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Temporary Tood,Permit 4} , ,
DATE PRINTED: 08/01/2012 ,� n
ESTABLISHMENT NAME: Salem Common Neighborhood . `rt
File Number:BHF-2004-000239 .�' POBox 8608 -
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Permit Type Permit No. . Permit Issued Permit Expires Fee Restrictions/Notes'v,'` #
TEMPORARY FOOD BHP-2012-0557. Aug 2,2012 Aug 15, 2012 Event: Movie Nights Location:s-
Salem Commons Food to be Served:'
prepackaged foodsand drinks
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PERMIT EXPIRES ' ugtist 15,2012
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Board of Health 00
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r CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET,4"'FLOOR
TEL. (978) 741-1800
HIIVIBERLEY DRISCOLL FAZ(978) 745-0343
MAYOR lramdiii@salem.com
LARRY RANIFAN,RS/RFI IS,CI{O,CP-P'S
HFAI:rH AL,I:N r
CHECK PAYABLE TO THE CITY OF SALEM,NO CASH
FEE: NON-PROFIT=$25 1-3 DAYS=$300 4-7 DAYS=$600
OVER 7 DAYS=>7 DIVIDED BY 7 X 600=THE AMOUNT DUE (EXAMPLE: 14 DAYS DIVIDED BY 7=2x 600=$1200)
APPLICATION FOR ATEMPORARY FOOD [SpERVICE PERMIT
NAME OF EVENT Q V I`�Q ' 11Jk�$ an Q ' Gki�0n LOCATION Sa rL M C6Mi'10n
DATE(S)0F EVENT _ CJ 11 �+ '7
NAME OF APPLICANT �E�/I/Lr—�Z� SG•/nl� —6CIVT"rI Tn�E-L.EPHONE# 4 -17 7q�603L
ADDRESS r V , Board 1-tem k1
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NAME OF BUSINESS pp� ]-r c,.( [� /TELEPHONE# 1p
ADDRESS P,6 , soy � Jul I�I'7 H(7 Q l"I r7 / '
CERTIFIED FOOD MANAGERS NAME: / CERTIFICATION#:
We well Berl; ace Snac F prlhKs Pk� sed S S'
A PLAN OFT ES ABLISH NT FOR THE EVENT MUST BE ATTACHED TO COMPLETE THIS APPLICATION*
FOR ESTABUSHEMNTS OUTSIDE OF SALEM.MA:
wA COPY OF THE CERTIFIED FOOD MANAGERS CERTIFICATE AND ESTABLISHMENTS PERMIT MUST BE ATTACHED TO COMPLETE THIS APPLICATION.*
TYPE OF REFRIGERATION: _GAS ICE DRY ICE OTHER
METHOD FOR COOKING/HOT HOLDING: GAS OTHER
METHOD FOR SANITIZING: CHEMICAL OTHER
SOURCE OF FOOD: NAME: ADDRESS
FOODS TO BE SERVED INCLUDING INGREDIENTS AND METHOD OF PREPARATION:
I HAVE READ THE BOARD OF HEALTH,"REQUIREMENTS FOR TEMPORARY FOOD ESTABLISHMENTS."I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS REGARDING
THOSE REQUIREMENTS. I UNDERSTAND THEM,AGREE TO ABIDE BY THEM AND UNDERSTAND THAT FAILURE TO DO SO WILL RESULT IN REVOCATION OF MY
TEMPORARY FOOD ESTABLISHMENT PERMIT.
PURSUANT TO MGL C62c, A,I C.RTIFY UNDER THE PENALTIES OF PERJURY THAT 1,TO MY BEST KNOWLEDGE AND BELIEF,HAVE FILED ALL STATE TAX
RETURNS AND PAID AL ATE TA) EL1U112ED 2
UNDER LAW.
RE DATE SOCIAL SECURITY OR FEDERAL ID#
CHECK#: DATE AmD PND:
APPRG DBY: DATE:
TCI.IDADDI in-ii nnn I IDn AT=n C/17/11 -
Guidelines for Temporary Food Vendors
In order to ensure that safe and sanitary foods are served to the public, your temporary food permit is issued
based on the following conditions:
• Your Certified Food Manager certificate, temporary food and propane permits (if applicable) must be
conspicuously displayed on site.
• Only the foods stipulated on your temporary food permit may be sold.
• Foods must be obtained from an approved commercial source. Proof of source such as boxes, receipts etc. must be
on site.
• All potentially hazardous foods such as hot dogs, commercially pre-cooked sausages, hamburgers, prepared
vegetables, must be maintained either above 140°F or below 41°F.
• Only mechanical refrigeration or crushed / cubed ice is allowed as a cooling medium. Foods shall not come in
contact with water or undrained ice. Packaged foods may not be stored directly in ice if it is subject to the entry of
water.
• Cooking temperatures are as follows:
§ Commercially pre-cooked products -140°F
• All foods, drinks and condiments shall be handled and stored in a manner that prevents contamination such as using
clean covered containers, storing equipment and food up off the ground etc. Trash bags are not to be used for food
storage.
• Running water with liquid soap and disposable paper towels for hand washing must be available and set-up prior to
food preparation. Bottled water with a pull out spout is acceptable. Check with the Health Department for other
acceptable methods.
• All food handlers shall wash their hands after utilizing the toilet facilities, smoking, eating, changing tasks, and
changing gloves or when hands become contaminated. All wrist jewelry and adornments must be removed.
• Bare hands may not contact ready-to-eat foods. Suitable utensils shall be used such as deli tissue, spatulas, tongs,
single-use non-latex gloves etc. Bare-hand contact shall be minimized with foods that are not ready-to-eat.
• All equipment, utensils, containers etc. shall be in clean, sanitary condition. Where there are no warewashing
facilities obtainable; a spare set of work utensils shall be available.
• All carts must be thoroughly pre-cleaned before set-up at the event.
• People handling the food shall wear clean outer garments, hair restraints, and utilize good hygienic practices.
• Vendors licensed to sell scooped ice cream must store scoops individually in each tub of ice cream or provide
dipper well with running water
• Smoking is prohibited within 10 feet of a cart or food storage area. Employee must wash their hands thoroughly
with soap before returning to work.
• Garbage and refuse shall be disposed of in a satisfactory manner. The premises shall be kept clean.
• A stem type of thermometer that has been properly calibrated must be available for testing potentially hazardous
foods on site. The thermometer must be cleaned and sanitized before and after use in a manner approved by the
Health Department. Refrigerated units must have thermometers
• A labeled spray bottle of sanitizer prepared at proper concentration must be on site and used on all food contact
surfaces, utensils etc. Proper concentrations should be determined with pH papers. Concentrations are as follows:
§ Chlorine sanitizer: 50— 100 PPM § Quaternary sanitizer: 200 PPM
If any of these conditions are not set-up and maintained, your temporary food permit will be immediately
revoked and you will be ordered to stop serving food.
If you have any questions regarding the above conditions, call the Salem Board of Health at 978-741-1800 prior
to the event.
I have read understood and agree to adhere to the above conditions.
Permit Holder Date