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SILVERMOON COMICS - ESTABLISHMENTSuniversal one,m www.myuniversalop.com phone: 1-800-756-4676 UNV161 22 MADE IN USA ^9f !> J1 a UI ✓�C{ � � ��� EO KIMBERLEY DRISCOLL MAYOR CITY OF SALEM, MASSACHUSETTS BOARD or• HI%Al:tl I 120 WAS6❑NOTON Snuii='t, 411� FLooiz Tea.. (978) 741-1800 FAx (978) 745-0343 Immdin@salem.com LAI1ItYIt, ANIDIN, RS R@:IFIS, CITO, C11 -1;,S HF AFri I AG I!,N'P Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: y,4 R 2) Establishment Address: S' SeV^4 PIACiLAI&I 131 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: 9 79 -S9 - 5) Applicant Name &Title:41,"11/4MZ77Cle-0Q06 70 r TooD Rele,e e Colo 6) Applicant Address:/0yf 427 ESI6 a : D 61f E 7) Applicant Telephone No: 9 2,9 -30 -E 624 Hour Emergency No: % - g•3Js- Email: S,YveA, 4 ucr7pa 8) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): 10) Establishment Owned by: An association A corporation An individual A artnershi Other legal entity 11) If a corporation or partnership, give name, title and home address of officers or partner. Name Title Home Address c ; fl GGIN Av7# SN 4UA-& 7-.C11oow7rz inealzzw 12 Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor, Manager, etc. Name & Title: Address: 400-/-A� 2 Telephone No: Fax: Email: 's Emergency Telephone No: — 7JW - % y 722 13) District or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: Fax: Email: Check Date: aeks) V Af4h. CdH( 07 wo. c4,y I.7 Food Establishment Information 14) Water Source: 15) Sewage Disposal: DEP Public Water Supply No: (if applicable) y i -7 7--7-Wutr 9.0-7,e 16) Days and Hours of Operation: FZ: ridk 9 _8,,. 17) No. of Food Employees: 18) Name of Person in Charge Certified in Food Protection Management: Required as of 101112001 in accordance with 105 CMR 590.003(A) 19) Person Trained in Anti -Choking Procedures ( if 25 seats or more): ❑ Yes No 20) Location: 22) Establishment Type (check all that apply) (check one) ✓Permanent C (Retail ( 1760 Sq. Ft) ❑ Caterer Structure ❑ Food Service -( Seats) ❑ Frozen Dessert Manufacturer Mobile ❑ Food Service - Takeout ❑ Residential Kitchen for Retail Sale ❑ Food Service - Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and Breakf....... .........ast Establishmen.ts ......... 21) Length Of Permit: (check one) RETAIL STORE RESTAURANT ✓Annual ❑ Less than 1000sq.ft. $ 70 ❑ Less than 25 seats $140 Seasonal/Dates: ❑ 1000-10,000sq.ft. $280 ❑ Residential Kitchens $140 ❑ More than 10,000sq.ft. $420 ❑ 25-99 seats $280 ❑ More than 99 seats $420 ...................... .................... --............................................................................................. ❑ Bed & Breakfast/Childcare Services /Nursing Home $100 Temporary/DatesMme: ------------- - - - - - ------------------------------------------ ADDITIONAL PERMITS -------------------------------------------- ......... ❑ MAKE ICE CREAM, YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 ❑ ALL NON-PROFIT* $25 *Including, church kitchens, state funded childcare 8 private club 23) Food Operations: Definitions: PHF-potentially hazardous food (time/temperaturecontrols requireco (check all that apply): Non-PHFs - non -potentially hazardous food (no time/temperature controls required) RTE —rea to -eat foods Ex. sandwiches, salads, muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Coo -Chill Prepared by Consumer Reheating of Commercially Customer Self -Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan (including bare hand Service Within 4 hours contact alternative, time as public health control. Customer Self -Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Utters RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage, Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application 1, the undersigned, attest to the accuracy of the information provided in this application and 1 affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. 24) Signature of Applicant: ` `lam Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge 9d belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 4/ % -/?_98 30.3 26) Signature of Individual or Corporate Name: It i ¢ CITY OF SALEM, MASSACHUSETTS BOARD OF H&1L.TH 120 WASHINGTON STREET, 4` FLOOR TEL. (978) 741-1800 Fax (978) 745-0343 KIMBERLEY DRISCOLL lramdin(@salem.com MAYOR 1P PublicHealth Prevent, Promote. Protect. LARRY RArv1D1N, RS/RE.1-IS, CHO, CP -FS HEALTH AGENT Procedures to obtain a Food Establishment Permit Salem is a business friendly community and a destination for many restaurants. In order to facilitate a smooth licensing process and to ensure you can meet your opening targets. We are providing Food Establishments with this guide to the licensing process. The Food Establishment permitting procedure is a (2) part process Y Plan review e Food Establishment Permit Inspection Plan Review 1. Schedule a meeting with Health Agent to discuss proposal and requirements for licensure 2. Schedule a site visit. The site visit allows the applicant to describe their plans for the location and the Board of Health to provide information on necessary work to be done to ensure the facility meets compliance for licensure. Because the Public Health codes change, facility upgrades may be necessary. Even if you are going to conduct a similar type of business as previously existed at the location. 3. Submit plan review application a. Plan review application has to completely filled out b. Plans must be submitted 30 days prior to the start of construction c. Professionally drawn plans must show: i. Site plan and floor plan, ii. Elevation and wall floor joint details, iii. Lighting, plumbing/drainage details, iv. Lighting schedule and surface finish schedule. d. Specification sheets for all equipment and surfaces must be provided with plan e. Menu f. Fee These requirements are all detailed in the plan review application Once the plans are reviewed a plan review approval will be issued and construction can begin, once approvals from the building and other municipal state and federal departments has been received. The Board of Health may visit during the construction to ensure that the construction is following the plans submitted. If there are any changes to the approved plan, please contact the Board of Health office, as soon as possible before proceeding. This allows us to make an assessment, as to whether there is any negative food safety impact on the change and advise on actions that can be taken to remediate those negative impacts. Food Establishment Permit In order to ensure that your food establishment is inspected and permitted, to meet your projected opening date. Please contact the Health Department (1) week prior to your proposed opening date to schedule an inspection and submit your food establishment permit application with the appropriate fee. Permit Documents The documents that are needed will depend on the type of operation. Some may not be applicable to your establishment. We will advise you as to what is needed at the time of the plan review application. The following are documents that may be needed to schedule the inspection are: 1. Food Establishment Application form and fee( Check made out to the City of Salem) 2. Certified Food Manager Certificate ( for establishments that sell anything other than prepackaged food) 3. Allergen Awareness Certificate 4. Workmen's compensation insurance affidavit 5. Pest Control Contract _ _._ .--..._ - _ -._ _._ - — - 6. Trasli disposal contraot------- -- -__—_ ____. _-- -- 7. Grease disposal contract 8. Choke Save training certificate -if you have 25 or more seats 9. Lab results- if you prepare frozen Desserts 10. Variance requests with supporting documentation The food establishment permit inspection should be scheduled after other departments (except the Building Department), have completed their inspections. Once the inspection is completed and the facility has met the requirements for their Food Establishment permit, the inspector will sign the building card for the occupancy permit. We will also advise the Licensing Department that we have completed our inspection so they can issue the Common Victualler permit (if needed). The Food Permit will be issued to you to begin operations after the Building Department has issued the Certificate of Occupancy. Please feel free to contact us at 978-741-1800 if you have questions.