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RITAS WATER ICE - ESTABLISHMENTS Rita's Water Ice 188 Essex Street P V 11 3 P F \ n H _ .... m �Y-+• n v _ �.- ��!'T -y. v.._ .. iw.f`•yry « � .tu +n '.�. ♦.m. � s-r. V )f � n L 0 b �A Y1 11 Commonwealth of Massachusetts • q City of Salem Board of Health Kimberley Driscoll 120 Washington Street;4th Floor Mayor SALEM,MA 01970 Foo&Retail Establishment Permit DATE PRINTED: 03/1212012 , ESTABLISHMENT NAME: Rita's Water Ice File Number:BHF-2007-000057 - 188 Essex Street East India Square Mall SALEM MA 019710 LOCATED AT: 'SALEIt7, MA 01970 Permit Type. Permit No. Permit,Issued Permit-Expires Fee Restrictions/.Notes - FOOD SERVICE BHP-2012-0385 Mar 12,2012. Dee 11, 2012 $280.00 ESTABLISHMENT FROZEN DESSERTS BHP-2012.0386 Mar 12,1012 Dec 311,2012 $25.00 Total Fees: $305.00 PERMIT EXPIRES Oiecember 31, 2012 Iq�lll Board of Health i This Permit isnot 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 revonaiions,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, 10 aj MASSACHUSETTS F,y H Ith BOARD OF HEALTH 120 WASHINGTON S1REE'r,411'FLOOR KIbIBERLEY DRISCOLL TFL.(978)741-1800 FAX(978)745-0343 LARRY RAMDIN,RS/REHS,CHO,CP-F£ MAYOR Irarndin@.salem.com HEALTH AGENT Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: CPS COOL TREATS, LLC 2) Establishment Address: 188 ESSEX STREET, SALEM MA 01970 3) Establishment Mailing Address(if different): 4 Establishment Telephone No: 978-741-7482 5) Applicant Name&Title: CYNTHIA WEAVER/OWNER 6) Applicant Address: 12 ANDERSON STREET, PEABODY,MA 01960 7) Applicant Telephone No:978-5364328 24 Hour Emergency No:978-394-0270 Email: ritasicesalem(&omc t.ne 8) Owner Name&Title(if different from applicant): 9) Owner Address(if different from applicant): 10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers or partner. An association Name Title Home Address "A corporation An individual CYNTHIA WEAVER/MBR/ 12 ANDERSON ST,PEABODY,MA A partnership Other legal entity '"LLC KEVIN WEAVER/MBR/ 12 ANDERSON ST PEABODY MA 12 Person Directly Res onsible For Daily Operations Owner,Person in Charge,Supervisor,Manager,etc. Name&Title: CYNTHIA WEAVER Address: 12 ANDERSON ST PEABODY MA 01960 Telephone No: 978-536-4328 Fax: Email:ritasicesalem comcast.net Emergency Telephone No: 978-394-0270 13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: Fax: Email: � 1411g,4�0! Food Establishment Information 14) Water Source: CITY OF SALEM 15) Sewage Disposal: CITY OF SALEM DEP Public Water Supply No: (if applicable) 16) Days and Hours of Operation: SUN-SAT 12-9PM 17) No.of Food Employees: 5 18) Name of Person in Charge Certified in Food Protection Management: Required as of 101112001 in accordance with 105 CMR 590.003(A) CYNTHIA WEAVER 19) Person Trained in Anti-Choking Procedures(if 25 seats or more): C Yes No 20) Location: 22) Establishment Type(check all that apply) (check one) ❑ Retail ( Sq. Ft) ❑ Caterer X Permanent Structure X Food Service-( 32 Seats) ❑ Frozen Dessert Manufacturer Mobile ❑ Food Service-Takeout ❑ Residential Kitchen for Retail Sale ❑ Food Service-Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and 21) Length Of Permit: Breakfast Establish_men_ts „ (check one) RETAIL STORE RESTAURANT .. .. Annual ❑Less than 1000sq.ft. $70 13 Less than 25 seats $140 X Seasonal/Dates: ❑ 1000-1 0,000sq.ft. $280 ❑ Residential Kitchens $140 ❑More than t 0,000sq.ft. $420 1,$25-99 seats $280 MAR-NOV 17 More than 99 seats $420 Temporary/Dates/Time: ....................................................... ................................................. .............................. ❑Bed& Breakfast/Childcare Services/Nursing Home $100 -------. ................. ----------- ............................... ----------------- - ................................... ADDITIONAL PERMITS IXMAKE ICE CREAM, YOGURT/SOFT SERVE $25 ❑TOBACCO VENDOR $135 ❑ALL NON-PROFIT $25 (including,church kitchens,state funded childcare&private clubs 23) Food Operations: Definitions: PHF-potentially hazardous food(time/temperature controls required) Non-PHFs-non-potentially hazardous food(no time/temperature controls required) check all that apply): RTE-ready-to-eat foods(Ex.sandwiches,salads,muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control. Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: $305 Payment is due with application I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C,sec.4 A, I certify under the penalties of perjury that I,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 26-121-5369 26) Signature of Individual or Corporate Name: CJ'S COOL TREATS, LLC 3 Commonwealth of Massachusetts ` * City of Salem Board of health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/06/2011 ESTABLISHMENT NAME: Rita's Water Ice --_ File Number:BHF-2007-000057 188 Essex Street East India Square Mall SALEM MA 019710 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2011-0260 Jan 1,2011 Dec 31,2011 $280.00 ESTABLISHMENT FROZEN DESSERTS BHP-2011-0261 Jan 1,2011 Dec 31,2011 $25.00 Total Fees: $305.00 PERMIT EXPIRES December 31, 2411 Board of Health AM LEI This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS J BOARD OF HEALTH � * 120 WaSI-IINGTON STREET,4""FLOOR TEL. (978) 741-1800 KIT%,[BERLEY DRISCOLL FAZ(978) 745-0343 MAYOR uGRrRNRAUtd((1).4ALEM.COM DAVID GREENBAum RS S�4d KE-7a 4 ;-2- I Z/�y/ /!-I A ACTING HE I ALTH AGENT J _ trGrtwAt 4eol� rNd F/NE , 9� C; S 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT--L *-S (/_.027/ 7CA7S. LL(f TEL# ?g- 7 C//- ADDRESS OF ESTABLISHMENT / 829 ES-TF )�( / l ,5A FAXVA O ) g -70 MAILING ADDRESS(if different) d�eescyl 1 ?$G�r o i g est n EMAIL- Business': 066 L'7� d ALL AiQdZW� t 11^ OWNER'S NAME ( �K,� ,a,' W eA I/ P TEL# 9 7 8- 5 3 _J ADDRESS STREET - CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAMES) Pro 4i A 1/bll9qWee CERTIFICATE#(S),51�� 7y95 (Required in an establishment where potentially mood is prepared) EMERGENCY RESPONSE PERSON to cA veg HOME TEL# q S-6_31P - Y3 2 a �DAYSOF'OP,E,RATION y._.�nrMonda ' .-,Tuesday: '" Wednesda � ..,7hurgday� " `.Friday` Saturday, ,. Sunday - HOURS OF OPERATION Please write in time of day. /y. For example Ilam-11 )� / /o — ' f I 0e] TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES ©O less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 RESTAURANT YES NO less than 25 seats 0 (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 t'Z�) NO 40 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. Purs nt 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 retu and paid I st tax required under_the_law. 2 /21 S3(o Signeve Date Social Security or Federal Identification Number y�, ------�-,/---- - -------------- Revised ionli 1 FOODAP201 Ladm Check#&Dater KIS 'I I • M r 11,11, r • µ r + + N a 1 i ��A1w"��VVV / \ J _... _._. ..._. ..... _...r a CERTIFICATE OF it r i ALLERGEN AWARENESS TRAINING j .I N;tmc of Rc ilncnt: Cynthia Zawislak Catificatc NUmbcr: 116061 ( La J llatc cit Col"Plcric n: 12/26/2010 � ti „ 1)atc �7f Es��iratic�n: 12/26/2015 ` + l 's WV 11 f)/' N1R i0NAi � »r ,,. .. I c,-fAURAN \(Ga ai-s'dfil 1il�r �rr77. ,a. 1)r-,,n7In,w j l'uh ., lk'?/l/r l DC7( �I f()N,,, '17 rrr'.':r.l 1. /l,' loi C'Mk „JU.U(l0i( .'(,�„d7. ?L;,..r i .. .t, Ro:rr . w. A. 'li7t� r �(i:rrr_,:.I11/�: :,r;nl/ /t '.'j;! t r, . riritn:/r71 :�� .r,7j�l•'i:%rt. 8 ,03 rrr ; CITY OF SALEM BOARD OF HEALTH Establishment Name: �� { S Date:_ �� I I �J Page:_ of Nem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Dete No. Reference R-Red Item Verified PLEASE PRINT CLEARLY ctidAA(2 tAfeW Y N re �c� i�i pr C . 5 C"Vtp c :D6 "SCrr/� ?er r, P, fiYl u rf tS re-Go We t 4 o 't ' C) _- ,rY"PY-P g! -=L v I 1 r Z _0 a A Ar nr " 13. 41(-ct - - - Discussion With Person in Charge: Corrective Action Required: Cl .No ❑ Yes i I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance o Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion comply with all mandates of the Mass/Federal Food Code. I understand that 13 Re-inspection Scheduled ❑ Emergency Suspension noncompliance may result in daily fines of enty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure Xourfoodpermit. `Ui ❑ Voluntary Disposal ❑ Other: 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness.Intervention$and Risk According to law Cooled to Factors(Items 1-22) (Cont) 41'F/45°F Within 4 Hours, PROTECTION FROM CHEMICALS3-501.15 Cwhng Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-50L)6(E) Cold PHFs Maintained at or below 3-202.12 Additives* 540.004(F) 410/450 F* 3-302.14 Protection from Unapproved Additives* 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances Identifying 140°F. 7-101AI Information-Original 3-501.16(A) Roasts Heid at or above 130°F. Containers* 7-102.11. Common Name-Working20Containers* 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.(104H) Variancel un.'ement 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 WashingProduce,Criteria° 21 3-801.11(A) BeverageR Unpasteurized t Pre-packaged Juices and 7-204.14 'n sots.Criteria* $eves es with Wanting labels* 3-801.11(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Ccmtatx,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed S outs Not Served. 7-206.12 Rodent Bait Stations* 3-80I.I UC) Un ned Food Package Not Re-servLd. 7-206.13 Tracking Powders,Pest Control and Monitor9n * CONSUMER ADVISORY TIMFJTEMPERATURE CONTROLS 22 3-603.I1 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Anneal Foods That are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.11A(1)(2) Eggs- 155`F 15 See. Pathogens.* *+n rxt Eggs-immediate Service 145°F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(Aj(2) Comminuted Fish.Meats&Game Eggs* Animals-155°F 15 sec. * SPECIAL REQUIREMENTS 3-401.11(B)(1)(2) Pork and Beef Roast-130'F 121 thin* 590.009(A)-(DI Violations of Section 590.009(A)-(D)in 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 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 3401.14(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 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3403,11(A)&(D) PHFs 165°F 15 sec.* (Items 23-30) 3403.11(B) Microwave-165'F 2 Minute Standing Critical and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3403.11(0 Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140" 590.000. 3403.11(E) Remaining Unsliced Portions of Beef Item I Good Retail Practices 1 .FC 590.000 Roasts" 23. 1 Manariamant and Personnel 'FC-2 .003 18 Proper Cooling of PHFs j 24. Food and Food Protection Fr C3 .004 I 25. Equipnvint and Utensils FC-4 .t105� 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 FacilityFC-6 007 to 41'F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC 7 .008 i 3-501.14(B) Cooling PHFs Made From Ambient 29. -Special Requirements .009 1 Temperature Ingredients to 41 017/450F 30. Omer - I Within 4 Hours* """"'"""rt'2 *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. Commonwealth of Massachusetts City of Salem IGmberiey Driscoll Board of Health Mayor 120 Washington Street,4th Floor SALEM,MA 01970 Temporary Food Permit DATE PRINTED: 06/29/2010 ESTABLISHMENT NAME: Rita's Water Ice File Number:BHF-2007-000057 188 Essex Street East India Square Mall SALEM MA 019710 :. LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes TEMPORARY FOOD BHP-2010-0469 Jul 4,2010 Jul 4,2010 Food to be served; Italian Ice Total Fees: PERMIT EXPIRES July 4,2010 Board of Health Page 1 ss CITY OF SALEM, MASSACHUSETTS • BOARD OF HEALTH 120 WASHINGTON STREET,404 FLOOR TEL. (978) 741-1800 KIMBERL.EY DRISCOL.L FAX(978) 745-0343 MAYOR D%RFLNBAUM SAI EM.COM DAVID GREENBAUM, ACTING I'IEALTH AGENT APPLICATION FOR A TEMPORARY FOOD SERVICE PERMIT FEE: 1-3 DAYS= $300 NON-PROFIT=$25 4-7 DAYS= $600 OVER 7 DAYS= >7 DIVIDED BY 7 X 600=THE AMOUNT DUE. (EXAMPLE:14 DAYS DIVIDED BY 7=2%600=$1200) -f CHECK PAYABLE TO THE CITY OF SALEM,NO CASH � NAME OF EVENT t 4 pF LOCATION 1�-F.{��1 DATE($)OF EVENT L1 bo V NAME OF APPLICANT 4 'e. TELEPHONE# ADDRESS-L2 fide 6, od IN 0/ I'Co NAME OFBUSINES^S� 1\ -7 A` S -Tad C i,Ai.+ / E t �] - TELEPHONE# 9 ! ADDRESS o 1 A (1-: SS 4 X , S 'o (",-} J'ym (/�° CERTIFIED FOOD MANAGER'S NAME O\jt4 I-A I/U ,eAj -M CERTIFICATION# A PLAN OF THE ESTABLISHMENT IS: ENCLOSED DRAWN ON THE BACK TYPE OF REFRIGERATION: GAS ICE DRY ICE V OTHER METHOD FOR COOKING/HOT HOLDING: GAS ✓ OTHER METHOD FOR SANITIZING: .1/ CHEMICAL OTHER SOURCE OF FOOD: NAME: K-� A`S ADDRESS 1`C3 FI f S SC- �y FOODS TO BE SERVED INCLUDING INGREDIENTS AND METHOD OF PREPARATION: I HAVE READ THE BOARD OF HEALTH, "REQUIREMENTS FOR TEMPORARY FOOD ESTABLISHMENTS."I HAVE HAD THE OPPORTUNITYTO ASK QUESTIONS REGARDING THOSE REQUIREMENTS. I UNDERSTAND THEM,AGREE TO ABIDE BY THEM AND UNDERSTAND THAT FAILURE TO DO SO WILL RESULT IN REVOCATION OF MY TEMPORARY FOOD ESTABLISHMENT PERMIT. PERSUANT TO MGL C62C,S49A,I CERTIFY UNDER THE PENALTIES OF PERJURY THAT 1,TO MY BEST KNOW LEDGE AND BELIEF,HAVE FILED ALL STATE TAX RETURNS AND PI ALL STA E AXES OU ED J UNDER LAW. SIG ATURE DATE SOCIAL SECURITY OR FEDERAL ID# TEMPAPPL REVISED II/25/02 PERMIT# CHECK#&DATE t Massachusetts Department of Public Health Bureau of Environmental Health/Food Protection Program Q&As for MDPH Allergen Awareness Regulation The following are actual questions we have received from food establishments. V The Food Allergy Awareness Act 1.1 What is the Food Allergy Awareness Act? The Act Relative to Food Allergy Awareness in Restaurants(FAAA)was signed into law by Governor Patrick in January 2009.The purpose of the Act is to minimize risk of illness and death due to accidental ingestion of food allergens by increasing restaurant industry and consumer awareness of regulations and best practices with respect to major food allergens. 1.2 What does the Act require? The Act requires that certain food establishments comply with regulations developed by the Massachusetts Department of Public Health(MDPH)that will include provisions for the prominent display of a food allergy awareness poster in the staff area of food establishments, a notice on menus for consumers with food allergies, and additional food allergy training for certified food protection managers.The FAAA also requires the Department, in cooperation with the Massachusetts Restaurant Association(MRA)and the Food Allergy&Anaphylaxis Network(FAAN),to develop a program for restaurants to be designated as "Food Allergy Friendly" (FAF)and to maintain a listing of restaurants receiving that designation on the Department's website. Participation in the FAF program will be voluntary. In response to the statutory requirements of coordinating with MRA and FAAN,the Department established a FAF workgroup to develop the initial regulatory amendments. The Department has asked that a representative from local health be added to the workgroup for designing the FAF guidelines and requirements for restaurants to receive the designation. The requirements will include, but not be limited to, maintaining on the premises and making available to the public, a master list of all the ingredients used in the preparation of each food item available for consumption and strict adherence to procedures that prevent cross contamination. More information will be made available once the voluntary program requirements are completed. — 'Effective Dates _ 1.3 When do the new food allergy awareness regulations go into effect? On October 1, 2010,the food allergen poster and menu advisory requirements will go into effect. By February 1,2011,food establishments subject to the regulations must have on staff a certified food protection manager who has viewed the training video and obtained a training certificate.Workshops j designed for local boards of health to enforce the new regulations have been scheduled and will be completed prior to the effective date of the regulations. 1.4 Would MDPH delay implementation to allow restaurants to properly prepare and allocate appropriate time and funding? No. Per 105 CMR 590.009(H), poster and menu requirements must be implemented no later than October 1,2010 and Food Allergen Awareness Training must be implemented by February 1,2011. 77 2 . ;Definitions - 105 CMR 590.002(6) ` 2.1 What is the definition of food allergen in the new regulations? Major Food Allergens are clearly defined as: (1)Milk,eggs,fish (such as bass,flounder, or cod), crustaceans(such as crab, lobster, or shrimp), tree nuts(such as almonds, pecans, or walnuts), wheat, peanuts, and soybeans; and (2)A food ingredient that contains protein derived from a food named in subsection (1). "Major food allergen"does not include: (a)Any highly refined oil derived from a food specified in subsection(1)or any ingredient derived from such highly refined oil; or (b)Any ingredient that is exempt under the petition or notification process specified in the federal Food Allergen Labeling and Consumer Protection Act of 2004(Public Law 108-282). 2.2 Are allergens in distilled spirits and alcoholic beverages required to be disclosed? No. Distilled spirits or wine, in themselves, are not known to present a risk.Allergens are not in distilled bevera es as there are no proteins left for them to be attached to. If a bar area has a menu, it would be Page 1 of 6(8119110) Massachusetts Department of Public Health Bureau of Environmental Health/Food Protection Program Q&As for MDPH Allergen Awareness Regulation required to post the allergen statement on its bar menu. There are foods with major allergens used in many bar settings such as milk, nuts, and flavorings that may be an ingredient in certain alcoholic mixed drinks. The Department believes that bar areas should be considered in the same manner as other food service areas when establishments are putting in place actions related to compliance with 105 CMR 590.009(H). 3 Establishments - 105,CMR`590.009(H) _ w _ . 3.1 Who must comply with the Act? MDPH regulations apply specifically to"all food establishments that cook, prepare, or serve food intended for immediate consumption either on or off the premises." 3.2 Some food stores may have just a few seats or a small seating area for customers,). Is this considered a seating area and how is it impacted? It does not matter whether or not the grocery store has a seating area. The key issue is whether or not the store cooks, prepares, or serves food intended for immediate consumption. 3.3 Is"take-out" defined in the regulations or is it in any way relevant? "Take-out" is not defined, but the concept is encompassed in the portion of the regulations stating"food establishments that cook, prepare, or serve food intended for immediate consumption . . . off the premises." 3.4 How would a supermarket setting deal with an independent sushi counter?These are folks who lease space. Since sushi is intended for immediate consumption either on or off premises, a sushi retailer who leases space would be required to comply with the food allergen awareness regulations. 3.6 When a store boils lobsters and gives them to a customer, is that considered a food intended for immediate consumption either on or off the premises? Since boiled lobster is intended for immediate consumption either on or off premises, a store that boils lobster for its customers would be required to comply with the food allergen awareness regulations. 3.6 Will establishments with the highest risk of reactions,such and bakeries and candy stores, need to comply with the new regulations? Any bakery or candy store that cooks, prepares, or serves food intended for immediate consumption either on or off the premises will be required to comply with the food allergen awareness regulations. 3.7 Are the new regulations focused ONLY on the major allergens listed?If so, some may view this as only affecting Seafood and Bakery departments of certain establishments/grocery stores. The allergen awareness requirements are not restricted to seafood and bakery departments.Any food establishment(or department in a food establishment)that cooks, prepares, or serves food intended for immediate consumption either on or off the premises will be affected. 3.8 Do food service establishments have to maintain a list of all the allergens that they have on site? No,food service establishments are not required to maintain a list of allergens they have on site. 4. Poster,- 105 CMR 590.009(H)(1) " 4.1 Where can an approved food allergen safety poster and other guidance materials be obtained? Free food allergy safety guidance for local boards of health and industry, including a food allergy awareness poster approved by the Department, are available for downloading from the MDPH Food Protection Program website- hftp://mass..qov/doh/fpp. General food allergy information can be found at Food Allergy&Anaphylaxis Network- http://www.foodallergy,0ro/and MA Restaurant Association - http://www. http://www.marestaucanlgaagLgEgl 4.2 Allergen Poster: It says .......shall prominently display in the employee work area......What is the definition of employee work area? The work area is a conspicuous and accessible place where notices to employees are customarily placed AND that permits employees to readily read the poster. Page 2 of 6(8/19/10) Massachusetts Department of Public Health Bureau of Environmental Health/Food Protection Program Q&As for MDPH Allergen Awareness Regulation 4.3 Can a food establishment create its own poster? Food establishments must use the approved allergen poster developed by FAAN, in cooperation with the MRA and the MDPH,that is available for downloading at http://mass.gov/dph/fpp.,It may be printed and used in color or black and white. _ 4.4 Is there a procedure for getting an alternate allergy awareness poster reviewed and approved by the Department? 1 Due to extremely limited staff resources, the Department cannot commit to review/approve alternate posters prior to the effective implementation date(10/01/10). Food establishments must have the Department-approved poster displayed by October 1,2010. If an establishment wishes to display a pre- existing poster in the same area,this is fine, as long as the approved poster is also displayed. 1Mihiacceptabletice0 CMR 590.009(H)(2) s 's anconsumer notice on the menu? A clear and conspicuous notice on a printed menu will need to state: "Before placing your order, please inform your server if a person in your party has a food allergy".Alternative language is not an option. 5.2 Our current menu statement Is"Not all ingredients are listed in the menu.Please let your server know if you have any food allergies." Is this consistent with the requirements of the regulation? No.The regulations require specific language:"Before placing your order, please inform your server if a person in your party has a food allergy". 5.3 1 was previously advised that"The requirements apply to all food stores that cook, prepare,or serve food intended for immediate consumption either on or off the premises("take-out"),whether or not they have a seating area. However,also it was also stated that; "The menu notice requirement only applies to food stores that have menus or menu boards."Almost all of our members do have"take-out" (prepared sandwiches, hot meals,sushi,etc.)but do not have a "menu or menu board".Are they NOT required to place the menu notice requirement anywhere? If food establishments do not have either a menu or menu board,they are NOT required to place the customer notice anywhere. Keep in mind that informal chalk or highlighter boards used by some establishments to list daily specials with their prices are considered menu boards. in addition, automated menus or menus posted on a website are considered"menus provided outside the establishment"or "printed menus"and must contain the notice.The poster and training requirements do apply to all food establishments that cook, prepare,or serve food intended for immediate consumption. 5.4 Would the menu notice have to be placed in an advertisement circular, if it is considered a"menu" since it does have a food list and/or pictorial display of food items and is distributed outside of the establishment?How about on-line announcements? Menus are printed lists of food items and prices from which a customer can order food, either in person, by telephone, or online.The purpose of the allergen notice is for the consumer to be alerted that he or she should notify the server about the consumer's food allergy.Advertising circulars and on-line announcements, if they are not intended to generate speck consumer orders, are not considered menus. If they are intended to be used by consumers in ordering food,they are considered menus and must include the notice. 5.5 Where must the notice be placed in a food store to inform customers to advise their server if they have a food allergy? The menu notice requirement only applies to food stores that have menus or menu boards. If a menu board is used,the notice must be either(1)on the menu board itself, (2)adjacent to the menu board, OR (3)at each point of service where the food is ordered. For example, if the point of service is a deli counter, the notice could be securely placed on the counter in such a way as to be easily seen and read from a distance of five feet by a person standing at or approaching the counter. 5.6 Should the point of purchase or the point of sale,which would be at the cash register display the notice? The regulations specify the point of service where food is ordered, not the point of sale. Page 3 of 6(8119110) Massachusetts Department of Public Health Bureau of Environmental Health/Food Protection Program Q&As for MDPH Allergen Awareness Regulation 5.7 What if a customer purchases for example a sandwich and beverage and takes it over to the seating area?Is the aisle where they picked up the candy bar required to have such a notice? Does it have to be done at every counter where they can pick up their food, e.g., deli, bakery,sandwich area,etc.? The notice must be at every counter where a person may order food intended for immediate consumption, IF there is a menu at the counter or a menu board behind the counter. 5.8 Where must the consumer notice be posted? The consumer notice is required on printed menus and on indoor and outdoor menu boards, including drive-through menu boards. In lieu of placing the notice directly on the indoor or outdoor menu board itself, the food establishment may post the notice adjacent to the menu board or at each point of service where food is ordered. 6 Training — 105 CMR 590A09(H)(3) 6.1 Many of our members already provide allergen training with programs designed for a food store setting. Should they be discontinued and replaced with the Department's allergen awareness requirements? Food establishments should NOT eliminate their present training procedures. The statutory requirement to view the video is additional, and is intended to raise allergen awareness but is NOT intended to substitute for existing training programs. Certified food protection managers will be required to obtain food allergy awareness certification from an MDPH approved vendor. Vendors will charge up to$10.00 to participants to issue the certificate after participants have viewed the video. Separate from the training requirement, the video will be made available for free online for anyone who would like to view it. 6.2 Will the training video illustrate the only way to meet compliance? No, the training video includes allergy awareness topics to protect your consumers. It does not contain regulatory or inspection information. 6.3 The way the information that you sent reads, a certificate goes with the video. Does this mean that all future trainees must watch the same video that is recognized only by MDPH? If so will there be a monetary charge?Who will be responsible for administering the viewing and training for the trainees?Can a private entity do their own customized training and have it meet the required regulations? The regulation states"Food establishments shall have on staff a certified food protection manager who has been issued a Massachusetts certificate of allergen awareness training by an allergen awareness training verification program recognized by the Department."A certificate is issued to the trainee after they have participated in the allergen awareness training. There is one training video approved by the Department. The certified training is being conducted by 3 MDPH approved vendors for a charge of up to $10.00. If you would like other staff to watch the video, they may do so free of charge on the MDPH website, but they will not receive the training certificate. If a private entity chooses to do its own customized training, it can do so, but it will not substitute for the required MDPH approved allergy awareness training and will not result in receipt of a required certificate for food protection managers. 6.4 Will the state supply the video to local Boards of Health, and also to trainers that do Food Safety certification training? The video will be available for free online for anyone to view. However, only the three MDPH-approved vendors can issue the food allergy awareness certificate to certified food protection managers. 6.5 Can local colleges administer certificates,or CEUs,through their institutions that training in this area has been completed? Local colleges will not satisfy the certification requirement. The Department followed Commonwealth of Massachusetts procurement procedures in issuing a request for response(RFR)to select vendors for the training component. The procurement period has closed. In accordance with 105 CMR 590.009(H), the certified food protection manager is required to participate in the allergy awareness training that has been approved by the Department and is administered through MDPH approved vendors. MDPH approved vendors may choose to offer the opportunity to view the video and provide certification services, in conjunction with existing restaurant training programs,through colleges or other institutions, and/or Page 4 of 6(8/19/10) Massachusetts Department of Public Health Bureau of Environmental Health/Food Protection Program Q&As for MDPH Allergen Awareness Regulation accredited food safety training programs. 6.6 Supermarkets typically have a more than one certified Person-In-Charge(PIC), usually one for each department, bakery,seafood,etc. Do the servers need to be certified or the PIC?Staff sometimes switch as far as who the server may be,they may have to fill in at another store,another shift,etc. and it may be the PIC or not. The person in charge should not be confused with the certified food protection manager. The certified food protection manager is the only person required to be certified by one of the MDPH-approved food allergy awareness training vendors. When the certified person is not present at the establishment, another employee must be designated to be the person in charge. The designated person in charge does not need to be certified, but must be knowledgeable about food allergy awareness and have the authority to initiate necessary actions and/or emergency responses. In addition, all staff must be trained and knowledgeable in food allergy awareness as it relates to their assigned duties, as required by 105 CMR 590.009(H) (3)(b)2. 7 .Video approved by MDPH — MGL Ch:r,:140, s. 613, subsection (c) , 7.1 Is there any procedure for input on the video for allergen awareness training by the Association to make sure it is also compatible with a food store setting? No. As stated previously, the video will raise awareness but is not intended to substitute for a comprehensive allergen training program. 7.2 How do you get approved to be on the vendor list to issue a certificate proving the training video was fully viewed? The Department followed Commonwealth of Massachusetts procurement procedures in issuing a request for response(RFR)to select vendors for the training component. The procurement period has closed. 7.3 Would MDPH allow for the approval of national training programs already in use by multi-state operators, provided that those programs include allergen awareness components? No,the video was produced specifically to implement Massachusetts'Allergen Awareness statute to address food allergy awareness through regulatory requirements. 7.4 How will the Department proceed with approving future video proctors, assuming those approved now are not approved for life? Many in our industry have in-house food safety specialists who would like to incorporate the required video training for their employees; As stated in question 6.5, DPH issued an RFR for vendors , and the procurement period has closed. The vendors for the first 5 years have been selected. In-house food safety specialists can contact approved vendors who are posted on the DPH website to form a business relationship. 7.5 At some point will there be a chance to update or revise the video with a retail focus as opposed to a restaurant focus?The Food Marketing Institute may have funding available to do just that. There are currently no plans to pursue other avenues to address the food allergy awareness training.As previously stated, the intent of the regulation is to increase awareness with food establishments and increase consumer awareness. 8' Exemptions - 105 CMR 590.009(H)(4) 8.1 Who is exempt from the Act? Food establishments that DO NOT cook, prepare, or serve food intended for immediate consumption are exempt from the allergy awareness regulatory requirements. Public and private schools, educational institutions, summer camps, childcare facilities, and other child care programs approved to participate in USDA Child Nutrition Programs are exempt, provided that they have written policies and procedures for identifying, documenting, and accommodating students with food allergies, and documentation verifying participation in food allergen training recognized by the Massachusetts Department of Elementary and Secondary Education and the Massachusetts Department of Public Health. However,these institutions must ensure that their employees are properly trained in food allergy awareness as it relates to their assigned duties. Food service operations in institutional settings in which food is prepared and/or served to a specific Page 5 of 6(8/19/10) Massachusetts Department of Public Health Bureau of Environmental Health/Food Protection Program Q&As for MDPH Allergen Awareness Regulation population (i.e. hospitals, non-profits, charitable food facilities, etc) are exempt ONLY from the menu notice requirement.They must still comply with the poster and training requirements. Temporary food establishments operated by non-profit organizations are exempt from all of the allergen awareness requirements, in accordance with 105 CMR 590.009(H)(4)(c). 8.2 What are the requirements for schools that are not approved to participate in USDA Child Nutrition Programs? Schools that are not required by USDA to follow ADA and make school meal accommodations must comply with the Allergen Awareness Regulation. Private schools, for example,that do not belong to the USDA School Lunch Program would not be exempt, and would have to meet the requirements listed in the Allergen Awareness Regulation. 8.3 Are cafeteria-style dining areas in retail food stores exempt or excluded from the regulation? The type or size of a dining area does not determine whether the regulations apply or not. Food establishments that cook, prepare, or serve food intended for immediate consumption either on or off the premises must comply with the requirements. 9 Enforcement - 106 CMR 590.013 9.1 Who is responsible for enforcing the food allergy awareness regulations in 105 CMR 590.000? The Act gives the authority for enforcement of the regulations to local boards of health as the primary agencies responsible for enforcing the State Sanitary Code. 9.2 What happens if a food establishment does not comply with the regulations as required? Failure to have a poster, menu notice, or proof of training when required will be debited by the local board of health as a critical item on the inspection report requiring corrective action within 10 days. Local boards of health may use fines and other enforcement actions available under 105 CMR 590.000 and state law to achieve compliance. 9.3 Are there any reporting requirements to the local board of health if someone has an allergic reaction in a food establishment requiring immediate medical attention? The occurrence of an accidental ingestion suggests that there may be conditions that can result in an imminent health hazard. The permit holder will be required to notify the local board of health in accordance with 590.001 (FC 8404.11: Ceasing Operations and Reporting)to ensure that all preventive measures have been taken. Note that a food establishment need not discontinue operations in an area of the establishment that is unaffected by the imminent health hazard in accordance with FC 8-404.11(6). 9.4 Would MDPH allow for an annual certification on the food service renewal forms,as an alternative to the mandatory training and posting requirements? No, MDPH is not considering alternative avenues to comply with the regulation. The video viewing requirement was set by statute. 10 Food Allergy Friendly,Designation - MGL Ch.Uo,s.,6B, subsection (g) 10.1 Do the requirements(employer poster in work area,advisory for consumers to disclose any allergy,training and development of a food allergy friendly program)apply to all food stores that have take-out and a courtyard for seating,or just to those with a seating area? The poster, menu advisory, and training requirements apply to all food stores that cook, prepare, or serve food intended for immediate consumption either on or off the premises("take-out"),whether or not they have a seating area. The Department will amend regulations to address FAF programs at a later date,and such programs will be entirely voluntary. Page 6 of 6(8/19110) Food Allergies what you need to know AMillions of people have food allergies that , can range from mild to life-threatening. Most Common Food Allergens P i k` ( ', 4 Peanuts Tree nuts Fish Shellfish r Eggs Milk Wheat Soy Always let the guest make their own informed decision. When a guest informs you that someone in their party has a food allergy, follow the four R's below: • Refer the food allergy concern to the chef, manager, or person in charge. • Review the food allergy with the guest and check ingredient labels. • Remember to check the preparation procedure for potential cross-contact. • Respond to the guest and inform them of your findings. * Sources of Cross Contact: • Cooking oils, splatter and steam from cooking foods. When any of the below come into contact with food allergens, all must be washed thoroughly in hot, soapy water: • All utensils (spoons, knives, spatulas, tongs, etc.), cutting boards, bowls and hotel pans. • Sheet pans, pots, pans and DON'T FORGET FRYERS AND GRILLS. 4jolf a guest has an allergic reaction, 011* notify management and call 911. 0 2005 The Food Allergy&Anaphylaxis Network Commonwealth of Massachusetts r City of Salem Board of Health Kimberley driscoii 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED:. 03/10/2010 ESTABLISHMENT NAME: Rita's Water Ice File Number:BHF-2007-000057 188 Essex Street East India Square Mail SALEM MA 019710 LOCATED AT: SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2010-0376 Mar I0,2010 Dec 31,2010 $280.00 ESTABLISHMENT FROZEN DESSERTS BHP-2010-0377 Mar 10,2010 Dec 31,2010 $25.00 Total Fees: $305.00 i I i PERMIT EXPIRES r ecember 31, 2010 Board of Health f ..J 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 m a. BOARD OF HEALTH 120\1%ASI-IINGTON STREET,4-FLOOR TEL. (978)741-1800 KINIBERLEY DRISCOLL FAX(978) 745-0343 NLA,YOR DGRE.ENBAUM(a S ALLM.CON{ DAVID GREENBAUM, ACTING I-IEALT7-I AGENT Zoi D W APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT RITA'S ITALIAN ICE TEL# 978-741-7482 ADDRESS OF ESTABLISHMENT 188 ESSEX ST,SALEM,MA 01970 FAX# N/A MAILING ADDRESS(if different) (AFTER OCTOBER 31) ALL MAIL FORWARDED TO HOME ADDRESS EMAIL-Business': CSSCOOLTREATSLLCOAOL.COM Websile: WWW.RITASICE.COM OWNER'S NAME CYNTHIA WEAVER TEL# 978-536-4328 ADDRESS 12 ANDERSON STREET PEABODY MA 01960 STREET CITY �STATE ZIP P/� CERTIFIED FOOD MANAGER'S NAME(S)CYNTHIA L. WEAVER CERTIFS ICg7E#(Sll 5 969177 7 S (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON CYNTHIA WEAVER HOME TEL# 978-741-7482 DAYS OF OPERATION Monday Tuesday Wednesday Thursday Nday Saturday Sunda HOURS OF OPERATION Please write in fime of day, 12PM-9PM 12PM-9PM 12PM-9PM 12PM-9PM 12PM-9PM 12PM-9PM 12PM-9PM For example Ilam-11 TYPE OF ESTABLISHMENT � FEE (check onlvl 1111 RETAIL STORE YES ( ` 0 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$2 25-99 seats $280 more than 99 seats ....................... ...... ..... BED/BREAKFAST/ YES NO $100 CHILDCARE-SERVICES/NURSING HOME ADDITIONAL PERMITS - - MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES ALL NON-PROFIT(such as church kitchens) YES 7��f6J\ $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. Pu an to M L Ch er 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 ret n and Pa II at tax s required under the law. 3/10/10 26-121-5369 Sign Date Social Security or Federal Identification Number i CITY OF SALEM, MASSACHUSETTS BOARD OF HFE u-TH bra 120 WASHINGTON STREET,4" FLOOR TEL. (978)741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 MAYOR DGRF.ENBAUMa)SALEM.COM DAVID GREENBAUM, ACTING HEALTH AGENT Revised 4/24/07 FOODAP2008.adm Chmk4&Date 174 $ 305 — --J CITY OF SALEM BOARD OF HEALTH Establishment Name: rP Date: > I (1 I I f_1 Page:1 of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified t PLEASE PRINT CLEARLY rp Ci,v tr - r- • - vvrl v � ._�I ILr�.r L. /L v 1 '•.'1 '� G' Ire /N (l,l I fi t {� I^,( fin, .:n� rr _t ? � !�\)t (tQ �I.'1(> iM�d/In r7 11"li C —+� ! (�,( -l--V fan cv /c-• t��' { -T\ v l;� f`yi v`�a P,i(-(C'F I v1.; TP kr-p (A n n•� r� �n r�� i r �/ r1 r ,Jin ;-'4.-,K AA (%1/1 n0,i.�c A /r 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/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure •f your food permit. //�� l ,t.�h 1.,.J ❑ Voluntary Disposal ❑ Other: �r/ F 1.)4(C) PHFs Received at Temperatures Violations Related to Foodborne fitness Interventions and Risk According to Law CooW to Factors(Reins 1.22) (Cont) 41`F/4-5'F Within 4 Hours- 3-501.15 owl.3-501.15 Cooling A4ethods for PHFs PROTECTION FROM CHEMICALS 19 PHF Hot and Cold Holding 14 Food or Color Additives 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 AdcLuve>'* ,590.(Ni4(F; 41°745°Fes' 3-302.14 Protection from Unapproved Additives'r 3-501.16tA) l Int PHI c Maintained at or above 15 Poisonous or Toxic Substances _ -101.11 Identifying lnfoi mauon-Otiin i 40'F. —�- Contact er ' ? 561 150�) Ro'sts Hold a[or nbotc 1311 P'. L7-202-12 32.11 Ccmntol Am:v Lb-tt p;n^Ccm.tin rim L2. �� Time as a Public Health Control t (s �� tm ac tfubhet-leal h( �ntmfr r0 t.itai 021' i Rcst-ti.1 on-Pr once-and t sc Condition.,of Uw- REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-?0111 Toxic f u unmet F'roh bi,ion a POPULATIONS{HSP) -26417 Sannvers Criteria thunu Is _ __. 7 211 Chutw ils krz l5 tcttu l s educe C rite n i"� 21 I -t'R{)1.I I C6tij� UnT! tem(red Pre p,u, agcd Juices alai I' --� — - Rot ra ev with R nn!n IabdS` ! 7-204 14 Dian At eats.(ri r!1l 1 ('--�------1 ---{ i-S0114B)�Us £tPa�it,mzed �72n5-I1 1ncIP ntai Foxiruirau !tali canis.. I —`�---- -- - Td» : Cat or 1'attiall f�xti.�.l Atnmal Ftxn-1 and � ( 2!36 1 I Re !! f tt I si;Pe Ludt. C! t t r _ ..___.� a rCa x !I v-runt tit 1 Srrvca 7 t)6.1 r ! Rcxt nc b ` :nm n- �' — '--- _. ---' «u*i t R'- TIMEfTEMPERATURE CONIP.OLS i rc u,f r r t t cu� aua o. _ �_. PromCo"ing Temperatures lo- 16 i ( ! ! Pti!" i I W rr1 ,u tc+nrt a e� I r.,[01.t kit 1 Lr_ u5 G K cnj x� i ,h ii:.G &t.+.tl SPECIAL FIEQUtRE7ECrI _ _ _. I '(;Rk '!3!(1 '� � i t tr, t- �! kn t 1 r) t 1 r.rtr`� 1 ,. ��--� - �::;:: `rittie�t� ,t. liJO.!'3ta1431ti.3)t-----7 cat errI 1 r,(.iJ� t r( +*izp xr:a!ad_ x t ).3, ,.r,i ( P u�t c, ,a t,.,t,�, Stir rod)rut ,,. :...:-a.,, .t,,.r..u.a..., ,!tr ..ii'ze F d3rr._Con nim. 'is( 't',t. Debit c - tzr thc,m prvnr3nr„sec�tiHlis .L. S 3 it li .3 1? R `searin'7 tot Hoz boli gag I WOLA1IO iS RELATED TO GOC.:t RETAIL PRA ,ICES _. rq3. 17' !S? ( rill t c - (Items 23-30) 1 ,- 1! H. l6a uti nc I W f Minnie S :¢ding rra r.2r r <r r_a1 < r t r:, ;rrcY do-oe I ehl t, ri!r to)odhetci I . tict1' rs t r ' - zrt f.-e 403.11 tC � ' 'AIR < i r .c lU t iJi 00 e-41� ').i 1 E. 1 ttr.ia3 u rin+�LI.ttiree! Portions of'Iiee; } !tent Good Rera!t Practices FC 590,0W , ivtanag !nt i sad P r-ra Fi_ 7u t j F6Jn d art Proier o FC "I G^4 ! Lt Proper Cooling of PHFs j I- -, -- -- t - - - i - - --- - 1 25 Equi tant and Una sis Fr, 4 rt05 1 x_$01.f4;A) t ,xti�nc Ctxnk_d PHls from 1 iFtc) r- - i - stet P t mbin --_ _ r f Within 2 Hou ,nd From �_2I Fh1s Fac 4ts FG b ,✓17 _- ._ ..- _ _ ( t .11114,'f N-tthm- H ru ! zct �r2s ran t r>}a rl' er +s_ C 7 ,Mt3 ,_.._ e _ _.. 1-501 1416) Ci olms PHF. '.il,.d. Free Ambient _ e r spec q Fs li a !nt�t 4CJ t cnrla`ra[att (n.r d^a! ,.a 111 of/.t5`1; 36 4tlc -1 At'itli n 4_Hrx!u-i ^ ° •�, r IIUat1 s t£ -'!1 urrr I .1 1 iij(. L t • . IMPORTANT MESSAGE FOR �/ z DATE —TIME 3M OF- PHONE 11�A$7•_ '6C 5'_ 'C_-'�kJcr U � NSON , U FAX U 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 SIIGGN}E�D s FOR 4009 Y�/� FO N IJ.S.A. CITY OF SALEM BOARD OF HEALTH Establishment NameiR Cbk? /S owl s Date: l a, .La d Iq Page: L of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date : No. Reference R-Red Item ` ,verified PLEASE PRINT CLEARLY l 1 FF::: Discussion With Person in Charge: Corrective Action Required: LiNo ❑ 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 Exclusion _ P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 0 Voluntary Disposal ❑ Other: 3-501.14{C') PHFs Received at Temperatures Violations Related to Foodborne Illness interventions and Rlsk - According to Lau•Cooled to Factors(&arm 1-??) (Cont) I 41"-F/45'F Within 4 Hitui's. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs -- L9 PHF Hot and Gold Holding 14 Food or Color Additives_ 3-501.1-6(B) Cold PHFs Maintained at or below 3-202.12 Additives* 590 OM(Fl 41`145`F* 3-302.14 Protection front Unapproved Additives* r , _15 Poisonous or Toxic Substances 3-50 L lh(A) Hot PHFs Maintained at or above 7-(01.11 Identifying Into)mai r n-Original 14U R ` .,t 116(A) Roasts field at or above 130'F, Container,- r — i2U Time as a Public Health Control j 7-102.1 t ` Common dame R ,rkln"Crnurin ra* r- - -j �- -- — -- -- ° 50, I r lame as a Public Health Control' 7-20(.11 1 S<fsal ruon 5rrnag. 1ts� - --'-� 7kestnu<n presence tud 3[ 0411) �V nmce -202.11 ai cem�nr _� 7-202.E C,ondulom of Use .Toxic Cont 6ne f'rohihition,' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-303.11 POPULATIONS(HSP) 7-204.71 Sannlgets Cri erin Chanicntc ( � ot11A) naIcdreta her ss odneCon7:04.1 "tedceuul—) -- -- - l �_ � I3cvela es with RniniII2 ahais, j ? 304.14 UrFn 4.veute.Criteria" -- t-t301 11113} Us of Pa�towiYe!1 ---- 2{}5.11 htcid on(a I k rxJ t unit(( 1 chi I6a:I s' 7 3�SOT11[t)I RawtrPirtinll (Itt,:dAnttnalFlxdal>31 1 1 ?--206.11 Raxinc tl sc: Pr 4t e Gitrul 1 � — noun, vc r k rvc u 7-1-06.12 — _.� Favi i i . 1\D R, -.rtiirL't- r-_',.6.I1 ' Iral (., i4l uudci 1 C'om fund I \tim 11 In CONSUMER ADVISORY _ 1 Ci 011 I r li ,SSOi i P t.'1 C,i GIo :tn1111Dn of TIME/TEMPERATURE CONTROLS vw.lI e+d ,tit cIt s I It ..tr$edc. l 16 1 Proper G,colu g Temperatures atures for 1 .. It,t 1 ,r I, t l �"101.1� ltt _ PHFs _ _ 1 i Fr�r rt j < < ri - I f t I nmcdl is 5e ,Ic F-t. . w Ettlx � ,c k� j i 401.)N U l cilrowmuled F h r. , t ' i r - i ._.._ SPECIAL REQUIREMENTS 401 I'(13tI l I?1 1 h d arid I3 ef do tt I_99 # 3'1 Taiw ----- — — - — ? ,.111c.Its I `, F 1) . -.r 9?t:. G'i41J, r11_ r_ 4,�.I C :,)O.i,YIh A, in ,-Wren . MOhll,rcx,� :cn,I� ra . ,nd i ..,t: H_,I t ix,l t,[i@., 4i.I to i?r' 3 Prt ttiti m ��.Es cu' S '3, ' i I `! I 1 q 1 l d. I.i' A7 17 �+ • y� i[!e { 0 to,,isaflHel f_ng _- (tOLATIONS REL+ITEC o GOOD RETA.if PRACTICES 09.1111 d.i13i65,F 1 30-.JJB) hlul0n1§tW- II F 2 'vlowl SI. adill� clot"(1i jild'Wri,riiil:a' J +s wigr,hdonr: Ciare, ov U( f rnUQl[Itr i/It S, ( ravCxt rt [bt it i (7t tort1 :k /ctr r. If 11 or''—' r 3-40111(C=) { >nt aatia�iv Pt ex utti x 1&„J inn S se: > r;no rood c oucm ° ' 1'+ r.1fR 40 F” P._ 3-403 1 I{E) Run uniug l nskc d Por to.�1if 1?cYt I- temGoodRetalt----Practices fC S-OAf1L 3 0anagpmert a .F oar i Ft, 2 003 1g �--- Prager Cooling of PHFs i4 t c xi Ind i oc>a F ac tion _ FC 1 G,4 - - ° Utensils FC 4 f105 b 3o rn ant and _ 50 , [ ;11 Wit hi F 41 to au wid Fr,nn 10 1' i 1'-78 �is.,roa,or hx hod sJa ' �C 5 W6 tl.L4(A) t tool ❑I Gx�l, dPHI s L Im IAI 3 f,` ) 20 r Watt P! nbn^ _ 7 77 ... al Fa !i FC-6 001 v xr` ,r,. , _ C .00c _.� ..._ ^-501.14(b} C r 1 ht g PR Ri Ir From Ambient Special - i T nF r.iolrp Inrredierns to J 1 145<F 30 OthFr ! ! Mit Ir ! llcnn "o :` `lien ^.C,^:ucaLuen r Its j<k r `<39 FeAd C It r 1lC{t111 591100@. CITY OF SALEM BOARD OF HEALTH Establishment Name: t�f�� )&±,04 Date: Page: L of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item f verified PLEASE PRINT CLEARLY v� r o I O 00 /b�A t"' n iA e nr. I J I -� - _ I I x � Pnnnnr I i l p.� I . 1 rt" - VI-10,11 > 1 I I Com. SPM u Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes { ❑ Voluntary Compliance ❑ Employee Restriction/ r I have read this report, have had the opportunity to ask questions and agree to correct all Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ EmergencySuspension ? comply with all mandates of the Mass/Federal Food Code. I understand that p y � noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure z ' iyour food permit. ❑ Voluntary Disposal ❑ Other: 4 Y 1 -S 3-501.14(0 PHFs Received at Temperatures Violations Related to Foodborne Illness interventions end Risk According to Law Cooled to Factors(Rents 1.22) (Cont) 41°F/45`F Witbin 4 Howl. ' PROTECTION FROM CHEMICALS 3-501.15 Cooling,Methods for PHFs 19 PHF Hot and Cold Holding 14 Food or Color Additives -- 3.501.16($) Cold PHFs Maintained at or below 3-202.12 Additives' 590.004(F) 3-302.14 Protection front UnapproNed Additives* 3-501.I6(A) H'rx PHFs Maintained at or above 15 Poisonous or Toxic Substances 101.11 Identifying lnfc,lnatien--Original d{) F Cnntut rs` . �fli 16{Ai Risists Held at or above 0301, , — —a 1 20 Time as a Public Health Control t 7-102.1 I ' Gammon Name 14 lrifil) C roti nw," '- --- -- .� 3 5(j( I ..._ Tint"as a Public,Health Control, -- 7-20t.11 Sr im r In n�sn.rxhc- 140.MkT H) V"Irildlce Rc`tmre-meat ? 202.1 i Rcstticnon--Pruner and i. c � 7-202,12��. Conditiom of Llsc�` 7-203.11 _ Tonic ion, nec--lxrobih"eiuns" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 7-204.71 Sannvets, — 7-204.1"' Ch.vu hk st 45 cin fneit< Cntcria" 21 ;-801.1 1(A) t:npa Tcurized Yre;s tc ;zged luiees aid � -.^- - -- 43evera>e„c tvith Warning l abaic` { 7 ?04.I4 -D; jr lsentc.Crn��rt� _ __..� �{i3 Iltt3} U� utPa-tcAm dltgc* "( 7 205.11 Inadrntal } Xld Cunl5C1LONIcatri ` -- - -{ St?) ted) h.) trl'ui1nll rt 5},cti -tae nti Food and / �OG.I( R.->ntc( ntsr Pc utdE Cry iii il I ! � _ lt-t Sn a �4aronr c Sc.rvca i 7-)06 1P.tt4T k S,.:,nr n1 h-..� F r,— aR;" It C . t=;� nz nc clt��><x r ' c �^Nn tti nc, scr � I 7-'0612 Lackw, . a i'ttttddr i' uf_ua`i ,land _ ..� -�.-.- .�1 14Cmtc urY ` CONSUMER AQ ir+nn., r.t _ °x.211 1 3-00=If ' ,trimmer An fort '.. -d!or C°onaninf),ion of � TI1V?OJTEMPEPAl URE CONTROLS nine 1 ! u.I i!t;T Ra, L-r jel,w d.ed I6 Pruser Cooking Tempsr'zlurE far ' - t PHr 1 T f1t t x Prz Fli t 1 i;.. t r t I I , x S,. S t d" eV' k.tt Shelf -)tiTne do s c -in i5 a I �x..- f { ( ! I 4 3 4 L IfA)G' Gai,tt SPECIAL REQUIREMENTS fl F lnd !7 Rem st - 1 t6 F121 71 nim' -,- -+ 1 793.Oof)ihlt6) 1 l 5 h 1 C inrxlr* T7 hi3" 2 a lemoura,v iind 1 T-.. tCIi. L, t n e,: T' , Prsa T`"iTg Im, I Bel ,, ,aks ;aura ^t ., ,.._, ^ . -,crt1 F)tilc's 0,00 t r 1 .. 4 PoRenisng Inn!tat HoldingVIOLAT{ONS P.EL,ATEL 14 aOG?2 FTE7ABL rF 3%TfC . iO3A1t tvJ,tl)^) i PHI io 1 (,lienls2.3-31) _— 1 ^=.4(73.11tB) � titin cw.:vr (r °F1. L9nw . Standing � Gro l;anti!',',» ,-i)i�at sro +t•;us. ;iriclr.:a tion Ertu ..t:=:^ I Int _ i l':rrt+ttr ran 1(t i s n u vent ,t .t r; t jT,tr rc(:. rd n r. ni»br �4'}3.U(t".) i ( m t -ictallyPtlx :c.dfY(} fuunr' i -Fm lei n rc =e, >r nr oodCode ae al�n (,WR I 40'F � 3463.11(h) fir (,ti un� t l tt:r cd PorTto ot`licef 1 ;_Item 1 Good Retail Practices FG i 54p.110f1 It m 'i �_ tanayrmt i and Per ust c - F" 04 r- ------- ?t F Mn rd Rxxi P ode;turn FC, 4 {qlG ( (!f , Proper Coaling of PHFs �- --+ _ .. ,- . n ant ?-501,14(A) `<xhinxC'wk,dPHFs Iran, 14f)'F lif 26, t,Valef Pt .tttn�-vc1J)ste , ) I 1Lithin 2 Hrwrs and lnrn701' 1 - 1"— 007 - �� _� 0 4 '/a.,`F N itI in 4 H tnr,. ` a 1 26 11 cis�nous or t" rG 7 008 3-501.(-1it3) t olio 111I'F N do Frota ``mbient i_JO 5 ,oc a!F it m vis ( - _ Ota_ C nl ruucin).redchisis IP45`1 1 ' 30 ' Other .__ , — l .�._...._ i4 n n 4 Massachusetts Department of Public Health Salem Board of Health120 Washington Street,4t" Floor Division of Food and Drugs Salem, MA 01970-3523 L FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name [Risk ate Tvue of ODerationfs) Tvae of Inspection C5 ❑ Food Service ❑ Routine Address ❑ Retail ❑ Re-inspection n Ir� evel ❑ Residential Kitchen Previo'usf Ins ection Telephone 9 1 - q `c _ ❑ Mobile Date: ` -+6Owner ACCP YM Temporary ❑ Pre-operation Caterer ❑ Suspect Illness Person in C rge(PIC) me ❑ Bed&Breakfast ❑ General Complaint In: ❑ HACCP Inspector Out: Permit No. ❑Other Each violation checked requires an exp l ation 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 ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities 'EMPLOYEE HEALTH _ .,;a, PROTECTION FROM-CH' EMICALS1 ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded [115.Toxic Chemicals ,.FOOD FROM APPROVED SOURCEm _,.e„ ❑ 4. Food and Water from Approved Source iTIMEITEMPERATURECONTROLS(potentially Haazardous 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 El 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 SUSCEPTIRLEPOPULATIONS(HSP)".'u' El21. Food and Food Preparation for HSP E] 10. Proper Adequate Handwashing ❑ 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 C I N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.0044))) 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)(590.008) 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:590NspeMForm6-14.Cw Inspector's Signature: Print: PIC's Signature: Print: Page_of Pages ,. `�._ it/l •'r... '� .. ,�.... .IS. J +i•r` 4r fie'. ^ Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 590.003(A) Assignment of Responsibility* 3-302.11(A)(]) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* 2-103.11 Person in charge--duties Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH _ Other* 2 590.N)3(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11.(A) Food Protection* applicants* 3-302.15 WashingFruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge' Contamination from the Consumer 590.003(6) Reporting by Person in Char !- 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated orContaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Fes* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance Temperatures?' ti itizaon with Food Law* 4-501.11 t Manual Warewashing-Hot Water 3-2,01.12 Food in a Hermetically Sealed Container* San ' 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shelf Eggs* Sanitization Temperatures* - 3-202.14 Eggs and Milk Products,Pasteurized* 4-501..114 Chemical Sanitization-temp.,pH, concentration and hardness.Ice Made From Potable Drinking Water* S 3-2D2.16 c d 1.11 5-101.11 DrinkingWater from an A 4-6 roved System 0 (A) Equipment Foal Contact Surfaces and Utensils Clean* 590.006(.4) Bottled Drinking Wa er* 590.006(B) Water Meets Standards in 310 CMR 22.0" 4 602.11 Cleaning Frequency of ti Food- 590,006(B) Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-70111 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreational ly 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 Anus* 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(0) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 1.1 Good Hygienic Practices Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11 - PIIFs Received at Proper Temperatures* 2401.12 Discharges From the Eyes, Nose and 3-202.15 Package Integrity* Mouth* 3-101.11, Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained" - Employees* Tags/Records:Fish Products 13 Handwash Facilities 3402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(7) 1 Labeling of Ingredients` 5-204.1.1 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11S ecialized ProcessingMethods* Devices 3-502.12 Reduced oxygen packaging,criteria* (i-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-30]..1.2 Hand Drying Provision '*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. h„ ` I "�ij'4ir'°B.'�Y:✓�Z, f�t�,triJY�.-.x.,^r,.++- �b"1�.,c.5R�^/�� I Massachusetts Department of PublicoHealth Isal m Board of Health ° Division of Food and Drugs 120 Washington Street,4th Floor 9 Salem, MA 01970-3523 A.K FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745b343 Name y Date Tvoe of Ooeration(s) Tvoe of Inspection ( ❑ Food Service ❑ Routine Address \ S o Risk ❑ Retail ❑ Re-inspection Level [IResidential Kitchen Previous Inspection (� Telephone (1 q _ El Mobile Date: 4-q-c Owner V ` LH HACCP Y/N [-ITemporary E] Pre-operation 1,Lp ❑ Caterer ❑ Suspect Illness Person in Ch�ge (PIC) (� Time El Bed&Breakfast E] General Complaint In: ❑ HACCP Inspector Aj, D Out: Permit No. ❑Other Each violation checked requires an expati6ln on the narrative page(s)and a citation of specific provision(s) violated. UNon-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) [_1 590.009(F) ❑ action as determined by the Board of Health. ,a EJFOOD PROTECTION MANAGEMENT L, 12. Prevention of Contamination from Hands F-11. PIC Assigned/Knowledgeable/Duties Eli-EMPLOYEE HEALTH 13. Handwash Facilities „ s. `,PROTECTION FROM CHEMICALS + h, -T F G E] 2. Reporting of Diseases by Food Employee and PIC . ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals �❑4. FoodD FROM�dW WaterSOURCE u=�0L �� :�'_. �:�.._.��.,..�.",1 j1"TIME/rEMPERATURECONTROLSiPMeiitislii'Hazardous Foods �' "' m Approved Sourcewv.. .n,� . .q Y ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 16. Cooling PROTECTION FROM CONTAMINATION �1 ;"_ ❑ 19. Hot and Cold Holding ❑ 6 Separation/Segregation/Protection M _ ❑ 20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing - 1lTREQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) El21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices rCONSUMER ADVISORY _ ,;-„, ,"-�°'� ❑22. Posting of Consumer Advisones 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 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.50011s10Fmm 14.d. Inspector's Signature: P.. A Print: r I C C7 rn PIC's Signature: �\ Print: J Page_of Pages v Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT $ Cross-contamination 1 590.003(A) I 590 003(B) Demonstration of Knowledge* � 3-302.11 A)ii.} Row ed anal Foals Separated from d P _�_ �- Knowledge" ked and RTE Taxis* 2-103.11 Person in charge-duties Contamination from Raw Ingredients - 3-302A I(A)(2) Raw Animal 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 fail employees and 3-302.11(A) Food Protection* a tllcants* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Foal Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) Re otdng b Person in Char>e* 3-306.14(A)(B) Returned Food and Reservice of Food' 3 590.003(1)) Exclusions andRestrictions* Disposition ofAdulterated orContaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Foo& 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590O04(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Scaled Container* Sanitization Tem eratures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eg. s* Sanitization Temperatures* 3-202.14 E �s and Mrlk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, concentration and hardness. 3-202.16 Ice Made From Potable Drinking Water* 5-101.11 DrinkingWater from an A roved System* 4-601.11' (A) Equipment Food Contact Surfaces and 590.006(A) Bottled DrinkingWater* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0" 4-602.11 Cleaning Frequency of Equipment Food- Contact Surfaces and Utensils* ShelNish and Fish From an Approved Source 4=-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Reereational'ly Caught Molluscan Food Contact Surfaces of E ui ment* 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 Re ulato Authorft 2-301.11 - Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.1.1 PHFs Received at Proper Temperatures* 2-401.1.2 Discharges From the Eyes, Nose and 3-202.15 Mouth* 3-101.11 Food Safe and Unadulterated* 3-30112 Preventing Contamination When Tasting* 6 Tags/Records:Sheilstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification * 590.004(,E) Preventing Contamination from 3-203.12 Shetlstock Identification Maintained* Em to ees* TagstRecords:Fish Products 13 Handwash Facilities 3-40111 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacifies* 590.004(J) Labeling of Ingredients' 5-204.11 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 Handwashinz Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-301.1.2 Hand Drying Provision Denotes critical item in the federal 1999 Fond Code or 105 CMR 590.000. - '.�5*w-r*yt�^'�'�i.vf{w:^+•rrnsmK.11.�t1� 4.. 'F.+'._.� ,lb*..,rw.,.-"�+LS+1`. .w,T*drv' .d+n,-�..r�-+E'sq�'�'Mt'�+f`Ii,w..'1��..,M.,-J 1. Massachusetts Department of Public Health Salem Board of 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 Name Date T of Ooeration(s) Type of Inspection lz�q( Sr Food Service Routine Address v G S` _ Risk to`Retail Re-inspection C TIY P_ Level 15 Residential Kitchen Previous Inspection Telephone Cu r I ((_ ❑ Mobile Date: Owns I r HACCP YIN El Temporary ElPre-operation r1inn/\ I i .x ` ,Q )A4 A)_0 ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time [IBed&Breakfast El General Complaint lOf,lMwIn:11 'U0 ✓' ❑ HACCP Inspector )-)1�n)n ,� ( Out:L} , Permit No. ❑ Other Each violation checked requires alS explanation on the narrative page(s) and a citation of specific provision(s)violated. U 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)-tr�seo.e09(F),� action.as determined by the Board of Health. FOOD PROTECTION MANAdEMENT -d�; `"" € ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties ❑ 13 Handwash Facilities EMPLOYEE HEALTH i- " � �� 1 -�'` E �" 1�3 - ,;,,µ .r �r ;„- .,ice .�. r „m..... .�; .PRbTECTION FROM ❑ 2. Reporting of Diseases by Food Employee and PIC � - - �m,a „ ,.„ _•„ _--� m„-,�' .t &, - a ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.TOXIC Chemicals j`'FOOq FROM APPRUVEb SOURCE=r` „ol ❑ 4. Food and Water from Approved Source f,TIMErrEMPERATURE CONTROLS(,PiikhHallyHa"za'rdous Fo6ds) rl- bimwP>s ❑ 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 STM I s � �x f 7 q tr F 13 El 19. Hot and Cold Holding a-vpdc. s. El❑�B.�Separation/Segregation/Protection 20.Time As a Public Health Control , ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REpUIREM NTS FOR HIGHLY ,U k,TIaLE Pt3PULATICN5(HSP): El21. Food and Food Preparation for HSP El 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices f1coNsuggg ADISOR , jz , " ❑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 C by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(990.009) 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 Ior revocation of 25. Equipment and Utensils (rC-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)(590.008) 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 5901nspeclFo,mb14,tlw Inspector's Signature: '�,> /�� !/ Print:- PIC's Signature: 4 �� Print: 0 5 [i v / 1 Page_ of Pages r- violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION__ FOOD PROTECTION MANAGEMENT S Cross-contamination 1 590.003(A) Assignment of Respimsibility* 3-302.11(A)(]) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* 2-103.11 Person in charge---duties Contamination from Raw ingredients 3-302.11(A)(2) Raw Animal Foals Separated from Each EMPLOYEE HEALTH Other` 2 590.003(C) ,Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11.(A) Food Protection* applicants* 3-30115 Wa.sbing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) _ Re orcin b Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 3 1 590.003(ID Exclusions and Restrictions* OfspositionofAdulterated orContaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.1.1 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCEFood* L4 Food and Water From Regulated Sources F 9 Food Contact Surfaces 590A04(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Ford in a Herm_eticall•Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.1.4 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanifizatmn-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness.* 5-101,11 DrinkingWater from an Approved System' 4-601..11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled DrinkingWater* Utensils Clean* 4-602.1t Cleaning Frequency oP E:quipment Fcwd- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Sheish 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* 4-70311 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* to Proper,Adequate Handwashing Game and Wild Mushrooms Approved by ReLu toryAuthorlt 2-301.11 Clean Condition-Hands and Arius* 3-202.18 Shellstock Identification Present* 2-301..12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 1.1 Good Hygienic Practices Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2401-12 Discharges From the Eyes, Nose and 3-20115 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Togs/Records:Sheiistock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification * 590.004(B) Preventing Contamination from 3-203-12 Shellstock Identification Maintained* - Employees* Tags/Records:Fish Products 13 Handwash Facilities 3402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Reoords.Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(7) Labeling of Ingredients' 5-204.11 Location and Placement* g Conformance with Approved Procedures 5-205.11 Accessibilit O rexation and Maintenance JHACCP Plans Supplied with Soap and Hand Drying 3-502.11 S ecialized Processin Methods* Devices 3-502.12 Reduced oxygen packaging,criteria* 6-301.11. Handwashing Cleanser, Availability 8-103.12 Conformance with Approved Procedures* r6-301 12 Hand Drying Provision '"Denotes critical item in the federal 1999 Food Code or 105 CMIZ 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name:c_�� C""— Date: Page: of Date Item Code j C-C riticaitte DESCRIPTION OFNIOLATION/ PLAN OF CORRECTION rVerified No. Referencead Item j R R a.z �LE�Sii PRINT 6�6��Y 4 A', �)b L/ 410 1 TA PAA-1, A-,` D � C' V A t f A 0 v SII Discussion With Person in Charge: Corrective Action Required: 0 0 Yesy Employee Restriction I have read this report, have had the opportunity to ask questions and agree to correct all Lj Voluntary Compliance E) Exclusion violations before the next inspection, to observe all conditions as described, and to o Re-inspection Scheduled 0 Emergency Suspension comply with all manclates.of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ED Embargo 0 Emergency Closure your food permit. CJ Voluntary Disposal Lj Other: 5f}1 latC1 'e zeefive at emlserxiurca Violations Related to Foodborne Illness Interventions and Risk Accordi ag to Lain Cooled to Factors(fterms 1-22) (Cont) _- -.- _ 4 1 IF/45F Within 4 Hours, PROTECTION FROM CHEMICALS S_7t12.75 Ce"Ijn,,,NRdn:d�to PH�=UT Fs_r " E7--_ 19 PHF Hot and Cold Holding 14:] Food or Color Additives _4: �-,150!.16(B) Cold PHI Manna inc-1 at or beli,w 3.202.12 A7dkfi t i v as, 590,004ff� 4P/45`F' _�o�c�tLon front tan lint Protcction frau Urt��_ 17 501 I6(A) int IHFe Maintained at or above L15 j Poisonous or Toxic Substances - 101.11 Idenfifyiro, mfolmalion 140'F orl"'Inall 3-��N,16(ik) Roasts Held at or—'+.'coozr - ------- containers* L F—Time as a Public Health Control 24) Comelon'XaiW5_`k 3-i01 Time a, a[Public—Health Control' --I 590.004H) Variance Ircw ent 1-202.11 Restriction--Presonce and Use* 7 202.12 Coridhiop"of uso* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 203.11 Toxic Cuiaainzi, -PidnRidome POPULATION S{HSPS _�a r-204.1! mlf7en'Criteria -clicinicals* 21 5-8011;(A) Uirpa�tcirriizd PIc-packaged Ivicts and 7725212 cficnlicale for WaSh1u_Li:aqncc' clitcriw Bcvvraees w Waron I !"'W' 7204 14 Crneria� ------ '4 -pie'teari7ed EE�L,* 7-205,i I Incidt-mal F'>xl Corta(t,Lubricants' "-80 1,11(B) UsQ of or PailiAl,,Ccoked Animal FiIod and RQ"oi c'11'ad Pe,ricalas,Cri te I ta* 3-801A I t,D) Raw Rae, SLII�11 4 ii 7-206A2 1 Roelem Bait Stauoas 3,80 1 11(c) -served, 7-20615 1 racking PowderiN�r Control and �Fcod Pack, ais� No CONSUMER ADVISORY _ - TIMEITEMPERATURE CONTROLS L22 TZw7 TTcoosurnor As!'IsorF postcdTlr coulamptnat Of ttileal 1,"(I&That trc Raw. Undercooked ia 16 Proper Cooking Temperatures tar A PHF5 Not Oflter. irc Proceqioed to Eliminate 1,11A(l)(2) Fgg,- 155'F 15 Sec. -1 302 13 �11 RA 14.i'Fl5sec- A P�Ntcuriz-d E&g�.Subsfitm�kit -,a,Shell ael� 40 Ll I(A)(2) Conant cited Fi'�lo Meets&Gaine Animals- 155"F 15 secSPECIAL REQUIREMENTS 7451 Pork and Beet Roast - 1304` 121 mink 3 410 1.11(A)(2) 590Of79{A}-f D; of 6t ns of Sctkton 59O(X)9(A)-(D) in 155+15 scc'. catering, rnohihfitod, temp wai v and ii 3-401.I I(A)C3) Poultry,Wild Game,Staffed PRFs, resident'A kitchen operations should he Sinding Conuaining Fish,Nam, dchned under the appropriate.sections 1 ou3�or Ratnois-165"T }5 ties. abuvo if related to Rxxiborne illnsti 3-40LIJtC)f3j 'Nhole na*elcImart Reaf Sleaks inteiventionia,)d risk factors Other 590k009 violations rehaing to,,00d rehul ed in tv debited un 3-401J2 akk Annual Foods Ccxagder#29 - Nliciow ve 165'F _401,11rAi(I)Ib) All Oliva PHFs-- 145,1715 sec ; - L117'ell",_111�111111'c'111�111�_! -VIOLATIONS RELATED TO GOOD RETAIL PRACTICES IL_117 Reheating for Hot Holding 3-40TUXT&W) llflt, 165°F 15 swc. (items 23-30) 3-403,11(B) Microwave- 105F 2.Mima,Standing Genital arid non-f raiecil ctulatiuris,'which do nal ,elate to the `time" foodborne fluters bywi ventiono Mid roklactors licecd abm,e can be 3-403A 1(C) Commercially Processed RTE Kood- fir=tjnd in I4,kwaulogstations ol"he Foorl Code a !05' ('Nfl? 140'F`' 590'(W)0. �Rem T&d -RetmFor cd — 3-40111(F ) Rel"ainin urazliced Portions of Beef -4, 540060 Roast,* ent and Per,onnpl PC -2 1 �003 Proper Cooling of PHFs 24 Food and Ford Prol(x1ion PC '004 - ---------- -- ment FC 4 005 140%) E w.rltng Calked PF'fFs from 140 P to 2cr t Nater Pt[snhi,i enc" --- warte I PC-5 006 7WF Within 2 Hours and From 70"1' 27, Physical Fadlfty_ ---------i io 21 F 145F Within 4 Hour. I 26 Poisonous or T,))k lvkilena!s FC -7 008 Coolina PHFr Made Front Ambient 2L lisp iznA;im 669It i rompe r anire Ingredients to 4PF/45 IF 3_0--- other__ -------- _j Hours" I Deno es non In lh'r"(kel i CITY OF SALEM (� - � n BOARD OF HEALTH Establishment Name:RJ;6� � U XJ1X RlL�)c F� Date: -CA Page: of. Item, Code C-Critical item t- T s " f" DESCRIPTION OF VIOLATION/PLAN OF CORRECTION u ' ' Date, fi No ? Reference 'R-Red Item _ �- A Ven-ed ,. v --,tttri''.. _. '` = PLEASE PRINT CLEARLY .^. k; �.% 4 -'S. �' x is '.'4' kA - a"eTA ,t Il _'i'!t,1/Y� l�/nirl'(lOnnOA l/vl �e�, ,.n,n I �!•. A v�/ •e.. A J-9 pX, � 97e Y n (l /n l i1 ra k / v i q�'\ " nny (C/ 76 0.P � �� , Qom` ,�� -r. ; c. C P Q zn f ® qua of U �OA", 0\(.i17 t Discussion With Person in Charge: v Corrective Action Required: ❑ No es , 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 P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure iyour food permit. ❑ Voluntary Disposal ❑ Other: L ' S violations Related to Foodborne illness interventions and Risk Aclondin,to Law Cooled to Factors(Itents 1-22) (Cont) At I'0745`�F Wilbin,,` Hours coll1im,NRLW's for PBF PROTECTION FROM CHEMICALS PHF Hot and Gold Holding xq Food or Color Additives Cold PH mami'lifled at or below 3-202, --tAddiUvI, 3-3(12.14 i Protection from Unapproved aetdinves`-- -3Toi.16,A) I lot PHFc Maintained at err above Poisonous or Toxic Substances I -I ---- j4(j'F. R)LI1 tilemit'ving lflftii Illation -Origii at 1 koaas Held at or,,itaive 1301F 20 1 Time as a Public Health Control I Common Namz;-- workml,,Cowin ners" 3-501 19 Diat asaPublic lithin(Aintrol' Variance mL,,,,,ut awal-Sna alo�` 7-20111 Rest,ict ion -Prestucc and I',e" E7:2102 I LConditions(if Uso, REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203 11 1 atnel-.--Prof 4bi�I—vnoPOPULA I NS(H SP 204.1—1 Naaviwts.Crileria --0claicals" Chi meats fai Wati�lyg �-�ahtcc,CEdetial 21 L80 1,t I(A) I lopv aelin�cd I lre-pacfa�cd All ces all, -17-11204,!2 Belo!rjaes with 04 14 41 ae Ile of faausn cd Fit". i0,5,11 landamill Rxxl Contact,I-Aol icaliti,� Raw or Paitiall'i Coot-d Aritnal Foi TFI I I I(D) I Told lie PeNticides.Criteria" Raiv,Seed�� 7�206.12 Rmlent B�ii Stati(cc,' ?nnzts to Ld. tin inciresl X t-R a, 206.1 'Trackill ptbi C.ontrol and CONSUMER ADVISORY 22 3-6( Cl, er , d%isory 'Nwiol for(Alusumption of TIMEITEMPERATURE CONTROLS T)n—�u —le 16 1 Proper Cooking Tempma v es r Anhwd That art:Raw. Undercooked ia PHFs Not 0diermse,11rcx,e,sseal to Elblifflate 401A 1 J-,gg-- 155 Pa` �infdlaie Service 16,911,5,sec' 11�7! 113'," —3 1)� FIJI,, Seurii-ed Ege:;sobvitult fill Raw shell T 3-401AI(02) cortullintwxi &Galne Aidinais SPECIAL REQUIREMENTS 746l.l l(B)(I 2) _ Pork and Beef Roam 00"F121 mi0 590 009(A -(i 'iolalmnz,cif Secliou 5WW9(A)-(1D') In Rat le� lojecfed N�Rat� 15,S'F 15 caterinmobik "xi, kernporary and rt�tnlfnrlial Litcfien ope[alions Should tin '-401.11(q)r3) Piadtrp,Wild Gamn. $in Fted i4TCs, Slotting Con!aining Finn b4ea IcInted finder the appropriate sections Poultry or Raoics-1(51- above if is lated to foudborne illness Sao' 0-1 111�(-) , NIT/11a, lnuselvintact Beef steaks Intel vont:onq Alld Jsk faclors. Other 145'T 5140,009 violationa, relatin', to "1, A retail 0 a 3-40JA2 Raw Aninuil Flxxk Cookcd ill a practices iihould lie ticbittrif under 1129 - Special Requircan-aits, I _Wj—,Fi,�TA) All Other Pffl--s-- 1451: 15 �ec, Eli 7 lleheltffiq for Hot Holding VIOLATIONS RELATED TO GOOD RETAX PRACTICES 3-103,11(A)&,(1)) Ptll�, 1652 15 sec. (Items 23-30) +-403,1 l(B) -Mieik)wave- 10'P2 Mianle Standing clinra!wid nun-critical violqPoas, which do no relare p)rte Time' ltoodhorne tflnest ilaei ventiony and ilskfih,tors lishiff-, abne. enol be /leoidin theJollowing i� he Ffuld Cade ao1 d 0-5 C'M 4011 i(C) 1 Comro�rciallv Pna:elsed RTE FW - I 'It 40'F1 590.00l), -Tte;W-T dcodigetall-PrecTiceis PC 00 Remainim,Undiced Portion;of Beef —--------- 23� �Mialawffrlalnl Ind Per c.nnei Roast-:* ... 24, Fioxi;and Food ProtLc�tivon FC:�3 1 064 Proper Cooling of PHFS —,----- --l- -E�JjjL 25 Equ (irlty�d -_;iq C, 001 !2n ------------ 26 FG-5 1 X-6 -—---------- 70'F Within 2 1 lour�and From 70'F 27, -�,Physiralracilh� FC-6 i i 28. 1 Poisonous or T,,:lnr Mater a!x FC -7 008 3-501A4,(B) Clowa PHFb Made From Ambient ficla e-quirema009nis Tempolaolre lngredients to L30- L01h-cr--,--- -j Within 4 floins' of Dlavlles Ml 1-al gem in IV,,rok li .! 19,1),)toml Gere or 105 C k4k 590 006 Commonwealth of Massachusetts b City of Salem Board of Health 1Gmberiey Driscou 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Foo"etail Establishment Permit DATE PRINTED: 12/30/2008 ESTABLISHMENT NAME: Rita's Water Ice File Number:BHF-2007-000057 186 Essex Street East India Square Mall SALEM MA 019710 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2009-0332 Dec 30,2008 Dec 31,2009 $280.00 ESTABLISHMENT FROZEN DESSERTS BHP-2009-0333 Dec 30,2008 Dec 31,2009 $25.00 Total Fees: $305.00 PERMIT EXPIRES December 31, 2009 Board of Health j , 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 f CITY OF SALEM, MASSACHUSETTS f BOARD OF HEALTH 120 WASHINGTON STREET,4"FLOOR TEL. (978)741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 NtWOR JDtoNNECa�S ALent.COM JANET DIONNE, ACTING HEALTH AGENT 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT �/p NAME OF ESTABLISHMENT ��ItS ( "VA7t'2 LC TEL# ADDRESS OF ESTABLISHMENT ACX ��5�� Sly FAX# LVA MAILING ADDRESS(ifdifferent) EMAIL-Business': ( - 1 /_ T27. `�� Website: CVM OWNER'S NAME ` <t /� STEL# ADDRESS Z �Jr D / STREET CITY - STATE p r� ZIP //� / CERTIFIED FOOD MANAGER'SNAME(S) �d `i(JE-4Y CERTIFICATE#(S) 5 /�O / y�b (Required in an establishment where potentially / ar o��u//s food is prepared) EMERGENCY RESPONSE PERSON ;" " y HOME TEL# �06 DAYS OF OPERATION Monda LTuesda ' 1 ' Wednesda ,, :I-:y.Thursda rz I ' .:Friday Saturda . Sunda ` HOURS OF OPERATIONrAt l S -F S— F Please write in time of day. i ! (For example l lam-11pm) A"t TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES \/NO less than 1000sq.ft. _$70 1000-10,000sq.ft. /C-$280 more than 10,000sq.ft. = 420 RESTAURANT YES NO less than 25 seats $140 (Outdoor Stationary Food Cart$ 10) 25-99 seats 280 more than 99 seats --------------------------------------------------------------- - -- -------------------------------------------------------------------------------------------- BED/BREAKFAST/ YES (!TJ $100 CHILDCARE SERVICES -- ---------------------------------- -- - --- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YE NO 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. Purs alrt 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 retu pnd pai I state es quired under the law. 2 -12-1 6 Signa Date Social Security or Federal Identification Number -------------------------------- ------------------ ---- J i Revised 424/07 FOODAP2008.adm Check#&Date 16 e-Ia CITY OF SALEM i BOARD OF HEALTH / !!! Establishment Name: V\ias were '(- (-t Date: `7L�1 taT Page: ' of ? Item =, Codes r +C-Critical nem �'� _� DESCRIPTION OF VIOLATION"/PLAN OF CORRECTION „ r:o- Date No Reference R—Red Item ' ' t�mx m %' m 9,,. •f.x„ /'t J" a'kA" �'-' .;a s +',, mow -PLEASE PRINT CLEARLY 'm «".,P>T>s W s. .f'. ;01, mfr: a-,. a -ro: as Verified f't -Iris ec.'t o n 0+ -Nis midu c ted 6,W, c�t u i S(i { 1 tl S 1 � I 1 S I S 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 i violations before the next inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension i comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollarslor suspension/revocation of C3Embargo ❑ Emergency Closure your food permit. /� 1_eet t kL ❑ Voluntary Disposal ❑ Other: �A f v 3-50114(0 PfIFs Reonved at Temperatures Violations Related to Foodborne fitness Interventions and Risk Acaudili?to Lav Cooled to 10 an Factors(hands 1-221 {Cont.j 41�F!45'F Within 4 Fbqtrs. PROTECTION FROM CHEMICALS 1 15 Coolin"'Methods for IlffFS PHF Hot Holding 19 L14 Food or Color Additives F? 3-50!,16(B) Cold PHI Maural tined at or below ---t 590.004(F) W/1151�F� .201,E Akiid�I��,1 1 3-3(12J4 Protectl�ui from polsonous at Toxic Substances 14WR 16(.A) Roasts Held at in above 1301. containurs, Time as a Public Health Control 7-102,11 Councon Name-Workim,Coanoflers* LLAL---- 3.501 19 7 inal as a Public Health Contrill s90.()04(H) V"Mitince -2�f2 11 Rest0,on -FresLnco and US 7-20i 12 Condition"of Uso* 77631 it REQUIREMENTS FOR HIGHLY SUSCEPTIBLE ToKic,Conlamct�- Prohibitions' 7- 1 Sanhi/ttq,Criteria-Chemicals, —POPULA IONS QHS�P 204.1 1-- 21 01.11(A) Unfla%ucurizzil Pre-flack1ged stlicirs Win 7?04.IZ 014 D A ts_C iteria, 3-80 1,1 ILB2 _BRLe ol Past�Lu ist�izsti�d lLp�s 7-12�0 5,11 4j1m:i:A,.n1al Nslil Contact.Lubricants' -'llcdind L7-25I L_ critelta� -e Rav,st d S l mv;Not Servet ved 7 '06.12 Rodcul Bnit Stations' ULA, 11-06 1 l 'I'mcking Powderi. Control and CONSUMER ADVISORY 22 3 4lio--1 11 (on annel Aaislsv poitcd A',w t ottsu notion of TIMErrEMPERATURE CONTROLS [-16 Proper Cooking Temperatures for— Anklol f caidc)liar art Raw, undercook-ed of PHFS Sec Not Othei v,iw llox:ess�,d to Elimmice latho"em -,—40 1 11 At)(21 F.gg,- 1,55-TTS 14fFl5sec, 3-3010 Pzere qll lizd Eg&.:Sobstitlde inRa"Sn", -401 TI(Aik,) Aniumus- lin 1 isec. '� SPECIAL REQUIREMENTS .3 401 11(B)(1)(2 i Perri Ino ftet Roast 130 1 121 min* 590X9(A)-(D) Viohnioms of Section �90.W9W,(D) in hiiectcd Wals-- 15'F Ls se, catering, alobilofood, temporary and 1 3-401.11{A)13) Poultry, Wild Game,Stuffed IlIfFs" rc,idcibial kitchen operations should be Suilfijig Comaining Fish.Meat, I Johiled urolcr the appropriate sections Poubry or Ratites-i65'1,'15sec. ' aliove,if related to ftAxiborric illness 3 10 1.11(C)(3) Whole-mus'.1c, Intact 130J Steaks Intel Vellijolls and risk taetias, OthcT 145F 590.009 violaliuns relating to flood retail 3-40-1 Raw Amnall FiNxis Cooked in a prat bees should 1-i,debited under#29 - Miciowave 165'F* Special Requireme=nts. a Ehll la,, VHF s-- 145V 15 sec. l7 -- Reheating lot Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-;iT3 11�(A) �0) Pt-lf;, 165"F111 sec. :*. (Items 23-30) 3.403.11(6) Nficrowavc- 165'F 2 Mimic, Standin,, CjWrol and non-criiwal isolfalloim, which do not relati,w mr. TiWO, fifelborne dlrw5s and i-akfinfors t,tied ahoic (on be 3-4011.1(C) Commercially Pfocsed RTE Fivid found in li/Ae Food Code and 10-5 CWR 140'P 5-463)t{131 Rentainin", ullshced Portionill of licer latin Good Retail Practices FC 5".000 2i- _tijL nagernLnt An C!jjer-,cslrP.,l PC -2 1 N3 _ _ Ig 0" FG- 3 �004 24, Foodand Food Prolecn Proper Cooling of PHFs 25 mli-3�,CU Cen�,-1 FG-4 005 3-501 14W Cooling Cookz'd PFIF's frorn 14(FF it) 1-- 26, W Bier P1 rnbin PC-5 W6- 11 ---- -t-a i-1 - - -1 70'F Within 2 Hours and Rom 701 hysicaijacillirl 007 _?7 P r 28� Poisonous or Tom Niiter Ws 1 PC -7 1 .008 ;,—W , ,4B) CooliuL PHR Made Front Ambient—' 2 _ 2�Sp Jallq,1 tm�Lto 'wil _ ther Tcuiperature In to 41"F/451F DO,- - -2� Withm 4 Bolus� S I Devva , [a:.0 4na)in th"1�denel 1954 Food C,Aor 105(AR 591)000 CITY OF SALEM (Inn tt BOARD OF HEALTH { Establishment Name: 1 If 5 � ('ur iCE' Date: �I IOC' Page: I of I nem„ ,Code C—Critical item , DESCRIPTION OF, VIOLATION!PLAN OF CORRECTION . , fir: Date �No. Reference a "R—Red Item a -y c y d Verified - ^,± -- " �« �'^ - % 4 * - PLEASE PRINT CLEARLY '* '*� _ _ x.,, e, A re_ -iv,� t?ec+oy) ¢� this es-I-ab 11 l� v110 nt tact conduc`1 , and f�i l Y Fri e,n cxt",�6� + -7.er is ( )i-\ bl e roc l"CAiV (r)t(2,011 -rnC4-M(3 eter-, wid ' all v )t lee- 614il)J at ccirreizt trarcpacdores. bI.15hwLarit V�� c�5t !-,o -,e a (CU,0s-ftd �3s1 -c�rrtro l O �Ge�r p ; or to op-ul;nci . •,o s Ye -in�_bee 11 on iS s ct�l�d -Eor ��v ��iy 187"Cart �O'Ic;C�tm , �"�Sani Bran r 1 r f i t 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 (DVoluntary Compliance ❑ Employee Restriction / Exclusion violations before the next inspection, to observe all conditions as described, and t0 ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines/of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ( � —ft^w ❑ Voluntary Disposal ❑ Other: A E v r F> 5111 -j#C,T- -—--—-- , ItIvId ai i7em ldre� Iffolations,Related to Foodborne illness Intonrentlons and Risk According to 1,ac Cooled to Factors(item 1-22) (Cont) 41'F45 F Within 4 Hours. PROTECTION FROM CHEMICALS L!-9- PHF Not and Cold Holding Lj L4 or Color Additives 350'"—16(6) To-41 PHF,Maintained at r>r—befow 3-2()2,12 Atkiitive," 590 00(F) 41045"F* 3 V2 14 ProtcU nnf2m trnaplttoted Addirjvcs' 3-50 1.16(A) I he PHF,� Maintained at or above Poisonous or Toxic Substances Fdeail Conedall infontenton -Ori-inal -ti— --4 1 0 -50L16(A) I Roasts Held ai or above 1309% neW t Time as a Public Health Control L i-102 11 1 Common Name--�s�ordnn Coutaincrs* LAL 3-iol 19 1 Tono as a Naha Health Control, 7-20 1.11 Lll�amdoa so�� ---- 90�00400 coann 7-202.11 �1 iou-Pr(-,"nx and 7-102.12 Coadition�of'Use' 7-203,1,1 Toxic Containers- REQUIREMENTS FOR HIGHLY SUSCEPTIBLE - POPULA IONS(HSP 72 4.11 sarfililer�,Criteria -Chemic-20 21 3-8131 71(Iv; Ullpti,acul-wx!Pre-pacF,97d iolccs and Chenlical�for Rcvene,,cs withRainml,ib is CoraAct.Lubrictm[0 rT26 11 Incidval F" -5-801.1 tiff} F Lcl_0t=MZIA_P� 2 01 Raw or Paiiiaib,ClK)k-dA;jimAI Food and ff--2061 R,��oiccd-LNe Cntnata� 71 (5T - - Raw Sc ed 1proavNot Served. 7-206J2 1 Rodent Bait Stasi n' r-l—' ------------ 3-80 ED-11—�E "06 1 tracking Powder.Pesa Control and CONSUMER ADVISORY TIM&TEMPERATURE CONTROLS 22 3 TT"Alunsulne, . asotv Po swd fort ons cit Uirlal I-,Kxis floaary Raw, Under"kedc) 16 Proper Cooking Temperatures for PHFS Not Other,,\iw Processed to!�,ldnimar Patfiocm 3,401.1 IA(1)(2) F-Igp,- 155'F 15 Se c. ---�� i45,115sec'r piqeam"I Fqg: Sub&btlfte tor Raw Shell Animals- hat I7 sec. " 3 121 Iran*1717,iiT) l '(,if and beat Roast 1507 SPECIAL REQUIREMENTS I 590,W91A)-lD) Vioijwn!,�of Section 40009(A) (Pion 1-40 Raote�, Iniecicki %tuals - 155�F 15 (A)Q� entering, -nottricfood, temput in and 3-40t.11(A)13) resident- I kitchen open ations should be Stuffint;Containing Fish, Meat, I debited under the appropriate seefions Poultry(it Ratites-165",F 15 sett Atove if related to ftx)dtxa-ne turns 13-401 1-10013) Whok aluscle, Intact Beef Sleaka, interventions and risk factors Other 145'1; 5d0.009 violations relatin, to qPW retail 3 -401.12 Raw Animal PoWs Cooked in a practices.ihoold be debited under #29 - Microwave 165'F* Speekji R0Q0irCM0nt1- 3-401,1 ffAi(I)fb) All Other PH11-1-- 145`1715 sec. Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAILPRACTICES ;03.1 ( T17 FIHFI 1651, 15 sec, ^ (Items 23-30) 7—403—.It(b) -'Aicrowave- 165°F 2101nule standing Crus(-al and non-crit viol deans,iviir.hdo not relate the foodborne illness wvi lcmiony w;d nskjaciors Rvtedabove, call b" 3-40111(C) Comincicialiv Pirie-Sled RT'E.Food- found in rhe finflclo;ioc ections ol(the Food Carle maty Joi CUR 140'F er 3-401 I I(F) Rernamin- Unshved Portions of Beef - -----art actives C 5,90.0w --- Roas(s M nagemlent and perzonnel i FC 2 1 .003 1 Food and Food Proper Cooling of PHFs Cooling Ccoked PHFs from 14f)'F to ---------- -------- ----------- 26, FC-5 i .006 7 F Within 2 Hours and From )0°F' K-6 o)41-F/45'F Within 4 Films. 28 1 Poisonous or Tom kensriw_ �FC T 008 3,501.14(B) Ccnhug PHR Made From Arnbilail -29, SPeea Re �i evit's -1— Temperature Ingredients io4l`K45`F --Other ------------- ------- -.—.----- ----------.----- DMAes cnucal acin ill lbe(Jer,0 1999 Food C(gle of 105 CMR 590 0W CITY OF SALEM 1 �/y BOARD OF HEALTH 7 Establishment Name: Date: I__, �g Page: of j nem Code ;, C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION 'g"- ' 7 Date r No. Reference R–Red Item y, r '. a %""� , ' "'-""'' .. rep .Verified PLEASE PAINT CLEARLY n f)p 1 rn IYl < .�PCf/7nL3t -N/11< P5� eP �� mo_ /I.t C r.�h� i� 4C. l i 4wk1111) , lcPyr. s v 72)_ in ,rb ac-p- U ro u,i Y7iV29 VY1(Sc�l'la P� _"LSCC 1 czf 1c Q_t S-�CI P n . ,F-P J csr�c Ua�h �S , rP lA cR.11 - un a er w and siva tr2`tV a.6rl u .k ; Ivi1"5� ci�S . oom_ Mvii vlP �veVS YVt u4 ezh Z_' S1 I r cc�t t zrp Hecq ( a re- Y)s F'( t x C i am all esu nt o-t- in :ottero -r n er 'h 3 1 a Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance 13 Employee Restriction I have read this report, have had the opportunity to ask questions and agree to correct all Exclusion / i 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,twennty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. L f�( �/ �,• � � �— �� ❑ Voluntary Disposal ❑ Other: A t 1 3-50 1 14W) f"IfFs Recciwd ut Temperatures Violations Related to Foodborne illness Interventions and Risk Am)ofiaf,to La" Cooled u) Factors(iia rm 1-22) (Cont) 41=F/4S-EWiinn 4Hume. PROTECTION FROM CHEMICALS — Nfetbo&�for[111Fs 19 PHF Hot and Cold Holding F God or Color Additives 3-50!,J&B) Cold PHFs Maintained at(w bel-ow - -_202.i2 -1 ' 590.()()4(F1 41�/45`F- AdZmcll LLSlim PHF.xtdaintainedere oridnove- Poisonous of Toxic Substances 140'F 116 Roasts Held at or ,bow 130-1 Container:' L2fl T- --j T"ime,as a—Public—HeafthControf , 7 102,11 1 Common Name- Workin,Container,* 3-5011"90,004E H) Prone as a Public Health C 1, V�Jrjcc,'e �202 11 riction-Prc's(nce and Us�,* 7-20112 couditiorc,of UsvREQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203 n� S(HSP- -Pnohibnio0' POPULA ION 1-204-lT SanitizetTritt�rin-Chemic ifs* 2 FTT-�F)i`F�A7;-- 1131pa Rtculn f"I Juices—wid 7-204.1 2—T ilemicak fi it Wasit L�)Lh� e 7 20414 Pil Critcria fleverascs,uth Warnia-Labsis' , _ �' -L'�s 3-801AI(Bi U,e-o!"Pa,tcumed 7 Inciat met. e-801,11{7>) Raw or Partially Ccx)ked Animal F(Kd and ,de at F�xxl Co— -T206.11 RosmucdUse Pa nudes. Raw'Sted'ST'rouls Not Served. -206.12 mmti lent Bait Soas� P R - RC served. �T�0— 1 6,13 Tracking Powder.,Psi Control and Z CONSUMER ADWSORY----------� � , IT Consumer Auviscxv P(Ated for(-onsumpuion of TIME/TEMPERATURE CONTROLS C 22- -T0Ak)hnA &'T Fsihat arc Raw C, idercookcd is Proper Cooking Temperatures for Not Orhom ise Prot ssed w Elinnate PHFs P b 1, 3-x401.1 FL S- 15,5'F 15 Svc.. L "oiLs" 145'Fl5sec, --302.I I P,wum-dFgt., SubsHtw,!foi Raw Shell 1-401.11W(2, Comminuted Nnh Meats&, Game Animals - 1551, 15 sec. " - ---- SPECIAL REQUIREMENTS oi and ficel Roast 1301' 121 nauO 3-401.11(8)(ITt2 I violulif)ns of Section 590�009(A}-(D) in _74t)1.11(S)(2) fioie�,dlnieoodfvlcats- 155'F 15 "'co. catcrinl- mobil c food,ternporary and - 'oultry,Wi FdEawe, $(urfrxl PITFs, Is mdouf4al kitchen operations should be Swffiug Conhumm,FishIdeal, debited und-In the appropriato ,ecuools Llomlup or Ranter 165=t 15 sec. above if related to fbexiborne 11111C,15 3-401.t I iCti!) whole-rewele huacl Beo'I'Sleaks intervelnicins and risk factors Otbf-r J4501* --- 590.009 violations relating t0 .,,o(tj retail 3-401,12 Raw Animal Fofyj.,s Cooked in a pmcticcs ,hould t debited under f29 Mwrowave 165'F* Spcend Requkernortle. —.ml othen Pivs - 145�F 15 sec- j7 Reheat-ing for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-1,03.1,l(A)&,(17) Pilt,lbs -5 Utems 23-30) 1'65"cF 2 Minot,Standul" wi'dchdry ria velure todw Tj Inc' foodhorns iihwss on,"l veneom'wid rokfir(lorr liilcd above. con be 3-403.11(C) 1 Commercially Prociwd RTE Kxsf f(mrid in the joli0it ingserrions of tae Food Code and 105(.,IIR 140'1-* ,90l000. 3-403.11(F) Remaijun- Unsliced Portions of Beef LAO-ft! T Good Retail Practices FC 590,00 r24 23� F C 3 004 Proper Cooling of PHF5 --1 Equipment and Utensils FG 4 t305 ?.-501.14(A) Cilwoo rood Cksd PRFs from 17)zk ill 2 1 6, i ?WT Within 2 Hour�and From 70T i FC-6 007 io 4 1 1-145'F'Wilhin land Houn. 28, Poisonous or Tom MatercilG 1 FC-7 1 D08 -7-50114( Coofifig PHFs Made Flunk Arribrent 24 -qpn -59ayirff ant-i Temperature Ingredients to 4l'F/45cF O Within 4 lhmr r IMPORTANT MESSAGE FOR pp 9 n /� DATE �Z�'U 7J TIME ,-�AP-RJI-- M !�,/OcZU�iLJ OF PHONE AREA CODE NUMBER EXTENSION ❑ FAX ❑ MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED In E CALL C!}ME TO SEE YOU WILL CAU_AGAIN WANTS TO SEEYOU RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE G SIGNED V ps FORM 4009 ��iii��// MARE IN U.S.A. NOTES - - - IMPORTANT MESSArpE ` FOR /j DATE -�� "0e TIME a2_ .M. M OF PHONE AREA CODE NUMBER EXTENSION O FAX O MOBILE AREA CODE BER 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 FORM 400 MAGE IN U.S. ,/ � d � . 1 CSS t � � �'i 'i � ,, \\ � , � �, � \ � s � �` � 1 � \ 1 ';; J�� J ,---� IMPORTANT MESSAGE FOR L) �7 - ll ! DATE /nn1 U0103 TIME . P.M. M n ( i4rLT Q OF //CJ bH"s �iJG1IaPc�� PHONE �U-KU-�ad AREA CODE NUMBER EXTENSION ❑ FAX I] MOBILE AREA CODE NUMBER TIME TO CALL rTELEPHONE[) - .PLEASE CALL E CAME TO SEE YOU WILLCALLAGAIN WANTS TO SEE YOU RUSH` RETURNEO YOUR CAU_ WILL fAX TO YOU MESSAGE 4 Ze ge-,/n SIGNED FORM 09 q . MAOE { �___ _ -__ -�,� � 1 -- - - i t r i ' - - - _� .. _ i _,- - - - _ « T_ -� - - - --� 2009-04.27 12'49 RITAS ITALIAN ICE 19787417482>> 978 7450343 P I i7 Integrated Pest Management altha n Detailed Service Report �- 1. 1111111511111111111 Waltham Services 817 Moody Street Waltham, MA 02453 781-8931810 Client: 966606 Service Location: 9666D6 RITA$ RITAS CYNTHIA WEAVER CYNTHIA WEAVER 158 ESSEX ST EBB ESSEX ST SALEM,MA 01970-3705 SALEM,MA 01970-37DS Customer Signature: TacchhnkUn Eic Signature: 1!9arfitketione , Tme In: 4/27/09 11:57:54 AM Time Out: 4/27/09 12:19:15 PM robin k ERIC HOMAN - Order# / invoice Service Date Description 1617473 04/27/2009 Commercial Service Agreement Deficiencies/Observations Resolved Today Area/Device Deficiency or Observation Severin Responsibility Resolved INTERIOR law TBD 4/27/09 Condition: Trash left out overnight,main source of red eyed fruit Ries. Device Past Summary Device Summary With Without Totel Device Exception Pkat Activity Quantity Device Type Activity Activity Inspected Replaced Removed Inaccessible Nopesticawo,found RODENT BAIT STATION EXTERIOR(2) 0 2 2 0 0 a RODENT BAIT STATION INTERIOR(1) 0 I 1 0 0 0 -Tonh 0 3 3 0 0 0 Additional perr AAndims maty ham been observed,Apex gee deficiencies end mmrrenh for mere details. Material Application Summary Material Applied EPA Number Dosage Dilutor Unit Quantity App,Method Lot No. Conax Blm - 124SS-79 0.0050 1 Ounce 2.00 STATION Area of Application.INTERIOR o SERVING->Device 1 Target Priv:Rodents PHANTOM TERMITICIDE-INSECTICIDE 241-392 00000 O.W Fluid Ounce 12.00 SPOT Arae of Application:EXTERIOR Target Picts:ANTS PHANTOM TERMITICIOE•INSECTICIDE 241-392 00000 0.125 Fluid Ounce 6.00 SPOT Area of Application:INTERIOR-,BACK STORAGE Target Rests: FUNGUS GNA PHANTOM TERMITICIDE•INSECTICIDE 241-392 0.0000 0.125 Fluid Ounce BOO SPOT Area of Application:INTERIOR->DINING Target Peso:ANTS Pape 1 Commonwealth of Massachusetts ` City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Temporary Food Permit DATE PRINTED: 07/31/2009 ESTABLISHMENT NAME: Rita's Water Ice File Number:BHF-2007-000057 186 Essex Street East India Square Mall SALEM MA 019710 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes TEMPORARY FOOD BHP-2009-0528 Jul 31,2009 Aug 3,2009 Food to be served: slush Total Fees: PERMIT EXPIRES August-3, 2009 Board of Health YA Page 1 b .Sr CITY OF SALEM, MASSACHUSETTS + BOARD OF HEALTH 120 WASHINGTON STREET,4°'FLOOR TEL. (978) 741-1800 KINIBERLEY DRISCOLL FAx(978) 745-0343 MAYOR DGREENBAUM&ALEN1.COM DAVID GREENBAum, ACTING HEALTH AGENT APPLICATION FOR A TEMPORARY FOOD SERVICE PERMIT FEE: 1-3 DAYS= $300 NON-PROFIT=$25 4-7 DAYS= $600 OVER 7 DAYS= >7 DIVIDED BY 7 X 600=THE AMOUNT DUE. (EXAMPLE:14 DAYS DIVIDED BY 7=2 X 600=$1200 CHECK PAYABLE TO THE CITY OF SALEM NO CASH NAME OF EVENT (c) /^/� r LOCATION Jc.( 6 it l�O DATE(S)OF EVENT NAME OF APPLICANT 1 G' l"1'�"U S TELEPHONE# ADDRESS L ^{-- } Ct ,Q NAME OFBUSINESS .. TTELEPHONE# ADDRESS rXOC ( J CERTIFIED FOOD MANAGER'S NAMEifhf' "c t Cioal�. CERTIFICATION# A PLAN OF THE ESTABLISHMENT IS: ENC OSED DRAWN ON THE BACK TYPE OF REFRIGERATION: _GAS ICE DRY ICE OTHER METHOD FOR COOKING/HOT HOLDIfI GAS _OTHER METHOD FOR SANITIZING: CHEMICAL OTHER SOURCE OF FOOD: NAME: ADDRESS FOODS TO BE SERVED INCLLIPING INGREDIENTS AND METHOD OF PREPARATION: RU t Ge_ S Cl !?T 42-4 1 HAVE READ THE BOARD OF HEALTH, "REQUIREMENTS FOR TEMPORARY FOOD ESTABLISHMENTS."I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS REGARDING THOSE REQUIREMENTS. I UNDERSTAND THEM,AGREE TO ABIDE BY THEM AND UNDERSTAND THAT FAILURE TO DO SO WILL RESULT IN REVOCATION OF MY TEMPORARY FOOD ESTABLISHMENT PERMIT. PERSUANT TO MGL C62C,S49A, I CERTIFY UNDER THE PENALTIES OF PERJURY THAT I,TO MY BEST KNOWLEDGE AND BELIEF,HAVE FILED ALL STATE TAX RETURNS AND PAIATATE TAXES REQIJJb2EDl./1 UNDERLAW. X11 �l('/�J~�J)�,/l,1 - SIGNATURE DATE SOCIAL SECURITY OR FEDERAL ID# TEMPAPPL REVISED 11/25/02 PERMIT# CHECK#B DATE CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH • 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO Kimberley Driscoll HEALTH AGENT Mayor REQUIREMENTS FOR TEMPORARY FOOD ESTABLISHMENTS These requirements are in accordance with the State Sanitary Code of the Massachusetts Department of Public Health, 105 CMR 590.030. This code states, 'The Board of Health may impose additional requirements to protect against health hazards related to the conduct of the temporary food establishment, may prohibit the sale of some or all potentially hazardous foods, and when no health hazard will result, may waive or modify the requirements of these regulations." Therefore the Salem Board of Health reserves the right to evaluate individual establishments and make necessary requirements to protect the public health. FOOD MANAGER CERTIFICATION IS REQUIRED OF ANY TEMPORARY FOOD ESTABLISHMENT THAT PREPARES POTENTIALLY HAZARDOUS FOODS. ALL TEMPORARY FOOD ESTABLISHMENTS MUST COMPLY WITH THE FOLLOWING: • The Board of Health must receive the application for a temporary food establishment at least one week prior to the planned event Halloween vendors must submit their applications at least three weeks prior to the event. Unpermitted establishments shall be excluded from the event. • Foods served are limited to the following: Baked goods, fresh fruit and vegetables, and pre-cooked potentially hazardous foods. Raw chicken, raw beef, raw pork, or other raw potentially hazardous food is NOT allowed. • The application must be filled out completely. Incomplete applications may result in a refusal to permit the establishment. • The application shall include a plan of the set-up of the establishment including the location of equipment, cooking facilities and cooling units. • Necessary permits for the operation of the establishment, including the Food Permit, must be conspicuously displayed. • Running water with liquid soap and disposable towels for hand washing must be available. Bottle water with a pull out spout is acceptable. All food handlers must wash their hands after utilizing toilet facilities, eating, or smoking. Smoking is not allowed within 10 feet of the establishment. • All utensils and food contact surfaces must be sanitized with an approved sanitizing solution. Test strips for that sanitizing solution must be used to verify its strength. • Premises must be kept clean. Refuse and garbage must be disposed of in a satisfactory manner. • All utensils, equipment, and containers must be maintained in a clean and sanitary condition. • Food handlers must wear clean outer garments and utilize good hygienic practices. • A permit from the Fire Department is required for the use of propane. Contact Fire Prevention at 978-745-7777. • A permit from the Electrical Department is required for the use of a generator. Contact the City Electrician at 978-745-6300. • Permits may be required from the Licensing Department. Contact Licensing at 978-745-9595. TEMPORARY ESTABLISHMENTS MUST ENSURE FOOD PROTECTION BY ADHERING TO THE FOLLOWING REQUIREMENTS:. • Only foods listed on the permit may be served. • Cold foods must be maintained at a temperature of 40F or less. • Hot foods must be maintained at a temperature of 140F or higher. • Food must be obtained form a permitted source. Proof of the source must be on site. • Stem thermometers must be on site to check that proper temperatures are being maintained. • All food must be covered and protected during transportation, storage, preparation, and display. Food shall not be stored on the ground. Trash bags shall not be used as storage containers. • Bare hand contact of food is not allowed. Tongs, tissues, clean gloves must be used when handling ready-to-eat- foods. ON SITE INSPECTION OF YOUR ESTABLISHMENT WILL BE CONDUCTED BY BOARD OF HEALTH SANITARIANS TO ENSURE COMPLIANCE WITH THE CODE AND THESE REQUIREMENTS. IF VIOLATIONS ARE OBSERVED YOU MAY BE REQUIRED TO CEASE OPERATION AND TO LEAVE THE EVENT. Joannes folder:tempfood " ' Commonwealth of Massachusetts e i City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01470 Food/Retail Establishment Permit DATE PRINTED: 07/03/2008 ESTABLISHMENT NAME: Rita's Water Ice File Number:BHF-2007-000057 186 Essex Streeet East India Square Mall SALEM MA 019710 LOCATED AT: SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2008-0480 Jun 23,2008 Dec 30,2008 $280.00 ESTABLISHMENT FROZEN DESSERTS BHP-2008-0481 Sun 23,2008 Dec 30,2008 $25,00 Total Fees: $305.00 PERMIT EXPIRES December 30,2008 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beefre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS • • BOARD OF HEALTH 120 WASHINGTON STREET,4°1 FLOOR TEL. (978)741-1800 KIMBERLEY DRISCOLL FAX(978)745-0343 MAYOR COM JOANNE SCOTT, HEALTH AGENT 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT ViTAI.S WATEIe. 1046 TEL#TCFdl/dki ADDRESS OF ESTABLISHMENT SSEX a -Aisw FAX#�L" MAILING ADDRESS(if different) EMAIL- Business': C71SCJ00L79E-AT-CLL(' eAol Website: L/nik)-'Ri=AS IC9. CUM OWNER'S NAME Oto 44j;ft VJE'AU�6.4 CorrN TEL#_ 906- 3� -?201 ADDRESS Zy 0A"-r i2 K6 LIMA/ A n I i` � STREET �� '',I II CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAMES) 1// 71%1%A WEh II CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) TO EMERGENCY RESPONSE PERSON HOME TEL# DAYS OF OPERATION Monday Tuesday Wednesday 1 Thursday Friday Saturday Sunda HOURS OF OPERATION Please write in time of day. /() — /0 /0-/d 10- /0 /o II /o -// 10 ' �Q (For example l lam-1 l pm) TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORENO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 1 0,000sq.ft. =$420 --- ----------------- ------------------------------ RESTAURANT YES less than 25 seats =$140 (Outdoor Stationary Food Cart$2 25-99 seats =$280 X more than 99 seats =$420 -------------------------------- ---------------------------- ---- --------------------------------------------------------------------------------------------- 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. Purs nt 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 retu s nd paid state t es r fired under the law. , Lame &h748 /Z S Signat Date Social Security or Federal identification Number SOD k Ca ll7�d 8 e syn � ,� Lveavar wal 4v •uv Iih1 A-w P/ow/,nto-yw rt ar, w �d I o> ot`r CITY OF SALEM, MASSACHUSETTS LICENSING BOARD 120 WASHINGTON STREET ti? A _., jt SALEM. MA 01970 TEL. 978-745-9595 EXT. 5648 DAVID J.SHEA,CHAIRMANJOHN H CASEY 9�c�MMe FAx 978-744-6775 RICHARD C. LEE BARBARA A.SIROIS KIMBERLEY DRISCOLL CLERK OF THE BOARD MAYOR HEATH DEPARTMENT NOTIFICATION FORM IF YOUR APPLICATION INCLUDES THE SERVING OF FOOD YOU MUST HAVE THIS FORM SIGNED BY THE HEALTH DEPARTMENT PRIOR TO SUBMITTING YOUR APPLICATION TO THE LICENSING BOARD. (this form MUST be signed and returned with your application). NAME OF BUSINESS Corporate name: 9 Coo I TecA7 S LL.(; d/b/a: i T A+ SL-AJ f3Tn+2 a E LOCATION: i TELE. # Tvs;da,.c i TYPE OF LICENSE ' -ra APPLICANTS INFORMATION Name: Kfv;Af tA)EA\tEe Homeaddress: zc/Caejeee-zed City: LYn,l State: *,7A Zip: p 19 a Home tele. # -7 8 t_ :SIR 7 Z-7 HEALTH AGENT/INSPECTOR'S COMMENTS: 0�44 CIL Ll DATE_ °�) H Agent cowl dcpi.notil ions RITA'S ICE 168 ESSEX ST. TENANT FIT-OU ,ME�FYEI�T EXISTING TENANT SPACE 001 0 N1H o AiOWCiION II --J �� M051MdOS:arthtlecnve W \ ®4 R Ply! SALEM,MA 01970 W - -- — - 97&745.9541 h � � - L viww.Be051u0bs.Cwn K II .TA'4 5E191 S I I I0e1 —t $LONGE/OFFICE I `\ QED GED GEDaaD GED 2c al t I N0 ELEG l= PANELS +w meatmao a OL1lIP4NBMPl: o DDD QOD DDD a�0 a -D EXISTING TENANT SPACE O03 EXSTING TENANT SPACE MALL Ell F CE ] \ [ 008 l01 (\`T/V� � fteMebne Om MALL ENTRANCE (INTERIOR) 100 ►1RIfA5.10E SCHEMATIC DESIGN FLOOR PLAN�MUSEUM PLACE I sx�vw SmL: SCHEMATIC INFORMATION DESIGN ONLY FOR FLOOR OWNER REVIEW- PLAN NOTFOR CONSTRUCTION 070259_RITA_11x8.5_M1enu_3add 3/27/07 3:29 PM Page 2 e. t¢d n , {/a�f R Pot-Free,cool treat meds Prom Ica and real Frult. a - q hyering of our Vanilla or Chocolate _ P - Made Fresh doll with over 30 to uetin it ,,. `k 1 g n9 n9 f Frozen Custard and your Favorite A- 10 s ,r Fw10 Flavors. $$nH sueoi. .seas i Pkwor of Italian Ice or Cream.Ice" e�OO s,. a 6000 9000 6000 _ 9 O 9 fi. 's OUART$0.00,GALLON$MOO 00 00 •% ' PARTY BUCKET(25 GAL)SMOO m ITALIAN ICE FLAVORS e, - s 5; . _ Alex's Lemonade(Lemon) Pino Colada Vr'- Ei: s1 r Banana Raspberry �L�nn C��pj f Blueberry Raspberry Lemonade W V I M.M�.[°6 k ,✓ .} 3 Cherry - Root Beer SS -P Chocolate A creamy cool shake that blends our Vanilla or T - Strawberry _- - Citrus Blast_ `^ Tangerine Chocolate Frozen Custard and your Favorite Plovor . Grape Tropical Punch of Italian Ice or Cream Its,to create an ' Green Rpple Twisted Melon Incredible boste sensation. ' Island Fusion'-' -Vanilla ROOM .+ooEt Kiwi-Strowberry ° Watermelon - 6000 6000 Mango Wild Berry Passion Fruit Wild Block Cherry Sugar-Free Pink Lemonade Sugar-Free Root Beer - Sugar-Free Cherry c Suger-Free Tangerine ° n � " # ` CREAM ICE FLAVORS JeAW - CU A}CLAil`' • x ,;I 'v s Bonano Split Cream , Fudge Brownie ,x*.- - A gourmet soFt serve with o smooth sobiny texture.' Berry Banana Croom Mint Chocolate Chip Made with the highest qualiby Ingredients to make "- ' •+ Cappuccino Cream Orange Cream the toete richer and smoother;Alto%Custard »§� Chocolots Chip Cookie Dough pistachio 'e .r. Vanilla Coconut'Com . Is b Far the best. P CookiesN Cream xxnH $Ea. na spE . ; _ 9000 9000 9000 '�.' M Custard Flavors `'OP - � + Vance SPRINKLES 000 WAFFLE CONE;000 - „` . Chocolate ' ^r. _'B �• r . Twist n 0 . a A delicious blend OF creamy Frozen Custard, t- ,-. strawberry ° N Fresh Italian Ice and cookie bits that's sure a to satisFy any sweet tooth - ff 7oppich A deliciously sweet coating of Hot Fudge or Not;Caramel 3- T } x4kws ,�� ,�r>ea�.w Is the perFect complement to our a , +'� t • . _,. '" + ' `s 'tasty Frozen Custard. EmHO 00 9 $Eos. „p 000 Hot Fudge Hot or mal 6 BOTTLED WATER$0.00 PRETZELS 000 EACH 3 FOR$0.00 rr ° Tri9t �snk.I.gLcn.t:"a O'CVU�QL .. � _ F, q �-�� B � � a a� " r m�> •. = [ MAP,ORE O and NRW A or registered brademorks of He Hokllngs,Inc. gt " Prices do net include soles tae. � � � � ACCEPTED MR 090259_RITA_11x8.5_TOMenu_3add 3/2]/0] 3:29 PM Page 1 - a: ♦ y - wti +W. W . .. y. 1.11,111►11111Ma r F dc' v Cu,o=tc A 4appu rbb. It all stooled in the summer of 1984. For months, Bob Tumolo and his mother Betty had been experimenting and -' developing.the best-Costing Italian Ice. When they Found _ just the right delicious recipe, RiGo's was born. News of • ` .` RiGo's tastytreats quickly spread throughout Philadelphia 4P g and by 1989,RiGo's began Pronchising. In May 2005, Rita's `twos purchased-by McHnight Capital Partners, which ° served as o7ounching point Por the company. Currently there ore over 400 Rito s stores in 14 stoles and growing _ Y ^^ our goal or Rito's to produce,the highest quality - �sy4 - s •<' v products at reasonable prices,while providing exceptional Pamily-Priendly service. To ensure that our products are '"- consistently great.tasting, we Freshly prepare our + r produces oG each store location every morning.Freshness - r�A- '.''s # ✓' is something we will never sacriPlce.This we promise you. % -_o 1 a TF ...a ,. _. We ore extremely dedicated to providing every guest with ° o memorable store experience. Each Rito's location is .. $� �': 9 -ry. jindependently owned`on&operoted and our Franchise s Q 11'artners aim to -wow" you with every visit/We hope this visa is special and we look Forward to seeing your smile again soon. _ F .•Jim Rudolpb Choirmon oP the.Board&Chiep Executive OPPicer r ' i Visit us Ot: _ 1052 W.Emmons Ave. _ 1905 Union Blvd 9914-18 Tilghman St. Allentown,PA 18103 Allentown,PP 18103 Allentown,PA 18104s' i ra -0 610-43"01010-435.1199 kv. 610-797 666 `a b e� 6141* any k ' WWW AlkA6LCE.COfM1 w. - .1 + ' FA _ 3ss '.3; +4 'A� b a .'.r e X o � V l f- 10 I TM I Finish Schedule & Material Specifications n4Ai'a Wover ( 0 q08- 33$- 7Aol �•sf Tndra �quNr !Matt Finish and Material Schedule Page 2 of 23 Table of Contents FINISH TYPE CODE PAGE Flooring —Armstrong VCT FF-00 3 Wall base WB-00 3 Flooring -Altro FF-00 6 Paint PT-00 7 Front Face of Counter FC-00 8 Wall covering WC-00 10 Chair Rail CR-00 14 Countertops CN-00 15 Ceiling Tile CT-00 16 Furniture FN-00 17 Decorative lighting DL-00 19 Fluorescent lighting FL-00 20 Track Lighting TL-00 21 UPDATED 9-17-07 Finish and Material Schedule Page 3 of 23 FLOOR FINISH CODE SOURCE DESCRIPTION SAMPLE/NOTES Vinyl Composite Tile FF-01 Armstrong Armstrong World Manufacturer: Armstrong s r r Industries P.O. Box 3001 Product: Vinyl Composite Tile; ut Lancaster, PA 17604 Standard EXCELON Imperial `- Texture ' ' a ' Contact: Local Wholesaler, Product#: 51880 see wholesaler list Color: Marachio Thickness: 1/8" Size: 12"x12" Location: Customer Seating area; Bath and Service area optional Vinyl Composite Tile FF-02 Armstrong Armstrong World Manufacturer: Armstrong Industries P.O. Box 3001 Product: Vinyl Composite Tile; Lancaster, PA 17604 Standard EXCELON Imperial Texture Contact: Local Wholesaler, Product#: 57508 see wholesaler list Color: Blue Dreams Thickness: 1/8" Size: 12"x12" Location: Customer Seating area; Bath and Service area optional Vinyl Composite Tile FF-03 Armstrong Armstrong World Manufacturer: Armstrong Industries P.O. Box 3001 Product: Vinyl Composite Tile; Lancaster, PA 17604 Standard EXCELON Imperial Texture Contact: Local Wholesaler, Product#: 51809 see wholesaler list Color: Desert Beige Thickness: 1/8" Size: 12"x12" ` Location: Customer Seating area; Bath and Service area optional WALL BASE CODE SOURCE DESCRIPTION SAMPLE/NOTES Wall Base WB-01 JOHNSONITE Manufacturer: Johnsonite — --' www.iohnsonite.com Description: 4" Rubber Base with lip Color: 192 Tide Water Color Palette C Contact: Don Brickweg Mfgr Location: Order counter and perimeter P: 513.560.1032 walls Camillus Musselman Rep P: 614.554.6005 UPDATED 317-07 Finish and Material Schedule Page 4 of 23 V,iom i NZ n ^! l m. 1 Y yam ` 3 4 UPDATED 9-17-07 Finish and Material Schedule Page 5 of 23 ..^. tea.. + r ; i r sa iy.;. s � UPDATED 9-17-07 Finish and Material Schedule Page 6of23 FLOOR FINISH CODE SOURCE DESCRIPTION SAMPLE/NOTES Seamless Flooring FF-04 Altro Floors www.attrofloors.com Manufacturer: Altro Product: High performance safety r. flooring °1 " Collection: Altro Impressionist 11 o Color: Rame Red �"� ` Contact: Louis Quinn CERTIFIED ALTRO INSTALLATIONS ONLY } P: 800.377.5547 F: 412.841.4275 Location: BOH/Kitchen; Behind quinnfs@aol.com Service Counter and Bath optional UPDATED 9-17-07 Finish and Material Schedule Page 7 of 23 PAINT FINISH CODE SOURCE DESCRIPTION SAMPLE/NOTES PT-01 Sherwin Wiltiams Manufacturer: Sherwin Williams Product#: 6406-14931 Color: Bright White Finish: Semi Gloss Location: All interior Trim UPDATED 9-17-07 Finish and Material Schedule Page 8of23 Front Fate of Counter CODE SOURCE DESCRIPTION SAMPLE/NOTES FC-01 FORMICA Manufacturer: Formica www.formica.com Product#: 7197-58 P: 800.formica Color: Dover White Finish: Matte Location: Front side of Service counter Note: Distributor Places orders on Tuesdays and Fridays, one week Lead time from FC-02 QUAKER CHROMA Ordering date. 225 Executive Drive, Suite 10 Manufacturer: Quaker Chroma Moorestown, NJ 08057 See Special Order Form Contact: Elissa Levy ce{ustara Nappinn P: 856.382.0750 Location: To be applied to front side F: 856.382.0772 of service counter on top of white laminate elevy@quakerchroma.com UPDATED 9-17-07 Finish and Material Schedule Page 9 of 23 u qw " C Hip OPP Ls 14 �� IIID ee•,,;e®�, F- 4� v - y -• Ice.CU a ines r UPDATED 9-17-07 Finish and Material Schedule Page 10 of 23 WALL COVERING CODE SOURCE DESCRIPTION SAMPLE/NOTES WC-01 MARLITE FRP Panel 202 Harger Street, Dover Ohio 44622 Manufacturer: Marlite P: 330-343-6621 Product: Symmetrix www.marlite.com Part#Identifier: C 100044 Color: White Contact: Bill Mcdonald Panel size: 4'x8' or 4'x10' P: 973.831.8324 Panel Thickness: 3/32" C: 330.260.7628 Pattern: 4" squares E:bmcdonatd@marlite.co m Location: Behind Service Counter, restrooms below chair rail MARLITE FRP Panel WC-02 202 Harger Street, Dover Ohio 44622 Manufacturer: Marlite P: 330-343-6621 Product: Pebbled www.marlite.com Part#Identifier: P-199 Color: Brite White Contact: Bill Mcdonald Panel size: 41x8' or 41x10' , P: 973.831.8324 Panel Thickness: 3/32" C: 330.260.7628 Finish: Pebble Surface r E:bmcdonatd@marlite.co m Location: BOH/Kitchen WC-03 MARLITE PVC Molding 202 Harger Street, Dover Ohio 44622 Manufacturer: Marlite P: 330-343-6621 Product: Comer/ Edge www.marlite.com Guards Inside Comer Contact: Bill Mcdonald Product#: P: 973.831.8324 Inside Comer: M350 C: 330.260.7628 Outside Comer: M360 E:bmcdonald@marlite.co Outside Corner-High Traffic: M M961 Outside Comer Outside Edge mid-wall: M370 Division between panels: M365 Size: 8'/10' X 3/32" FLOutside Comer-High traffic Color: White Location: BOH Kitchen, restrooms, Service areas Routside Edge mid-watt PLI—.-Division between panels �'TO BE USED WITH PEBBLED ONLY UPDATED 9.17-07 Finish and Material Schedule Page 11 of 23 i �41 T i* S e CU9T7t t9Ez nrx I" PI 1 We ww ; �► UPDATED 9.17-07 Finish and Material Schedule Page 12 of 23 WALL COVERING CODE SOURCE DESCRIPTION SAMPLE/NOTES Wall Covering WC-04 WOLF GORDON 33-0047 th Avenue Manufacturer: Wolf Gordon Long Island City, NY 11101 Description: Montage www.wolf-gordon.com Product ID: G 476 4073 Color: Arctic Width: 54" Contact: Ginny Laird Unit Measure: Linear Yard P: 800.347.0550 Actual Product#: MTG 5.7504 F: 718.361.1090 C: 216.288.1073 Location: Walls of customer area above chair E: ginnyt@wolf-sordon.com rail Note: Please contact Ginny Laird for coordination. Wall Covering WC-05 WOLF GORDON 33-00 47th Avenue Manufacturer: Wolf Gordon Long Island City, NY 11101 Description:Mirabel 2 www.wolf-aordon.com Product ID: G 474 3179 Color: Arctic Width: 54" Unit Measure: Linear Yard Actual Product#: 709.01 Contact: Ginny Laird P: 800.347.0550 Note: Please F: 718.361.1090 Contact Ginny Laird for coordination. C: 216.288.1073 E: Rinnyi@wolf-Rordon.cam Location: Walls of customer area below chair rail locations allowing for a 3-4 week lead time. UPDATED 9-17-07 Finish and Material Schedule Page S@a � W\ � m / 2 � 4,41 } - . � ww } .. . � . � . . g +r . . . . UPDATED 9-17-07 . Finish and Material Schedule Page 14 of 23 CHAIR RAIL CODE SOURCE DESCRIPTION SAMPLE/NOTES CR-01 Obtained locally by general Description: MDF chair rail with contractor routered edge Size: 4"x'/s" Mounting: Bottom at 29"AFF, top at 33"AFF Color: Painted White Location: Seating area UPDATED 9-17-07 - Finish and Material Schedule Page 15 of 23 COUNTERTOP CODE SOURCE DESCRIPTION SAMPLE/NOTES Solid Surface CN-01 DUPONT Manufacturer: Conan corian.com : Color: WHITE CAP , Contact: Dave Greening Edge: Bull nose Ohio Valley Supply Co. P: 800.696.5608 X 6116 ` P: 614.759.7144 Location: Service Countertop F. 614.759.7144 Dave.greening®ovsco.com UPDATED 9-17-07 Finish and Material Schedule Page 16 of 23 CEILING TILE CODE SOURCE DESCRIPTION SAMPLE/NOTES CT-01 USG CEILINGS Manufacturer: USG 6603 RENWICK COURT Description: Frost ClimaPtus WEST CHESTER, OH 45069 Ceiling Panels, Fine textured, 7 www.use.com good acoustical properties Color: White 7 Size: 2'x 2' x 3/4" CONTACT: MARTY HAAKE Product Number: 414 P: 513.907.6985 Profile: SLT shadow tine tegular F: 312.214.6624 Edge: SQ Grid: Donn Brand T: 800.874.5219 X 8220 ZXLA; 15/16"; Flat White MHAKKE@USG.COM WWW.USG.COM Location: Customer/seating area i +,•>.:° Y V .Sglfr Note: Standard product in stock with a maximum of a 2 week lead time. CT-02 USG CEILINGS Manufacturer: USG 6603 RENWICK COURT Description: Sheetrock Lay-in WEST CHESTER, OH 45069 Ceiling Panel Clima Plus, www.uss.com smooth textured, non- acoustical, USDA food service " CONTACT: MARTY HAAKE approved P: 513.907.6985 Size: 2'x 2'x 1/7' (3260)/ F: 312.214.6624 2'x4'x1/2" (3270) § T: 800.874.5219 X 8220 Product Number. 3260/3270 It MHAKKE@USG.COM WWW.USG.COM Location: BOH Kitchen, service _. area, and Bath z UPDATED 9-17-07 Finish and Materiat Schedule Page 17 of 23 FURNITURE CODE SOURCE DESCRIPTION SAMPLE/NOTES American Trading Company Dinning Chairs FN-01 12 Headley Place Fallsington, PA 19054 Name: Valencia Side Chair w/o Arms Contact: Paul Weintraub Product Type: Aluminum P: 215.295.4040 Seating C: 267.879.1689 Stackable F: 215.295.4488 Size: Overall- 18W x 23D x 32H Color: Red www.amtradeco.com ' i Location: Dining Area FN-02 American Trading Company Dining Table base T 12 Headley Place Description: Cast Iron Cross foot 1 Fallsington, PA 19054 base with adjustable plastic glides Contact: Paul Weintraub Finish: Black matte Finish P: 215.295.4040 Size: 22"L x 22"W x 28"H t G 267.879.1689 Thickness: 3" F. 215.295.4488 Table top www.amtradeco.com Description:Molded laminate, Rita,s custom B-14 bine,SM EZ Perso with white border Dimensions: 24"x 24"or 36" round Location: Dining Area UPOATE0 9-17-07 Finish and Material Schedule Page 18 of 23 a� t mill . r t v ` v UPDATED 9-17-07 Finish and Material Schedule Page 19 of 23 DECORATIVE LIGHTING CODE SOURCE DESCRIPRON SAMPLE/NOTES WESTERN EXTRALITE Pendent Light DL-01 COMPANY - distributer 2444 Northline Industrial Manufacturer: Besa Lighting Maryland Heights, MO Discription: Line-voltage pendant 63043 Item#: 237-CHR-RB-SN-F Color: 1509 Ruby Contact: Mark Kaner Finish: Satin Nickel P: 314.432.4560 Mount: Monopoint C: 314.503.4790 Voltage: 120 F: 314.432.3877 Wattage: 40 E:mkaner@westemextralite. Dimensions: 4.5"W x 8.0"H com E LIGHTING PACKAGE FOR DETAILS OR SE Location: Dining area and over counter Accusery Louisville, KY 40218 SEE REFLECTED_CEI LING PLAN FOR EXACT LOCATIONS Contact: Charlie Jacobs P: (877) 707-7378 "coordinate with Lighting rep on appropriate light specification per ciacobsiMaccu-serv.com location. Z PEW= UPDATED 9-17-07 Finish and Material Schedule Page 20 of 23 FLORESCENT LIGHTING CODE SOURCE DESCRIPTION SAMPLE/NOTES WESTERN EXTRALITE FL-01 COMPANY - distributer Description: Parabolic 2444 Northtine Industrial Size: 2'x2' Maryland Heights, MO 63043 SEE LIGHTING PACKAGE FOR DETAILS Contact: Mark Kaner Location: Seating area P: 314.432.4560 C: 314.503.4790 SEE REFLECTED CEILING PLAN FOR EXACTI F: 314.432.3877 LOCATIONS E:mkdner@westemextratite. ^ com •coordinate with Lighting rep on OR appropriate light specification per location. Note: 2 week lead Accusery time for in stock Louisville, KY 40218 fixture. Contact: Charlie Jacobs P: (877) 707-7378 ciacobs@accu-serv.com FL-02 WESTERN EXTRALITE COMPANY- distributer Description: Light troffer with prismatic 2444 Northline Industrial tens Maryland Heights, MO Size: 2'x4' 63043 SEE LIGHTING PACKAGE FOR DETAILS Contact: Mark Kaner P: 314.432.4560 Location: BOH Kitchen; service area only C: 314.503.4790 if required by health department F: 314.432.3877 E:mkaner@westemextraLite. SEE REFLECTED_CEILING PLAN FOR EXACT com LOCATIONS, OR •coordinate with Lighting rep on Accusery appropriate light specification per Louisville, KY 40218 location. Contact: Charlie Jacobs P: (877) 707-7378 cjacobs@accu-serv.com UPDATED 9-17-07 Finish and Material Schedule page 21 of 23 TRACK LIGHTING CODE SOURCE DESCRIPTION SAMPLE/NOTES TL-01 WESTERN EXTRALITE Description: Track section COMPANY - distributer Size: 4' or 8' sections 2444 Northline Industrial Maryland Heights, MO SEE LIGHTING PACKAGE FOR DETAILS 63043 Location: Service area, mounted 2' back Contact: Mark Kaner from menu boards P: 314.432.4560 C: 314.503.4790 SEE REFLECTED CEILING PLAN FOR EXACTI F: 314.432.3877 LOCATIONS E:mkaner@westemextra li te. com .coordinate with Lighting rep on appropriate light specification per OR location. Accusery Louisville, KY 40218 Contact: Charlie Jacobs P: (877) 707-7378 cjacobs@accu-serv.com TL-02 WESTERN EXTRALITE Description: Track Heads- PAR30 Holder COMPANY - distributer 2444 Northline Industrial SEE LIGHTING PACKAGE FOR DETAILS Maryland Heights, MO 63043 Location: Service area, mounted along track Contact:Mark Kaner P: 314.432.4560 SEE REFLECTED CEILINGPLAN FOREXACT C: 314.503.4790 LOCATIONS F: 314.432.3877 c y E:mkaner@westemextralite. .coordinate with Lighting rep on \ r. com appropriate light specification per location. OR Accusery Louisville, KY 40218 Contact: Charlie Jacobs P: (877) 707-7378 cjacobs@accu-serv.oom UPDATED 9-17-07 Finish and Material Schedule Page 22 of 23 Mrs . F � t l.:.a.4 xe a R y� x k; UPDATED 9-17-07 { t t � � 528 �1xJ L"J t T+ten.R erc ll,y •M12 54� sa. m M14 gas 532 ......vR@ iT5 4 57 5` .—TRA PORNeK . 544 :Mt ':5I'✓. 542 O ,56 11 g2, H i MIS 1 94 112 SS I ce AREA ,sec � sea-at su tr > i ai 625- sa t { •M@90 'IM l m M1i X00„) 406 et,6 $+0 j lt9 frit ` f47 51.4 ry09 J is E%IT 1. _,.. s h IA M7 4 Ml - - ATRSOM� s ' 6 7J 501 � c y a 10 S0 Y[STIO'3LE L1 talli<tjl,,A s O os M6 st r 'j. tt` ■tA9 � j�7 of �i `y 1 t t m _ — �� . , .. �. L_Z�C� �� . �� q�S� L ILIO . j { i I - E nn b SttRA6E - ,EN=rox G �C]D aoDaoDaoD ��•D ® - � � I G9D G9E)G9DG9D tO-«D 2R .O 3 070254_RITA_11Xa.5_TOMeau_3add 3/27/07 3,29 PM Page 1 _ J dcz.. CLLAd .d,. Rappirvba. ��] 'IC all start .y{�y�ed in the summer or 1984. For months, Bob M ` —a06twA,' Tumolo and his mother Betty had been experimenting and developing the best-Gost(ng Italian Ice. When they Pound - just; the right delicious recipe, Rita's was born. News or ie Ritas tosGy treabs quickly spread throughout Philadelphia i and by 1989 Rita's began Pronchising. In May 2005, Rito's was purchased by McHnight Capitol Portners, which served as o launching point Por the company. Currently there one over 400 Rita's stores In 14 states and growing. IC's our gaol of Rita's to produce the highest quality i products at reasonable prices,while providing exceptional ,+ -- - j Pomily-Friendly service. To ensure that our products are - consistently great tasting, we Preshly prepare ourIt I products at each score location every morning.Freshness is something we will never socriPice.This we promise you Awl ` r We ore extremely dedicated to providing every guest with a memorable store experience. Each.Rita's location is b: Independently owned and operated and our Franchise Partners aim to "wow"you with every visit. We hope Chis visit is special and we look Porword to seeing your smile ' 1 again soon. Jim Rudolph .. 'Chairman or the Board&ChieP Executive OPPicer Y ViSib us ob: ' z'=ro1052 W.Emmaus Rve. 1905 Union Blvd. 1912-18 Tilghman St. .r, - Rllentown,PA 18103 Allentown,PR 18103. Allentown,PR 18104 - 610-797-0666 610.434-8010 "610.435.1199 - r, 4 _ www.nikoeic&.cam p` 070259_AITA_11xe.5_T0R0mu_3add 3/27/07 3:29 PM Page 2 - I ..�.....�....- ++-w. Mme..._ R Pat-Free,cool treat mode Prom Ice and real Fruit. 4 p layering oP our Vanilla or Chocolate Mode Presh doily with over 30 tonguetln hog f Frozen Custard and your Favorite ° a. Fruit Flavors. 8 ma00 6 X00 8.ev00 ,� Flavor of Itohon ke or Cream Ice. RHO. rases O O O 0000 4000 QUART SUCK GALLON$ato PARTY BuacEr cu GAL)corm . ITALIAN ICE FLAVORS e Alex's Lemonade(Lemon) Pima Colada Banana Raspberry _ ��```` ny�rr.. 1 - Blueberry Raspberry Lemonade mWW VII.WW - Cherry Root Beer A creamy cool shake that blends our Vanilla or Chocolate StrawberryChocolate Frozen Custard and our Pavorite Flavor_ Gorr.Blast Tropicanaeriney • Grope Tropical Punch ��. OF Italian Ice or Cream Ice,to creole on 1 Green Apple Twisted Melon Incredible taste sensation. SEG. I.a !. a Fusion Vanilla y -- 0000 X000 0 KIWI-S Kiwl•Strowberry Watermelon Mango Wild Berry ° Passion Fruit Wild Black Cherry ' Sugar-Free Pink Lemonade Sugar-Free Root Beer Cherry Sugar-Free Tangerine CREAMI CREAM CE FERVORS Banana Split Cream Fudge Brownie t�lr R gourmet soPt serve With o smooth satiny tezbure. Berry Bonano Cream Mint Chocolate Chip '7 1 Mode with the highest quality Ingredlents to make _ - Cappucclno Cream Orange Cream '"` a the taste richer and smoother,Ribo's Cuatord ' Chocolate Chip Cookie Dough PistachioVanilla - .. Is by For the best, sxae aso. r. E Coconut Cream Vanilla Chip f . �Ooo e00o m000 Cookies'N Croom pn aw _. - - x• Cuatord Flavors Vanilla Chocolate SPRINKLES 00¢ WAFFLE CONE 00¢ IV I C Y r n�f.n• Twist L.Gd Is blend do Strawberry d A delicious blend oR creamy Frozen Custard, r i .,�•.``, Fresh Ibanon Ice and cookie bits that's sure _ a- to satisPy any sweet tooth. RHO ), - 0000 ZJUPPEhA A delicto - ° (17 usly sweet coating of Hot Fudge or Hot Coromel Is bhe perfectcomplement to our bosty Frozen Custard. auaa. aso. -e _ Hot Fudge Hat Coromel BOTTLED WATER$0.00 0 0 f - PRETZELS 000 EACH 3 FOR$0.00 _ t z� WIC OREO and NILLA ere regleter¢d trodemorb oP HF Haldlnpe,Ina Paces do not Include soles lox. ACCEPTED L s 7 .vw c Commonwealth Of Massachusetts e ` City of Salein : r Kimberley Driscoll ye' Board of Health �a o f x °D 120 Washington Street,4th Floor 'r° y " z . u , SALEM,MA. 01970; apt Temporary Food Perniit xe r DATE PRINTED f 08/01/2012 �,•: �'�°� x�� s " rte. _ a'9 i8� #: '�` z' '�'3 ;_ r • T .� ESTABLISHMENT NAME Rita's Water Ice _ .File Number,BHF2007'000057' " 188 Essex Street 5 • ,'� ;, �. East.India Square-,Mall Ia k'�' ' SALEM Ln MA 019710 . LOCATED AT- Ag. � SALEM, MA 01970 ' r a.. ,. A .. Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/No[es TEMPORARY FOOD BHP-20120559 ,Aug 5,2012 Y Aug 5,2012 y' ,- EVENT: Truck Tour LOCATION '� jm ' m y —. Salem Willow s FOOD TO BE SERVED Italian Ice w' w*,.yyTOtfll Fees- " @e8 fir. •fl. `ev. ", r xs �y i PERMIT,EXPIRES ugust 5,2012 y3 " ..V, �.. - . . fi Board of H@alth §, *. sPage 1 4 . " 'i - 'a i ;1 Ti CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4"FLOOR KIMBERLEY DRISCOLL TEL. (978) 741-1800 MAYOR FAX(978) 745-0343 Iramdin(@salem.com LARRY RAN4DIN,RS/RF'1-1S,CHO,CP-17S HiAI:iT-1 AGENT CHECK PAYABLE TO THE CITY OF SALEM,NO CASH FEE: NON-PROFIT=$25 1-3 DAYS=$300 4-7 DAYS=$600 OVER 7 DAYS=>7 DIVIDED BY 7 X 600=THE AMOUNT DUE (EXAMPLE: 14 DAYS DIVIDED BY 7=2x 600=$1200 APPLICATION FOR A TEMPORARY FOOD SERVICE-PERMIT NAME OF EVENT SALEM ICE CREAM BOWL LOCATION SAELM COMMON DATE(S)OF EVENT TUESDAY,AUGUST 7 FROM 6-7:30 P.M NAME OF APPLICANT ��7 .5/��Z'.'J� 414,ev,-re7lei ��, I�;,tu�l,� TELEPHONE#(978)744 0004 ADDRESS 265 ESSEX STREET,SALEM. MA 01970 nig /7(� NAME OF BUSINESS K 7/�`Shy- I�IJ m,"o /Cf TELEPHONE# g /CJ , / AA W 2- ADDRESS ADDRESS JL �P A14 62 /� 2 CERTIFIED FOOD MANAGER'S NAME:NAME: '�n We-,4 0 CERTIFICATION#: J gL[� ,..5 `F' 7J "A PLAN OF THE ESTABLISHMENT FOR THE EVENT MUST BE ATTACHED TO COMPLETE THIS APPLICATION" FOR ESTABLISHEMNTS OUTSIDE OF SALEM.MA: 'A COPY OF THE CERTIFIED FOOD MANAGERS CERTIFICATE AND ESTABLISHMENTS PERMIT MUST SE ATTACHED TO COMPLETE THIS APPLICATION.' TYPE OF REFRIGERATION: GAS ICE DRY ICE OTHER METHOD FOR COOKING/HOT HOLDING: GAS _OTHER METHOD FOR SANITIZING: ✓n ,,CHEMICAL �OTHER SOURCE OF FOOD: NAME: ,lWM C 4S fie•�/�ADDRESS �}/ FOODS TO BE SERVED INCLUDING INGREDIENTS AND METHOD OF PREPARATION: �) j , .wa,%z, Si�q Ag I HAVE READ THE BOARD OF HEALTH,"REQUIREMENTS FOR TEMPORARY FOOD ESTABLISHMENTS."I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS REGARDING THOSE REQUIREMENTS. I UNDERSTAND THEM,AGREE TO ABIDE BY THEM AND UNDERSTAND THAT FAILURE TO DO SO WILL RESULT IN REVOCATION OF MY TEMPORARY FOOD ESTABLISHMENT PERMIT. PURSUANT TO MGL C62C,$49A, CERTIFY UNDER THE PENALTIES OF PERJURY THAT I,TO MY BEST KNOWLEDGE AND BELIEF,HAVE FILED ALLSTATE TAX RETURNS AND PA ALL ST ET ES CURED UNDER LAW. �j 2(0 --)a i, s 3raq SI ATURE DATE SOCIAL SECURITY OR FEDERAL ID# CHECK#: DATE AMOUNT PAID: APPROVEDBY: DATE: TF I,AD CODI 1D-11 nn,1 1 P C TFn A/1 O/11