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SALEM GROCERY - ESTABLISHMENTS SALvW, CG�c-Q M MOM=" ZIA PC-,um G a 45-\- 5 1 �' Commonwealth of Massachusetts F City of Salem Board of Health FGmberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: . 02/09/2010 ESTABLISHMENT NAME: Salem Grocery File Number:BHF-2004-000106 24 Palmer Street Salem MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2010-0355 Feb 9,2010 Dec 31,2010 $70.00 TOBACCO VENDOR BHP-2010-0356 Feb 9,2010 Dec 31,2010 $135.00 Total Fees: $205.00 PERMIT EXPIRES December 31, 2010 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 00 CITY OF SALEM, MASSACHUSEZTS �', BOARD OF HEALTH 120 WASHINGTON STREET,4"'FLOOR TEL. (978) 741-1800 1CIMBERLEY DRISC:OLL FAX(978) 745-0343 UwOR u<;R[;E.NBAUN[rW' ALEM CONI DAVID G REENBA UM, ACTING HEALTH AGENT 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT S >Cm \ cin .� TEL# C112 '%ul I - Off`' S ADDRESS OF ESTABLISHMENT oNt Qlrnos S�. �ewn t�Y� FAX.# MAILING ADDRESS(if different) EMAIL-Business`- \ Website: OWNER'S NAME �t)dt�w 1J�1 CoxnMA.r. C!C u- ti-Nh TEL# ADDRESS 15D 'Z-A� `] AP-V N I%MA. D\q-10 STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON41ZW165CO Ct2,5'1 I II 0 HOME TEL#0479 8511 ��C/S Y. a .Y-:- ;r ,k. ,�';` -z44'+=�;x •:�: - yvl; lFs...'.. 'wt,�,I?F;,�u' 'zFi':-{ wDAY$Q6,OFERATIQN , ?,Monday'<�-zla':�aTuesday;:=`�=^•�a=:Wetloesd�y�;�;i,;.;;:T.hursd'ay =����w'`,r;"F..ntlay, ..�;,r :>',Safu"rday_t - ..,�Su`ntlay�:., .-. HOURS OF OPERATION Please wntelntime ofday �kr ,kM� le`"^' 'lp""`� 'la"` ' �qv+t" ty�y_ (for example Ilam-11pm) It P. tt yN It to a A•r^ a YM tt �•t"t t) IAhL TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE ES NO less than 1000sq.ft. _$707� 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 -- • - ---•• ----------------------------- - -----------•----..-----•------- -------------le---- h------------•----....------ -- -------- RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 - -- --------------- -------------------- - . BED/BREAKFAST! YES NO $100 CHILDCARE SERVICES/NURSING HOME....----- --------------------------- -----------.-------------------•------------- ---------------- ADDITIONAL PERMITS MAKE(not just serve) ICE CREAM, YOGURT/SOFT SERVEYFS NO $25 TOBACCO VENDOR YES 4§ $ 3 ALL NON-PROFIT(such as church kitchens) "Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted In a prominent Iocatio in the Establishment In accordance with the State Sanitary Code, before any renovations, Improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I cerlify under the pains and penalties of perjury that 1,to my best knowledge and belie(,have filed all state tax returns and pard all state taxes required under the law. t rvt �,� CRS C:71 -7 -- /4 �/b�` Signature Date Social Security or Federal Identification Number •---------------•- ---'- -" --- ---- Revised 4/24/07 FOODAP2008.adm Chmk#&Date_„ ._ - _ S T MIT ENT A-1 1 ��, erm'n-ftors ���� PLEAS 10,Lyn ,MA 0 90 -03 163/'SIHEPARD/1STREET,LYNN,,MAA 019024397 IiNVP.O.Box 370,Lynn,MA 07903-0390 At 701392-27$1 94*0426-4M VAX T81-592.7641 '1 547425 CURRENT 30 DAYS 1 60 DAYS 1 90 DAYS Pest and Termite Control Professionals ++ TYP ACCT NO Rr V05Due 161 01 ATI 101 CASTILLO GROCERIES FO REGULAR PEST CONTROL SERVICE CHARGE 50. 00 24 PALMER ST NUMBER UNIT PRICE AMOUNT SALEM MA 01970 MOUSEGLED 978-141-7295 11/e4/09 ANYTIME MULTI-CT TRAP _. . DATE�^ J"1^ I� PROTECTA PROTECTA LP CHECK NO. RTD BAIT STA i COMMENTS i ❑MC ❑VISA RAT GWE BD STORE/RR/OFFICE S BSMT ONLY ❑DISCOVER 11 AMEX SALES TAX �— CDD❑ CHG❑ WC LI TOTAL DUE TOTAL AMODNT PD Vo O a+ r ADDITIONAL COMMENTt ' R COMMERCIAL SANITATION REPORT J YES NO Floors-Clean ............................._...................... .......... ❑ Q dd{ Counter Surfaces-Clean ..............a.;........_................ ❑ ❑ 7 ' Dram Areas-Clean ....................................................... ❑ Q .I Rest Rooms-Clean ....._._._... Dining Areas-Clean ............................._....._............- ❑ ❑ a _. Employee Areas-Clean •.••..•••-•- ---- ❑ ❑ RESIDENTIAL WARRANTY INFORMATION Locker Areas-Clean•-.....................................--.... ❑ Q y DWELLING TYPE WARRANTY YES❑ NO❑ Storage Areas-Organized ---........................-....._.. Q Q 1 1 Family ❑ 3 Family ❑ 30 Days ❑ SO Days ❑ Comments 2 Family ❑ 6 Family ❑ 90 Pays O S Mos. ❑ REASON FOR NO WARRANTY >1 •Partial service requested .........-.........................................._.................... ..._❑ •Poor sanitation..........:-.-........................--........---.................................... .❑ POST APPLICATION REQUIREMENTS •1Gtchentbethroom cabinets not prepared .....................................I....1,........-it OCCUPIED AREAS MUST BE VACATED FOR HOUR •ClosetsthrrnBure not prepared........_........._._....»..__._.............................❑ THOROUGHLY VENTILATE TREATED AREAS95FORE THEY AR •Rodent proofing needed...................................................................................❑ REOCCUPIED,DO NOT ALLOW ADULTS,CHILDREN, OR PETS 4 .Other TREATED SURFACES UNTIL DRY, CONTRACTING ENTITIES HAVE RECEIVED ALL MASSACHUSEM DEf krItIVENT OF 1`000 a AGRICULTURE:,PESTICIDE f TIME IN BUREAU CONSUMER SHEETS.WRITTEN STATEMENTS.POSTING NO ICESAND HAVE AGREEO TO NOTIFY TENANTS 2.7 1 DAY$PRIOR TOAPPLICATIO N TIME.THE ABOVE SERVICE HAS BfEN SATISFACTORILY COMPLETED. Nss+ CUSTOMER SIGNATURE LIC.4 SIGNATURE TECH TECH NO. r�e12- ©A CA I SEE REVERSE SIDE FOR PERTINENT INFORMATION White-Office Copy Canary-Customer Copy ( IMPORTANT MESSAGE ) FOR _)/AV DATE I I TIME M.M. M l C o f c�t7 �C/vt rti OF r trlf, / CG�R1�a I/�OS PHONE7`�i AREA CODE NUMBER EXTENSION O FAX O MOBP F AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN i WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU t•,^ MESSAGE {�ke r: �'&,A wYCA Y SIGNED CS FDRMARE J 4 a NOTES CITY OF SALEM BOARD OF HEALTH Name of Establishment: Salem Grocery Address: 24 Palmer Street Owner(s): Maria del Carmen Camilo Phone: 978-744-9710 February 4, 2010 The owner of this proposed establishment presented plans for review in accordance with the State Sanitary Code. No changes to the current floor plan are being implemented. Any changes to the current floor plan must be approved by the Board of Health prior to implementation. ITEMS FOR SALE All food items displayed and offered to the public must be from a source permitted as a Wholesaler from the Mass Department of Public Health. FLOOR PLAN All surfaces must be intact, impervious and easily cleanable. All refrigeration units must have accurate internal thermometers. Refrigerated food must be held at 41 degrees Fahrenheit or lower, freezers at 0 degrees Fahrenheit or lower. EXPIRATION DATES All expiration dates on products must be clearly visible. Out dated items must be promptly removed from display. TRASH Owner must store and maintain all trash in a clean and sanitary manner. EXTERMINATION Monthly services of a Licensed Pest Control Operator are required. Please keep receipts for inspections. Outside area of premises must be kept clean and sanitary. A change of ownership inspection will be conducted on February 4, 2010 at 2:OOPM David Greenbaum Date Acting Health Agent Maria del Carmen Camilo Date Owner Ala C��tit hJ " N o Iff d u in 6 �9 }fN S 4322D i 4 vi o two -7 a 6-M -�2"7 �,�rva 1��"� G;,•, to _.., ._�.,