRISCOLL FAx(978)745-0343 MAYOR iscoTrn4sALEM.COM RECEIVE® JOANNE SOOTT, HEALTH AGENT DEC, 3- 2007 CI IY OF SALEM BOARDbF HEALTH 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENTTEL#QN _�7 cCS ~I LI -�c7 ADDRESS OF ESTABLISHMENT (o LA r rJI e� ``7Tr FAX# MAILING ADDRESS(if different) C Cela_ -cam /7 S7 5;? /0 -- 9 FS n EMAIL-Business': 6kDC,, � t''c-,L=i'ov 0 Website: CkMCL"c,U S sn L-)o C°c.X'7 OWNER'S NAME p �Y-� �� �tX.;r.�- 1, 10.1;1�nlc�, • P+_-, TEL# �.1+� ADDRESS i`�arY—moi STREET CITY ,. STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) 1\D L-c--e-lp- -> CERTIFICATE#(S) 0 /) p ( t � (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# DAYS OF OPERATION 1 Monday Tuesday Wednesday Thursda Friday Saturday Sunda HOURS OF OPERATION X09- (�70 � ,br-� I.;0", _zoo Please write in fime of day �-�14 l 1 S� j For example 11 am-11 m `7 a- 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 NO less than 25 seats =$140 _ (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 --'—'-------------------------------------- ---------- ---------------...--"-----"-'------------------- �--------...... ---- o------------------------ BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES.___ - -------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES 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 fled all state tax returns and paid all stat taxes required under the law. ��P i / /,?'721) '7 r)i9 -L4Q - ' � fnt/` � Signature Date �al Security or Federal Identification Number -----------------------------'----------------------!---l!- --------y— --- -------�--- --------------'----'--"-------- Revised 4/24/07 FOODAP2008.adm Checkd&Date (�(o ��/e2'� ' °""" *'y"y"*k *e.w._ +..�s,w•y_a-....ty `s•'n �fi�ra's°"."m ',rxp`-5'*'Y.^JE'C'"""^7 'S=Xn'1t-"t5X....'" �'""»�+,.>� WaR FSv !: "51<1`-Y,#5 {f 5 `Fn 1&}4?F U2 4!'+i 8�' �. '+>tiR(,�14' '�(5H ,y., �VSF•e`e{St4v44:Y hY-xi{ X34'? i�+W l };'u 4'n+�^(42H N iTJ�"lT �1S-"° 3.�+� ya ,tr sx. zs@rtutxb Jf, 6.7yar ^3.��'."3.i?t xx k,y.,-�..:` .r: wr�r�:L ySs F�•-axc,.s� m:; �rv�z.«xs!�5�i-t�.a.. ..�s"h.r:SSM.tj+;�,ar,a�` L � Y' rt�#firA Asa• 'R,�'- r a•-.. * .mw ^'4 t�k y"`�rrr c�'"r � ,.r'i y.3 .N. r �^` ,� �' `� !' �. •'&�' ++'�` -� +. r w .'7 , Commonwealth of Massachusetts n = ° �tta�' ♦ ev. w'r.+3 �.. .� � "� r r:�'+M.s Nv+�k"?a Nce.kP Ci of Salem � � .s •'ai.,�. ate, >,n y„-. r*�H ty '""a`1°d'"b .x Rte'. ,-:. : : in 'a:.-s x41 h'. X� w ,r,„b,"�'.>+ - Board of Health T iGmberiey Dnst6ll a.; 120 Washington Street,4th Floor " MayOf t SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 02/13/2007 ESTABLISHMENT NAME: Amelia Payson Guest House File Number:BHF-2004-000129 16 Winter Street Salem MA 01970 LOCATED AT: 0016 WINTER STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2007-0408 Feb 13,2007 Dec 31,2007 $100.00 ESTABLISHMENT Total Fees: $100.00 PERMIT EXPIRES December 31, 2007 Board of Health This Perniit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations, improvements, or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 of 3 Y CM OF SALEM, MASSACHUSETTS 120 WASHIPlLi ON STRUT,4TH FLOOR EC NCE SALEM.MA 01870 TEL 978-741-1800 FFR 1 -1 200] FAX 878-745-0343 WWWSAWMI-COU CI?"y SALEM Kimberley Dfiscolt BOARD OF HEALTH mayorJt'uwHe SCOTT.MPH, RS, CHO HEALTH AGEw 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT . NAME OF ESTABUSHMF_NTL,�,rna _ Cit ':Zk i6e _TEL# ADDRESS OF ESTABLISHMENT )(p ir_ art FAX# t,,) MAILING AD SS(if different) Srxx� t: (:MATT-'Business': b ' S.Q AQ L ' 4a�Ownet s � i OWNER'S NAME jC'1_4 ADDRESS - STREET CITY - STATE ZIP CERTIFIED FOOD MANAGER'S NAME($). -A L._ sm CERTIFICATEWS) _1,; (Required in an food Is prepared) EMERG RESPONSE PERSON HOME TEL .�• t S't- h t set t4mao�d� o?y ;-1`4 i ZtN a 44 i 0-a#4 I Q t j tTarettattadet�t�t 1 i I I � i TYPE OF ESTABLt HMENT FEE (check only) RETAIL STORE YES NO fess than 1000sq.fl. =$50 1000-10=054ft_ =$100 more than 10,000sq.fL =$250 .................... - -... - - . .------------- --------••--------^ --••--_.,_, --_..., --- -•--- -$1,00. RESTAURANT YES td4 less than 25 seats =$100 25.99 seats =$150 more than 99 seats =$200 .................. 8EO18REAKFAST YES NO $100 .....................••----. -----• ------ .. ..... .................I---.-.... ADDITIONAL PERMITS MAKE(not just serve) ICE CREAM,YOGURT,SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NUN-PROMT(such as church kitchens) YES NO $25 `Please pay total with one check payable to the City of Salem. This Per mit is not transferabie and must.be reissued upon change of:ownership.The Permit must be posted in a . prominent location in the Establishment. n In accordance with-the State Sanitary Code,before any renovations, improvements;or egaiomant changes are made,all ptaiis for such must be submitted to and approved py the Sateen Board of Health. - Pursuant to MGL Chapter 62C,Section 49A•I certify under the pains and penalties of perjury that 1,to my bast knowledge and belief, haavvee filed all state tax returns and paid all state taxes required under the law. Signature Date Social Security or Federal Id"fication Number, R(essed 11113M FOOpAP2097stlm Check#6 DatU�f:_ $ I9 3Wd '3AWU SNMM l"N i9£gT£98L6 W8I LOW/go/ze �. t ^3.vn,•,,�q,�rp,* .. '! �'+are..A w'�"' a� rs ryt'`s ar m� t�r7 � r �" y «�`..""p`x �=�Fa�+A. tR'r 3 r 3' "k-a4 fj .';�-� � , k• s .'fir P . Commonwealth of Massachusetts , ' , ,' ,; t " Board o[Health b 120 Washington Street,4th Floor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/05/2006 4 WHO'S PLACE OF BUSINESS IS: Amelia Payson Guest House File Number:BHF-2004-0129 16 Winter Street Salem MA 01970 LOCATED AT: 0016 WINTER STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2006-0007 Jan 1,2006 Dec 31,2006 $100.00 ESTABLISHMENT Total Fees: $100.00 i r PERMIT EXPIRES December 31, 2006 Board of Health j �g'�� This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 4 of 18 Cmc OF SALEM, MASSACHUSETTS BOARD OF HEALTH' 121)WASHINGTON STREET, 4TH FLOOR SALEM,MA 01970 o spa-7a1 1800--'._ r S - STANLEY J. USOVICZ. JR,-....:' ..;--a, FAx 978-745-0343 MAYOR , WWW.SALEM.COM_. JOANNE SCOTt MPH, RS,.CHO <)y HEALTH AGENT 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT ti S TEL# �7 7 - 7��- 6030 ADDRESS OF ESTABLISHMENT MAILING ADDRESS(if different) OWNER'S NAME .J 1 rXo _ \ / . K bc-_P_f-� TEL# 0-c-11 = 999--?/C) 991V ADDRESS CRY STATE ZIP CERTIFIED FOOD MANAGER'S NAMES � CERTIFICATE#(sj n I (required in an establishment where potentially hazardous food is prepared.) ,,nn EMERGENCY RESPONSE PERSON �� (__ HOME TEL# S� ., — Lr HOURS OF OPERATION: Mon. Tue. Wed.�Thu. Fri. Sat. Sun. TYPE OF ESTABLISHMENT FEE (check onlx) RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft- =$100 more than 10,000sq.ft. =$250 ........................................... less than 25 seats $100 266-99 seats =$150 more than 99 seats -$200 ..... ----------------------- l3ED/BREAKFAST YES NO 'I.......... ... ............... . O $100 �...... ADDITIONAL PERMITS ... - --------------------------- MAKE(not just serve) ICE CREAM,YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES 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 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. Signature Date Social Security or Federal Identification Number Revised l 1/08/05 FOODAP2adm Check#&Date �/o d S0 39Vd -13AVNi SNOSV3S I-IV 19EBTES816 ZV:TT 5002/0£/TT M CITY OF SALEM9 MASSACHUSETTS •"^rt BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR c 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: Bed & Breakfast Name of Establishment: Amelia Payson House Address of Establishment: 16 Winter Street Owner's Name: Ada Roberts Restrictions: Application Date: 11/16/04 Permit for Food Establishment 005-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 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, MASSAClHIlIJSEfX(CgUV�0 BOARD OF HEALTH ,. � / $ 120 WASHINGTON STREET, 4TH FLOOR NOV 16 2004 c SALEM, MA 01970 TEL. 978-741-1800 CITY OF SALEM FAX 978-745-0343 BOARD OF HEALTH STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT - 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT ` NAME OF ESTABLISHMEN j _TEL# 97cS- ADDRESS OF ESTABLISHMENT _S4 MAILING ADDRESS (if different) OWNER'S NAME /' 'Jy— TEL# ADDRESS ^ C_ Ci T f STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) boe CERTIFICATE#(s) a39SG� (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON G„ HOME TEL# HOURS OF OPERATION: Mon. c/Tue._�-�Wed._-cThu. � Fri._, Sat. / Sun. TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES NO l-P less than 25 seats =$100 25-99 seats =$150 more than 99 seats BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES $5 TOBACCO VENDOR YES NO $50 ALL hIGN-PROFIT(such as church kitchens) YES Nn $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 be knowledge andibelief, ave filed all state taxeturns and paid all state taxes required under the law. Q/ Signature Date Social Security or Federal Identification Number -------- -------- - --------- ----- - --- -- - ----- -- ----- Revised 11/03/03 FOODAP2.adm Choc k#& Date C� All a CITY OF SAS-EM, MASSACHUSETTS - - BOARD OF HEALTH e 1 120 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 1 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 s Establishment in the City of Salem is hereby granted to: , Type of Establishment: Bed & Breakfast { Name of Establishment: Amelia Payson House Address of Establishment: 16 Winter Street Owner's Name: Ada Roberts Restrictions: Application Date: 11/14/2003 Permit for Food Establishment 16-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 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 aCITY OF SALEM, MASSACHUSETTS CIL ll� BOARD OF HEALTH120 WASHINGTON STREET, 4TH FLOOR- NOV 13 2003 SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 .��,� STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT T OPERATE A F/O�-OOD ESTABLISHMENT NAME OF ESTABLISHMENT M `' TEL �/�7� 7`��-� `� ADDRESS OF ESTABLISHMENT I Cp lnJ 1 rJ + e2 MAILING ADDRESS (if differente._4 �- � /qA�� n SII OWNER'S NAME _/ T A b���� TEL# r1`�� al o C1�i l u ADDRESS Se�_Mc� _ CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(SI, (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME TEL# 9/7? ___,2gV430V HOURS OF OPERATION: Mon. ✓Tue. ✓Wed. ✓Thu. Fri. ✓✓Sat. i/ Sun. TYPE OF ESTABLISHMENT FEE check only `��'� _ may' RETAIL STORE YES NO less than 1000sq.ft. _$50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES NO 1 less than 25 seats =$100 �a tf 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO 1 V $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES 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 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-i---nat-ure "-- -------------- ----- Date � Social Securit or Fed�al d fatio Number ------------- - -i _ Revised 11/03/03 FOODAP2.adm Check#&Date. / 7—x I CITY OF SALEM, MASSACHUSETTS BOARD OF. HEALTH 120 WASHINGTON STREET, 4TH FLOOR po SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR - HEALTH AGENT April 28, 2004 Ada & Don Roberts 16 Winter Street Salem, MA 01970 Dear Sir/Madam: In accordance with Chapter III, Sections 127A and 127B of the Massachusetts General Laws, 105 CMR 400.00; State Sanitary Code, Chapter 1: General Administrative Procedures and 105 CMR 410.00: State Sanitary Code,Chapter 11: Minimum Standards of Fitness for Human Habitation, an inspection was conducted of the property 16 Winter Street occupied by(Bed & Breakfast) conducted by Virginia Moustakis & David Greenbaum,Sanitarians on Tuesday April 27, 2004 @10:00 a.m. Notice: if this rental unit is occupied by a child or children under the age of 6 years, it is the property owner's responsibility to notify tenants of lead related reports and tests, and to ensure that this unit complies fully with 105 CMR 460:000: Regulations for Lead Poisoning Prevention and Control. For further information or to request an inspection, contact the Salem Board of Health at 978-741-1800. ' You are hereby ORDERED to make a good-faith effort to correct the violations listed on the enclosed inspection report. Failure on your part to comply within the time specified on the enclosed inspection report will result in a complaint being sought against you in Salem District Court. Time for compliance begins with receipt of this Order. Should you be aggrieved by this Order,you have the right to request a hearing before the Board of Health. A request for said hearing must be received in writing in the office of the Board of Health within 7 days of receipt of this Order. At said hearing, you will be given an.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 in 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. Please be advised that the conditions noted may enable the occupant(s)to use one or more of the statutory remedies available to them as outlined in the enclosed inspection report form. , I For the Board of Health Reply to: Joanne Scott Virginia Moustakis & David Greenbaum Health Agent Sanitarians cc: Licensing Building Inspector fire Prevention Councillor Michael Sosnowski k t, CITY OF SALEM, MASSACHUSETTS Q BOARD OF HEALTH -' 120 WASHINGTON STREET, 4TH FLOOR a SALEM, MA 01970 TEL. 978-741 1800 , FAX 979-'745-0343 Page 1 of _ STANLEY USOVICZ. JR .JOANNE SCOTT. MPH. RS. CHO MAYOR HEALTH AGENT State Sanitary Code, Chapter It: 105 CMR 410.000 - Minimum Standards of Fitness for Human Habitation Occupant r Phone: F90 Address: Apt.# ums Floors Owner.,4oa. drtZ_ &w eems r Address: ,fir/�, 7YGc 0/97O Inspection Date: k-a7 vy Time: Conducted Byylemmxlis _n r Accompanied Anticipated Reinspection Date: n/on/ '11.tlf�euc r Specified Time Reg.#410.. Violation(s) • , ' ti� INS .cam' �r/4cC0 � �� ✓c 0" P 01000. ' Oh Pa3 /e k o ? o { o - v N / e ' One or more of the above violations may endanger or materially impair the health safety, and well being of the'occupant(s) Code Enforcement Inspector Este es documento leqal importante. Puede que afecte sus derechos. ra.._�_ _��.: �...a.........., .�.. ,... .. �...,.... .....°�corin 11�r nl talpfnnn 701-1 Ann Appendix II (14) Legal Remedies for Tenants of Residential Housing The following is a brief summary of some of the legal remedies tenants may use in order to get housing code violations corrected : 1. Rent Withholding (Massachusetts General Laws, Chapter 239, section 8A): If Code Violations Are Not Being Corrected you may be entitled to hold back your rent payments. You can do this without being evicted if You can prove that your dwelling unit or common areas contain code violations which are serious enough to endanger or materially impair your health of safety and that your landlord knew about the violations before you were behind in your rent. You did not cause the violations and they can be repaired while you continue to live in the building. You are prepared to pay any portion of the rent into court if a judge orders you to pay it. ( f=or this, it is best to put the rent money aside in a safe place) 2. Repair and Deduct(Massachusetts General Laws, Chapter III, section 127L):The law sometimes allows you to use your rent money to make the repairs yourself. If your local code enforcement agency certifies that there are code violations which may endanger or materially impair your health,safety,or well-being,and your landlord has received written notice of the violations,you may be able to use this remedy. If the owner fails to begin necessary repairs(or to enter into a written contract to have them trade)within five days after the notice or to complete repairs within 14 days alter notice,you can use up to four months rent in any year to make repairs. 3. Retaliatory Rent Increases or Evictions Prohibited (Massachusetts General Laws,Chapter 186, section 18, and Chapter 239,Section 2A):The owner may not inerease your rent or evict you in retaliation for making a complaint to your local code enforcement agency about code violations.If the owner raises your rent to try to evict within six months after you have made the complaint, he or she will have to show a good reason for the increase or eviction which is unrelated to your complaint. You may be able to sue the landlord for damages or if he or she tries this. 4. Rent Receivership (Massachusetts General Laws Chapter It, section 127 C-H):The occupants and/or the Board of Health may petition the District or Superior Court to allow rent to be paid into court rather than to the owner. The court may then appoint a"receiver"who may spend as much of the rent money as is needed to correct the violation. The receiver is not subject to a spending limitation of four months'rem. S. Breach of Warranty of Habitability: You may be entitled to sue your landlord to have all or some of your rent returned if your dwelling unit does not meet minimum standards of habitability. 6. Unfair& Deceptive Practices (.Massachusetts General Laws, Chapter 93A) : Renting an apartment with code violations is a violation of the consumer protection act and regulations, for which you may sue an owner. The information presented above is only a summary of the law. Before you decide to withhold rent or take anv other legal action, it is advisable that you consult an attorney. If you can not afford to consult an attorney, you should contact the nearest legal services office, which is E North Shore Community Action Northeast Housing Court Programs Inc. 2 Appleton Street 98 Main Street Lawrence, MA. 01840 Peabody, MA. 01960 (978) 689-7833 (978) 531-0767 r ° CITY OF SALEM, MASSACHUSETTS � BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR 5,a 1s2 SALEM, MA 01970 o' ✓' T E L'. 978-741-1800 gBCIry,Ng FAX 978-745-0343 STANLEY.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 : Owner ' s Name : Ada Roberts Name of Establishment : Amelia Payson House Address of Establishment : 16 Winter Street Type of Establishment : Bed & Breakfast Application Date : 12/04/2002 Restrictions : Permit for Food Establishment 5-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 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 Board of Health. HEALTH AGENT rE CITY OF SALEM, MASSACHUSETTS lL9 " BOARD OF HEALTH k " • 120 WASHINGTON STREET, 4TH FLOOR 1n ' SALEM, MA 01970 DEC 4 ZOOZ TEL. 978-741-1800 FAX.978-745-0343p' LA=M U STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO Ftp^ OF HEALTH MAYOR - HEALTH AGENT 2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENTiQ ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different)C. OWNER'SNAME -A 4- UorwSL�St �1� TEL# cS ADDRESS Scr�c� CITY STATEZIP. CERTIFIED FOOD MANAGER'S NAME(S) A AaL 1x2 S CERTIFICATE#(s) Q,:396667 (required in an establishment where potentially hazardous food is prepare.) t EMERGENCY RESPONSE PERSON--Act ,toe9�i� HOME TEL# p HOURS OF OPERATION: Mon. Tue.1Wed. /Thu. ✓ Fri. / Sat. ✓ Sun. TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO ��/O 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 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVE 4 YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 Please pay total with one cheek payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my be��ssYR)lowledge amd-h/eli$,f,, have�filed all state tax returns and paid all state taxes required under the law. O 1 Ll - 4 -4&,4 ) Signature Date Social Security or Federal Identification Number -- ---- -- -- -- - --- -G---- -- ---- ------------------ Revised 11/25/02 FOODAP2.adm Check#&Date I o OL— Z/-,l"a 1 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR o' SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT May 6, 2003 Ada & Don Roberts 16 Winter Street Salem, MA 01970 Dear Sir/Madam: In accordance with Chapter 11, Sections 127A and 1278 of the Massachusetts General Laws, 105 CMR 400.00; State Sanitary Code, Chapter I: General Administrative Procedures and 105 CMR 410.00: State Sanitary Code, Chapter 11: Minimum Standards of Fitness for Human Habitation, an inspection was conducted of the property at 16 Winter Street occupied by (Rooming House) conducted by Virginia Moustakis,Sanitarian on Tuesday April 29, 2003 @ 10:30 A.M. Notice: If this rental unit is occupied by a child or children under the age of 6 years, it is the property owner's responsibility to notify tenants of lead related reports and tests, and to ensure that this unit complies fully with 105 CMR 460.000: Regulations for Lead Poisoning Prevention and Control. For further information or to request an inspection, contact the Salem Board of Health at 978-741-1800. You are hereby ORDERED to make a good-faith effort to correct the violations listed on the enclosed inspection report. Failure on your part to comply within the time specified on the enclosed inspection report will result in a complaint being sought against you in Salem District Court. Time for compliance begins with receipt of this Order. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for said hearing must be received in writing in the office of the Board of Health within 7 days of receipt of this Order. At said hearing, you will be given an 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. Please be advised that the conditions noted may enable the occupant(s)to use one or more of the statutory remedies available to them as outlined in the enclosed inspection report form. For �t'� h"ee eeBBoard of Health: Reply to: i�oa_nne Scot Virginia Moustakis Health Agent Sanitarian cc: Councillor Regina Flynn, Licensing Board, Fire Prevention, & Building Inspector JS/ mfp c-h-violet ' CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH • i 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL- 978-741-1800 FAX 978-745-0343 Page 1 of STANLEY USOVICZ, JP JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT State Sanitary Code, Chapter II: 105 CMR 410.000 Minimum Standards of Fitness for Human Habitation Occupant :,cmej4o �&Sey ys s / e wHt�&Ir Phone: e�g�) 7,y,/-83oy Address: is ui,N7<e �sf Apt.# ujgFloor r- ;z Owner: Ano_ 2rtcL .ng, .QAe.0Address: le C xl xa e s r 9%0 Inspection Date: /j-,2,7-e3 Time: lo.-3d .�Pr�/s a,�' 5oa ct c6ia�RM� Conducted By: y ru_kc Accompanied By:,s,, i{a e� Anticipated Reinspection Date: 161-0/rCL fire � J 4 w.e-d�drj�.cd oe's c'eP ye- SpecifiedTime Reg.#410.. Violation(s) 6Zrvve �°� r v e C 4cS e P , &G Q 2 ' 7` AL lesc q 0 =z e e f F✓GnLem3 �G e e tiv P _ one or more of the above violations may endanger or materially impair the health safety, and well being of the occupant(s) Code Enforcement Inspector �� iut �i� �i7JtC�LL4R Este es documento legal importante. Puede que afecte sus derechos. frovinrrinn A- � #M fn cine nnroearin Ilamar al fwlPfnnn 741-1900. a CITY OF SALEM, MASSACHUSETTS b '� BOARD OF HEALTH 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 23,2002 Ada and Don Roberts. Amelia Payson Bed&Breakfast 16 Winter Street Salem, Ma 01970 Dear Mr. &Mrs. Roberts: A routine inspection was conducted at your establishment in accordance with Chapter II, State Sanitary Code, CMR 410.000. No Health Code violations were observed at this time. Thank you for your cooperation. i For The Board of Health Reply to: oanne Scoft ' Virginia Moustakis. Health Agent Sanitarian cc: Licensing Board,Fire Prevention, Building Inspector City Councillor Regina Flynn I i , � ayff •6 : CITY OF,SALEM:HEALTHDEPARTMENT N� 120 WASHINGTON'STREET 4TH FLOOR Salem, Massachusetts 01970 Page 1 of _L_ ' x State Sanitary#Code, Chapter IL' 105 CMR 410.000 ; Minimum Standards of Fitness for Human Habitation -„v .k. & v..cr e+ a 1 tis,. x <: e' j^. N'4•,y' '.i cn Occupant'l%;n�laa Phoneyy' 30y'. s xs <s a Address: /6 a,&zH .$f Apt.# & ,,s Floor •2 Owner: A„� Address: /6 /U„✓ -��Sf- { Inspection Date: -u-a3-aa Time >e.-Ar Conducted By l�lniretnirxt Accompanied By:jgen3,x &kl �t.�ltte�rsj ' An,t.mici ated Reins ecztion Date: J9 u '' FL i.,�rcz�iMfr�/Nsfto��7bf= FYa�PCL,rI/Ls�/�l/�s c%d Specified Time Reg.#410.. Violation(s) 66 491 zle) A ai�4”, S� J' a a.ani's�-<tr�q5�•.-:, i.s+-�.s��' Yr:.;, k1�, 3 "*' - 'w: �i. _.,-7. .z_ .::r ' .,iv. b F' i - � i/i la ' s ee cz �s n NB P rf k le IY 6 c ` a e .Fe % `r :: f� �., R 3 'F� . � `x3 s a ,� + .S✓...„,_._ . . k y b One or more of the above violations may endanger or materially.Impair.the health safety, and well being of the occupant(s) L3urLc�/fir 6f Code Enforcement Inspector c�1GIIv +a Este es documento legal Importante. Puede que, •fele sus derechos ' M �P9i Na /f y N x G i P°`f fa+YE, 4 �'F t ' ` Pnrxii+ ilfinuirir una4raduccionde esta:formasies necesario Ilamar all telefono 741;1800. N { P . Appendix II (14) Legal Remedies for Tenants of Residential Housing 'The following is a brief summary of some of the legal remedies tenants may use in order to.get housing code violations corrected 1. Rent Withholding(Massachusetts General Laws, Chapter 239,section 8A): If Code Violations Are Not Being Corrected you may be entitled to hold back your rent payments. You can do this without being evicted if: You can prove that your dwelling unit or common areas contain code violations which are serious enough to endanger or materially impair your health of safety and that your landlord knew about the violations before you were,behind in your rent: You did not cause the violations and they can be repaired while you continue to live in the building. . You are prepared to pay any portion of the rent into court if a judge orders you to pay it. (For this, it is best to put the rent money aside in a safe place) 2. Repair and-Deduct(Massachusetts:General Laws, Chapter III,section.127L): The law.sometimes allows. you to use your rent money.to make the repairs yourself. If your local code enforcement agency certifies that there are code violations which may endanger or materially impair your health, safety, or well-being, and your landlord has received written noid of the violations,you may be able to use this remedy. Ifthe owner fails_to begin necessary repaus(or to enter into 11 a written contract to have them made)within five days after the notice or to complete repairs within 14 days after notice,you can use up to four months rent in any year to m S .'ake.:i"r 3 repaus.i, 3. Retaliatory Rent Increases or Evictions Prohibited(Massachusetts General Laws, Chapter 186, section 18,and Chapter 239, Section 2A): The owner may not increase your rent or evict you in retaliation for maki a complaint to your local`code Ariforcement agency about code violations. If the owner raises your rent to try to evict within six months after you have made the complaint,he or she will have to.show a good reason for the increase or eviction which is unrelated to your complaint. You maybe able to sue the landlord for damages or if he or she tries this. 4. Rent Receivership (Massachusetts General Laws Chapter 11,section 127 C-H): The occupants and/or the Board of Health may petition the District or Superior Court to allow rent to be paid into court rather than to the owner. The court may then appoint a"receiver"who,may spend as much of the rent money as is needed to e6ff&fthi violation.The receiver is not subject to aspending limitation of four months'rent._. 5. Breach of Warranty of Habitability: You may be entitled to sue your landlord to have all or some of your rent returned if your dwelling unit does not meet minimum standards of habitability. 6. Unfair& Decer 6i Practices (Massachusetts General Laws,Chapter 93A) : Renting an apartment-with code violations is a violation of the consumer protection act and regulations, for which you may sue an owner. The information presented,above is only a summary of the law. Before you decide to withhold rent or take any otherlegal,action;it is advisable that you,consult an alto ney. If you can:not afford to.consult an attorney, You N should contact the nearest legal services office;,whieh is-x€-t Neighborhood Legal Services t^ 37.FriendStreet Lynn,MA• 01902 ' - - y t �.f�i arc i ,`F: i'..^t r r ' :::'2ra.g g. (781)-599 7730 w ' % ✓i s" CITY OF.SALEM4S MASSACHUETTS ` Y1 BOARD OF.H EACTH - 3 - 120 WASHINGTON STREET, 4T:H-FLOOR - SALEM, MA 01970 if8 V $ TEL. 978-741-1800 - s ' ,FAX 978-745-0343 - Y STANLEY USOVICZ, JR. ,JOANNE SCOTT, MPH, R5, CHO ' s .MANOR- - 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 * -Food"Establishment"in the City of Salem is hereby granted to., Owner' s Name: Ada Roberts Name of- Establishment : Amelia Payson House Address of Establishment : 16 Winter Street Type- of Establishment : Bed & Breakfast - ` Applicat;ion1,Date: ' 11/,'26/2001 .?` . Restrictons: `< }. e ' S ` -0 � A-..'.Jw is • a 'a„>, � �'"8-S`°3J,L iP6rmit_.for• Food?Establishment '35-02 'v. Frozen'Desserts/Ice Creamw t ,p Permit for the Sale of Tobacco Products , These Permits'Expire` Dec'erillier;,31, 2002 s - This per>nit 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: . :y In'`accordance with the State Sanitary Code, before"any renovations, improvements, or equipment changes are made, all plans for such must b"e submitted .to and approved -by the Salem Board of Health. $ 4 a t HEALTd AGENT 4 - - o CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH � a 120 WASHINGTON STREET, 4TH FLOOR 9 - SALEM, MA 01970 (q(p }}''''��\ TEL. 978-741-1800 PR \VQ 1110Fax 978-745-0343 777��� 1)I B�I�`11199p STANLEY LISOVICZ, JR. ,JOANNE SCOTT, MPH, RS, CHO , , MAYOR HEALTH AGENT NOV2 6 2001 CITY Ow SALEM HEALTH DEPT. 2002 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT MrQ sp3�� TSc�r }o�TEL# ADDRESS OF ESTABLISHMENT�1 (o LA I r7 MAILING ADDRESS (if different) OWNER'S NAMTEL# �l ADDRESS f�- o -n CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) ERTIFICATE#(S)�8 6 6 (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME TEL# Sp✓''1 �-- DAYS/HOURS OF OPERATION: Mon.pLTue.,pLLWed. --�V Thu.aW Fr.—Sat.,�Sun TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO A $40 RESTAURANT YES NO 40 BED & BREAKFAST YES NO $4O ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO 10 NO CHARGE FOR NON-PROFIT(such as church kitchens)PLEASE INCLUDE COPY OF TAX EXEMPTFORM 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 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Signature Date Social Security or Federal Identification number Revised 11/1/01 foodapZadm Check#&Date 4r LD, 0-V Examination Form No. 647 Certificate No. 2395667 P P TO ADA ROBERTS for successfully completing the requirements set by the National Restaurant Association Educational Foundation for the ServSafe Food Protection Manager Certification Examination, which is recognized by the International Food Safety Council. Presented by the National RestaurantAssociatibn Eduaztional Foundation 8128/00, DATE OF EXAMIINATION This Sen✓Safe certification is-valid'for 5 years. Check With your local health department for their speoffis requirements. LS D A G CHIEF OPERATINGOFFICER i National Restaurant Association / EDUCATIONAL FOUNDATION • - aDNa�ionaltkslaunmtAsmcetion EtwsaOonal faurdatPon www.edfound.org Q 2000 klwal Fede wi kmtion Educatiorel roundahn a � t' CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT,MPH,RS,OHO HEALTH AGENT NINE NORTH STREET Tel:(978)741.1800 Fax:(978)740.9705 April 17, 2001 Ada R Don Roberts 16 Winter Street Salem, MA 01970 Dear Sir or Madam: In accordance with Chapter III, Sections 127A and 1276 of the Massachusetts General Laws, 105 CMR 400.00; State Sanitary Code, Chapter I: General Administrative Procedures and 105 CMR 410.00: State Sanitary Code, Chapter II Minimum Standards of Fitness for Human Habitation, an inspection was conducted of the property 16 Winter Street occupied by(Amelia Payson House)conducted Virginia Moustakis, Sanitarian on Wednesday,April 11,2001 at 10:00 A.M.. Notice: if this rental unit is occupied by a child or children under the age of 6 years, it is the property owner's responsibility to notify tenants of lead related reports and tests, and to ensure that this unit complies fully with 105 CMR 460.000 : Regulations for Lead Poisoning Prevention and Control. For further information or to request an inspection,contact the Salem Health Department at 741-1800. You are hereby ORDERED to make a good-faith effort to correct the violations listed on the enclosed inspection report. Failure on your part to comply within the time specified on the enclosed inspection report will result in a complaint being sought against you in Salem District Court. Time for compliance begins.with receipt of this Order. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for said hearing must be received in writing in the office of the Board of Health within 7 days of receipt of this Order, At said hearing, you will be given an 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. Please be advised that the conditions noted may enable the occupant(s) to use one or more of the statutory remedies available to them as outlined in the enclosed inspection report form. Fo the Board of ealth: Reply to: • f oanne Scott Virginia Moustakis Health Agent Sanitarian cc: Councillor Regina Flynn, Licensing Board, Fire Prevention,&Building Inspector JS/sjk c-h-violet i CITY OF SALEM HEALTH DEPARTMENT Nine North Street �i Salem,Massachusetts 01970 Page 1 of`_ y State Sanitary Code, Chapter II: 105 CMR 410.000 Minimum Standards of Fitness for,Human Habitation Occupant :,gr,,uayreyffouse Phone:_ wl- k3ov Address: ii' �/i.,v�r ��f- Apt.# Floor Owner: azA 9 1)ey 12a6ER7CS " Address: Y6 Cf%i.vt .N :S ��gZgZV d 0/f 70 Inspection Date: v-/i-a.o/t/ Time:` o, oo Conducted By:, Ll 'Accompanied: ,jiPjr�yu ated Reinspection Date- ,} T; e Antici P p /dui/—cL'i'Alf Specified Time Reg.#410.. Violation(s) . Alf r S" N One or more of the above violations may endanger or materially Apair the health cya, 6/C#x6/ti9 . _ Fi. e ASE "°a safety, and well being of the occupant(s) =,q 3 ; (s�/u(i vy �J✓6 :/°l Coo,r�e//.GOA Code Enforcement Inspectori�,7s� rl_YNAl Este es documento legal importante. Puede que afecte sus derechos. Puede adquirir una traduccion de esta forma sies necesario Ilamar al telefono 741-1800. 4J +" � €tet�' b wj { r %.iP Kee r `sqq ;k�' ?. »•.. TYr > f p ;."k`�mm .'' + � i 3 ➢n�� r M r .s J + s�4 »� e.+f R d X ' 'i`a,' ,si:. d v � 3'!ry-Ea ayyy x � •�;f s _ RAST ! CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928. t JOANNE SCOTT,MPH,RS,CHO, NINE NORTH STREET ' >'.HEALTH AGENT - Tel:(978)741-1800 - . -- - - Fan:(978)740-9705 . COMMONWEALTH OF MASSACHUSETTS t PERMIT TO OPERATE A FOOD "ESTABLISHMENT f n accordance with 'regulations'p'romulgated under authority of Chapter ection '305A='yarid Chapter .III, . Section"5 of ;tYe General- .Laws, to`operate ,ra`Food Establishment in the City of Salem :is hereby,'granted to: p Owners Name , Ada & Donald Roberts x ' Name"of Establishment : --Amelia Payson Houset Address of:;,Establishment �-l6 :Winter: Street .-A Establiaskiment -EBed'& .Breakfast $ °._ {z, ? -, `` `. ; Application Date: 12/07/2000 e .:AR es.trlctions: S �Permitx,for Food Establishment 91 01 } s•e r frp Frozen "D25'SertS/ Ce Cream . n Permit for: the Sale of 'Tobacco Products Permits` Expire December 31, '`2001 t aa. This}permit is not transferable and must be reissued upon change of. { . lownership ort'location . The"permit must be "posted in a prominent location - " ` ', insthe Establishment _`rt In *accordance with the'=State' Sanita Code,- before an renovations,_ x'Y ' Y 7;t ovements; or equipment "changes are made;'tall ;plans for `such mus't'.:be subnutted to ; nd, approved by. the' Salem Board of Health. 1 U f § HEALTH HEALTH GENT b I b j P 4 - x h IMPORTANT MESSAGE FOR A.M. DATE �Zi c IME ��-�P.M. M 121,— G— Q6 {�—7 OF[—/YYISLX 7 /_//. ,f/df:U-A.iiy. /'M PHONE / !t 7 C?30 AREA GOOE NUMBER EMENSION ❑ FAX ❑ MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASECALL +. CAME TO SEE YOU WILL.CALL.AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE dncL SIGNED sFORM 4009 MARE IN U.S.A. 2 �� � � a �, � �, \ \ � � � � ,� � , � �� � , ,, �, , � � � �� � � � � �i ,� , . , _. _�---� ' -"Dec 06 00 11 . 05a Joanne Soocn Salem BOH 978 740 9705 p• 2 r' W ?If DEC? _ CITY OF SALEM BOARD OF HEALTH CITY SALEMSalem. Massachusetts 01970-3928 JOANNE SCOTT,MPH,RS,CHO � NINE NORTH STREET HEALTI4 AGFai1 Tel 1978)747-16W Faz:(978) 740-9705 2001 APPLICATION FOR PERMIT TO OPERATE A FOOL} ESTABLISHMENT NAME OF ESTABLISHMENT rVJ-.n' 1 rn Ver .S``t}n TEL ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different) OWNER'S NAME TEL# Cr�.T+'7 Q , ADDRESS cmc n c� CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S)„4cRnc>i w o 1 S CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON 11 x.r.. i o I ��.�5 HOME TEL# Hca TYPE OF ESTABLISHMENT f -6 r FES check only RETAIL STORE YES $40 RESTAURANT YES07 #seats #nonsmoking_ $40 BED 8 BREAKFAST ES NO _540 � I ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT k SOFT SERVE YFS N S5 TOBACCO VENDOR YES NO NO CHARGE FOR NON-PROFIT(such as church kitchens)PLEASE INCLUDE COPY OF TAX EXEMPT FORM Please pay total with one check �O 0l1 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 stablishmentIn 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 49A1 I certify under the pains and penalties of perjury that 1. to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. i nature Date Social Security or Federal identification Number Revised 1112V00 roodaP2.-adm Check#tt Date •; Examination Form No. 647 , Certificate No. 2395667 HSG 7 2000 CITE'OF SALEM HEALTH DEPT, TO ADA ROBERTS for successfully completing the requirements set by the National Restaurant Association Educational Foundation for the ServSafe®Food Protection Manager Certification Examination, which is recognized by the International Food Safety Council. Presented by the National Restaurant Assocfation.Educational Foundation 8/28/00 DATE OF EXAMINATION This ServSafe cartlicatlon is valid Wr 5 years. check with your local health department for their specific requirements. FRESiDENT A 0 CHIEF OPERATING OFFICER National Restaurant Association EDUCATIONAL FOUNDATION? OuaRaslavemAsmdai�n Ea�ata twma www.edfound.org ' ©20oa Nmional AcmaummAssxiatirm EtluCetlrnW FOUntla46a CITY OF SALEM, MASSACHUSETTS �v LICENSING BOARD 1 95 MARGIN STREET P.O. BOX 1042 TEL.(978)744-0171 EXT.130 CLERK Chairman, Harold F. Blake,Jr. JUDY DAVENPORT James M. Fleming John H. Casey March 14, 2001 Ada & Donald Roberts Amelia Payson House 16 Winter Street Salem, MA 01970 LODGING HOUSE LOCATION: 16 Winter St. ALONG WITH THE BUILDING DEPARTMENT AND THE HEALTH DEPARTMENT, THE LICENSING BOARD HAS SCHEDULED THE YEARLY INSPECTION OF YOUR LODGING HOUSE FOR APRIL 4, 20015 AT 9:30 A.M. ENCLOSED YOU WILL FIND RELEASE FORMS FOR YOUR TENANTS TO SIGN, WHICH WILL ALLOW THE INSPECTORS ENTRANCE INTO THEIR AREA. PLEASE MAKE EVERY EFFORT TO HAVE THESE RELEASE FORMS SIGNED PRIOR TO INSPECTION TIME. IF YOU HAVE ANY QUESTIONS PLEASE CONTACT THE LICENSING BOARD AT THE NUMBER LISTED ABOVE. SALEM LICENSING BOARD cc: Health Dept./ Bldg. Dept. Fire Prev. lodging insp notif 3 1� YFrF gj CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH, RS,CHO .I NINE NORTH STREET HEALTH AGENT Tel:(978)741-1800 Fax:(978)740-9705 - t 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 : Ada & Donald Roberts Name of Establishment : Amelia Payson House Address of Establishment : 16 Winter Street Type of Establishment : Bed & Breakfast Application Date: 03/22/2000 . ' Restrictions: Permit for Food Establishment 130-00 Frozen Desserts/Ice Cream - Permit for the Sale of Tobacco, Products These Permits Expire December 31, 2000 This permit is not transferable and must be reissued upon change of ownegrship or location. In accordance with the State Sanitary Code, all plans of renovations, improvements, equipment changes must be approved by the Health Department. L T Y .� dMM AM4YF 3fu . tvYSM.�'f k� k Re+. Cv .nlv t r 5. ' s, 3 +i. P MAR 2 1 901nn CITY OF SALEM CITY OF SALEM BOARD OF HEALTH HEALTH DEPT. Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH, RS, CHO NINE NORTH STREET HEALTH AGENT Tel:(978)741-1800 Fax:(978)740-9705 2000 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT--,Annc-L, —>401 BSc TEL# ADDRESS OF ESTABLISHMENT Co MAILING ADDRESS (ifp different) t. OWNER'S NAMEo TEL# Same' ADDRESSlr�� CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON TEL# ESTABLISHMENT'S DAYS & HOURS OF OPERATION h CDU j G1�. �� �G�w s�S �D 14S I. TYPE OF ESTABLISHMENT 136-6b FEE check only RETAIL STORE YES NO $40 RESTAUF��A,NT YES NO #seats_ #nonsmoking_ $40 r+-`v�c��IC-{�w5 ADDITIONAL PERMITS MAKE FROZEN DESSERTS YES NO $5 TOBACCO.VENDOR YES NNOu�/1 $10 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. 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. pt rfy he"paias�d9peuraities'of>�e�tryrtiaYt�to�rty��.�-_ _ --: best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. gnature Date Social Security or Federal Identification Number -------------------------------------------------------------------------------------------------------------------------------- Revised 10/20/98 foodap2.adm Check#&Date la 5n Aox a CITY OF SALEM HEALTH DEPARTMENT BOARD OF HEALTH 9 North Street Joanne ,Scott. , Salem, Massachusetts 01970 HEALTH AGENT 508-741-1800 RESIDENTIAL KITCHENS IN BED AND BREAKFAST HOMES AND ESTABLISHMENTS Name of Establishment: Address of Establishment: I Co UO v�_i *_R_ N e & Address of Establishment �}� wo Owner: Name of Contact Person and Telephone Number: R�36Y Please check one of the following: [] Bed and Breakfast Home - means a private owner-occupied house where three or fewer rooms are let and a breakfast is included in the rent. Bed and Breakfast Establishment - means a private, owner-occupied house where four or more rooms are let and a breakfast is included in the rent. Total Number of Rooms:-4 [] Other: Type of Breakfast: �(I Continental Breakfast - means a breakfast meal restricted to the follow- ing foods. ✓'(a) Beverages such as coffee , tea and fruit juices. ✓(b) Pasteurized Grade A milk. Nb rj-toVe- ✓(c) Fresh fruits. 1/1 ` d1mnC (d) Frozen and commercially processed fruits. ✓(e) Baked goods, such as pastries, roils, breads, and muffins which are non-potentially hazardous food. ✓'(f) Cereals. -'(g) Jams, jellies, honey and maple syrup. ✓(h) Pasteurized Grade A creams and butters, non-dairy creamers or similar products. (i) Commercially manufactured hard cheeses,.commercially manufactured cream cheese and commercially manufactured yogurt. [] Full Breakfast - means a breakfast meal including foods other than those listed in the definition of "Continental Breakfast". 1 gONU(T Q 3 � 4 �f CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH, RS, CHO NINE NORTH STREET HEALTH AGENT Tel:(978)741-1800 Fax:(978) 740-9705 August 30, 2000 Amelia Payson House c/o Ada & Don Roberts 16 Winter Street Salem, MA 01970 Dear Owner/Manager: The Board of Health, Building and Fire Departments are scheduling yearly inspection of all establishments licensed as rooming houses . The Salem Licensing Board will review inspection and reinspection reports in accordance with its license renewal procedures . The inspection will include dwelling units and common areas, therefore each tenant must be present or he/she must sign the enclosed release form which will allow the inspectors to enter the unit . Your establishment at 16 Winter Street has been scheduled to be inspected on Wednesday November 8, 2000 at 11: 30 am. Thank you for your anticipated cooperation. Sincerely, For the Board of Health )banneott Health Agent CC : Frank DiPaolo, Inspector of Buildings Charles Latulippe, Fire Prevention Harold Blake, Chairman, Salem Licensing Board � CONDfT 3 a Q. CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH, RS,CHO NINE NORTH STREET HEALTH AGENT Tel:(978) 741-1800 Fax:(978) 740-9705 July 27, 2000 Amelia Payson House c/o Ada & Don Roberts 16 Winter Street Salem, MA 01970 Dear Owner/Manager: The Board of Health, Building and Fire Departments are scheduling yearly inspection of all establishments licensed as rooming houses . The Salem Licensing Board will review inspection and reinspection reports in accordance with its license renewal procedures . The inspection will include dwelling units and common areas, therefore each tenant must be present or he/she must sign the enclosed release form which will allow the inspectors to enter the unit . Your establishment at 16 Winter Street has been scheduled to be inspected on Wednesday August 16, 2000 at 11:00 am. Thank you for your anticipated cooperation. Sincerely, For the Board of Health 36anne Scott Health Agent CC : Frank DiPaolo, Inspector of Buildings Charles Latulippe, Fire Prevention Harold Blake, Chairman, Salem Licensing Board Z 447 277 •942 �OS Postal Service Aeceipt for Certified Mail No Insurance Coverage Provided. Do not use for Iriternational Mail ,Spee reverse Se -, /j St et&Nu ber Postoflice,Stat &ZIP e S'f}4101476 Postage $ Certified Fee Special Delivery Fee Restdcted Delivery Fee N � Return Receipt Showing to Whom&Date Delivered m Realm Receipt Showing to Whom, Q Date,&Addressee's Address CO TOTAL Postage&Fees $ 0 Pbsbnark or Date E 5 LL a Stick postage stamps to article to cover First-Class postage,certified mail fee,and charges for any selected optional services(See front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service m window or hand it to your rural carver(no extra charge). 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the Q return address of the article,date,detach,and retain the receipt,and mail the article. N 3. If you want a return receipt,write the certified mail number and your name and address m on a return receipt card,Form 3811,and attach in to the front of the article by means of the gummed ends if space perils. Otherwise,affix to back of article. Endorse front of article 'a RETURN RECEIPT REQUESTED adjacent to the number. 4. If you want delivery restricted to the addressee, or to an authorized agent of the O O addressee,endorse RESTRICTED DELIVERY on the front of the article. Go cri 5. Enter fees for the services requested in the appropriate spaces on the front of this E receipt. It return receipt is requested,check the applicable blocks in item 1 of For 3811. LL 6. Save this receipt and present it if you make an inquiry. 102595-98-M-0548 a i I` A Mee 14 P � CONOIT �v CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH, RS,CHO NINE NORTH STREET HEALTH AGENT Tel:(978)741-1800 Fax:(978)740-9705 November 9, 2000 Ada & Don Roberts 16 Winter Street Salem, MA 01970 , Dear Sir or Madam: ` In accordance with Chapter III, Sections 127A and 127B of the Massachusetts General Laws, 105 CMR 400.00; State 1 Sanitary Code, Chapter I: General Administrative Procedures and 105 CMR 410.00: State Sanitary Code, Chapter 11: ;Minimum Standards of Fitness for Human Habitation, an inspection was conducted of the property 16 Winter Street occupied by(Bed & Breakfast)conducted by Virginia Moustakis, Sanitarian on Wednesday, November 8, 2000 at 11:30 A.M.. Notice: If this rental unit is occupied by a child or children under the age of 6 years, it is the property owner's responsibility to notify tenants of lead related reports and tests, and to ensure that this unit complies fully with 105 CMR 460.000 : Regulations for Lead Poisoning Prevention and Control. For further information or to request an inspection, contact the Salem Health Department at 741-1800. You are hereby ORDERED to make a good-faith effort to correct the violations listed on the enclosed inspection report. Failure on your part to comply within the time specified on the enclosed inspection report will result in a complaint being sought against you in Salem District Court. Time for compliance begins with receipt of this Order. Should you be aggrieved by this Order, you have the right to request hearing before the Board of Health. A request for said hearing must be received in writing in the office of the Board of Health within 7 days of receipt of this Order. At said hearing, you will be given an 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. Please be advised that the conditions noted may enable the occupant(s) to use one or more of the statutory remedies available to them as outlined in the enclosed inspection report form. For the Board of Health: Reply to: oanne Scott Virginia Moustakis Health Agent Sanitarian cc: Fire Prevention, Building Inspector, & Councillor Regina R. Flynn Certified Mail #Z 447 277 942 JS/sjk c-h-violet - i CITY OF SALEM HEALTH DEPARTMENT p Nine North Street Page 1 of / <z Salem, Massachusetts 01970 - State Sanitary Code, Chapter II: 105 CMR 410.000 Minimum Standards of Fitness for Human Habitation Occupant.:vm�a o„ /VoV,se &&AWA44.jsr- Phone: 7tiy- 83oi_/ Address: 16 Mzy;'c e <S� Apt.#zy�5 Floor Owner: Aax e, j?er ee.efs Address: /6 AI Alt-E/2 ,S cal.n . :2na 0197,� Inspection Date:ji- 8-0v Time: ) ) : 3 U '4m• Conducted By: j1.&,Asfz.kis Accompanied By: Anticipated Reinspection Date: Nd 9_1�,3 e ri sccG�pd Specified Time Reg.#410.. Violation(s) co �Ea rQsf A?dV-77i✓e- C UCA/ =0dk412,9 © L c� a yo°G- � a P v/a 9/e Nor/ so LP . c> n 14e E✓w, One or more of the above violations may endanger or materially impair the health �Gfo f L0/ safety, and well being of the occupant(s) rkyA;A/ Code Enforcement Inspector Este es documento legal importante. Puede que afecte sus derechos. Puede adquirir una traduccion de esta forma sies necesario Ilamar al telefono 741-1800. SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 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 so that we can return the card to you. C. Sie ■ Attach this card to the back of the mailpiece, X �% Agent or.on,the front if space permits. - ` 11 dressee D. Is delivery address different from item 1? U Yes 1. Article Addressed'to: If YES,enter delivery address below: ❑ No Ada & 'Don Roberts 16 Winter Street Salem, MA ' 01970 3. Service Type AN Certified Mail ❑ Express Mail ❑ Registered ❑ Return Receipt for Merchandise ❑ Insured Mail ❑ C.O.D. ( 16 Winter St. B.&B.) VM 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number(Copy from service label) Z447 2.77 !942 f i i ?i i ? ii i PS Form 3811,July 1999 Domestic Return Receipt 102595-00-M-0952 UNITED STATES POSTAL SERVICE First-Class Mail I USPS e 6 Fees Paid Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box I RECLSIV I q1' ARD OF HEALTH NOV 1 4 2000 alerri, MA 101970 - 39a8 I CITY OF SALEM HEALTH DEPT. I I