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MEETING PACKET SEPTEMBER 2012 CITY OF SALEM, MASSACHUSETTS lu BOARD OF HEALTH 120 WAS 1:1.ING 3T()N SI"RE-'1141T 41' Public..O, '' F�ILOR P-m-nt,11....... (978)741-180()I�.,\, (978) 745-0343 1.rqmdJg@sa1cqi.coi.Ti twWRY RANIDIN!'RS/Iwli IS,cl MAYOR i,A((&NT NOTICE OF MEETING You are hereby notified that the Salem Board of Health will hold its regularly scheduled meeting Tuesday, September 18, 2012 at 7.-00 PM City hall Annex, 120 Washington St Room 311 MEETING AGENDA 1. Call to order 2. Approval of Minutes from July 10 and July 24, 2012 3. Chairperson Announcements 4. Election of Chairperson and Appoint of Clerk 5. Public Health Announcements/Reports/Updates a. Health Agent b. Public Health Nurse Report c. Administrative d. Council Liaison 6. Northshore Shared Public Health Services Project Inter-municipal Agreement 7. Bath Salts as a Public Health Problem 8. Reinstatement of retail tobacco permit Sunny Comer 9. Miscellaneous 10. Adjournment Larry Ramdin Health Agent cc: Mayor Kimberley Driscoll, Board of Health, City Councilors • Next regularly scheduled meeting is October 9, 2012 at 7pm at City Hall Annex, 120 Washington Street Room 311 Know your rights under the open meeting law MGL Chapter 39 Section 23B and City Ordinance section 2-2028 through 2-2033 CITY OF SALEM BOARD OF HEALTH MEETING MINUTES July 10, 2012 DRAFT MEMBERS PRESENT: Dr. Barbara Poremba, Chairperson, ,Gayle Sullivan, Robert Dionne&Dr. Larissa Lucas OTHERS PRESENT: Larry Ramdin Health Agent, Justina Polvere, Public Health Nurse MEMBERS EXCUSED: Martin Fair, Councilor Liaison Thomas Furey TOPIC DISCUSSION/ACTION 1. Call to Order 7:06pm 2. Minutes of Last Meeting Dr. Lucas motioned to approve G. Sullivan 2nd approved (June 190, 2012) unanimously 3. Chairperson Announcements Save the day. There will be a retreat for all BOH members and staff on Saturday September 22, 2012, location TBA. A. Health Agent Report Larry Ramdin will be training along with his inspectors to follow FDA standardized program for food establishment inspections. Dogs as of now will not be allowed in food establishments and patios unless they are a service dog. A letter to be sent to all establishments about the dog/animal enforcement. B. Public Health Nurse Accepted into the Record Report C. Administrative Accepted into the Record Report D. City Council Liaison None Presented Updates R. Dionne motioned to except the reports Dr. Lucas 2nd approved unanimously 5. Public Hearing— Regulations#22 Tobacco Dr. Poremba, Chairperson, announced the opening of the public and Nicotine sales hearing and advised the audience to allow everyone to speak without interruption. A 3 minute limit was given to comment about the proposed regulations and Joyce Redford and DJ Wilson will be available to advise the board and address questions the Board and the audience may have at the end of the comment section of the hearing. Dildar Hussain - Globe Gas Station 200 Canal Street -Opposed banning of single sales of cigars under$2.50 Derek Arnold, Witch Dr.109 Lafayette Street—Opposed banning blunt wraps Guenevere Blanchard—Ben&Jerry's 60 Washington St—Asked if the Board can look into ban smoking within 20 feet of food Establishments. Mike Allen - Red Lion Smoke Shop—Asked if adding a lock out devise to his cigar room would put him in compliance with these new regulations. —In favor Dianne Night- Director of North East tobacco free community partnership, 1 Canal St Lawrence MA- In favor Steve Ryan, Stoughton MA New England Convenience Store Association-Opposed 2 parts of proposed regulation—The banning of single sales of cigars under$2.50 &the cap on Tobacco Sales Permits allowed in the city. Both parts of the regulation are putting restrictions on small businesses in Salem thus making it harder for them to thrive in this economy. Joyce Redford—Director of the North Shore Cape Ann Tobacco Collaborative will address the concerns about the regulations so far. The reason for banning the sale of single cigars under$2.50 is not to encourage additional smoking but to detour young people from smoking. There were recently 3 cases of single sales of Black and Mild's to minors in Salem. Some of these individual cigars are between .59 & .75 cents and also geared towards our youth. The cap on tobacco permits is a public health issue when you have an inordinate amount of outlets and accessibility where these products can be sold. Also a ban at pharmacy would increase sales for local businesses. DJ Wilson - MA Municipal Association—Explained to the Board that a city wide buffer zone is hard to enforce. Danvers has a buffer zone of no smoking within 15-20 feet of a building and it's not being enforced because you have to chase down individuals and by the time the inspectors get there, they are gone. Joyce Redford can provide information for establishments including signage. In regards to the single sales of cigars; Boston has banned single sales of cigars and mini packs under$2.50 and it's working there since February 2012. Blunt wraps are an issue because they are sold for $1 or less and are geared towards children. "Roll your own" machines will no longer be an issue because the federal government is passing a bill that includes a ban the use of these machines unless you're a manufacturer. Just the clarify the capping issue; the successor of the establishment will get the tobacco permit. Mike Lash—28 Balcomb St. Mike's Museum LLC—Asked the Board to give everyone a fair amount of time to comment on the proposed regulation. PC Nicolas - Witch Doctor- 109 Lafayette St - Opposed on banning blunt wraps Closed 7:45pm 6. Miscellaneous A Special Meeting will be held July 24, 2012 to vote on the Tobacco Regulations 7. MEETING ADJOURNED: 7:50pm i Respectfully submitted, li Ismeather Lyons-Paul Clerk of the Board Next regularly scheduled meeting is September 11, 2012 at 7pm At City Hall Annex, 120 Washington Street,Room 311 Salem. CITY OF SALEM BOARD OF HEALTH MEETING MINUTES July 24, 2012 DRAFT MEMBERS PRESENT: Dr. Barbara Poremba, Chairperson; Gayle Sullivan; Robert Dionne; Dr. Larissa Lucas OTHERS PRESENT: Larry Ramdin, Health Agent; Council Liaison Thomas Furey MEMBERS EXCUSED: Martin Fair TOPIC DISCUSSION/ACTION 1. Call to Order 7:00pm 2 Accepted with corrections . Minutes of Last Meeting p (July 10, 2012) 3. Chairperson Announcements Board of Health retreat will be held Sept 22"d from 9-3PM at the Public Health Museum located on the grounds of Tewksbury State Hospital. We will begin by having a private tour of the museum before working on revising our mission, objectives and short/long term goals. 4. DiscussionNote on New DJ Wilson submitted a document regarding the concerns of the Tobacco Control Salem business owners from the public hearing on July 10, 2012 Regulations (document was submitted as part of the record). The Board carefully reviewed and discussed the proposed regulations. In Section P. #4, "sale to a minor occurred"was changed to "any sale occurred". Councilor Furey supports the proposed regulations. Motion by G. Sullivan to accept the Tobacco Control Regulation to be effective on Sept 12012 except for cigar sales restrictions will be effective February 4, 2012. 2"d Larissa Lucas Motion approved unanimously. 5. MEETING ADJOURNED: 7:35pm Respectfully submitted, Heather Lyons-Paul Clerk of the Board Next regularly scheduled meeting is September 11, 2012 at 7pm At City Hall Annex, 120 Washington Street,Room 311 Salem. • Health Agent Report July/August 2012 Announcements • Household Hazardous Waste day will be held on October 6, 2012 from 8:00 am- 12:00 pm at the Salem High School. The hazardous waste collection day is a shared with the City of Beverly. • The City went "live" (again) on MAVEN on September 13. Justina Polvere and Larry Ramdin are Maven certified. • The Salem Board of Health was awarded a$2,500 grant by the Food and Drug Administration(FDA) to support the voluntary program Standards assessment and meeting of program standard efforts. • Delilah Castro has completed her probationary period as is confirmed as a full- time Sanitarian with the Salem board of Health • Sara Lee an MPH intern is working on a capstone project with the Salem Board of Health, she will be developing public health outreach articles for the Board of Health utilizing social media as the medium for dissemination • The Board of Health Tobacco regulations became effective on September 1. Joyce • Redford has met with each tobacco vendor and discussed the regulations. • Staff attended a meeting with the Salem REACT team to work on providing grab and go kits for senior citizens • Kayla Lugo student intern was assigned to the Board of Health offices for the month of August, she assisted the staff in clerical duties, this enabled us to reduce the backlog in filing and allowed Heather Lyons-Pauls to attend to outstanding paperwork • Administrative hearings were held with 2 Salem restaurants to discuss ongoing sanitary violations and discuss strategies for serving safe food at the establishments Meetings and Trainings • David Greenbaum, Elizabeth Gagakis and Larry Ramdin attended Lead Determinator recertification on August 9. The program discussed the Lead law, Lead determination processes and enforcement requirements if lead is discovered in the dwelling unit. • Staff attended a NERAC sheltering exercise in Middleton,where they learned how to set up an emergency shelter Significant Communication or Complaints from Residents • • We have received several complaints of rat sightings in Salem, we are baiting and trapping the storm drains and providing information to residents on actions they can take to protect their properties from • rodents ® Mosquito spraying was conducted in the Gallows Hill and Witchcraft heights neighborhood that is bounded by Highland Avenue and Boston Street to the Peabody and Lynn lines. There has been a significant finding of positive West Nile virus pools in Peabody border and in keeping with its charge to protect the Public Health the decision was made to spray the area to reduce the risk of infection from West Nile Virus. The 2012 mosquito season is extremely troubling as it has been the most active in recent years to date there have been 13 human West Nile Cases and 3EEE cases, 2 WNV and 3 EEE animal cases. Other Public Health Information Other Activities Inspections Certificate of Fitness Inspections — 87 Certificate of Fitness Re-inspections — 14 Court Hearings — 5 Food Service Inspections — 77 • Food Service Re-inspections — 17 Housing Inspections — 23 Housing Re-inspections — 8 Beach sampling - 69 Meetings — 4 Rodent Inspections — 13 Nuisance Complaints- 1 Seminars — 2 Trash Inspections- 29 Phone calls- 654 • i Health Agent Report September 2012 Announcements • Identification cards have been issued to all Board of Health Staff • Household Hazardous Waste day was held on October 6, 2012 from 8:00 am- 12:00 pm at the Salem High School. 133 Cars from Salem and 10 from Beverly. • Influenza Vaccination clinics have started. The details are in the Public Health nurse's report • Food Establishment permits issued to Jo's Freedom Coffee Shop, Essex Street former Cafe Valverde site) and I taco located Essex Street mall( Bagel Place). • The food establishment permit for Giovanni's Pizza was suspended as the establishment was deemed to pose an immediate threat to Public Health. Violations included Dogs kept in cages in Food Preparation area. food being thawed at room temperature, uncovered food in walk-in coolers, no certified and food manager available. The establishment was required to hire a consultant to retrain food employees on basic food safety and develop master cleaning schedules, opening and closing protocols. Meetings and Trainings • Larry Ramdin Health Agent and Mike Lutrzykowski Assistant Building Inspector have been awarded a scholarship by the National Environmental Health • Association and the EPA to attend Radon Resistant New Construction Workshop from November 27-29. The Health Agent applied for the scholarships and was notified on October 19 that they application was approved. The training will permit the attendees to gain knowledge on Radon risks and methods to remediate the risks. • Attended meetings that discussed solid waste and recyclables collection contracts • Participated in meetings that discussed application for Community Improvement Challenge grant to fund inspection program and hardware • Attended Hurricane Sandy Planning meetings. Board of Health staff was prepared to respond to emergencies related to Hurricane Sandy. Only 2 businesses were impacted by power loss. The made alternative arrangements and perishables were not impacted. • Larry Ramdin met with Rinus Oosthoek, Director of the Salem Chamber of Commerce to discuss the food establishment permitting process and provide input on guidelines being developed by the Board of health Staff. • Justina Polvere and Larry Ramdin together with Paul L'Heureux, Salem Schools Facilities Director, conducted a site visit of the Salem High School Emergency Dispensing site and shelter. Significant Communication or Complaints from Residents • Plan reviews submitted for Amazing Pizza, 102 Webb Street and Salem Pasta, • 84 Derby Street. Plan review approvals issued. Inspection Activities Certificate of Fitness Inspections - 39 Certificate of Fitness Re-Inspections— 1 Food Service Inspections—25 Food Service Re-Inspections—21 Retail Food Inspections—4 Retail Food Re-Inspections— 3 Housing Inspections - 10 Housing Re-Inspections—2 Meetings—4 Rodent Complaints—2 Trash Inspections— 14 Temporary Food Inspections - 103 • • WNV and EEE Summary by County, as of 9/10/2012 . . . . . Animal Couinty Towns'at Critical Risk w Towns at,High Risk Human Cases Cases Barns#able Berkshire Pittsfield 1 WNV Acushnet, Freetown, New Bedford, Bristol Easton, Raynham, Taunton Norton, Rehoboth Pukes Boxford, Groveland, Methuen, Newbury, o Essex Georgetown Rowley, Saugus, West Newbury 1 EEE Franklin �' ` Orange Erving, New Salem, Warwick, Wendell 1 EEE Holyoke, Ludlow, Palmer, Springfield, Hampden. Chicopee West Springfield 1 WNV 2 WNV Amherst, Granby, Pelham, South Hadley, Hampshire , Belchertown Ware 1 EEE Arlington, Belmont, Everett, Hopkinton, Lexington, Malden, Medford, Melrose, Middlesex Cambridge Newton, Somerville, Watertown 9 WNV, 1 EEE Nantucket " Norfolk " " Brookline, Canton Halifax, Plympton, Bridgewater, Carver, East Bridgewater, Rochester, West Hanson, Kingston, Lakeville, Plymouth Bridgewater Mattapoisett, Middleborough, Pembroke 2 EEE Suffolk Boston Chelsea Winthrop Revere 1 WNV z Auburn, Grafton, Northborough, Petersham, Phillipston, Shrewsbury, Athol, Royalston, Southborough, Templeton, Upton, Worcester i ' Westborough Worcester 1 EEE, 1WNV 13 WNV 2 WNV 3 EEE 4 EEE On 917/12, 210 communities still at remote or low risk were raised to moderate risk in addition, one horse from NY state was probably exposed to EEE in Plymouth county 1 /l • 1USTINA POLVERE SALEM BOARD OF HEALTH PUBLIC HEALTH NURSE PUBLIC HEALTH NURSE REPORT SEPTEMIBER 2012 Reporting from JUly 91h-September 18th 2012 Salem Board of Health "GO LIVE" on MAVEN September 13, 2012 Disease Prevention • Investigated 32 reportable diseases and reported case information to MDPH • In contact with North Shore Pulmonary Clinic on current active cases, as well as 4 New Arrivals . and their contacts • Weekly medication refill for active TB case discharged from DOT; currently self-administering medications -Skin tested 2 case contacts of an active TB case;this was a re-test measure done 8-12 weeks after initial testing -Conducted two rounds of stool sampling for 48 food handlers: identified suspect cause of salmonella outbreak -Assisted owners/managers of three food establishments in the distribution and signing of "Food Employee Reporting Agreement Forms." * I have attached this to my report • Excluded 3 food handlers diagnosed with a foodborne illness from employment until negative stool samples were obtained • Fr 1 F 1 Health Promotion • -Attended Salem's Farmers Market and offered information on health topics and conducted blood pressure screenings. Some of the topics covered: sun safety, hypertension, nutrition / healthy eating,tick borne diseases, mosquitos, and rabies -Attended Salem Council on Aging's First Annual Wellness Fair for seniors and provided seniors with information on: heat safety, diabetes, hypertension, and tick borne diseases Meetings/Clinics • House visit of 4 new arrivals: skin tested 3 people/4 referrals given to North Shore Pulmonary Public Health Clinic -Met on two different occasions with members of North Shore REACT, NSES, Boards of Health, Salem Police, and Salem Council on Aging on an Emergency Preparedness Project for seniors called "Grab & GO": The goal is to put together emergency kits for seniors that they can take with them in the event of an emergency. We have a target date for mid-October at the Senior Center on the day of the annual flu clinic. The goal is to have 500 prepared "Grab & Go" bags to hand out to seniors that day. Other goals are being discussed now. • • Attended NS REACT meeting with David Greenbaum-discussed emergency preparedness for seniors and current seniors at risk • Attended North Shore Cape Ann Emergency Preparedness Coalition-viewed a presentation on extreme heat planning, discussed flu clinic planning, and community issues. Home visit of a Salem resident with David Greenbaum-checked on living status/offered services;will be checking back with him in a month -Inspected Schooner Summer Camp with Elizabeth Gagakis-permitted to open for 2012 season • Met with Peabody's PHN—gained knowledge and training from her on PHN position;flu clinic planning • Met with a new resident of Salem: referred her to numerous resources and gave support to her as needed •Met with restaurant owner involved in salmonella outbreak on 5 different occasions regarding food safety, disease prevention, and employee health safety • David Greenbaum and I met with two other restaurant owners on similar issues • 1 Health Promotion • -Attended Salem's Farmers Market and offered information on health topics and conducted blood pressure screenings. Some of the topics covered: sun safety, hypertension, nutrition / healthy eating,tick borne diseases, mosquitos, and rabies -Attended Salem Council on Aging's First Annual Wellness Fair for seniors and provided seniors with information on: heat safety, diabetes, hypertension, and tick borne diseases Meetings/Clinics - House visit of 4 new arrivals: skin tested 3 people/4 referrals given to North Shore Pulmonary Public Health Clinic -Met on two different occasions with members of North Shore REACT, NSES, Boards of Health, Salem Police,and Salem Council on Aging on an Emergency Preparedness Project for seniors called "Grab &GO":The goal is to put together emergency kits for seniors that they can take with them in the event of an emergency. We have a target date for mid-October at the Senior Center on the day of the annual flu clinic. The goal is to have 500 prepared "Grab & Go" bags to hand out to seniors that day. Other goals are being discussed now. -Attended NS REACT meeting with David Greenbaum-discussed emergency preparedness for seniors and current seniors at risk -Attended North Shore Cape Ann Emergency Preparedness Coalition-viewed a presentation on extreme heat planning, discussed flu clinic planning, and community issues. - Home visit of a Salem resident with David Greenbaum-checked on living status/offered services;will be checking back with him in a month -Inspected Schooner Summer Camp with Elizabeth Gagakis-permitted to open for 2012 season - Met with Peabody's PHN—gained knowledge and training from her on PHN position;flu clinic planning - Met with a new resident of Salem: referred her to numerous resources and gave support to her as needed •Met with restaurant owner involved in salmonella outbreak on 5 different occasions regarding food safety, disease prevention, and employee health safety • • David Greenbaum and I met with two other restaurant owners on similar issues • • Attended August's MAPHN meeting in Tewksbury—viewed a presentation given by Esteban Cuebas-Incle PhD., Entomologist, on ticks and mosquitos and disease prevention ■ Fit Tested with an N95 mask at Quadrant Health Strategies on August 14th, 2012 •Attended Medicare Reimbursement Training for the 2012-2013 Flu Season- *MassHealth is participating in the flu vaccine reimbursement project this year effective September 1, 2012. • Met with Ann Kelley(RN at Lifebridge)to discuss the 2012 flu clinic • Completed MAVEN training given by Deven Smith-Clarke of MDPH • Met with Melissa Wilson program coordinator NSPHDIG (North Shore Public Health District Incentive Grant)-discussed the PHN role and what areas could improve or change. -Working with Melissa on ways to adjust schedule in order to include more health promotion time • Met with Chief David Cody to discuss 2012/13 flu clinics • David Greenbaum and I met with Joann Sanchez, clinical liaison for Peabody Glen and Essex Park in Beverly, and Teresa Burns, marketing director of Essex Park,to discuss the "Grab & Go" emergency project -They have confirmed their support and interest in aiding us with this this project -David Greenbaum and I were asked to present and speak about "Grab & Go" at their meeting at Peabody Glenn on October 25th,which is held for many health professionals • David Greenbaum and I solicited Salem Five on the "Grab &Go" project for donations of bags -Awaiting their response •Attended "Legal Nuts and Bolts of Isolation and Quarantine" at Tewksbury Hospital- networked with Attorneys and Health Educators of DPH;gained knowledge on the legal-side of disease investigation • Met with John Grullon of VOCES, and Carol MacGown of Salem Housing Authority regarding upcoming flu clinics/blood pressure clinics • Met with Nurse Nancy at Lydia Pinkham -Met with Bill Woolley of the Salem Council on Aging regarding the October flu clinic, and • setting up blood pressure clinics -Met Keith Willa from "On Point"to discuss being a part of the program • Monthly Report of Communicable Disease July-September 2012 Disease Reported #Of Cases New Carry Over Discharged campylobacter 3 2 1 3 Salmonella 8 8 0 7 Pertussis 1 1 0 1 HGA 5 4 1 4 Giardia 1 1 0 1 Hep C 11 1 0 11 Group A Strep 1 1 0 1 Group B Strep 3 3 0 2 Yersinia 1 1 0 1 Lyme 12 0 0 12 • Babesiosis 1 1 0 1 Shigella 1 1 0 1 Vibrio 1 1 0 1 Tuberculosis 5 4 1 4 Summary of Communicable Diseases for September 2012 Campylobacteriosis: Case#1:The following information was obtained from case's PCP (case was not able to be reached). The case is not a food handier and does not work in a daycare. Case has no close contacts that are ill. None of the close contacts work in a daycare or are food handlers. Case has fully recovered. Case#2:This case is a food-handler and was removed from work as soon as the BOH was notified of this diagnosis. Case submitted a negative stool sample and then returned to work. Case did not work during infectious period. Cause of this infection has not been identified. Case has fully recovered. -Met Keith Willa from "On Point"to discuss being a part of the program Monthly Report of Communicable Disease July-September 2012 Disease Reported #Of Cases New Carry Over Discharged campylobacter 3 2 1 3 Salmonella 8 8 0 7 Pertussis 1 1 0 1 HGA 5 4 1 4 Giardia 1 1 0 1 Hep C 11 1 0 11 Group A Strep 1 1 0 1 Group B-Strep 3 3 0 2 Yersinia 1 1 0 1 Lyme 12 0 0 12 Babesiosis 1 1 0 1 Shigella 1 1 0 1 Vibrio 1 1 0 1 Tuberculosis 5 4 1 4 Summary of Communicable Diseases for September 2012 Campylobacteriosis: Case#1:The following information was obtained from case's PCP (case was not able to be reached). The case is not a food handler and does not work in a daycare. Case has no close contacts that are ill. None of the close contacts work in a daycare or are food handlers. Case has fully recovered. Case#2:This case is a food-handler and was removed from work as soon as the BOH was notified of this diagnosis. Case submitted a negative stool sample and then returned to work. Case did not work during infectious period. Cause of this infection has not been identified. Case has fully recovered. i Case #3:This case was seen and treated in the hospital. The case is not a food handler and does • not work in a daycare. Case has no close contacts that are ill. None of the close contacts work in a daycare or are food handlers. Case has fully recovered according to hospitalist- unable to reach case or case's family. Case #4:The case was seen in the hospital and treated. The case is not a food handler and does not work in a daycare. Case has no close contacts that are ill. None of the close contacts work in a daycare or are food handlers. Case has fully recovered. Salmonella: The following 6 cases are part of a "Cluster" of Salmonella cases Case#1:This case has been identified as a possible source of the outbreak. Case is a food handler and the cases place of employment was fully inspected by David Greenbaum, with the aid of the Food Protection Program (FPP) at DPH. All employees were tested at the place of employment and the case is the only one whose test came back positive. Case did work during her incubation period because she was asymptomatic. Case is currently excluded from food handling duties until two negative stool samples are produced. No other employees have been sick. No close contacts have been ill. No close contacts are food handlers (besides co-workers) and no contacts work at a daycare. This case is currently being followed by MDPH; case now resides in another location. Case#2:This case ate at the suspect restaurant that was investigated. Case is not a food handler. No close contacts have been ill. None of the close contacts work in a daycare or are food handlers. Case fully recovered. Case #3: Case did not eat at suspect restaurant but lab results showed a matching strand of Salmonella. Case fully recovered. Case is not a food handler and does not work in a daycare. Case has no close contacts that are ill. None of the close contacts work in a daycare or are food handlers. Case#4: Case ate at the suspect restaurant that is currently being investigated. Case is a food handler and worked during incubation period. No sick employees and no sick customers have been noted. As soon as the Board of Health was notified of the diagnosis,this case was excluded from work until 2 negative stool samples were produced. No close contacts have been ill. None of the close contacts work in a daycare or are food handlers. Case #5: Case ate at the suspect restaurant that is currently being investigated. Case is not a food handler and does not work in a daycare. None of the close contacts have been ill. None of • the close contacts work in a daycare or are food handlers. Case fully recovered. Case#6: Case ate at the suspect restaurant that is currently being investigated. Case is not a • food handler and does not work in a daycare. None of the close contacts have been ill. None of the close contacts work in a daycare or are food handlers. Case fully recovered. ------ End Cluster Case#7:This case is not related to the cluster. After thorough investigation the source of the illness has not been identified. The case is a food handler and did work during the incubation period. As soon as the Board of Health was notified of this diagnosis the case was excluded from work until the case produced a negative stool sample. There have been no sick employees or customers identified. Case does not work in a daycare. None of the close contacts have been ill. None of the close contacts work in a daycare or are food handlers. Case is fully recovered. Case#8:This case is lost to follow up. Pertussis: Case #1: It is suspect that this case became ill after contact with another infected person. All close contacts have received prophylaxis. Case hasn't completed her immunization schedule due to age. Case fully recovered. • Human Granulocytic Anaplasmosis(Ehrlichiosis): Case #1:The lab results show this is an old infection. Case did not have any symptoms related to this illness. No treatment was recommended by PCP. No evidence of any other tick-borne illnesses was found. Health education on prevention of tick bites was given in detail. Case#2: The lab results show this is an old infection. Case did not have any symptoms related to this illness. No treatment was recommended by PCP. No evidence of any other tick-borne illnesses was found. Health education on prevention of tick bites was given in detail. Case#3:The lab results show this is an old infection. Case did not have any symptoms related to this illness. No evidence of any other tick-borne illnesses was found. Case is an avid runner in the Salem woods. Health education on prevention of tick bites was given in detail. Case #4: Lab results show an old infection. No evidence of any other tick-borne illnesses was found. Case was treated with an antibiotic and has fully recovered. Case #5: Lab results show an old infection. Case is currently being investigated. • i i • Case#6: Case ate at the suspect restaurant that is currently being investigated. Case is not a food handler and does not work in a daycare. None of the close contacts have been ill. None of the close contacts work in a daycare or are food handlers. Case fully recovered. ------- End Cluster Case#7:This case is not related to the cluster. After thorough investigation the source of the illness has not been identified. The case is a food handler and did work during the incubation. period. As soon as the Board of Health was notified of this diagnosis the case was excluded from work until the case produced a negative stool sample. There have been no sick employees or customers identified. Case does not work in a daycare. None of the close contacts have been ill. None of the close contacts work in a daycare or are food handlers. Case is fully recovered. Case#8:This case is lost to follow up. Pertussis: Case#1: It is suspect that this case became ill after contact with another infected person. All close contacts have received prophylaxis. Case hasn't completed her immunization schedule due to age. Case fully recovered. Human Granulocytic Anaplasmosis(Ehrlichiosis): Case#1:The lab results show this is an old infection. Case did not have any symptoms related to this illness. No treatment was recommended by PCP. No evidence of any other tick-borne illnesses was found. Health education on prevention of tick bites was given in detail. Case#2: The lab results show this is an old infection. Case did not have any symptoms related to this illness. No treatment was recommended by PCP. No evidence of any other tick-borne illnesses was found. Health education on prevention of tick bites was given in detail. Case#3:The lab results show this is an old infection. Case did not have any symptoms related to this illness. No evidence of any other tick-borne illnesses was found. Case is an avid runner in the Salem woods. Health education on prevention of tick bites was given in detail. Case #4: Lab results show an old infection. No evidence of any other tick-borne illnesses was found. Case was treated with an antibiotic and has fully recovered. Case #5: Lab results show an old infection. Case is currently being investigated. Giardia: • Case#1:The source of this illness has not been identified. The case is not a food handler and does not work in a daycare. Case has no close contacts that are ill. None of the close contacts work in a daycare or are food handlers. Case fully recovered. Hepatitis C: Case#1:This case did not have symptoms but has been involved with intravenous drug use. Health education was given in detail on the prevention of infecting others. Offered support as needed. Case is currently being followed by PCP. Case#2-11- 10 chronic cases; no public health follow up needed Group A Strep: Case #1:This case is lost to follow-up. Some information was obtained from infection control regarding case's drug history use. Otherwise, no other information has been obtained because physician is lost to follow-up as well. Group B Strep: Case#1:This is a post radiation Cancer survivor with a history of a mastectomy. Case has had similar infections in the past. Case was treated and no longer has evidence of infection. Case is unemployed (is not a food handler or healthcare worker). Case#2:This infection was found when the case was in-patient. Case was discharged, and fully recovered with no further evidence of infection. Case is not a food handler or a healthcare worker. Case#3: This is a post radiation Cancer survivor with a history of a mastectomy, lymphadenectomy, and recurrent cellulitis in the left arm. Case has been treated with antibiotics and no longer has evidence of infection. Case is unemployed (is not a food handler or healthcare worker). Yersinia: Case#1: Unable to identify cause of this illness. This case is not a food handler. This case does attend a daycare. After interviewing daycare owner it is has been determined that there have been no other sick persons at this daycare. Case fully recovered. Lyme: 12 Cases. No public health follow up needed. • Babesiosis: Case#1:This case has had a history of tick bites on many different occasions. Case does a lot of outdoor activities while traveling throughout New England where exposure to ticks is prominent. Health education on prevention of tick bites was given in detail. Case has a co- infection of Lyme disease and is being followed by PCP. Shigella: Case#1:This case is not a food hander and is not employed in any supervised care setting. Case is no longer exhibiting symptoms and has fully recovered. Cause of this infection has not been identified. Vibrio: Case#1:This case is believed to have contracted the Vibrio organism during a trip where there was swimming in a spring-fed pond. The case had acquired minor scrapes and cuts while tubing in the pond, which later became infected. The case did not consume any seafood products in the 7 days prior to onset of symptoms. Case has fully recovered after being on antibiotic treatment. TB: Case#1: Case discharged from DOT; now self-administering meds. Once weekly med refill/house visit by PHN 4 cases are new arrivals—all 4 referred to the NSPHPC; 3 were skin tested (4th case had a previous positive skin test overseas) i • 12 Cases. No public health follow up needed. Babesiosis: Case#1:This case has had a history of tick bites on many different occasions. Case does a lot of outdoor activities while traveling throughout New England where exposure to ticks is prominent. Health education on prevention of tick bites was given in detail. Case has a co- infection of Lyme disease and is being followed by PCP. Shigella: Case#1:This case is not a food hander and is not employed in any supervised care setting. Case is no longer exhibiting symptoms and has fully recovered. Cause of this infection has not been identified. Vibrio: Case#1:This case is believed to have contracted the Vibrio organism during a trip where there was swimming in a spring-fed pond. The case had acquired minor scrapes and cuts while tubing in the pond,which later became infected. The case did not consume any seafood products in • the 7 days prior to onset of symptoms. Case has fully recovered after being on antibiotic treatment. TB: Case #1: Case discharged from DOT; now self-administering meds. Once weekly med refill/house visit by PHN 4 cases are new arrivals—all 4 referred to the NSPHPC; 3 were skin tested (4th case had a previous positive skin test overseas) Food Employee Reporting Agreement Preventing Transmission of Diseases through food by Infected Food Employees The purpose of this agreement is to ensure that Food Employees and Applicants who have received a conditional offer of employment notify the Person in Charge when they experience any of the conditions listed so that the Person in Charge can take appropriate steps to preclude the transmission of foodborne illness. I AGREE TO REPORT TO THE PERSON IN CHARGE: SYMPTOMS 1. Diarrhea 2. Fever 3. Vomiting 4. Jaundice 5. Sore throat with fever 6. Lesions containing pus on the hand,wrist,or an exposed body part (such as boils and infected wounds, however small) MEDICAL DIAGNOSIS Whenever diagnosed as being ill with Salmonella Typhi (typhoid fever), Shigella spp. (shigellosis), Escherichia coli 0157:H7, hepatitis A virus, Entamoeba histolytica, Campy/obacter spp., Wbrio cholera spp., Cryptosporidium parvum, Giardia lamblia, Hemolytic Uremic Syndrome, Salmonella spp. (non-typhi), Yersinia enterocolitica, or Cyclospora cayetanensis. • PAST MEDICAL DIAGNOSIS Have you ever been diagnosed as being ill with one of the diseases listed above? If you have,what was the date of the diagnosis? HIGH-RISK CONDITIONS 1. Exposure to or suspicion of causing any confirmed outbreak of typhoid fever, shigellosis,E. coli 0157:H7 infection,or hepatitis A 2. A household member diagnosed with typhoid fever,shigellosis, illness due to E. coli 0157:1-17,or hepatitis A 3. A household member attending or working in a setting experiencing a confirmed outbreak of typhoid fever, shigellosis,E. coli 0157:H7 infection,or hepatitis A I have read (or had explained to me)and understand the requirements concerning my responsibilities under 105 CMR 590/1999 Food Code and this agreement to comply with the reporting requirements specified above involving symptoms, diagnoses, and high-risk conditions specified. I also understand that should I experience one of the above symptoms or high-risk conditions, or should I be diagnosed with one of the above illnesses, I may be asked to change my job or to stop working altogether until such symptoms or illnesses have resolved. I understand that failure to comply with the terms of this agreement could lead to action by the food establishment or the food regulatory authority that may jeopardize my employment and may involve legal action against me. Applicant or Food Employee Name (please print) Signature of Applicant or Food Employee Date • Signature of Permit Holder or Representative Date This is a model form created by MA Dept.of Public Health which is offered as a tool for industry to use to aid in compliance with 105 CMR 590.003(C)and Food Code 2-201.11 The use of this form is voluntary and is not required by state regulation. Revised:5/8/2001 • i � Administration Monthly Report July and August 2012 Burial Permits @ $25.00 $1,500.00 Permits $2,585.00 Certificate of Fitness@$50.00 $3,200.00 Copies $14.50 Fines $725.00 Total Monies Collected = $8,024.50 Annual Budget Expended Available Balance Total Salary/Longevity $363,600.00 $34,796.46 $328,803.51 Annual Budget Expended Available Balance Non-Personnel $19,600.00 ( $5,624.28 $13,975.72 Intermunicipal Agreement as Authorized by 1 by and between the North Shore Shared Public Health Services Program • (Salem , Beverly, Danvers, Lynn, Marblehead, Nahant, Peabody, and Swampscott) AGREEMENT TO JOINTLY PROVIDE PUBLIC HEALTH SERVICES THIS AGREEMENT is entered into by and between the municipalities of Beverly, Danvers, Lynn, Marblehead, Nahant, Peabody, Salem, and Swampscott, in . Massachusetts (hereinafter referred to individually as "Municipality" or collectively as "Municipalities"), as members of the North Shore Shared Public Health Services Program PURSUANT TO the terms and obligations of the Massachusetts Department of Public Health (MDPH) District Incentive Grant Implementation Funding Award, the Request for Responses for the Implementation Grants, attached as Appendix A and incorporated herein, and in order to embody the intention of the Municipalities to cooperate in promoting well-planned regional efforts in the provision of public health services; and, WHEREAS, the Municipalities desire to create a North Shore Shared Public Health Services Program ("Program") for the purpose of jointly providing local public health services and a regional initiative addressing indoor air quality issues through smoke-free housing campaigns and awareness programs for asthma triggers, as well p as and sharing in the cost of providing such services, as supported by the multi-year Massachusetts Department of Public Health District Incentive Grant Implementation Funds Award; and, WHEREAS, Pursuant to the terms of the MDPH District Incentive Grant, • execution of an inter-municipal agreement is required, each Municipality has obtained authorization for this joint undertaking pursuant to M.G.L. C.40, §4A by a vote of its respective Board of Selectmen or a vote of its respective City Council with approval by its Chief Executive Officer, or as required by special legislative act, as attested to by certified copies thereof contained in Appendix B. ; In addition, the Boards of Health of each Municipality have reviewed this Agreement and voted to recommend approval. NOW, THEREFORE, the Municipalities, in mutual consideration of the covenants contained herein, intending to be legally bound thereby, agree under seal as follows: 1. Term The term of this Agreement shall be five (5) years, commencing upon the date of the last Municipality executes this Agreement and shall expire on the same day and month of the year 2017, unless earlier terminated as set forth herein. The Agreement shall be renewed only through vote and approval of Municipalities' respective Boards of Selectmen, City Councils, and Chief Executive Officers "Governing Body". 2. Program There shall be established a program to be known as the North Shore Shared Public Health Services Program ("Program"). 3. Duties • The Program may perform all the duties required of local boards of health by Massachusetts law and specifically those necessary to accomplish the goals of the Program Plan (attached as Appendix D) including indoor air quality initiatives (smoke-free housing and asthma trigger awareness campaigns), as well as the provision of environmental health inspection services (optional services available to each Municipality) and any other services required by local boards of health as agreed to by the Municipalities through the Steering Committee. Notwithstanding the provisions of this Agreement, the Municipalities shall retain separate Boards of Health which shall retain their own legal authority and autonomy as provided by law. 4. Lead Municipality The City of Salem shall act as the Lead Municipality and, as such, shall contract or employ and provide Program staff, shall provide reasonable physical accommodations for Program staff and operations as necessary, notwithstanding any local restrictions on contractor's use of City resources, and shall perform all duties and provide all services consistent with the terms of the Implementation • NORTH SHORE SHARED PUBLIC HEALTH SERVICES PROGRAM 2 of 121212 Intermunicipal Agreement under M.G.L. Chapter 40 i authorization for this joint undertaking pursuant to M.G.L. C.40, §4A by a vote of its respective Board of Selectmen or a vote of its respective City Council with approval by its Chief Executive Officer, or as required by special legislative act, as attested to by certified copies thereof contained in Appendix B. ; In addition, the Boards of Health of each Municipality have reviewed this Agreement and voted to recommend approval. NOW, THEREFORE, the Municipalities, in mutual consideration of the covenants contained herein, intending to be legally bound thereby, agree under seal as follows: 1. Term The term of this Agreement shall be five (5)years, commencing upon the date of the last Municipality executes this Agreement and shall expire on the same day, and month of the year 2017, unless earlier terminated as set forth herein. The Agreement shall be renewed only through vote and approval of Municipalities' respective Boards of Selectmen, City Councils, and Chief Executive Officers "Governing Body". 2. Program There shall be established a program to be known as the North Shore Shared Public Health Services Program ("Program"). • 3. Duties The Program may perform all the duties required of local boards of health by Massachusetts law and specifically those necessary to accomplish the goals of the Program Plan (attached as Appendix D) including indoor air quality initiatives (smoke-free housing and asthma trigger awareness campaigns), as well as the provision of environmental health inspection services (optional services available to each Municipality) and any other services required by local boards of health as agreed to by the Municipalities through the Steering Committee. Notwithstanding the provisions of this Agreement, the Municipalities shall retain separate Boards of Health which shall retain their own legal authority and autonomy as provided by law. 4. Lead Municipality The City of Salem shall act as the Lead Municipality and, as such, shall contract or employ and provide Program staff, shall provide reasonable physical accommodations for Program staff and operations as necessary, notwithstanding any local restrictions on contractor's use of City resources, and shall perform all duties and provide all services consistent with the terms of the Implementation NORTH SHORE SHARED PUBLIC HEALTH SERVICES PROGRAM 2 of 12424-2 Intermunicipal Agreement under M.G.L. Chapter 40 • Funds Award Agreement with MDPH (Attached as Appendix A). In addition, the Lead Municipality shall perform the following duties: • Maintain accurate and comprehensive records of services performed, costs incurred and reimbursements and contributions received; • Perform annual audits; • Issue quarterly financial statements and services reports to all participants; • Contract a program coordinator through the search and recommendation of a hiring committee to the Purchasing Authority. The hiring committee will consist of no fewer than three (3) Steering Committee members; • Enter into contracts for goods and services; • Prepare a proposed budget for review and approval by the Steering Committee. 5. Steering Committee The Program shall be governed by a steering committee ("Steering Committee") comprised of one (1) representative from each Municipality who shall be either a Health Department Director or Health Agent managing local public health. In the • event the position of Director or Health Agent is vacant, the Municipality shall substitute a Board of Health member or member of their local Health Department staff to serve until the position of Director or Health Agent is filled. The Steering Committee is hereby established through this Agreement and shall be further delineated through bylaws to be approved by majority vote of members of the Steering Committee. The Steering Committee shall direct the establishment of polices, programs and procedures and prepare an annual operating budget and cost assessment schedule applicable to the Municipalities for approval by the Municipalities. 6. Program Coordinator The Program Coordinator shall be responsible for administration of the Program Plan (attached as Appendix D) as consistent with policies and performance standards adopted by the Steering Committee and in compliance with the grant award terms. The Program Coordinator shall serve as a liaison to all municipal departments in each of the Municipalities and shall be responsible for the following duties: distributing reports and training schedules, and coordinating directly with each Municipality's representative in order to accomplish the goals of the Program. NORTH SHORE SHARED PUBLIC HEALTH SERVICES PROGRAM 3 of 12424-2 Intermunicipal Agreement under M.G.L. Chapter 40 7. Fiduciary Responsibility • The budget for the Program is initially established through the adoption of the Program Plan through the contract with MDPH for the grant award, attached as Appendix D and as hereafter agreed to by the Steering Committee and approved by the appropriate Municipal authorities. A simple majority vote of the Steering Committee shall be necessary to approve a request to reallocate funds within the budget, provided however, the total budget amount shall not increase or decrease. Upon approval by the Steering Committee of a budget modification, the Steering Committee shall present such modification to MDPH for review, during the term of the MDPH grant, and final approval. All other future grant funds unrelated to the DIG Implementation fund shall follow budget guidelines as provided by the grantor and as agreed upon by a majority of the Steering Committee members. 8. Budget Assessments MDPH has awarded Implementation Funds up to $325,000 across four(4) grant years. No budget assessments are written into the Program Plan (attached as Appendix D or project budget as of Grant Year 1. The terms of the DIG PP ) P 1 9 Implementation Funds specify that grant funds are to be used to augment and enhance public health service delivery and that such funds shall not be used to • offset budget reductions to local public health departments. Any financial commitments, in excess of the DIG or other grants, of the Municipalities a party to this Agreement is subject to appropriation under their respective budgets and shall not exceed the amounts so validly appropriated. Apportionment of any associated costs may be assessed on a per capita basis or other basis as agreed to by the Municipalities through the Steering Committee. Failure to obtain approval for any such assessment by the Municipality shall affect the level of services provided to the subject Municipality. 9. Fee Structure Each Municipality may retain and establish their own fee schedules and shall be entitled to collect any environmental health services fees or fines assessed. 10. Other Municipal Services This Agreement applies only to those public health services statutorily and customarily rendered by local health departments under Massachusetts law. The Municipalities may, by amendment hereto, add or remove associated services to be delivered by the Program based solely on unanimous consent of the Municipalities as parties to this Agreement, but only after the passage of sixty (60) days following a request from the Steering Committee. • NORTH SHORE SHARED PUBLIC HEALTH SERVICES PROGRAM 4 of 12424-2- Intermunicipal Agreement under M.G.L. Chapter 40 7. Fiduciary Responsibility The budget for the Program is initially established through the adoption of the Program Plan through the contract with MDPH for the grant award, attached as Appendix D and as hereafter agreed to by the Steering Committee and approved by the appropriate Municipal authorities A simple majority vote of the Steering Committee shall be necessary to approve a request to reallocate funds within the budget, provided however, the total budget amount shall not increase or decrease. Upon approval by the Steering Committee of a budget modification, the Steering Committee shall present such modification to MDPH for review, during the term of the MDPH grant, and final approval. All other future grant funds unrelated to the DIG Implementation fund shall follow budget guidelines as provided by the grantor and as agreed upon by a majority of the Steering Committee members. 8. Budget Assessments MDPH has awarded Implementation Funds up to $325,000 across four(4) grant years. No budget assessments are written into the Program Plan (attached as Appendix D) or project budget as of Grant Year 1. The terms of the DIG Implementation Funds specify that grant funds are to be used to augment and enhance public health service delivery and that such funds shall not be used to offset budget reductions to local public health departments. Any financial commitments, in excess of the DIG or other grants, of the Municipalities a party to this Agreement is subject to appropriation under their respective budgets and shall not exceed the amounts so validly appropriated. Apportionment of any associated costs may be assessed on a per capita basis or other basis as agreed to by the Municipalities through the Steering Committee. Failure to obtain approval for any such assessment by the Municipality shall affect the level of services provided to the subject Municipality. 9. Fee Structure Each Municipality may retain and establish their own fee schedules and shall be entitled to collect any environmental health services fees or fines assessed. 10. Other Municipal Services This Agreement applies only to those public health services statutorily and customarily rendered by local health departments under Massachusetts law. The Municipalities may, by amendment hereto, add or remove associated services to be delivered by the Program based solely on unanimous consent of the Municipalities as parties to this Agreement, but only after the passage of sixty (60) days following a request from the Steering Committee. NORTH SHORE SHARED PUBLIC HEALTH SERVICES PROGRAM 4 of 124212 Intermunicipal Agreement under M.G.L. Chapter 40 • 11.EMPLOYEES An employee of any one Municipality, a party to this Agreement, who performs services, pursuant to this Agreement on behalf of another Municipality, a party to this Agreement, shall be deemed to remain an employee of the employee's hiring Municipality and shall retain all accrued benefits and shall be subject to standard personnel practices of such Municipality. 12.Indemnification The Municipalities shall hold each other and the City of Salem harmless from any and all claims related to employment or employee benefits, collectively bargained or otherwise, made by persons under their employ or contract prior to the commencement of operations of the Program and arising from the establishment thereof. Each party to this Agreement shall be liable for the acts and omissions of its own employees and agents in the performance of their obligations under this Agreement to the extent provided by law. By entering into this Agreement, none of the Municipalities have waived any governmental immunity or limitation of damages which may be extended to them by operation of law. Each party shall indemnify and hold harmless the other parties to t his Agreement from and against any claim arising from or in connection with the performance of services • provided pursuant to t his Agreement, to the extent the indemnifier would otherwise be liable under a direct claim pursuant to M.G.L. c. 258. 13. Termination Any Municipality, by approval of its Governing Body, may withdraw from and terminate its participation in this Agreement with the provision of at least one (1) year written notice to the other Municipalities. Such termination shall take effect at the close of the next full grant year following notification. Termination shall not relieve the terminating Municipality from any obligations of indemnification that may have arisen hereunder prior to such termination, nor from any financial obligations that by prior agreement extend beyond the termination date. Upon termination, the Steering Committee shall prepare a full statement of outstanding unpaid financial obligations under this Agreement and present the same to the terminating Municipality for payment within thirty (30) days thereafter. Upon receipt of a notice to terminate, the remaining Municipalities shall jointly consider whether to: a) Continue with the Agreement as written, b) Continue under an amended agreement subject to MDPH approval, or c) Dissolve this Agreement in a manner and on a date agreeable to all • Municipalities, in which case each Municipality shall thereafter be solely responsible for the provision of public health services within its corporate NORTH SHORE SHARED PUBLIC HEALTH SERVICES PROGRAM 5 of 12424-2 Intermunicipal Agreement under M.G.L. Chapter 40 jurisdiction and may forfeit MDPH DIG Implementation Funds as well as • other possible future grants applied for through the Program. 14. Assignment The Municipalities may not, individually or jointly, assign or transfer any of their rights or interests in or to this Agreement, or delegate any of their obligations hereunder, without the prior written consent of all of the other Municipalities. 15. Amendment This Agreement may be amended only in a writing signed by all Municipalities duly authorized thereunto at any time by vote of the governing bodies of the Municipalities. MDPH shall be promptly notified of any amendment to this agreement. The addition of non-grant funded communities to the Program shall be considered an amendment to this Agreement and shall require the same approvals as specified above. 16. Severability If any provision of this Agreement is held by a court of appropriate jurisdiction to be invalid, illegal or unenforceable, or if any such term is so held when applied to any particular circumstance, such invalidity, illegality or unenforceability shall not affect any other provision of this Agreement, or affect the application of such • provision to any other circumstances, and the remaining provisions hereof shall not be affected and shall remain in full force and effect. 17. Waiver The obligations and conditions set forth in this Agreement may be waived only by a writing signed by the Municipality waiving such obligation or condition. Forbearance by a Municipality shall not be construed as a waiver, nor limit the remedies that would otherwise be available to that Municipality under this Agreement or applicable law. No waiver of any breach or default shall constitute or be deemed evidence of a waiver of any subsequent breach or default. 18. Governing Law This Agreement shall be governed by, construed, and enforced in accordance with the laws of the Commonwealth of Massachusetts. 19. Headings The paragraph headings herein are used for convenience only, are not part of this Agreement and shall not affect the interpretation of this Agreement. • NORTH SHORE SHARED PUBLIC HEALTH SERVICES PROGRAM 6 of 12424-2 Intermunicipal Agreement under M.G.L. Chapter 40 jurisdiction and may forfeit MDPH DIG Implementation Funds as well as • other possible future grants applied for through the Program. 14. Assignment The Municipalities may not, individually or jointly, assign or transfer any of their rights or interests in or to this Agreement, or delegate any of their obligations hereunder, without the prior written consent of all of the other Municipalities. 15. Amendment This Agreement may be amended only in a writing signed by all Municipalities duly authorized thereunto at any time by vote of the governing bodies of the Municipalities. MDPH shall be promptly notified of any amendment to this agreement. The addition of non-grant funded communities to the Program shall be considered an amendment to this Agreement and shall require the same approvals as specified above. 16. Severability If any provision of this Agreement is held by a court of appropriate jurisdiction to be invalid, illegal or unenforceable, or if any such term is so held when applied to any particular circumstance, such invalidity, illegality or unenforceability shall not affect any other provision of this Agreement, or affect the application of such provision to any other circumstances, and the remaining provisions hereof shall not be affected and shall remain in full force and effect. 17. Waiver The obligations and conditions set forth in this Agreement may be waived only by a writing signed by the Municipality waiving such obligation or condition. Forbearance by a Municipality shall not be construed as a waiver, nor limit the remedies that would otherwise be available to that Municipality under this Agreement or applicable law. No waiver of any breach or default shall constitute or be deemed evidence of a waiver of any subsequent breach or default. 18. Governing Law This Agreement shall be governed by, construed, and enforced in accordance with the laws of the Commonwealth of Massachusetts. 19. Headings The paragraph headings herein are used for convenience only, are not part of this Agreement and shall not affect the interpretation of this Agreement. NORTH SHORE SHARED PUBLIC HEALTH SERVICES PROGRAM 6 of 124242 Intermunicipal Agreement under M.G.L. Chapter 40 • 20. Notices Any notice permitted or required hereunder to be given or served on any Municipality shall be in writing signed in the name of or on behalf of the Municipality giving or serving the same. Notice shall be deemed to have been received at the time of actual receipt of any hand delivery, upon the date of verified delivery by courier of package delivery service, or three (3) business days after the date of any properly addressed notice sent by mail as set forth below: For: City of Salem The Honorable Mayor Kimberly Driscoll 93 Washington Street Salem, Massachusetts 01970 For: City of Beverly The Honorable Mayor William F. Scanlon 191 Cabot Street Beverly, Massachusetts 01915 For: Town of Danvers • Mr. Wayne Marquis Town Manager 1 Sylvan Street Danvers, Massachusetts 01923 For: City of Lynn The Honorable Mayor Judith Flanagan Kennedy 3 City Hall Square Lynn, Massachusetts 01901 For: Town of Marblehead Mr. Jeffrey Chelgren Town Administrator 188 Washington Street Marblehead, Massachusetts 01945 For: Town of Nahant Mr. Andrew Bisignani Town Administrator 334 Nahant Road • I NORTH SHORE SHARED PUBLIC HEALTH SERVICES PROGRAM 7 of 121212 Intermunicipal Agreement under M.G.L. Chapter 40 Nahant, Massachusetts 01908 • For: City of Peabody The Honorable Mayor Edward A. Bettencourt, Jr. 24 Lowell Street Peabody, Massachusetts 01960 For: Town of Swampscott Mr. Thomas G. Younger Town Administrator 22 Monument Avenue Swampscott, Massachusetts 01907 21. Complete Agreement This Agreement constitutes the entire agreement between the Municipalities concerning the subject matter hereof, superseding all prior agreements and understandings. Any other agreements or understandings made or offered, whether oral or written, between the Municipalities concerning the subject matter hereof that are not contained in this agreement and its amendments are hereby • declared invalid. WITNESS OUR HANDS AND SEALS as of the dates here written. For the City of Salem By its Authorized Governing Body: X SIGNATURE NAME TITLE DATE For the City of Beverly • NORTH SHORE SHARED PUBLIC HEALTH SERVICES PROGRAM 8 of 12424-2 Intermunicipal Agreement under M.G.L. Chapter 40 a Nahant, Massachusetts 01908 For: City of Peabody The Honorable Mayor Edward A. Bettencourt, Jr. 24 Lowell Street Peabody, Massachusetts 01960 For: Town of Swampscott Mr. Thomas G. Younger Town Administrator 22 Monument Avenue Swampscott, Massachusetts 01907 21. Complete Agreement This Agreement constitutes the entire agreement between the Municipalities concerning the subject matter hereof, superseding all prior agreements and understandings. Any other agreements or understandings made or offered, whether oral or written, between the Municipalities concerning the subject matter • hereof that are not contained in this agreement and its amendments are hereby declared invalid. WITNESS OUR HANDS AND SEALS as of the dates here written. For the City of Salem By its Authorized Governing Body: X SIGNATURE NAME TITLE DATE For the City of Beverly NORTH SHORE SHARED PUBLIC HEALTH SERVICES PROGRAM 8 of 124242 Intermunidpal Agreement under M.G.L. Chapter 40 • By its Authorized Governing Body X SIGNATURE NAME TITLE DATE For the Town of Danvers By its Authorized Governing Body: X SIGNATURE NAME TITLE DATE For the City of Lynn By its Authorized Governing Body NORTH SHORE SHARED PUBLIC HEALTH SERVICES PROGRAM 9 of 124242 Intermunicipal Agreement under M.G.L. Chapter 40 X •SIGNATURE NAME TITLE DATE • For the Town of Marblehead By its Authorized Governing Body: X SIGNATURE NAME TITLE DATE For the Town of Nahant By its Authorized Governing Body • NORTH SHORE SHARED PUBLIC HEALTH SERVICES PROGRAM 10 of 124-2= Intermunicipal Agreement under M.G.L. Chapter 40 5 • SI SIGNATURE NAME TITLE DATE For the Town of Marblehead By its Authorized Governing Body: X SIGNATURE NAME TITLE DATE For the Town of Nahant By its Authorized Governing Body } NORTH SHORt SHARED PUBLIC HEALTH SERVICES PROGRAM 10 of 124242 Intermunicipal Agreement under M.G.L. Chapter 40 . X SIGNATURE NAME TITLE DATE For the City of Peabody By its Authorized Governing Body: X SIGNATURE NAME TITLE DATE For the Town of Swampscott By its Authorized Governing Body NORTH SHORE SHARED PUBLIC HEALTH SERVICES PROGRAM 11 of 12424-2 Intermunicipal Agreement under M.G.L. Chapter 40 X •SIGNATURE NAME TITLE DATE • NORTH SHORE SHARED PUBLIC HEALTH SERVICES PROGRAM 12 of 124242- Intermunicipal Agreement under M.G.L. Chapter 40 X SIGNATURE NAME TITLE DATE NORTH SHORE SHARED PUBLIC HEALTH SERVICES PROGRAM 12 of 12424-2 Intermunicipal Agreement under M.G.L. Chapter 40 Heather Lyons From: Joyce Redford <putitout@lynnma.gov> Sent: Tuesday, September 11, 2012 7:12 PM To: Larry Ramdin; Heather Lyons Subject: Training Sunny Corner attended and completed the Tobacco Control training on 9/11/2012 In attendance: Thomas Truong Lan Pham Chan Le Thank you, 30gee Joyce Redford,M.Ed.,Director North Shore/Cape Ann Tobacco Alcohol Policy Program 3 City Hall Square,Rm# 103 Lynn,MA 01901 781-586-6821 •www.makesmoking_histoa.org • 1 { y3 •qSEP ,q Op OFti slj�joy wexftc all'7a s. i hTeNOES) "I)A fro CITY OF SALEM9 MASSACHUSETTS 1PGi BOARD OF HEALTH �,,��, 7�^�¶�g� 120 WASHINGTON STREET,4m FLOOR Prdeven7t1��m1 [dd8 TEL. (978) 741-1800 FAx(978) 745-0343 �KIMBERLEY DRISCOLL lramdin@salem.com LARRY 1tAMDIN,RS/REHS,CHO,CP-FS MAYOR HEALTH AGENT May 17, 2012 Thomas Truong Owner Sunny Corner Market 331 Lafayette Street Salem MA 01970: Dear Mr. Truong, RE: Notice of Suspension of Permit to sell Tobacco Pursuant to its authority under Massachusetts General Laws Chapter 111 and Salem Board of Health Regulation 24. The Salem Board of Health has voted at a hearing, held at its regular meeting on May 8,2012 to suspend your permit to sell tobacco for four months,with effect from May 9, 2012. action is based on the fact that you have committed a sixth violation of the Salem Board of Health Regulation Regulation affecting the purchasing of tobacco products and posting of laws concerning their sale; by selling tobacco to minors and offering single cigarettes outside their original packaging. The Board has assessed fines of$300 for each violation for a total of$600.00 The Salem Board of Health also advises that the reinstatement of your permit is not automatic and you will have to apply for reinstatement of the Sale of Tobacco permit. Additionally, as a condition of reinstatement of your tobacco permit, the Board of Health is requiring that all employees of Sunny Corner Market,be trained in the rules governing the sale of tobacco per Salem Board of Health regulation 24 section III(c). Arrangements can be made with the Northshore Tobacco Control Program to facilitate the training. Further, any further violations of Regulation 24, can result in the revocation of your Retail Sales Permit The Salem Board of Health retains jurisdiction over this issue. Yours Very truly aid of Me,&tt MADI Larry Ramdin REHS, CP-FS, CHO �3 �lth Agent � V YlOVC 01 Salem,MP CC : Joyce Redford,Northshore Tobacco Control Program Elizabeth Rennard City Solicitor Received BY:;'...4, - I- -----__ _Printed Name: rr v Delivered BY: Printed Name �1� 13five,, Date: • 'C : Joyce Redford,Northshore Tobacco Control Program Elizabeth Rennard City Solicitor -eceived BY: ; _Printed Name: ►elivered BY: Printed Name Ay))b Mys,, late: • SEP-11-2012 04:13AM RNA- T-020 P.002/021 F-069 C o mMONWEALTH OF MASSACHUSJETTS ESSEX, Ss. SUPIERIOR COURT CIVIL ACTION NO. 10-00$74 AT�THUR THEOPIaLOPOULOS &others' VS. THE ROARD OF HEALTH OF THE C"r'II Y OF SALEM & another2 M E M QRAANDUM OF DECIS10N AND 0 V E R ON PLAIN'11FFS' Mt71'�N_ FOX,1!UiJGMENT ON THE PLEADINGS i Erj-?4P-UC Tr-ON Pursuant to G. L. c. 30A, § 14, the plaintiffs seek judicial review of a decision of the City of Saletn 90ftrd of T-lealth to ;.;rant to Salem mid Notiltside Carting, Inc. their Application for a Minor Modification to a Site Assigtlrnent for the Salem Transfer • Station. Currently before the Cotu-t is the plaintiffis' Motion fm Judgment on the Pleadings. After reviewiit<g the parties' submissions and the relevant law, the Court allows the plaintiffs' Motion for Jud&ramit on the Pleadings at:td vaastes the decision of the Board. BACKGROUND The Salem. Transfer Station is a 9.2 acre parcel of land located at. 12 Swampscott Road, in Salem. Administrative Record ("A.R.") Tab I1. On .Tune G, 1960, the Board assiglied the site of the station for use as a solid waste incinerator. A.R. Tab a. let 1975, t1le Department of Envirotunmial (duality Engineering Division of Environmental Health r 3asncs If. Rtsll; Bruce Glinski;Matthew CM011o; Mary Civicllo; Scott Morgan;Tend MOT9 Anthony Jcrmyrs; Deborah Gallo; Alan Sawilian; Young World Modemy, lne.; Anarpct Realry, Inc.: Thomas L. McAuliffe. Trustee of Hutchinson Fealty Tntst; Bruce Gliuski, Trustee of Green Dolp;xin vilittgr Condomirdom,Trust;Roger and Julio,Inc.;New Tri-City Realty Corp.;and One Way Lumber Corp. Norillside Caning,Inc,was permitted to inteivene as a defendant, • SEP-11-2012 04:13AM FR011- T-028 P.003/021 F-06$ • graIlYCdSalem's request to convert the use of the 17rapelly to that of a refuse transfer station. A.R. Tab 1. The DEQb:'s aPProval limited the operation of the transfer station to the handling of 100 tons per day 0 c refuse," 1d. On June 3, 1994, the Departlnel)t of Environin,ental P=oteetion granted Salem a peritlit by Rule to continue to operate the transfer station. A.R.Tab 3. in 2007, Salem issued a Request for Proposals to redevelop the Property. A-R. Transcript Day 1 at 43.3 Salem selected Northside's prop0sai. On June 23, 2009, Salem and Northside submitted the Application to the Board. A.R. Tab 11.' The Application's ilrtroduction states, "[t]lxe proposed project C0119i5ts of increasing the capacity of th-e cuxzrertt 100-ton-per-day transfer station. In accordance with the Solid Waste Regulations in 310 CMR 16.22, any increase in the daily or artilual tonnage limits of a. solid waste, facility is considexed a 'Minor Modification."' Id at 1. According to the Application., the • existing; building will be demolislred and the existing on-site landfill will be closed. Id at 1--2. 'floe existing building conlptises 5,500 square feet. Id, Fitpu-e 1 at 2. The tipping floor of the proposed new twilding will comprise approximately 7,500 square feet; however "the building will be expanded by approxilrUtlely 2,200 [additionall square feet to obtain additional space within the building for processing and loading operations." A.R. Tab I at 2. "The actual square footage of the building is expected to be apprOxinlately 9,700 square feet." Id. The Application also indicated that all existing driveways would be repavcd and that additional driveways would be added. Id. For rase of rending, the Cctu�t will refer to the November 10, 3009 nearing as Transcript Day t; the November 24, 2009 Ileazing as Transcript Day 2; tirr Dtcember 8, 2009 deliberative srssiaa as'!'ranscript Day 3;and the f)eccmber 15,2009 deliberative sc3aioa as'Tran�cript Day 4. 4 Prior to Submitting the Application,Jon Carrigan of the I)ZpaPtn,enc einailed Salem's City Solicitor, $erb "[a)s we discussed previously the cktartse is a minor modification not a major Rcnnatd,to inform her that modification,under 310 CMR 16.00"A.R.Tab 7. 2 SEP-11-2012 04:11AM FROM- T-028 P.004/021 f-•060 • The Application included a Traffic Impact and A.ccess S►:udy C Traff c Study„} that was conducted by Vanasse & Associat(;s. ITIC. {'Vanasse"), A.R. Tab 6, The Traffic Study concluded that expandirig the amount of waste processed at die transfer station from 100 tolls per day to 400 tons per day would "result in an additional 54 vehicle trips (27 entering and 27 exiting) on an average weekday[.)" id at 15. The Traffic Study, ktowever, was based on the prett]ise that the transfcr station was pfocessit•►g 100 tolls of waste per day when the traffic count was conducted in November. 2007. Id,..Table 4; Transcript Day 1 at 66:12-14, 75:3-7.5 Itt fact, when Vanasse conducted file traffic cOtult, the transfer station received only 58 torts of waste. A.R. Transcript Day 2 at 15:3-6. Vanasse subsequently corrected the traffIQ projections by assuming that when it cortdu.cted the traffic counts, the transfer station received 50 tons of waste per day and that in the future, it would receive 500 tons of waste. A,R. Trwiscript Day 2 at 15:1.6- • Vanasse subrilitted a sttpplernental Traffic 16:6, Tab 22 at 1. On November 9, 2009, Va Study,whichA increased the number of pddi.tioi)al vehicle tri-Ps to 84. A.R..Tab 1 S at 2. On November 19, 2009, Vanasse submitted a secund supplemental Traffic Study, which concluded that expansion of the transfer station would result in 90 vehicle trips beyond the nuraber that existed in November 2007, for a total of 230 daily vebicle trips.A.R.. '1-ab 22 at 1. Although a larger number of trucks might have been.expected using princi.,ples of simple math, that is trot the case here because the "trucks that are coming in there [to the transfer station] are the packer trucks, and titey can accommodate much more tonnage per vebicle going into the facility."A.11_'1'ransciipt Day 2 at 16:18-20. s in 2U0 7 Nonitside reported that the transfer station processed approximately 25 toes of waste per day. A.R. Trrutscript Day 1 at 65:17-66:1. Northside, huwever, contends, "over the comse of a 4-year average, in terms of receipts at the facility based on what was rcported to the DEP, the facility receives on averar&e about 43.2 tons per day(.)"A.R.Transcript Day 2 at 1.5:7-11. ._ • SEP-11-2012 04.13AM FROM- 7-028 P.005/021 F-069 • Nor 1 t Lside and Salem also submitted an Air Quality Modeling Report ("Aix Report") prepared l,y epsilon Associates, Inc. {C'Epsilon"). The Air Report concluded, "the cxistin.g and proposed Mick trips affiliated with Northside Carting are below the NA,AQS [National Ambient Air QLlality Standards] for tine particulate matter . . . and also below the EPA RfC [Reference concentration] t'or DVM [diesel particulate rnatter.]" A,R. Tab 11, Figure 2 at 1-1. On November t S, 20o9,Epsilon submitted an Updated Air Qttality Report ("Updated Air Report"), based upon the recently increased number of truck tries per day to 230. The inerea_se in vehicular traffic had a"very small" iUlpact on emissions. A.R.. Tab 24 at 1. The Updated Air Report also considered emissions from building operations. Id. Based on the asSw.nption that the transfer station utilized water mist stations, fast closing doors, and Negative pressure, 90% of the eztrissions would be released through the transfer station's emissions stack- Id. The Updated Air Report • at tlae maxiinum impact from building emissions "[is] well wttlna the concluded that p National Ambient Air Quality Standards. .Id at 2. A Noise ln'tpact Assessment Study ("Noise Study") was 01sO submitted with the A-pplicatiot). A.R. Tab 11, Figi= 4, The Noise Study concluded that the "sound level impact assessment for the proposed expansion at the Salem Transfer Station indicates that: predicted noise levels will comply with the most stringent daytime noise regulations." 1d, Figure 4 at 7-1. The report, however noted that tiuck "back-u-p alarms may temporarily result in `pure-tone' conditions a.t.locations to the nortl, and west"Id, Figure 4 at 7-1.6 on October 20, 2009, the Board publishescl notice that on November 10, 2009, it G Pure tone is defined as ,voadidons where one octave t)apd frequency is 3 dB or mere greater than an adjacent frequency. An example of f. 'pure tone' i, a fan with a bad bearing Ltrat is producing an objectionable squeaking sound•"A.R.T.Ab 11,Figure 4 ttr 3-1. 4 • SEP-11-2012 04:13AV FROM- T-028 P.000/021 F-069 would corrlrrtence public leanings on tllc defendants' Application. A.R.. Tab 12. Doctor Kenneth Whittaker, Esq.was appointed.as the he.iristg officer for the hearing. At the start of the November 10th heE ing, Dr_ Whittaker provided an overview of how the hearing would proceed. A.R. Transcript Day 1 at 10-15. The hearing officer informed those in attendance thar after Northside and Salem presented a summary of their proposal, the Board would have the opportunity to ask questions. A.K. Transcript Tway 1 at 12. 'Die public would then be permitted to questions TBpreseittatives from bath Northside and Salem and ,take comments. A.A. Transcript Day 1 at 12. In order to niaintairr order during the public con-iTtient portion of the hearing, the,hearing officer told members of the public to place their names on a sign-up sheer. A.R. 'Transcript flay 1 at 12. The hearing officer also informed the 1Tublic, that they could submit wt•itten comments to the B08rd- A..R.Transcript pay 1 at 14. Beth Retunard, City Solicitor, testified on behalf of Salem. Testifying on behalf of NorEhsrde were Alan Hanscorn, of Beta Group, hie., regarding the construction and design of the transfer station; jefferey Dirk, of Vanasse, concerning tlae project's effect on traffic; Dale Raczynski, fi-o"t Epsilon, regarding the;projeWs impact on noise and. air quality; acid William '1'11otTrson, a principal of Nordiside. Approximately nineteen citizens made statements or asked questions during the public eomrnent/quesv.otl portion of the hearing. A.R. Transcript Day 1 Al 110-185. The Board continued the hearing until November 24, 2009. During the second night of the pul)lic hearing, Nortlr.side's. witnesses supplemented some of the information that they had presented dtuing the first public hearing. Approxunately thirty-five individuals signed up to ask a question or make a 5 • SEP-11-ZO12 04:14AM FR01lr T-0Z8 P.007/021 P-009 • comment. A.R. 'Pransrript Day 2 at 31-32. Given thv ntunber of people wha signed tap, the hearing officer suggested that everyone who wanted to make a conunent limit his or her remarks to "2 mi.liutes or less, mid that way we'll get through that in approximately 30 to 45 minutes, just to leave a good =0401 of time for questi.o7ts, which will probably take a little bit longer." A.R. Transcript Day 2 at 32:4-8. As the various members of the public spoke the hcaring officer had to inform four individuals that they had exceeded their two-minute time allotment; However, each individual was allowed to conclude his or her remarks. A.R. Transcript Day 2 at. 44:19-45:4; 46:18-47:12; 49:15-50:8; 57.24-61.21. Paulette Puelu spoke for approximately five tninute;s, and was allowed to continue speaking after the heating officer infoaved her three times that she had exceeded her allotted time_ A.R. Transcript Pay 2 at 57:24-61:21. Before the heaving concluded, the bearing officer remitlded the public that they could submit written comments after the meeting concluded. A.R.Transcript lay?_ at 131-131. On December 8, 2009 and December 15, 2009, the }hoard deliberated on the defetldants' Application. A.R. Transcript Day 3 and 4. By a vote of four to two, the Soasd approved the application. Ors February 9, 2010 and 1^ebroary 11, 2010, the Board signed the Conditions of Approval for the modification of the site assigtunent. A.R. Tab 39. The Conditions of Approval increased the: daily overage pe7raitted waste processed at the transfer station to 400 tons per day, with a nMXimttrn of 500 tons per day. id, The Conditions of Approval placed forty-three resuictIons on the operation and maintenance of the transfer station. 1d_ The conditions most relevant to this proceeding include: (1) limitiiag the number of vehicles entering the transfer station to 115, which equates to 230 vehicle roundtrips; (2) requiring "routine litter control/policing and street sweeping along 6 SEP-11-2012 04.14AM FR09- T-028 P 008/021 F-068 • Swamp 'Ott Road froze the irtteTseclio n of Highland Ave to First 5treet" at least $emr- monthly; (3) requiring the facility to have ]sigh speed transfer doors that. are to remain closed except when. vehicles are entering or exiting the facility; (4) prohibiting waste from being "handled or stored outside the enclosed reccNing Facility;" (5) prohibiting vehicles from queuing on city streets; (6) requiring on-site vehicles and transfer trucks owned or controlled. by the facility operator to be retrofitted with after-ti3arket emission control kits; (7) requiring vehicles to use Olt",' low sulfur diesel filet; (9) requiring Northside to contract with a larofessional pest cotttrpl rraanagetnent firm before the coznmenceinent of operations and on a semi-nionthty basis; (9) requiring the use of odor acutralizing agents "in the misting Syste", to effectively neutralize any odors exiting the building;'! alzd (10) requiring traffic alterations. 14 a.t pairs. 3, 7, 11, 14 — 19, 25, 28, 38, • 40. On February 16, 2010, the Board published a Notice of the Conditions of Approval in the Salerrt News. Plaintiffs subsequently conunemed this action. The seventeen plaititiffs live in,the area surrounding the transfer station property. 1111tchinson Realty Trust owns property located at 331.-333 111ghland Avenue, Salem, which directly abuts the transfc--i station property and is located less than 500 feet frorcl the transfer statio,.1 itself Multiple health care practices are located within the building at 331.333 14i&dand Avenue. Young World Academy operates a daycare and pre-school progran, at 3 Grcc:n Ledge Street, Salem, which is located less than 500 feet from the transfer station property. Green Dolphin Village Condominiursz Trust awns a condominium complex located near the Property. The closest residential building within tlje (3reen Dolphin complex is located 2,12 feet. from the transfer station property, and the transfer station itself is approximately 600 feet f7:oni the complex. Bruce Glinsky and 7 • SEP-11-2012 04.:14AId I:ROM— T--020 P.009/021 F-069 • Alan Samiljan both resido in townhouses located within the complex. ,LJscuSSION I. Standing As an initial inatter the defcndatlts rcncw their contention that the plaintiffs lack standing to pursue this appeal because the plaintiffs' alleged injuries are speculative and common to the entire conintunity. For the reasons discussed in Justice Lowy's Mcpaor andwn of Decision and Order on vorthside Cnyting ln.c.'s Motion to Dismiss, this Court concludes that the plaintiffs have stwding, Justice 1_0wy previously decided that Hutchinson Realty Trust, Young 'World Academy, Jac., Green Dolphin Village Condominium Trust, and Anacpet Realty, lnc. had standing because of the .proximity of their properties to the transfer station. it is apparent as woll, based on the adrrtini,stxative record, that nuynerous other named plaintiffs live in close proximity to thQ transfer station and, therefore, will be uniquely affectud by the increase in traffic and noise, and a. possible reduction in air quality. See Cohen v. Zonin�d. of A�Leals of Etyin th,, 35 Mass, App. C:t, 619, 620-621 (1993) (where there is a multi-party appeal of a zoning board's decision it is oXtly necessary to determine whether at)y one plaintiff is aggrieved in order to decide standing issue). 11. Reviery o#_tit Board's Decision The plaintiffs contend that the .Board's decision was arbitrary, capricious, in excess of its authority, not in accordance with the 1,tw, and/or contrary to the regtiirernems of 0. L. c. l 11, §§ 150A and 150A%, and the Department's site assigm ent regulations, 31.0 Code Mass. Regs. §§ 16.00. Specifically, the plaintiff's allegc that the Board (l) improperly treated the defendants' Application as an application fora ininor 5 • SEP-11-2012 04:146 FROR- T-028 P.010/021 F-069 modification of a site assignment; (2) violated numerous provisions of the public hearings Hales, 310 Code Mass. ,Reps, § 16.20; (3) violated the site suitability criteria, 310 Code Mass. Kegs. § 16.40; and (4) violated nanterous provisions of the standards and criteria for siting of facilities,G. L. c. 1.11, �150r1 ii. The Court will address each claitti iri turn. A.. —tandaxd of review A reviewing court may modify or set aside an administrative agency's decision if that decision exceeded the agency's authority, was based upon an error of law, was unsupported by substantial ciridence, or was arbitrary and capricious or otherwise not in accor6ance with the law. G. I... c. BOA, § 14(7). Judicial review of an agency's decision is confined to tllc administrative recoxd. G. L c. 30A, § 14(5). A reviewing court is required to give due weight to the a.g,Fncy's experience, technical competencc, specialized knowledge, and the discretionary authority conferred upon it by statute. Hin an-i V. Deuartment of Telecart ,& Etterpy, 433 Mass. 198, 201. (20U1). A reviewing court tnav ztot substitute its ,judgment for that of the agency. Flcniin.g5 v. Contributo ._et. Anveal B(L,431 Mass. 374.375 (2000). B. Analysis a. ApQbcation for Site Modification Tlie plaintiffs argue that the defendants' Application was incorrectly classified and reviewed as all application for a minor modification. They contend that the defendants' Application should have been treated as an application for a Major modifcation. The defendants, however. aRsert that tlae Application was correctly treated as an application for a milior modification because the Application sought to increase tho daily permitted tonnage of solid waste processed ai the facility to an average of QUO tons 9 • SEP-11-2012 04:14AM FROM- T-0Z8 P.011/021 F-060 • per day, and tltat the regulations deeni simple increases in allowable tonnage a$ minor la Y> modifications. A brief summary of the statutory and regulatory fTanjework governing the siting and permitting of waste transfer stations is necessary at this point. General Laws C. 111, §§ 150A and 150A% outline the process for obtaining a site assignment for a waste transfer station. A site assignment is required for a new facility or,t11e expansion of an existing facility." G. L. c. 111, § 150A. "However, § 150A does not define the terms `new facility ar expansion of an existing facility,"' a task "the l:.egislature delegated to the department" Goldbergv. Board of Hearth of Granby, 444 Mass. 627, 629 (2005). Pursuant to this authority, the Department defined "Expand a Site" to mean "to move a solid waste facility,s operation to a previously unassigned site that is contiguous to the original site or to modify a solid waste facility's operations causing it to exceed any • ca achy or total volume limit stated in its current site assignment."' 310 Code Mass. A . Regs. § 16.02 (emphasis added). The Department's regulations differentiate betweetl major modifications and minor rnoclifications of a site assignment. A-Major-,:modification of tt siteYassigmnent includes"rnodificsation,required to_`Expand.a,Site!; vertical#expansioits'beYond`dle3limits r- of an approved plan; modifications as specified at 310 CMR 16.21(1) and 16.21(3); AYtentative Use of an Assigned Site.;or any request to waive any site assignment criterion _ - IL set Forth at 3l0 CMR 1fi.40(3) as it,applies to,the_existing.facility:'.310 Code Mass. t`_^--{ -. - .._ ®nment includes Regs. § 16.22(2) (emphasis added). A Mirror modification of a site ass' r the November 10,2009 public I'earu'fi Alan Hanscom of Beta Group,Inc_conceded that the During h � Property i,4"an exisEutg site assigned site(.)".A.R.Transcript Day l at 164:15. • SEP-II-2012 04:14AM FROM- T-028 P.012/021 F-069 "[alny request to modify a site assignment that is not subject to 310 CMR 16.22(1) or(2), including any request to,modify conditions established by the Board of Health in the site assignment, or any request to increase daily or annual tonnage limits, except as specified at 310 CMR 16,22(4) (Reserve Capacity Approvals)." 310 Code Mass. Regs. § 16.22(3) (einphasis added). The Departinerit's modification regulations are ambiguous, because if an applicant only seeks to increase the "daily or: annual tonnage-litnit',,%and makes no f modifications to the facility, the modification is deeined.minor. 3.10 Code Mass.Regs. §a 16.22(3); whereas if an, applicant-seeks=to modif, the "solid-waste facility's operations z - causing it to exceed Many-rapacity ,or total -volunic limit stated in its current, site assignment[,)" the modification is deemed major. 310 Code Mass. Regs. §§ 16.02, 16.22(2). • Whether a modification is classified as a major or minor modification is significant. A request ibr a major modification requires that the applicant submit to the board of health a new site assignment application, a site suitability detcrmination report from die Department, and participate in the board of health's public hearing. 310 Code Mass. Regs. § 16.22(2). A request for a minor modification, however., does not require the "filing of a new application by the applicant or site suitability report by the Department, provided the Board of Health provides public notice and holds a public hearing[.]"310 Code Mass.)begs. § 16.22(3). As-the party challenging the DeparttrEent's interpretation of its regulations, the plaintiffs carry the "fonnidable burden" of establishing that the Department's interpretation was not rational. Northbrid e v. Natick, 394 Mass. 70, 74 (1985). Courts "ordinarily accord an agency's interpretation of its own regulation[s] considerable 11 • SEP-11-2012 04:15AR FROW T-028 P-013/021 F-066 • deference." ar'cewicz v. Denurtrnent of L-nvtl. Prot., 410 Mass. 548, 550 (1991) (alteration in original). The principle of according weight to an agency's discretion, however, is "one of deference, not abdication, and [couns should]not hesitate to overrule agency interpretations of rules when those interpretations are arbitrary or unreasonable or inconsistent with the plain tens of the rule itself."FL elsteint v. Board of Re 'stration i 0 tgzgeW, 370 Mass. 476, 478 (1976). Although an agency is given the authozity to establish rules, once the agency disseminates the rules, the agency "cannot thereafter arbitrarily construe and apply its rules which as promulgated have dimensions and content not subject to infinite manipulation and expansion."Id. In support of their contention that the change here constitutes a minor modification, the defendants plane great emphasis on an email they received from. John Carrigan, of die Depatunent, stating, "as previously discussed the change is a minor • modification not a major modification under 310 CMR 16.U0"A.R.Tab 7z%Iwthe-Cotut's.,. view however, this email,is,not.eauitled.to,any weight--ivis-unclear..-what•information s 1 John Carrigan relied.:upon.in,tnaking-this•determination.- Nor ds.there_any-evideRcc showing what inibimation.the.Departinent-had-reviewed-when-it-originally-concluded_ that the Application constituted a minor�modificatiou.=--, An adii6nistrative regulation is to be construed in the same manner as a statute. Costa v. F River I-sous. Auth., 71 Mass. App. Ct. 269, 277 (2008); Tess v. (`pmmitisiouer Deyt of Iiansitional Assis , 41 Mass. App. Ct. 479, 482 (1996). "[A] basic tenet of statutory construction [is] that a statute must be construed `so that effect is given to all its provisions, so that no part will be inoperative or superfluous."' Bankers Life & Cas. Co v. Commissione of Ins., 427 Mass. 136, 140 (1998), quoting l2 • SEP-11-2012 04:15AU FROM- T-028 P.014/021 F-060 • 2A B. Singer, Sutherland Statutory Constraction 9 46.06 (5th ed.1992). "Courts will view a regulatory scheme as a whole and whenever possible will interpret ovfflapping or concurrent treatment of a common subject by multiple provisions harmoniously so as to preserve some useful effect for each one."fit sta, 71 Mass. App. Ct. at 277, The defendants' Application sought to increase the transfer station's solid waste processing capacity from 100 tons per day to an average of 400 tons per day, with a mWinurn allowance of 500 tons a day. A.R. Tab 11. The Application also proposed demolishing the existing transfer station and building a 4,200 square foot larger transfer station-8 Id. In essence, the defendants' Application seeks to increase the transfer station's daily tonnage limit and capacity by building a new transfer station capable of processing the increased tonnage. Mere, the proposed demolition of the existing facility and the construction of the • new facility is designed precisely to enable tlxe facility to "exceed [the] capacity or total volume limit stated in its current site assignment." 310 Code Mass. Kegs. §16.02.T,That being so,Tthe Applzcatiort._sought,to_"Expand,a;Site" within the=meanixtg of 310. Code Wass, Regs: § 16 02,,—and,-thusrmake;a rnajor modificatiait'to the site assignment,within;, Lute meaning of 310 Code Mass. Regs. §,16.2?(L), To conclude that the defendants' Application constituted a minor modification would require the conflation of the `increase daily or annual tonnage" 1ux►it language of§ 16.22(3) with the "to modify a solid waste facility's operations causing it to exceed any " As previously noted, the existing transfer station comprises 5,500 square feet The Application seeks to increase the size of the tipping roost floor by 2,000 square feet to 7,500 square feet. The Application then seeks to add an additional 2,200 square feet to the transfer station to provide space for processing and loading operations.A.R.Tab 11,.Figure'l, The new iransfer station, therefore,will be approximately 9,700 square feet,or 4,200 square feet larger than the existing transfer station. 13 SEP-11-101Z 04:15AM FROM- T-028 P.015/021 F-084 • capacity or total volume limit" language of 9 16.02, when it is apparent that the phrases have distinct meanings. If the phrases were ititUpreted to apply to the salve conduct, then the"Bxpand a Site"language that classifies a project as a major modification would be ,,,,ne,;essaty, See B rakers Life & Ca�., 427 Mass. at 140 (statute must be construed as to give effect to all its provisions). Based on the very language of the regulations, a minor modification occurs when the transfer station does not require any structural changes to handle an increase in the facility's daily tonnage lirnit 9 The "Expand a site" portion of the major modification regulation, therefore, only applies when the transfer station requires structural modifications to be able to process the increased toruiage limit.10 For the reasons just discussed, the Court tconcludes that the-_defendants' A,pplieatiot� was inrtpmpalY classified as an-application--for a minor-modification. anal, considered under the regula `ti.onsgoverning.E!Iit,or iiiudifications to a site assignment. The Board's decision,therefore„Lngst be vacated. However, in the event that a reviewing rcourt uiay disagree, this Court will address the other issues raised in the plaintiffs' Motion for Judgment on the pleadings. b. Public He r;�i The plaintiffs contend that the Board violated ni.tmerous sections of the Public Hearings regulations. See 310 Code Mass. Regs. § 16.20. For example, they contend that the Board violated 310 Code Mass. Regs. §16.20(10)(f)(D,which requires that a witness, 9 An example of a niinor modification is if a facility's site astign ent limits the facility to too tons of waste per day,but the facility is physically and structurally capable of processing 400 tons of waste per day and sought a modification allowing it to process 400 tons of waste per day, stiucnual �"' A major modification would consist of a situation where the transfer station would require changes or the construction of a new transfer sunion to proccse4 an increase in the facility's daily Manage limits, 14 . v....... ..........�•. .. . r ....v o I V o c. .........� V�I I V I L V\L .V c V n V 0 I � V.V I V G . SEP-11-2012 04:15AM FROM- T-OZO P.016J021 F-069 • testimony be made`pander oath or affirmation," because none of the witnesses was sworn prior to testifying at the public hearing. However, on November 25, 2009, Dirk, Hanscom, Reczynski, and Thomson each submitted a document entitled, "Attestation of Testimony," in which each magi swears that the testimony he gave before and the documents which lie filed with the Board were truthful. Memorandum of uitMenor Nortbside Cartiug, hic. In Opposition to Motion. for Judgment on the Pleadings, Ex. A.'� The regulations do not require any particular type of anemorialization of the oath or aftitniation, and the Court -sees-no- compelling.-reason .to.,invalidate..thc witnesses', testimony because.it.was asworn,to,after,it was-madeN,,See Cotymonwealth v. Cote, 15 Mass. App, Ct. 229, 237 ()983) ("We can see no compelling reason, however, to invalidate a complaint merely because it issued upon statements which were sworn to • subsequent to their making;."). Next, the plaintiffs argue that the hearing officer violated 310 Code Mass. Regs. §16.20(0)(c)(4) and (6) because Nortliside's experts were given an unlimited amount of time to testify and present evidence in support of the Application, while the hearing officer limited members of the public making comments during the public comment portion of the second hearing to two minutes or less. The hearing officer's duties include, `'assisting all those giving testimony to make a full and free statement of th facts in order to being all information necessary to determine whether a site is suitable or not suitable;" and "ensairing that participants have an opportilnity to present evidence whother orally or in writing, relevant to the suitability or non-suitability of a site." 310 tt There was no objcolion to the Courts consideration of these documents in COttnccdan with thCl3toti0n for judgment on the pleadints. 15 • SEP-I1-2012 04:15AM FROM- T-026 P.017/021 F-069 • 4 4 6 The regulations provide hearing officers with Cade Mass. Begs. § 16.20(11)(')( ), ( )- !; broad discretion; for example,the hearing officer"shall impose such time restrictions and limitations on oral presentations as he deems appropriate." 310 Code Mass. Regs. §16.20(l 1)(d)3. At the start of the public comment portion of the second night of the hearing, the hearing officer stated that there were fifteen people waiting to comment and twenty people waiting to ask a question. Because questions required more time than comments, the hearing officer suggested that people limit their comments to two minutes or less so that there would be sufficient time to answer questions. On four occasions, the hearing officer unformed individuals making comments ibat they had exceeded their two-minute time allotment. The healing officer, however, allowed each individual to conclude his or her comments. The hearing officer had to inform one of the speakers, Paulette Puleo, • three times that she had exceeded her two-minute time allotment before she concluded her remarks. Near the end of the public comment portion of the hearing, the hearing officer reminded the audience that the Board would continue to accept written comments after the hearing concluded. In light of the fart that the public was told it could make comments, ask questions, and submit written comments after the hearing,411e:.hearing., officer acted appropriately in limiting comments to two-minutes or less in-an effort to p eseT enough time,for hc,q%iestion portion of the hearing. , Additionally, the plaintiffs argue that the Board failed to make specific findings of fact in the Conditions of Approval regarding the site suitability criteria listed in 310 Code Mass. Regs. § 16.40. General Laws c. 30A, § 11(8) requires that every agency decision be "accompanied by a statement of reasons for the decision, including determination of 16 • SEP-11-2012 04:1SAM FROM- T-029 P.018/021 F-009 • each issue of fact or law necessary to the decision[.]" This requirernettt exists so that a reviewing court is thoroughly able to review the agency's decision for error. Nstar Elec_ Co. v. Degarmient of Pqb-,_U tils., 462 Mass. 381, 386-387 (2012). An Agency"need not set fotth a lengthy statement of factual and legal conclusions as long as its decision contains adequate reasons to allow the court to exercise its function of appellate review" Maddock v. ContributoryL&J. Appealed., 369 Mass. 488, 497 (1976). The Board's :failure::to make explicit,findings,offact•in the Conditions of'Approval is not fatal to its decision. The Board issued its decision after it extensively discussed -the defendants' Application during the two-night public meeting, i.e., the Novr..tnber 10th and 24th public hearings. The Conditions.of Approval included forty-three detailed conditions. Based on the Board's two-nights of deliberations, on December 8th and 15th, which were open to the public and were recorded, as well as based on the forty-three conditions included in • the Conditions 'of Approval., an adequate record exists for the court to review the correctness of the Board's decision. The detail.of the-discussions and the Conditions of Approval enable the Court to ascortain with t:()niidence the law and facts upon which the decision was.based. Finally, the plaintiffs allege that the Board tailed to publish the notice of its decision, within seven days of the decision being issued, in violation of 310 Code Mass. Regs. § 16.20(13)(b). This argument merits little consideration. Contrary to the plaintiffs' contention, the Board did not issue its decision on December 15, 2009. The Board voted on the defendants' Application at that time and issued its decision on February 11, 2010. The notice of decision was published on February 16, 2010. "The Board,therefore,complied with the notice regulation._ 17 SEP-II-2011 04:15AM FROM- 1-028 P.019/011 F-069 • c. Healtt ,are acllit Thy: plaintiffs argue that the Board should have denied the defendants' Application because a health care facility operates within 500 feet of the transfer station. The defendants argue Char the Board was not required to consider the site suitability criteria articulated in 310 Code Mass. Regs. §16.40, because the Application contemplated a minor modification. Because iri fact, the Application involved a major modification, the Board was required to consider the site suitability criteria articulated in the regulu6on. Title 310 Code Mass. Regs. § 16.40(3)(d)S.b.ii prohibits placing a transfer station handling solid waste at a site that is within 500 fret of a health care facility. The Court;does,nol-resolve..this, issue;-because the=Board•did> not_,actively consider the locatiol of .11%health.care..facilities. Ho,,vever, the Court notes that the Property located at 331-333 Highland Avenue is less than 500 feet from the transfer • station property mid houses multiple health care practices. d. Standards and Criteria for Siting Facilities The plaintiffs argue that because Nortliside's original Traffic Study was flawed and because the.Air Report and Noise Study were based otz-the flawed Traffic Study, the Board did not properly consider a variety of the standards and criteria for siting facilities as articulated in G. L. c. 111, § 150Ari. The plaintiffs contend the Board failed properly to consider the following provisions of G. L. c. 150A%: (6) the nature and extent of residential areas in proximity to the site; (7)the availability and suitability of access roads to the site; (9) the potential for adverse impact on air quality; (10) the potential for creation of a nuisance fi-om noise, windblown litter, or the proliferation of rodents, flies, or other vermin; (11) the potential for adverse public health and safety impacts; (14) the l� • SEP-I1-2012 04:16AM FROtf- T-020 P.020/021 F-069 • potential of increased traffic volwne on. the roads to the site; and (17) the potential adverse impacts on communities within one-half mile of the proposed site including the potential adverse it npacts on the considerations stated within this section for which site suitability standards and criteria are established. The defendants contend that the Board properly considered these criteria and that the Board's decision is supported by substantial evidence. The detail of the Conditions of Approval makes it apparent that the Board did take into account the relevant siting factors which the plaintiffs contends the Board i�ntored. The plaintiffs' ,argument that,the.Board.violated.the,standards,and criteria, . for,siting facilities,in,G_L. e_.1.11, §.150A%fails: As previously noted, the Conditions of Approval specifically incorporate many of the criteria which the studies assumed. For instance, the Conditions of Approval: limit • the number of commercial vehicles entering the transfer station to 115 (230 vehicle roundtrips); require that the facility operator conduct routine street sweeping along Swampscott Road from the intersection of Highland Avenue to First Street; require the transfer station to use high-speed transfer doors that are to be closed except when vehicles enter and exit; prohibit vehicles from idling; control traffic to mirdinize congestion; install after-market emission control kits on facility-owned or operated vehicles; conduct a noise evaluation within 180 clays of opening and, if the evaluation indicates that dBA levels exceed a 5 dBA increase, the facility ,must insuill noise attenuation features within 330 days of opening, contract with a licensed pest control management firm; install an air system capable of producing negative pressure in the transfer station; install a misting system; and continue to monitor the traffic situation to determine if additional alterations nc necessary. A.R. Tab 39(3), (7), (11), (14), (16), 19 10:G2 #097 P.021/021 SOP-11-2012 04:16AM FRUM- T-028 P.021/021 F-069 • (17), (23), (25), (26), (28), (J7), (38), and (40). In-sum, had the Board;s.proceedings.been-governed-by'310'Code Mass:•Begs:-§. 16.22(3), tlje regulatiq_n,governing minor.mod ifications.of a site assigunent;its.deeision____,, would.staud. The proceedings, however—were_actually.governed•by-the-more-stringent _3 4egulation,.310 Code,Mass.„) egs_§.16.22(2),-.which-outlines•thc�procedures-for-major-—` modifications,of a,site.assigmnent. .the proceedings were not conducted consistent with those procedures. As a result, the Board's decision is a nullity. O�RD�`R For the reasons stated above, the Plaintiffs' Motion for Judgment on the Pleadings is ALLOWED, and the Board of Health of the City of Salem's decision allowing the Application for a Minor Modification to a Site Assigrunent for the Salem Transfer Station is VACATED. ...-----` Howard J.Whitehead Justice of the Superior Court DATED: Septernber I0,2012 20 LE UnitedStates eartment of �. .a ealtho'o urnan Services U C- ; Z_ C=Rj-V A C— I - -.R VE Fy' SUMMARY OF THE HIPAA PRIVACY RULE • . - HIPAA Compliance Assistance • SUMMARY OF THE HIPAA PRIVACY RULE Contents Introduction......................................................................................................................... I Statutory& Regulatory Background...................................................................................1 Who is Covered by the Privacy Rule..................................................................................2 BusinessAssociates.............................................................................................................3 What Information is Protected............................................................................................3 General Principle for Uses and Disclosures........................................................................4 Permitted Uses and Disclosures..........................................................................................4 Authorized Uses and Disclosures........................................................................................9 • Limiting Uses and Disclosures to the Minimum Necessary............................................. 10 Notice and Other Individual Rights .................................................................................. I I Administrative Requirements............................................................................................ 14 OrganizationalOptions ..................................................................................................... 15 Other Provisions: Personal Representatives and Minors.................................................. 16 StateLaw........................................................................................................................... 17 Enforcement and Penalties for Noncompliance................................................................ 17 ComplianceDates ............................................................................................................. 18 Copies of the Rule &Related Materials............................................................................18 EndNotes.......................................................................................................................... 19 • i • SUMMARY OF THE HIPAA PRIVACY RULE Introduction The Standards for Privacy of Individually Identifiable Health Information ("Privacy Rule") establishes, for the first time, a set of national standards for the protection of certain health information. The U.S. Department of Health and Human Services ("HHS") issued the Privacy Rule to implement the requirement of the Health Insurance Portability and Accountability Act of 1996("HIPAA").1 The Privacy Rule standards address the use and disclosure of individuals' health information—called "protected health information"by organizations subject to the Privacy Rule—called "covered entities," as well as standards for individuals' privacy rights to understand and control how their health information is used. Within HHS, the Office for Civil Rights ("OCR") has responsibility for implementing and enforcing the Privacy Rule with respect to voluntary compliance activities and civil money penalties. A major goal of the Privacy Rule is to assure that individuals' health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public's health and well being. The Rule strikes a balance that permits important uses of information, while protecting the privacy of people who seek care and healing. Given that the health care marketplace is diverse, the Rule is designed to be flexible and comprehensive to cover the variety of uses and disclosures that need to be addressed. • This is a summary of key elements of the Privacy Rule and not a complete or comprehensive guide to compliance. Entities regulated by the Rule are obligated to comply with all of its applicable requirements and should not rely on this summary as a source of legal information or advice. To make it easier for entities to review the complete requirements of the Rule,provisions of the Rule referenced in this summary are cited in notes at the end of this document. To view the entire Rule, and for other additional helpful information about how it applies, see the OCR website: http://www.hhs.gov/ocr/hipaa. In the event of a conflict between this summary and the Rule,the Rule governs. Links to the OCR Guidance Document are provided throughout this paper. Provisions of the Rule referenced in this summary are cited in endnotes at the end of this document. To review the entire Rule itself, and for other additional helpful information about how it applies, see the OCR website: httl)://www.hhs.gov/ocr/hipaa. Statutory & The Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Regulatory Law 104-191,was enacted on August 21, 1996. Sections 261 through 264 of HIPAA require the Secretary of HHS to publicize standards for the electronic exchange, Background privacy and security of health information. Collectively these are known as the Administrative Simplification provisions. HIPAA required the Secretary to issue privacy regulations governing individually • identifiable health information, if Congress did not enact privacy legislation within OCR Privacy Rule Summary 1 Last Revised 05/03 • three years of the passage of HIPAA. Because Congress did not enact privacy legislation, HHS developed a proposed rule and released it for public comment on November 3, 1999. The Department received over 52,000 public comments. The final regulation,the Privacy Rule,was published December 28,2000.2 In March 2002, the Department proposed and released for public comment modifications to the Privacy Rule. The Department received over 11,000 comments. The final modifications were published in final form on August 14, 2002.3 A text combining the final regulation and the modifications can be found at 45 CFR Part 160 and Part 164, Subparts A and E on the OCR website: ht!p://www.hhs.izov/ocr/hipaa. Who 1S The Privacy Rule, as well as all the Administrative Simplification rules, apply to Covered b the health plans, health care clearinghouses, and to any health care provider who 3' transmits health information in electronic form in connection with transactions for Privacy Rule which the Secretary of HHS has adopted standards under HIPAA (the "covered entities"). For help in determining whether you are covered, use the decision tool at: http://www.cm s.hhs.gov/hi paa/hi paa2/support/tool s/decision support/defaul t.asp. Health Plans. Individual and group plans that provide or pay the cost of medical care are covered entities.a Health plans include health, dental, vision, and prescription drug insurers, health maintenance organizations ("HMOs"), Medicare, Medicaid, Medicare+Choice and Medicare supplement insurers, and long-term care • insurers (excluding nursing home fixed-indemnity policies). Health plans also include employer-sponsored group health plans, government and church-sponsored health plans, and multi-employer health plans. There are exceptions—a group health plan with less than 50 participants that is administered solely by the employer that established and maintains the plan is not a covered entity. Two types of government- funded programs are not health plans: (1) those whose principal purpose is not providing or paying the cost of health care, such as the food stamps program; and (2) those programs whose principal activity is directly providing health care, such as a community health center,5 or the making of grants to fund the direct provision of health care. Certain types of insurance entities are also not health plans, including entities providing only workers' compensation, automobile insurance, and property and casualty insurance. Health Care Providers. Every health care provider, regardless of size, who electronically transmits health information in connection with certain transactions, is a covered entity. These transactions include claims, benefit eligibility inquiries, referral authorization requests, or other transactions for which HHS has established standards under the HIPAA Transactions Rule.b Using electronic technology, such as email, does not mean a health care provider is a covered entity; the transmission must be in connection with a standard transaction. The Privacy Rule covers a health care provider whether it electronically transmits these transactions directly or uses a billing service or other third party to do so on its behalf. Health care providers include all "providers of services" (e.g., institutional providers such as hospitals) and "providers of medical or health services" (e.g., non-institutional providers such as physicians, dentists and other practitioners) as defined by Medicare, and any other • person or organization that furnishes,bills,or is paid for health care. OCR Privacy Rule Summary 2 Last Revised 05/03 • Health Care Clearinghouses. Health care clearinghouses are entities that process nonstandard information they receive from another entity into a standard (i.e., standard format or data content), or vice versa. ' In most instances, health care clearinghouses will receive individually identifiable health information only when they are providing these processing services to a health plan or health care provider as a business associate. In such instances, only certain provisions of the Privacy Rule are applicable to the health care clearinghouse's uses and disclosures of protected health informations Health care clearinghouses include billing services, repricing companies, community health management information systems, and value-added networks and switches if these entities perform clearinghouse functions. Business Business Associate Defined. In general, a business associate is a person or Associates organization, other than a member of a covered entity's workforce, that performs certain functions or activities on behalf of, or provides certain services to, a covered entity that involve the use or disclosure of individually identifiable health information. Business associate functions or activities on behalf of a covered entity include claims processing, data analysis, utilization review, and billing.9 Business associate services to a covered entity are limited to legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, or financial services. However, persons or organizations are not considered business associates if their functions or services do not involve the use or disclosure of protected health information, and where any access to protected health information by such persons • would be incidental, if at all. A covered entity can be the business associate of another covered entity. Business Associate Contract. When a covered entity uses a contractor or other non- workforce member to perform "business associate" services or activities, the Rule requires that the covered entity include certain protections for the information in a business associate agreement(in certain circumstances governmental entities may use alternative means to achieve the same protections). In the business associate contract, a covered entity must impose specified written safeguards on the individually identifiable health information used or disclosed by its business associates.10 Moreover, a covered entity may not contractually authorize its business associate to make any use or disclosure of protected health information that would violate the Rule. Covered entities that have an existing written contract or agreement with business associates prior to October 15,2002,which is not renewed or modified prior to April 14, 2003, are permitted to continue to operate under that contract until they renew the contract or April 14, 2004, whichever is first." Sample business associate contract language is available on the OCR website at: http://www.hhs.yov/ocr/hipaa/contractprov.litmi. Also see OCR "Business Associate"Guidance. What Protected Health Information. The Privacy Rule protects all "individually Information is identifiable health information'"held or transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper, or oral. The Privacy Rule Protected calls this information "protected health information (PHI)."" OCR Privacy Rule Summary 3 Last Revised 05/03 • "Individually identifiable health information" is information, including demographic data,that relates to: • the individual's past, present or future physical or mental health or condition, • the provision of health care to the individual,or • the past, present, or future payment for the provision of health care to the individual, and that identifies the individual or for which there is a reasonable basis to believe can be used to identify the individual.13 Individually identifiable health information includes many common identifiers (e.g., name, address, birth date, Social Security Number). The Privacy Rule excludes from protected health information employment records that a covered entity maintains in its capacity as an employer and education and certain other records subject to, or defined in, the Family Educational Rights and Privacy Act,20 U.S.C. §1232g. De-Identified Health Information. There are no restrictions on the use or disclosure of de-identified health information.14 De-identified health information neither identifies nor provides a reasonable basis to identify an individual. There are two ways to de-identify information; either: 1) a formal determination by a qualified statistician; or 2) the removal of specified identifiers of the individual and of the individual's relatives, household members, and employers is required, and is adequate only if the covered entity has no actual knowledge that the remaining • information could be used to identify the individual.15 General Basic Principle. A major purpose of the Privacy Rule is to define and limit the Principle for circumstances in which an individual's protected heath information may be used or disclosed by covered entities. A covered entity may not use or disclose protected Uses and health information,except either:(1)as the Privacy Rule permits or requires;or(2)as the individual who is the subject of the information (or the individual's personal Disclosures representative)authorizes in writing.16 Required Disclosures. A covered entity must disclose protected health information in only two situations: (a) to individuals (or their personal representatives) specifically when they request access to, or an accounting of disclosures of, their protected health information; and (b) to HHS when it is undertaking a compliance investigation or review or enforcement action.17 See OCR "Government Access" Guidance. Permitted Uses Permitted Uses and Disclosures. A covered entity is permitted, but not required, to use and disclose protected health information, without an individual's authorization, and Disclosures for the following purposes or situations: (1) To the Individual (unless required for access or accounting of disclosures); (2) Treatment, Payment, and Health Care Operations; (3) Opportunity to Agree or Object; (4) Incident to an otherwise permitted use and disclosure;(5)Public Interest and Benefit Activities; and • OCR Privacy Rule Summary 4 Last Revised 05/03 • (6) Limited Data Set for the purposes of research, public health or health care operations.1' Covered entities may rely on professional ethics and best judgments in deciding which of these permissive uses and disclosures to make. (1)To the Individual. A covered entity may disclose protected health information to the individual who is the subject of the information. (2) Treatment, Payment, Health Care Operations. A covered entity may use and disclose protected health information for its own treatment, payment, and health care operations activities.19 A covered entity also may disclose protected health information for the treatment activities of any health care provider, the payment activities of another covered entity and of any health care provider, or the health care operations of another covered entity involving either quality or competency assurance activities or fraud and abuse detection and compliance activities, if both covered entities have or had a relationship with the individual and the protected health information pertains to the relationship. See OCR "Treatment,Payment, Health Care Operations"Guidance. Treatment is the provision, coordination, or management of health care and related services for an individual by one or more health care providers, including consultation between providers regarding a patient and referral of a patient by one provider to another.20 Payment encompasses activities of a health plan to obtain premiums, • determine or fulfill responsibilities for coverage and provision of benefits, and furnish or obtain reimbursement for health care delivered to an individual21 and activities of a health care provider to obtain payment or be reimbursed for the provision of health care to an individual. Health care operations are any of the following activities: (a) quality assessment and improvement activities, including case management and care coordination; (b) competency assurance activities, including provider or health plan performance evaluation, credentialing, and accreditation; (c) conducting or arranging for medical reviews, audits, or legal services, including fraud and abuse detection and compliance programs; (d) specified insurance functions, such as underwriting, risk rating, and reinsuring risk; (e) business planning, development, management, and administration; and (f) business management and general administrative activities of the entity, including but not limited to: de-identifying protected health information, creating a limited data set, and certain fundraising for the benefit of the covered entity.22 Most uses and disclosures of psychotherapy notes for treatment, payment, and health care operations purposes require an authorization as described below.23 Obtaining "consent" (written permission from individuals to use and disclose their protected health information for treatment, payment, and health care operations) is optional under the Privacy Rule for all covered entities.24 The content of a consent form,and the process for obtaining consent, are at the discretion of the covered entity • electing to seek consent. OCR Privacy Rule Summary 5 Last Revised 05/03 • (3) Uses and Disclosures with Opportunity to Agree or Object. Informal permission may be obtained by asking the individual outright, or by circumstances that clearly give the individual the opportunity to agree, acquiesce, or object. Where the individual is incapacitated, in an emergency situation, or not available, covered entities generally may make such uses and disclosures, if in the exercise of their professional judgment, the use or disclosure is determined to be in the best interests of the individual. Facility Directories. It is a common practice in many health care facilities, such as hospitals, to maintain a directory of patient contact information. A covered health care provider may rely on an individual's informal permission to list in its facility directory the individual's name, general condition, religious affiliation, and location in the provider's facility.25 The provider may then disclose the individual's condition and location in the facility to anyone asking for the individual by name, and also may disclose religious affiliation to clergy. Members of the clergy are not required to ask for the individual by name when inquiring about patient religious affiliation. For Notification and Other Purposes. A covered entity also may rely on an individual's informal permission to disclose to the individual's family, relatives, or friends, or to other persons whom the individual identifies, protected health information directly relevant to that person's involvement in the individual's care or payment for care. 26 This provision, for example, allows a pharmacist to dispense filled prescriptions to a person acting on 40 behalf of the patient. Similarly, a covered entity may rely on an individual's informal permission to use or disclose protected health information for the purpose of notifying (including identifying or locating) family members, personal representatives, or others responsible for the individual's care of the individual's location, general condition, or death. In addition, protected health information may be disclosed for notification purposes to public or private entities authorized by law or charter to assist in disaster relief efforts. (4) Incidental Use and Disclosure. The Privacy Rule does not require that every risk of an incidental use or disclosure of protected health information be eliminated. A use or disclosure of this information that occurs as a result of, or as "incident to," an otherwise permitted use or disclosure is permitted as long as the covered entity has adopted reasonable safeguards as required by the Privacy Rule, and the information being shared was limited to the "minimum necessary," as required by the Privacy Rule?' See OCR"Incidental Uses and Disclosures"Guidance. (5) Public Interest and Benefit Activities. The Privacy Rule permits use and disclosure of protected health information, without an individual's authorization or permission, for 12 national priority purposes.28 These disclosures are permitted, although not required,by the Rule in recognition of the important uses made of health information outside of the health care context. Specific conditions or limitations apply to each public interest purpose, striking the balance between the individual privacy interest and the public interest need for this information. • Required by Law. Covered entities may use and disclose protected health information without individual authorization as required by law(including by OCR Privacy Rule Summary 6 Last Revised 05/03 29 • statute,regulation,or court orders). Public Health Activities. Covered entities may disclose protected health information to: (1) public health authorities authorized by law to collect or receive such information for preventing or controlling disease, injury, or disability and to public health or other government authorities authorized to receive reports of child abuse and neglect; (2) entities subject to FDA regulation regarding FDA regulated products or activities for purposes such as adverse event reporting, tracking of products, product recalls, and post- marketing surveillance; (3) individuals who may have contracted or been exposed to a communicable disease when notification is authorized by law; and (4) employers, regarding employees, when requested by employers, for information concerning a work-related illness or injury or workplace related medical surveillance, because such information is needed by the employer to comply with the Occupational Safety and Health Administration (OHSA), the Mine Safety and Health Administration (MHSA), or similar state law.30 See OCR "Public Health" Guidance; CDC Public Health and HIPAA Guidance. Victims of Abuse,Neglect or Domestic Violence. In certain circumstances, covered entities may disclose protected health information to appropriate government authorities regarding victims of abuse, neglect, or domestic violence 31 • Health Oversight Activities. Covered entities may disclose protected health information to health oversight agencies(as defined in the Rule)for purposes of legally authorized health oversight activities, such as audits and investigations necessary for oversight of the health care system and government benefit programs.32 Judicial and Administrative Proceedings. Covered entities may disclose protected health information in a judicial or administrative proceeding if the request for the information is through an order from a court or administrative tribunal. Such information may also be disclosed in response to a subpoena or other lawful process if certain assurances regarding notice to the individual or a protective order are provided 33 Law Enforcement Purposes. Covered entities may disclose protected health information to law enforcement officials for law enforcement purposes under the following six circumstances, and subject to specified conditions: (1) as required by law (including court orders, court-ordered warrants, subpoenas) and administrative requests; (2) to identify or locate_a suspect, fugitive, material witness, or missing person; (3) in response to a law enforcement official's request for information about a victim or suspected victim of a crime; (4) to alert law enforcement of a person's death, if the covered entity suspects that criminal activity caused the death; (5) when a covered entity believes that protected health information is evidence of a crime that occurred on its premises; and (6) by a covered health care provider in a medical emergency not occurring on its premises, when necessary to inform law enforcement about the commission and nature of a crime,the location of the crime or crime victims,and the perpetrator of the crime 34 OCR Privacy Rule Summary 7 Last Revised 05/03 • Decedents. Covered entities may disclose protected health information to funeral directors as needed, and to coroners or medical examiners to identify a deceased person, determine the cause of death, and perform other functions authorized by law.31 Cadaveric Organ, Eye, or Tissue Donation. Covered entities may use or disclose protected health information to facilitate the donation and transplantation of cadaveric organs,eyes,and tissue.36 Research. "Research" is any systematic investigation designed to develop or contribute to generalizable knowledge.37 The Privacy Rule permits a covered entity to use and disclose protected health information for research purposes, without an individual's authorization, provided the covered entity obtains either: (1) documentation that an alteration or waiver of individuals' authorization for the use or disclosure of protected health information about them for research purposes has been approved by an Institutional Review Board or Privacy Board; (2) representations from the researcher that the use or disclosure of the protected health information is solely to prepare a research protocol or for similar purpose preparatory to research, that the researcher will not remove any protected health information from the covered entity, and that protected health information for which access is sought is necessary for the research; or (3)representations from the researcher that the use or disclosure sought is solely for research on the protected health • information of decedents, that the protected health information sought is necessary for the research, and, at the request of the covered entity, documentation of the death of the individuals about whom information is sought.38 A covered entity also may use or disclose, without an individuals' authorization, a limited data set of protected health information for research purposes (see discussion below).39 See OCR "Research" Guidance; NIH Protecting PHI in Research. Serious Threat to Health or Safety. Covered entities may disclose protected health information that they believe is necessary to prevent or lessen a serious and imminent threat to a person or the public, when such disclosure is made to someone they believe can prevent or lessen the threat(including the target of the threat). Covered entities may also disclose to law enforcement if the information is needed to identify or apprehend an escapee or violent criminal.ao Essential Government Functions. An authorization is not required to use or disclose protected health information for certain essential government functions. Such functions include: assuring proper execution of a military mission, conducting intelligence and national security activities that are authorized by law, providing protective services to the President, making medical suitability determinations for U.S. State Department employees, protecting the health and safety of inmates or employees in a correctional institution,and determining eligibility for or conducting enrollment in certain government benefit programs.a' • OCR Privacy Rule Summary 8 Last Revised 05/03 • Workers' Compensation. Covered entities may disclose protected health information as authorized by, and to comply with, workers' compensation laws and other similar programs providing benefits for work-related injuries or illnesses 42 See OCR"Workers' Compensation"Guidance. (6) Limited Data Set. A limited data set is protected health information from which certain specified direct identifiers of individuals and their relatives, household members, and employers have been removed.43 A limited data set may be used and disclosed for research, health care operations, and public health purposes, provided the recipient enters into a data use agreement promising specified safeguards for the protected health information within the limited data set. Authorized Authorization. A covered entity must obtain the individual's written authorization Uses and for any use or disclosure of protected health information that is not for treatment, payment or health care operations or otherwise permitted or required by the Privacy Disclosures Rule 44 A covered entity may not condition treatment, payment, enrollment, or benefits eligibility on an individual granting an authorization, except in limited circumstances.as An authorization must be written in specific terms. It may allow use and disclosure of protected health information by the covered entity seeking the authorization, or by a third party. Examples of disclosures that would require an individual's • authorization include disclosures to a life insurer for coverage purposes, disclosures to an employer of the results of a pre-employment physical or lab test, or disclosures to a pharmaceutical firm for their own marketing purposes. All authorizations must be in plain language, and contain specific information regarding the information to be disclosed or used, the person(s) disclosing and receiving the information, expiration, right to revoke in writing, and other data. The Privacy Rule contains transition provisions applicable to authorizations and other express legal permissions obtained prior to April 14,2003.46 Psychotherapy Notesa'. A covered entity must obtain an individual's authorization to use or disclose psychotherapy notes with the following exceptions4': • The covered entity who originated the notes may use them for treatment. • A covered entity may use or disclose, without an individual's authorization, the psychotherapy notes, for its own training, and to defend itself in legal proceedings brought by the individual, for HHS to investigate or determine the covered entity's compliance with the Privacy Rules,to avert a serious and imminent threat to public health or safety, to a health oversight agency for lawful oversight of the originator of the psychotherapy notes, for the lawful activities of a coroner or medical examiner or as required by law. Marketing. Marketing is any communication about a product or service that encourages recipients to purchase or use the product or service 49 The Privacy Rule carves out the following health-related activities from this definition of marketing: • • Communications to describe health-related products or services, or payment OCR Privacy Rule Summary 9 Last Revised 05/03 • for them, provided by or included in a benefit plan of the covered entity making the communication; • Communications about participating providers in a provider or health plan network, replacement of or enhancements to a health plan, and health-related products or services available only to a health plan's enrollees that add value to,but are not part of,the benefits plan; • Communications for treatment of the individual;and • Communications for case management or care coordination for the individual, or to direct or recommend alternative treatments, therapies, health care providers, or care settings to the individual. Marketing also is an arrangement between a covered entity and any other entity whereby the covered entity discloses protected health information, in exchange for direct or indirect remuneration, for the other entity to communicate about its own products or services encouraging the use or purchase of those products or services. A covered entity must obtain an authorization to use or disclose protected health information for marketing, except for face-to-face marketing communications between a covered entity and an individual, and for a covered entity's provision of promotional gifts of nominal value. No authorization is needed, however, to make a communication that falls within one of the exceptions to the marketing definition. An authorization for marketing that involves the covered entity's receipt of direct or indirect remuneration from a third party must reveal that fact. See OCR "Marketing" Guidance. • LimitingUses Minimum Necessary. A central aspect of the Privacy Rule is the principle of "minimum necessary" use and disclosure. A covered entity must make reasonable and Disclosures efforts to use, disclose, and request only the minimum amount of protected health to the information needed to accomplish the intended purpose of the use, disclosure, or Minimum request 50 A covered entity must develop and implement policies and procedures to reasonably limit uses and disclosures to the minimum necessary. When the minimum Necessary necessary standard applies to a use or disclosure, a covered entity may not use, disclose, or request the entire medical record for a particular purpose, unless it can specifically justify the whole record as the amount reasonably needed for the purpose. See OCR"Minimum Necessary"Guidance. The minimum necessary requirement is not imposed in any of the following circumstances: (a) disclosure to or a request by a health care provider for treatment; (b) disclosure to an individual who is the subject of the information, or the individual's personal representative; (c) use or disclosure made pursuant to an authorization; (d) disclosure to HHS for complaint investigation, compliance review or enforcement; (e) use or disclosure that is required by law; or (f) use or disclosure required for compliance with the HIPAA Transactions Rule or other HIPAA Administrative Simplification Rules. Access and Uses. For internal uses, a covered entity must develop and implement policies and procedures that restrict access and uses of protected health information based on the specific roles of the members of their workforce. These policies and procedures must identify the persons, or classes of persons, in the workforce who • need access to protected health information to carry out their duties,the categories of OCR Privacy Rule Summary 10 Last Revised 05/03 • protected health information to which access is needed, and any conditions under which they need the information to do their jobs. Disclosures and Requests for Disclosures. Covered entities must establish and implement policies and procedures (which may be standard protocols) for routine, recurring disclosures, or requests for disclosures, that limits the protected health information disclosed to that which is the minimum amount reasonably necessary to achieve the purpose of the disclosure. Individual review of each disclosure is not required. For non-routine, non-recurring disclosures, or requests for disclosures that it makes, covered entities must develop criteria designed to limit disclosures to the information reasonably necessary to accomplish the purpose of the disclosure and review each of these requests individually in accordance with the established criteria. Reasonable Reliance. If another covered entity makes a request for protected health information,a covered entity may rely, if reasonable under the circumstances, on the request as complying with this minimum necessary standard. Similarly, a covered entity may rely upon requests as being the minimum necessary protected health information from: (a) a public official, (b) a professional (such as an attorney or accountant)who is the covered entity's business associate, seeking the information to provide services to or for the covered entity; or (c) a researcher who provides the documentation or representation required by the Privacy Rule for research. Notice and Privacy Practices Notice. Each covered entity, with certain exceptions, must Other provide a notice of its privacy practices.s1 The Privacy Rule requires that the notice • contain certain elements. The notice must describe the ways in which the covered Individual entity may use and disclose protected health information. The notice must state the Rights covered entity's duties to protect privacy, provide a notice of privacy practices, and abide by the terms of the current notice. The notice must describe individuals' rights, including the right to complain to HHS and to the covered entity if they believe their privacy rights have been violated. The notice must include a point of contact for further information and for making complaints to the covered entity. Covered entities must act in accordance with their notices. The Rule also contains specific distribution requirements for direct treatment providers, all other health care providers,and health plans. See OCR"Notice"Guidance. • Notice Distribution. A covered health care provider with a direct treatment relationship with individuals must deliver a privacy practices notice to patients starting April 14, 2003 as follows: o Not later than the first service encounter by personal delivery (for patient visits), by automatic and contemporaneous electronic response(for electronic service delivery), and by prompt mailing(for telephonic service delivery); o By posting the notice at each service delivery site in a clear and prominent place where people seeking service may reasonably be expected to be able to read the notice;and o In emergency treatment situations, the provider must furnish its notice as soon as practicable after the emergency abates. OCR Privacy Rule Summary 1 l Last Revised 05/03 r • Covered entities, whether direct treatment providers or indirect treatment providers(such as laboratories)or health plans must supply notice to anyone on request.52 A covered entity must also make its notice electronically available on any web site it maintains for customer service or benefits information. The covered entities in an organized health care arrangement may use a joint privacy practices notice, as long as each agrees to abide by the notice content with respect to the protected health information created or received in connection with participation in the arrangement.53 Distribution of a joint notice by any covered entity participating in the organized health care arrangement at the first point that an OHCA member has an obligation to provide notice satisfies the distribution obligation of the other participants in the organized health care arrangement. A health plan must distribute its privacy practices notice to each of its enrollees by its Privacy Rule compliance date. Thereafter, the health plan must give its notice to each new enrollee at enrollment, and send a reminder to every enrollee at least once every three years that the notice is available upon request. A health plan satisfies its distribution obligation by furnishing the notice to the "named insured," that is, the subscriber for coverage that also applies to spouses and dependents. • Acknowledgement of Notice Receipt. A covered health care provider with a direct treatment relationship with individuals must make a good faith effort • to obtain written acknowledgement from patients of receipt of the privacy practices notice.54 The Privacy Rule does not prescribe any particular content for the acknowledgement. The provider must document the reason for any failure to obtain the patient's written acknowledgement. The provider is relieved of the need to request acknowledgement in an emergency treatment situation. Access. Except in certain circumstances, individuals have the right to review and obtain a copy of their protected health information in a covered entity's designated record set.55 The "designated record set" is that group of records maintained by or for a covered entity that is used, in whole or part, to make decisions about individuals, or that is a provider's medical and billing records about individuals or a health plan's enrollment, payment, claims adjudication, and case or medical management record systems.56 The Rule excepts from the right of access the following protected health information: psychotherapy notes, information compiled for legal proceedings, laboratory results to which the Clinical Laboratory Improvement Act (CLIA) prohibits access, or information held by certain research laboratories. For information included within the right of access, covered entities may deny an individual access in certain specified situations, such as when a health care professional believes access could cause harm to the individual or another. In such situations, the individual must be given the right to have such denials reviewed by a licensed health care professional for a second opinion.57 Covered entities may impose reasonable,cost-based fees for the cost of copying and postage. Amendment. The Rule gives individuals the right to have covered entities amend • their protected health information in a designated record set when that information is OCR Privacy Rule Summary 12 Last Revised 05/03 • inaccurate or incomplete. If a covered entity accepts an amendment request, it must make reasonable efforts to provide the amendment to persons that the individual has identified as needing it, and to persons that the covered entity knows might rely on the information to the individual's detriment.59 If the request is denied, covered entities must provide the individual with a written denial and allow the individual to submit a statement of disagreement for inclusion in the record. The Rule specifies processes for requesting and responding to a request for amendment. A covered entity must amend protected health information in its designated record set upon receipt of notice to amend from another covered entity. Disclosure Accounting. Individuals have a right to an accounting of the disclosures of their protected health information by a covered entity or the covered entity's business associates.60 The maximum disclosure accounting period is the six years immediately preceding the accounting request, except a covered entity is not obligated to account for any disclosure made before its Privacy Rule compliance date. The Privacy Rule does not require accounting for disclosures: (a) for treatment, payment, or health care operations; (b) to the individual or the individual's personal representative; (c) for notification of or to persons involved in an individual's health care or payment for health care, for disaster relief, or for facility directories; (d) pursuant to an authorization; (e) of a limited data set; (f) for national security or intelligence purposes; (g) to correctional institutions or law enforcement officials for certain purposes regarding inmates or individuals in lawful custody; or(h) incident to otherwise permitted or required uses or disclosures. Accounting for disclosures to • health oversight agencies and law enforcement officials must be temporarily suspended on their written representation that an accounting would likely impede their activities. Restriction Request. Individuals have the right to request that a covered entity restrict use or disclosure of protected health information for treatment, payment or health care operations, disclosure to persons involved in the individual's health care or payment for health care,or disclosure to notify family members or others about the individual's general condition, location, or death 61 A covered entity is under no obligation to agree to requests for restrictions. A covered entity that does agree must comply with the agreed restrictions,except for purposes of treating the individual in a medical emergency.62 Confidential Communications Requirements. Health plans and covered health care providers must permit individuals to request an alternative means or location for receiving communications of protected health information by means other than those that the covered entity typically employs.63 For example, an individual may request that the provider communicate with the individual through a designated address or phone number. Similarly, an individual may request that the provider send communications in a closed envelope rather than a post card. Health plans must accommodate reasonable requests if the individual indicates that the disclosure of all or part of the protected health information could endanger the individual. The health plan may not question the individual's statement of endangerment. Any covered entity may condition compliance with a confidential communication request on the individual specifying an alternative address or method • of contact and explaining how any payment will be handled. OCR Privacy Rule Summary 13 Last Revised 05/03 • Administrative HHS recognizes that covered entities range from the smallest provider to the largest, Requirements multi-state health plan. Therefore the flexibility and scalability of the Rule are intended to allow covered entities to analyze their own needs and implement solutions appropriate for their own environment. What is appropriate for a particular covered entity will depend on the nature of the covered entity's business, as well as the covered entity's size and resources. Privacy Policies and Procedures. A covered entity must develop and implement written privacy policies and procedures that are consistent with the Privacy Rule.ba Privacy Personnel. A covered entity must designate a privacy official responsible for developing and implementing its privacy policies and procedures, and a contact person or contact office responsible for receiving complaints and providing individuals with information on the covered entity's privacy practices 65 Workforce Training and Management. Workforce members include employees, volunteers, trainees, and may also include other persons whose conduct is under the direct control of the entity (whether or not they are paid by the entity).66 A covered entity must train all workforce members on its privacy policies and procedures, as necessary and appropriate for them to carry out their functions.67 A covered entity must have and apply appropriate sanctions against workforce members who violate its privacy policies and procedures or the Privacy Rule.68 Mitigation. A covered entity must mitigate, to the extent practicable, any harmful effect it learns was caused by use or disclosure of protected health information by its workforce or its business associates in violation of its privacy policies and procedures or the Privacy Rule.69 Data Safeguards. A covered entity must maintain reasonable and appropriate administrative, technical, and physical safeguards to prevent intentional or unintentional use or disclosure of protected health information in violation of the Privacy Rule and to limit its incidental use and disclosure pursuant to otherwise permitted or required use or disclosure.70 For example, such safeguards might include shredding documents containing protected health information before discarding them, securing medical records with lock and key or pass code, and limiting access to keys or pass codes. See OCR "Incidental Uses and Disclosures" Guidance. Complaints. A covered entity must have procedures for individuals to complain about its compliance with its privacy policies and procedures and the Privacy Rule.71 The covered entity must explain those procedures in its privacy practices notice.72 Among other things,the covered entity must identify to whom individuals can submit complaints to at the covered entity and advise that complaints also can be submitted to the Secretary of HHS. Retaliation and Waiver. A covered entity may not retaliate against a person for exercising rights provided by the Privacy Rule, for assisting in an investigation by HHS or another appropriate authority, or for opposing an act or practice that the • person believes in good faith violates the Privacy Rule.73 A covered entity may not OCR Privacy Rule Summary 14 Last Revised 05/03 require an individual to waive any right under the Privacy Rule as a condition for obtaining treatment,payment,and enrollment or benefits eligibility.74 Documentation and Record Retention. A covered entity must maintain, until six years after the later of the date of their creation or last effective date, its privacy policies and procedures, its privacy practices notices, disposition of complaints, and other actions, activities, and designations that the Privacy Rule requires to be documented.75 Fully-Insured Group Health Plan Exception. The only administrative obligations with which a fully-insured group health plan that has no more than enrollment data and summary health information is required to comply are the (1) ban on retaliatory acts and waiver of individual rights,and(2)documentation requirements with respect to plan documents if such documents are amended to provide for the disclosure of protected health information to the plan sponsor by a health insurance issuer or HMO that services the group health plan.76 Organizational The Rule contains provisions that address a variety of organizational issues that may Options affect the operation of the privacy protections. Hybrid Entity. The Privacy Rule permits a covered entity that is a single legal entity and that conducts both covered and non-covered functions to elect to be a "hybrid entity."" (The activities that make a person or organization a covered entity are its • "covered functions. ,78) To be a hybrid entity, the covered entity must designate in writing its operations that perform covered functions as one or more "health care components." After making this designation,most of the requirements of the Privacy Rule will apply only to the health care components. A covered entity that does not make this designation is subject in its entirety to the Privacy Rule. Affiliated Covered Entity. Legally separate covered entities that are affiliated by common ownership or control may designate themselves (including their health care components) as a single covered entity for Privacy Rule compliance.79 The designation must be in writing. An affiliated covered entity that performs multiple covered functions must operate its different covered functions in compliance with the Privacy Rule provisions applicable to those covered functions. Organized Health Care Arrangement. The Privacy Rule identifies relationships in which participating covered entities share protected health information to manage and benefit their common enterprise as"organized health care arrangements."80 Covered entities in an organized health care arrangement can share protected health information with each other for the arrangement's joint health care operations 81 Covered Entities With Multiple Covered Functions. A covered entity that performs multiple covered functions must operate its different covered functions in compliance with the Privacy Rule provisions applicable to those covered functions."' The covered entity may not use or disclose the protected health information of an individual who receives services from one covered function (e.g., health care provider) for another covered function (e.g., health plan) if the individual is not involved with the other function. • OCR Privacy Rule Summary 15 Last Revised 05/03 • Group Health Plan disclosures to Plan Sponsors. A group health plan and the health insurer or HMO offered by the plan may disclose the following protected health information to the "plan sponsor"—the employer, union, or other employee organization that sponsors and maintains the group health plan 83: • Enrollment or disenrollment information with respect to the group health plan or a health insurer or HMO offered by the plan. • If requested by the plan sponsor, summary health information for the plan sponsor to use to obtain premium bids for providing health insurance coverage through the group health plan, or to modify, amend, or terminate the group health plan. "Summary health information" is information that summarizes claims history, claims expenses, or types of claims experience of the individuals for whom the plan sponsor has provided health benefits through the group health plan, and that is stripped of all individual identifiers other than five digit zip code (though it need not qualify as de-identified protected health information). • Protected health information of the group health plan's enrollees for the plan sponsor to perform plan administration functions. The plan must receive certification from the plan sponsor that the group health plan document has been amended to impose restrictions on the plan sponsor's use and disclosure of the protected health information. These restrictions must include the representation that the plan sponsor will not use or disclose the protected health information for any employment-related action or decision or in connection with any other benefit plan. Other Personal Representatives. The Privacy Rule requires a covered entity to treat a 'personal representative" the same as the individual, with respect to uses and Provisions: disclosures of the individual's protected health information, as well as the Personal individual's rights under the Rule 84 A personal representative is a person legally Representatives authorized to make health care decisions on an individual's behalf or to act for a p deceased individual or the estate. The Privacy Rule permits an exception when a and Minors covered entity has a reasonable belief that the personal representative may be abusing or neglecting the individual, or that treating the person as the personal representative could otherwise endanger the individual. Special case: Minors. In most cases, parents are the personal representatives for their minor children. Therefore, in most cases, parents can exercise individual rights, such as access to the medical record, on behalf of their minor children. In certain exceptional cases, the parent is not considered the personal representative. In these situations, the Privacy Rule defers to State and other law to determine the rights of parents to access and control the protected health information of their minor children. If State and other law is silent concerning parental access to the minor's protected health information, a covered entity has discretion to provide or deny a parent access to the minor's health information, provided the decision is made by a licensed health care professional in the exercise of professional judgment. See OCR "Personal. Representatives" Guidance. • OCR Privacy Rule Summary 16 Last Revised 05/03 • State Law Preemption. In general, State laws that are contrary to the Privacy Rule are preempted by the federal requirements, which means that the federal requirements will apply.85 "Contrary" means that it would be impossible for a covered entity to comply with both the State and federal requirements, or that the provision of State law is an obstacle to accomplishing the full purposes and objectives of the Administrative Simplification provisions of HIPAA.86 The Privacy Rule provides exceptions to the general rule of federal preemption for contrary State laws that (1) relate to the privacy of individually identifiable health information and provide greater privacy protections or privacy rights with respect to such information, (2) provide for the reporting of disease or injury, child abuse, birth, or death, or for public health surveillance, investigation, or intervention, or (3) require certain health plan reporting, such as for management or financial audits. Exception Determination. In addition, preemption of a contrary State law will not occur if HHS determines, in response to a request from a State or other entity or person,that the State law: • Is necessary to prevent fraud and abuse related to the provision of or payment for health care, • Is necessary.to ensure appropriate State regulation of insurance and health plans to the extent expressly authorized by statute or regulation, • Is necessary for State reporting on health care delivery or costs, • Is necessary for purposes of serving a compelling public health, safety, or • welfare need, and, if a Privacy Rule provision is at issue, if the Secretary determines that the intrusion into privacy is warranted when balanced against the need to be served; or • Has as its principal purpose the regulation of the manufacture, registration, distribution, dispensing, or other control of any controlled substances (as defined in 21 U.S.C. 802), or that is deemed a controlled substance by State law. Enforcement Compliance. Consistent with the principles for achieving compliance provided in the Rule, HHS will seek the cooperation of covered entities and may provide and Penalties technical assistance to help them comply voluntarily with the Rule. ' The Rule for provides processes for persons to file complaints with HHS, describes the Noncompliance responsibilities of covered entities to provide records and compliance reports and to cooperate with, and permit access to information for, investigations and compliance reviews. Civil Money Penalties. HHS may impose civil money penalties on a covered entity of$100 per failure to comply with a Privacy Rule requirement.S8 That penalty may not exceed $25,000 per year for multiple violations of the identical Privacy Rule requirement in a calendar year. HHS may not impose a civil money penalty under specific circumstances, such as when a violation is due to reasonable cause and did not involve willful neglect and the covered entity corrected the violation within 30 days of when it knew or should have known of the violation. • OCR Privacy Rule Summary 17 Last Revised 05/03 Criminal Penalties. A person who knowingly obtains or discloses individually identifiable health information in violation of HIPAA faces a fine of$50,000 and up to one-year imprisonment 89 The criminal penalties increase to $100,000 and up to five years imprisonment if the wrongful conduct involves false pretenses, and to $250,000 and up to ten years imprisonment if the wrongful conduct involves the intent to sell, transfer, or use individually identifiable health information for commercial advantage, personal gain, or malicious harm. Criminal sanctions will be enforced by the Department of Justice. Compliance Compliance Schedule. All covered entities, except "small health plans," must be Dates compliant with the Privacy Rule by April 14, 2003. o Small health plans, however, have until April 14 2004 to comply. P � .PY Small Health Plans. A health plan with annual receipts of not more than $5 million is a small health plan 91 Health plans that file certain federal tax returns and report receipts on those returns should use the guidance provided by the Small Business Administration at 13 Code of Federal Regulations (CFR) 121.104 to calculate annual receipts. Health plans that do not report receipts to the Internal Revenue Service (IRS),for example,group health plans regulated by the Employee Retirement Income Security Act 1974 (ER1SA) that are exempt from filing income tax returns, should use proxy measures to determine their annual receipts.92 See What constitutes a small health plan? • Copies of the The entire Privacy Rule, as well as guidance and additional materials, may be found Rule & Related on our website,hfp://www.hhs.gov/ocr/hipaa. Materials OCR Privacy Rule Summary 18 Last Revised 05/03 • End Notes ' Pub.L. 104-191. z 65 FR 82462. '67 FR 53182. 4 45 C.F.R. §§ 160.102, 160.103. ' Even if an entity, such as a community health center, does not meet the definition of a health plan, it may, nonetheless, meet the definition of a health care provider, and, if it transmits health information in electronic form in connection with the transactions for which the Secretary of HHS has adopted standards under HIPAA,may still be a covered entity. 6 45 C.F.R. §§ 160.102, 160.103;see Social Security Act§ 1172(a)(3),42 U.S.C. § 1320d-1(a)(3). The transaction standards are established by the HIPAA Transactions Rule at 45 C.F.R.Part 162. '45 C.F.R.§ 160.103. B 45 C.F.R.§ 164.500(b). 9 45 C.F.R. § 160.103. 10 45 C.F.R. §§ 164.502(e), 164.504(e). " 45 C.F.R. § 164.532 • 12 45 C.F.R.§ 160.103. 13 45 C.F.R. § 160.103 14 45 C.F.R.§§ 164.502(d)(2), 164.514(a)and(b). 15 The following identifiers of the individual or of relatives,employers,or household members of the individual must be removed to achieve the "safe harbor" method of de-identification: (A) Names; (B) All geographic subdivisions smaller than a State, including street address, city, county,precinct,zip code,and their equivalent geocodes,except for the initial three digits of a zip code if, according to the current publicly available data from the Bureau of Census (1) the geographic units formed by combining all zip codes with the same three initial digits contains more than 20,000 people; and(2)the initial three digits of a zip code for all such geographic units containing 20,000 or fewer people is changed to 000; (C) All elements of dates (except year)for dates directly related to the individual,including birth date,admission date,discharge date,date of death;and all ages over 89 and all elements of dates(including year)indicative of such age,except that such ages and elements may be aggregated into a single category of age 90 or older; (D) Telephone numbers;(E)Fax numbers;(F)Electronic mail addresses: (G)Social security numbers; (H) Medical record numbers; (1) Health plan beneficiary numbers; (J) Account numbers; (K) Certificate/license numbers; (L) Vehicle identifiers and serial numbers, including license plate numbers; (M) Device identifiers and serial numbers; (N) Web Universal Resource Locators (URLs); (0) Internet Protocol (IP) address numbers; (P) Biometric identifiers, including finger and voice prints; (Q)Full face photographic images and any comparable images; and®any other unique identifying number, characteristic, or code, except as permitted for re-identification purposes provided certain conditions are met. In addition to the removal of the above-stated identifiers,the covered entity may not have actual knowledge that the remaining information could be used alone or in combination with any other information to identify an individual who is subject of the information. 45 C.F.R. § 164.514(b). 16 45 C.F.R. § 164.502(a). • "45 C.F.R. § 164.502(a)(2). OCR Privacy Rule Summary 19 Last Revised 05/03 • 1845 C.F.R. § 164.502(a)(1). 19 45 C.F.R. § 164.506(c). 20 45 C.F.R. § 164.501. 2' 45 C.F.R. § 164.501. 22 45 C.F.R. § 164.501. 23 45 C.F.R. § 164.508(a)(2) 24 45 C.F.R. § 164.506(b). 25 45 C.F.R. § 164.510(a). 26 45 C.F.R. § 164.510(b). 27 45 C.F.R. §§ 164.502(a)(1)(iii). 28 See 45 C.F.R. § 164.512. 29 45 C.F.R. § 164.512(a). 30 45 C.F.R. § 164.512(b). 31 45 C.F.R.§ 164.512(a),(c). 12 45 C.F.R. § 164.512(d). 33 45 C.F.R. § 164.512(e). 14 45 C.F.R. § 164.512(f). • ss 45 C.F.R.§ 164.512(g). 36 45 C.F.R. § 164.512(h). 37 The Privacy Rule defines research as, "a systematic investigation, including research development, testing, and evaluation, designed to develop or contribute to generalizable knowledge."45 C.F.R. § 164.501. 38 45 C.F.R. § 164.512(i). 39 45 CFR§ 164.514(e). 40 45 C.F.R. § 164.5120). 41 45 C.F.R. § 164.512(k). 42 45 C.F.R. § 164.512(1). 43 45 C.F.R. § 164.514(e). A limited data set is protected health information that excludes the following direct identifiers of the individual or of relatives, employers, or household members of the individual: (i) Names; (ii) Postal address information, other than town or city, State and zip code; (iii) Telephone numbers; (iv) Fax numbers; (v) Electronic mail addresses: (vi) Social security numbers; (vii) Medical record numbers; (viii) Health plan beneficiary numbers; (ix) Account numbers; (x) Certificate/license numbers; (xi) Vehicle identifiers and serial numbers, including license plate numbers; (xii)Device identifiers and serial numbers; (xiii)Web Universal Resource Locators (URLs); (xiv) Internet Protocol (IP) address numbers; (xv) Biometric identifiers, including finger and voice prints; (xvi) Full face photographic images and any comparable images. 45 C.F.R. § 164.514(e)(2). 44 45 C.F.R. § 164.508. 45 A covered entity may condition the provision of health care solely to generate protected health • information for disclosure to a third party on the individual giving authorization to disclose the OCR Privacy Rule Summary 20 Last Revised 05/03 I • information to the third party. For example,a covered entity physician may condition the provision of a physical examination to be paid for by a life insurance issuer on an individual's authorization to disclose the results of that examination to the life insurance issuer. A health plan may condition enrollment or benefits eligibility on the individual giving authorization,requested before the individual's enrollment,to obtain protected health information(other than psychotherapy notes)to determine the individual's eligibility or enrollment or for underwriting or risk rating. A covered health care provider may condition treatment related to research(e.g., clinical trials)on the individual giving authorization to use or disclose the individual's protected health information for the research. 45 C.F.R.508(b)(4). 46 45 CFR§ 164.532. 47"Psychotherapy notes"means notes recorded(in any medium)by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group,joint, or family counseling session and that are separated from the rest of the of the individual's medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis,functional status,the treatment plan, symptoms,prognosis,and progress to date. 45 C.F.R. § 164.501. 48 45 C.F.R. § 164.508(a)(2). a9 45 C.F.R. §§ 164.501 and 164.508(a)(3). so 45 C.F.R.§§ 164.502(b)and 164.514(d). 5' 45 C.F.R. §§ 164.520(a)and(b). A group health plan,or a health insurer or HMO with respect to the group health plan, that intends to disclose protected health information (including enrollment data or summary health information) to the plan sponsor, must state that fact in the notice. Special statements are also required in the notice if a covered entity intends to contact individuals about health-related benefits or services, treatment alternatives, or appointment reminders,or for the covered entity's own fundraising. 12 45 C.F.R. § 164.520(c). "45 C.F.R. § 164.520(d). 54 45 C.F.R.§ 164.520(c). "45 C.F.R. § 164.524. 56 45 C.F.R. § 164.501. 57 A covered entity may deny an individual access,provided that the individual is given a right to have such denials reviewed by a licensed health care professional(who is designated by the covered entity and who did not participate in the original decision to deny),when a licensed health care professional has determined,in the exercise of professional judgment,that: (a)the access requested is reasonably likely to endanger the life or physical safety of the individual or another person;(b)the protected health information makes reference to another person(unless such other person is a health care provider)and the access requested is reasonably likely to cause substantial harm to such other person;or(c)the request for access is made by the individual's personal representative and the provision of access to such personal representative is reasonably likely to cause substantial harm to the individual or another person. A covered entity may deny access to individuals,without providing the individual an opportunity for review,in the following protected situations: (a)the protected health information falls under an exception to the right of access;(b)an inmate request for protected health information under certain circumstances;(c)information that a provider creates or obtains in the course of research that includes treatment for which the individual has agreed not to have access as part of consenting OCR Privacy Rule Summary 21 Last Revised 05/03 • to participate in the research(as long as access to the information is restored upon completion of the research);(d)for records subject to the Privacy Act,information to which access may be denied under the Privacy Act, 5 U.S.C. § 552a;and(e)information obtained under a promise of confidentiality from a source other than a health care provider,if granting access would likely reveal the source. 45 C.F.R. § 164.524. 58 45 C.F.R. § 164.526. 59 Covered entities may deny an individual's request for amendment only under specified circumstances. A covered entity may deny the request if it: (a)may exclude the information from access by the individual; (b) did not create the information (unless the individual provides a reasonable basis to believe the originator is no longer available); (c) determines that the information is accurate and complete; or(d)does not hold the information in its designated record set. 164.526(a)(2). 60 45 C.F.R. § 164.528. 6' 45 C.F.R. § 164.522(a). 62 45 C.F.R. § 164.522(a). In addition, a restriction agreed to by a covered entity is not effective under this subpart to prevent uses or disclosures permitted or required under §§ 164.502(a)(2)(ii), 164.510(a)or 164.512. 67 45 C.F.R.§ 164.522(b). 64 45 C.F.R. § 164.530(i). 65 45 C.F.R. § 164.530(a). 66 45 C.F.R. §160.103. • 67 45 C.F.R. § 164.530(b). 68 45 C.F.R.§ 164.530(e). 69 45 C.F.R. § 164.530(f). 70 45 C.F.R. § 164.530(c). " 45 C.F.R.§ 164.530(d). 7245 C.F.R. § 164.520(b)(1)(vi). 73 45 C.F.R. § 164.530(g). 74 45 C.F.R. § 164.530(h). 75 45 C.F.R.§ 164.5300). 76 45 C.F.R. § 164.530(k). 77 45 C.F.R. §§ 164.103, 164.105. 78 45 C.F.R. § 164.103. 79 45 C.F.R. §164.105. Common ownership exists if an entity possesses an ownership or equity interest of five percent or more in another entity; common control exists if an entity has the direct or indirect power significantly to influence or direct the actions or policies of another entity. 45 C.F.R. §§ 164.103. 80 The Privacy Rule at 45 C.F.R. § 160.103 identifies five types of organized health care arrangements: • A clinically-integrated setting where individuals typically receive health care from more than one provider. • • An organized system of health care in which the participating covered entities hold themselves out to the public as part of a joint arrangement and jointly engage in OCR Privacy Rule Summary 22 Last Revised 05/03 i • utilization review,quality assessment and improvement activities,or risk-sharing payment activities. • A group health plan and the health insurer or HMO that insures the plan's benefits,with respect to protected health information created or received by the insurer or HMO that relates to individuals who are or have been participants or beneficiaries of the group health plan. • All group health plans maintained by the same plan sponsor. • All group health plans maintained by the same plan sponsor and all health insurers and HMOs that insure the plans'benefits,with respect to protected health information created or received by the insurers or HMOs that relates to individuals who are or have been participants or beneficiaries in the group health plans. 81 45 C.F.R. § 164.506(c)(5). 82 45 C.F.R. § 164.504(g). "45 C.F.R. § 164.504(f). 84 45 C.F.R. § 164.502(g). " 45 C.F.R. §160.203. 86 45 C.F.R. § 160.202. $'45 C.F.R.§ 160.304 as Pub.L. 104-191;42 U.S.C. §1320d-5. 89 Pub.L. 104-191;42 U.S.C.§1320d-6. • 90 45 C.F.R. § 164.534. 9' 45 C.F.R. § 160.103. 92 Fully insured health plans should use the amount of total premiums that they paid for health insurance benefits during the plan's last full fiscal year. Self-insured plans, both funded and unfunded,should use the total amount paid for health care claims by the employer,plan sponsor or benefit fund, as applicable to their circumstances, on behalf of the plan during the plan's last full fiscal year. Those plans that provide health benefits through a mix of purchased insurance and self-insurance should combine proxy measures to determine their total annual receipts. • OCR Privacy Rule Summary 23 Last Revised 05/03 Administration Monthly Report July and August 2012 Burial Permits @$25.00 $1,500.00 Permits $2,585.00 Certificate of Fitness@$50.00 $3,200.00 Copies $14.50 Fines $725.00 Total Monies Collected = $8,024.50 Annual Budget Expended UOAvailable Balance Total Salary/Longevity $363,600.00 $34,796.46 $328,803.51 Annual Budget Expended Available Balance Non-Personnel $19,600.00 ® $5,624.28 $13,975.72 Heather Lyons • From: Joyce Redford <putitout@lynnma.gov> Sent: Tuesday, September 11, 2012 7:12 PM To: Larry Ramdin; Heather Lyons Subject: Training Sunny Corner attended and completed the Tobacco Control training on 9/11/2012 In attendance: Thomas Truong Lan Pham Chan Le Thank you, 30gee Joyce Redford,M.Ed.,Director North Shore/Cape Ann Tobacco Alcohol Policy Program 3 City Hall Square,Rm# 103 Lynn,MA 01901 781-586-6821 •www.makesmokinghistoi:y.org • 1 ftc SEP• r OF 0' �2 2o gRpOF�BEM ��Ty IAA D1°I70 Wye kS C� — �I�M�� i VZ,�ca►.� a :y �o CITY OF SALEM, IVIASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4m FLOOR PublicHealth Prevent.Promote.Protect. TEL. (978) 741-1800 FAx(978) 745-0343 KIMBERLEY DRISCOLL lramdinnsalem.com LAIutY 1tAMDIN,RS/REVS,CHO,CP-FS MAYOR HEALTH AGENT May 17, 2012 Thomas Truong Owner Sunny Corner Market 331 Lafayette Street Salem MA 01970: Dear Mr. Truong, RE: Notice of Suspension of Permit to sell Tobacco Pursuant to its authority under Massachusetts General Laws Chapter 111 and Salem Board of Health Regulation 24. The Salem Board of Health has voted at a hearing, held at its regular meeting on May 8,2012 to suspend your permit to sell tobacco for four months,with effect from May 9,2012. qt s action is based on the fact that you have committed a sixth violation of the Salem Board of Health Regulation :Regulation affecting the purchasing of tobacco products and posting of laws concerning their sale; by selling tobacco to minors and offering single cigarettes outside their original packaging. The Board has assessed fines of$300 for each violation for a total of$600.00 The Salem Board of Health also advises that the reinstatement of your permit is not automatic and you will have to apply for reinstatement of the Sale of Tobacco permit. Additionally, as a condition of reinstatement of your tobacco permit, the Board of Health is requiring that all employees of Sunny Corner Market,be trained in the rules governing the sale of tobacco per Salem Board of Health regulation 24 section III(c). Arrangements can be made with the Northshore Tobacco Control Program to facilitate the training. Further, any further violations of Regulation 24, can result in the revocation of your Retail Sales Permit The Salem Board of Health retains jurisdiction over this issue. Yours Very truly Larry Ramdin REHS, CP-FS, CHO tY[. =a � Oalth Agent rfav[so ``A� � ClMINE�O Salem,MP CC : Joyce Redford,Northshore Tobacco Control Program Elizabeth Rennard City Solicitor 'peceived BY: Printed ------__.._ Name: ��/�f � • �p S��/ � Delivered BY: Printed Namelr��`h � Date: