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ST PETERS CHURCH - ESTABLISHMENTS0 S4- .S 0 n f' n Kimberley Driscoll Mavor City of Salem, MagsacHusetts Board of Health 120 Washington Street, 4th Floor, Salem, MA 01970 Tel. (978) 741-1800 Fax. (978) 745-0343 i1CHP.��1 health@Salem.COm (Prevent. Promote. Protect. Larry Ramdin, MPH, REHS, CHO Health Aqent FOOD ESTABLISHMENT PERMIT (must be posted on the Premises of the Food Establishment) 2017 Permit Number: FM -17-408 Permit Type: Temporary Food Non -Profit Goods & Services: Food Service: Non -Profit Name of License Holder: St. Peter's Church Name of Food Establishment St Peter's Church. Halloween Cafe Address of Food Establishment 24 ST PETER STREET Restrictions: Soups Hot Dogs Sausage Sweets Coffee Cold Drinks This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on 10/31/2017 unless sooner suspended or revoked. Permit Fee: $0.00 Effective: 1017/2017 Larry Ramdin, MPH, REHS, CHO Health Agent (q7k) g3(O-2s(0) tk. n,k <r _ KIMBERLEY DRISCOLL MAYOR CITY OF SALEM; MASSACHUSETTS BOARD OF HEALTH DEPARTMENT 120 WASHINGTON STREET, 411' FLOOR TEL. (978) 741-1800 FAX (978) 745-0343 heahh .salern.Dom O PublicHealth Prevent. Promote. Protect. LARRY RAMDIN, RS/RE-FIS, CHO, CP -FS HEALTH AGENT APPLICATION FOR ATEMPORARY FOOD SERVICE PERMIT APPLICATIONS MUST BE RECEIVED AT LEAST 3 BUSINESS DAYS PRIOR TO EVENT *" *A Drawing of the Establishment's Set -Up at the Event Must be Attached to Complete This Application* FEES: 1-3 DAYS = $35 4-7 DAYS = $70 NON-PROFIT = $25 OVER 7 DAYS = >(DAYS) DIVIDED BY 7 X $70 = THE AMOUNT DUE (EXAMPLE: 14 DAYS DIVIDED BY 7 = 2 X $70 = $140) CHECK PAYABLE TO: CITY OFSALEM(CHECK OR MONEY ORDER ONLY- NO CASHINO CARDS) NAME OF EVENT Ij QM 0I k) P A l_IxerQ_ LOCATION 2-�t 'I � '(�'r St DATES) OF EVENT t) Q % 2 TIME OF DAY ' 2_ Yl nn r\ NAME OF APPLICANT 2CiI 24 / ) �iE C.AZ_Ay TELEPHONE# ff ADDRESS. 2� S'I . Pc__ rr'.< S� 5�.1 EMAIL Cl • Ca henQ cffl9,Dc-F, nc- NAME OF BUSINESS TELEPHONE# D A - %Y-.- 22.91 CERTIFIED FOOD MANAGERS NAME: ROM?C_0 CERTIFICATION#: FOR ESTABLISHEMNTS OUTSIDE OF SALEM. MA: *A COPY OF THE CERTIFIED FOOD MANAGER'S CERTIFICATE, ALLERGEN AWARENESS CERTIFICATE, AND ESTABLISHMENT'S PERMIT/COMMISSARY 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 FOOD TO BE SERVED/MENU: S ci 5 1 n <� r I I <Q O P I, f`lwp__e <1L LIST OF INGREDIENTS AND METHOD OF PREPARATION: (FOR HAZARDOUS FOOD, LIST PREPACKAGED FOODS) I HAVE READ THE BOARD OF HEALTH, "REQUIREMENTS FOR TEMPORARY FOOD ESTABLISHMENTS.° I HAVE HAD THE OPPORTUNITYTO ASK QUESTIONS REGARDING THOSE REQUIREMENTS. I UNDERSTAND THEM, AGREE TO ABIDE BY THEM AND UNDERSTAND THAT FAILURE TO 00 SO WILL RESULT IN REVOCATION OF MY TEMPORARY FOOD ESTABLISHMENT PERMIT. PURSUANT TO MGL C62C, S49A, I CERTIFY UNDER THE PENALTIES OF PERJURY THAT I, TO MY BEST KNOWLEDGE AND BELIEF, HAVE FILED ALL STATE TAX RETURNS AND PAID ALL STATE TAXES REQUIRED UNDERLAW. Ci CK# I Page ^ n DATE (b l `L 11! SOCIAL SECURITY OR FEDERAL ID # APPROWD BY: AMWNT PND: KIMBERLEY DRISCOLL MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH DEPARTMENT 120 WASHINGTON STREET, 4"` FLOOR TEL. (978) 741-1800 FAx (978) 745-0343 healthna,Salem.corn l'ubhcHealth Prevent. Pmmate.. Rotect. LARRY RANIDIN, RS/RUI S, CttO, C? -FS HEALTH AGENT Guidelines (checklist) for Temnorary Fond Vendor. 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: 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. x 11S�\ IV C N." rno nt LLI& Applicant's Signature Date 2 1 P a g e — -- 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. Cooking temperatures are as follows: Commercial) re -cooked products -140°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. 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 loves 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 ware washing 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 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 § Quaternarysanitiser: 200 PPM 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: 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. x 11S�\ IV C N." rno nt LLI& Applicant's Signature Date 2 1 P a g e — -- CITY OF SALEM, MASSACHUSETTS O BOARD 4 HEALTH DEPARTMENT 120 WASHINGTON STREET, 4: ' FLOOR PubhCHealth Pro•ent. Promotes Fm4et. TEL. (978) 741-1800 FAx (978) 745-0343 KIMBERLEY DRISCOLL healthgsalem.com LARRY ReAMllIN, RS/RL.HS, CHO, CP -ES MAYOR Hi >v.;fH AGENT Drawing of set up for establishment's station at event: Example: Draw area of food service/preparation (hot/cold holding) point of sales area hand washing station location of grills, tables layout and trash area 51 P 3 1 P a g e SILVESTRE ROMERO — for wcc sfuRy ww fkrq 16 lmdards sL4 forth for the ServSofe® Food Protedlam ARanagw Cartilica6m Examination, which is accredited by $le American National Sfam6ch inslNe (ANSIj-LmFenance for Food Pro edion {CFP}. �F=784659 10484 ftT- S aNUMBER EXAM FORM NUMBER 6128/2# x 6/28/2021 DATE Of E3j,8j`M DATE OF EXPIRATION ' locot � aPpl/ fa rxe+tiRmtian ra:cprirEmerJs. - � cam a �":. Ga mvAqwr a 1]3 W h,& mBial aro 1390, Chwgn,IL 60606 w SvaSokdmlwimr.o ON Kimberley Driscoll Mayor City of Salem, Massachusetts Board of Health 120 Washington Street, 4th Floor, Salem, MA 01970 Tel. (978) 741-1800 Fax. (978) 745-0343 pt1iCHE:Alth health@salem.com Prevent. Promote. Protect., Larry Ramdin, MPH, REHS, CHO Health Agent FOOD ESTABLISHMENT PERMIT (must be posted on the Premises of the Food Establishment) 2017 Permit Number: FM -16-476 Permit Type: Food Establishment 25-99 seats Goods & Services: Food Service: Non -Profit Name of License Holder: St. Peter's Church Name of Food Establishment St. Peter's Church Address of Food Establishment 24 St. Peter Street Salem MA 01970 Restrictions This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on 12/31/2017 unless sooner suspended or revoked. Permit Fee: $0.00 Effective: 12/1/2016 Larry Ramdin, MPH, REHS, CHO Health Agent KIMBERLEY DRISCOLL MAYOR CITY OF SALEM, lu MASSACHUSETT ,�� e PublicHeatth BOARD OI>HEALTH - •,`•`",.>•"' •,°�•`. 120 WASHINGTON SIREI-L, 41" Fl,ol/ 2 -] 2� I U TRL. (978) 741-1800 FAX (978) 745-03 Y JJ (LARRY RAMD[N, RS/REBS, CI t0, CP -FS healthQsalem.com CITY OF SALEM HFAurijAGENT BOARD OF HEALTH Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: S PIS/E;f �^�)<zSP,}L C)�it�G71% 2) Establishment Address: 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: 17 e, - 7* --5-- L 2- 5) Applicant Name & Title: 5:001--"U 5) 6) Applicant Address: sl*lk 7) Applicant Telephone No: rq Atm 24 Hour Emergency No: Email: ,! 3 Email: 6) 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 partnership Other legal entity 11) If a corporation or partnership, give name, title and home address of officers or partner. Name Title Home Address i 12 Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor, Manager, etc. Name & Title: �r,,j- 5 14� Address: Telephone No: Fax: Email: Emergency Telephone No: 13) District or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: Fax: Email: Check #: 1/67 Date: z.3 % Amount: I Z.S. Vz Food Establishment Information 14) Water Source: 15) Sewage Disposal: DEP Public Water Supply No: ( if applicable) 45, t\ 16) Days and Hours of Operation: W 17) No. of Food Employees: `^ 18) Name of Person in Charge Certified in Food Protection Management: � 4 Required as of 1011/2001 in accordance with 105 CMR 590.003(A) n) A0 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) O Retail ( Sq. Ft) 13 Caterer Permanent Structure V 0 Food Service - ( Seats) O Frozen Dessert Manufacturer Mobile O Food Service - Takeout ❑ Residentlal Kitchen for Retail Sale 13 Food Service _ Institution O Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and ---•••••••-•-•--••••••••••••••------------------------------- Breakfast Est_a_b_I_i_s__h__m__e_n_t_s_______________.___--_ 21) Length Of Permit: (c�k 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,OOOsq.ft. $420 O 25.99 seats $280 ❑ More than 99 seats $420 ----------------------------------------------------------------- --------------------------------------------------------------------- ❑ Bed & Breakfast/Childcare Services /Nursing Home $100 Temporary/DatesMme: ---------------------------------------------------- ADDITIONAL PERMITS ------------------------------------ .....-......... . ❑ MAKE ICE CREAM, YOGURTISOFT SERVE $25 O PASTURIZATION $25 ALL NON-PROFIT' $25 1ricludin , church kitchens, state funded childcare & private club 23) Food Operations: Definitions: PHF- potentially hazardous food (timettemperature controls required) Non-PHFs - non -potentially hazardous food (no time/temperature controls required) (check all that apply): RTE -read -to-eat foods Ex. sandwiches, salads, mutons which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs I for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self -Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan (including bare hand Service Within 4 hours contact alternative, time as public health control. Customer Self -Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage, Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application I, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. I � 24) Signature of Applicant: Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: C X !6 -,2k 26) Signature of Individual or Corporate Name: J QUESTIONAIRE - GREASE TRAPS 2013 1. NAME OF ESTABLISHMENT 2. ADDRESS OF ESTABLISHMENT: 3. DOES YOUR ESTABLISHMENT HAVE A GREASE 4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT HAVE? CAPACITY IN 5. HOW IS THE GREASE TRAP MAINTAINED? ON A DAILY BASIS? BY AN IN-HOUSE PERSON OR BY AN OUTSIDE CLEANING SERVICE? 6. WHAT IS THE FREQUENCY THAT THE GREASE IS REMOVED FROM THE TRAP? 7. WHAT IS THE NAME OF THE FIRM WHO REMOVES AND/OR PICKS UP THE GREASE FROM YOUR ESTABLISHMENT? 8. WHAT IS THE DATE OF YOUR LAST INVOICE FROM THE REMOVAL FIRM? Kimberley Driscoll Mayor City of Salem, Massachusetts 10 Board of Health 120 Washington Street, 4th Floor, Salem, MA 01970 Tel. (978) 741-1800 Fax. (978) 745-0343 PublicHealth Iramdin@salem.com Prevent. Promote. Protect. . Larry Ramdin, MPH, REHS, CHO Health Agent FOOD ESTABLISHMENT PERMIT (must be posted on the Premises of the Food Establishment) 2015 Permit Number: FM -15-298 Permit Type: Food Establishment nonprofit Goods & Services: Food Service: Non -Profit Name of License Holder: St. Peter's Church Name of Food Establishment Address of Food Establishment Restrictions: St. Peter's Church 24 St. Peter Street Salem MA 01970 This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on 12/31/2015 unless sooner suspended or revoked. Permit Fee: $25.00 Issued: 1/112015 T CITY OF SALEM, MASSACHUSETTS P„yyuu, BOARD of HEAV:1'H 120 WASHINGION S door r, V1 F1.001t KIMBERLEY DRISCOLL - TEL. (978),741-1800. FAX (978) 745-0343 LARRY R-AMDIN, RS/RI IIS, CFR), CV -FS in�d[m.com Iramdsale- MAYOR - - .__. HE;AI. L'I-I ZUNI' Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: CrTVAr4 ! 2 Establishment Address: 3) Establishment Mailing Address (if ddiifferent): q 4) Establishment Telephone No: �e�� 5) Applicant Name & Title: J� p� N --:: P1#& � hACE— ^W 6) Applicant Address: 7) Applicant Telephone No: %W S,j ^ 2'4 Hour Emergency No: Email: �/ak>s'�hC/ 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 partnership Other legal entity U �IBG�l� a Mfi� 11) If a corporation or partnership, give name, title and home address of officers or partner. Name Title Home Address ' s �� 12 Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor, Manager, etc. Name & Title: Address: 4-t tj 044 Telephone No: Fax: Email: Emergency Telephone No: 13) District or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: Fax: Email: Check#: / Date: Amount: Food Establishment Information 14) Water Source: 15) Sewage Disposal: DEP Public Water Supply No: ( if applicable) 16) Days and Hours of Operation: 17) No. of Food Employees: j� b Lsr ASS 18) Name of Person in Charge Certified in Food Protection Management: Required as of 1011/2001 in accordance with 105 CMR 590.003(A) 19) Person Trained in Anti -Choking Procedures ( if 25 seats or more): )f Yes No 20). Location: 22) Establishment Type (check all that apply) (check one) / O Retail ( Sq. Ft) ❑ Caterer Permanent Structure '✓ O Food Service - ( Seats) 13 Frozen Dessert Manufacturer Mobile O Food Service - Takeout ❑ Residential Kitchen for Retail Sale 13 Food Service - Institution O Residential Kitchen for Bed and ( Meals/Day) O Food Delivery r/W r -r j .......................................................Breakfast Breakfast Home ❑ Residential Kitchen for Bed and Establishments-,,,,,,,,----------,, 21) Length Of Permit: (chec one) - RETAIL STORE RESTAURANT Annual ❑Less than 1000sq.ft. $ 70 . ❑ Less than 25 seats $140 Seasonal/Dates 131000.10,000sq.ft. $280 ❑ Residential Kitchens $140 13 More than 10,000sq.ft. $420 - ❑ 25-99 seats $280 ❑ More than 99 seats $420 ----------- ---------- ----- -------------------------- ❑Bed 8 BreakfastlCh............... - ---- - ildcare Services /Nursing Home $100 Temporary/DatesMme: ADDITIONAL PERMIT ---------------------------------------------------- S -......------........................-------------- ❑ 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 (timeftemperature controls required) (check all that apply): Non-PHFs- non -potentially hazardous -to-eaf food (no timdtemperature controls required) RTE -rea foods Ex. sandwiches, salads, muffins which need no further processing Sale of Commercially - PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self -Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan (including bare hand Service Within 4 hours contact alternative, time as public health control. Customer Self -Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for P pares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, Out of Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application 1, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the. Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. s 24) Signature of Applicant: Pursuant to MGL Ch, 62C, sec. 4K I certify under the penalties of perjury that I, to my best knowledge and belief, . Have filed all state tax returns and paid state taxes required' under law. 25) Social Security Number or Federal ID: 0.2 /- 36 r�ieg 26) Signature of Individual or Corporate Name: Massachusetts Department of Public Health Division of Food and Drugs City/Town of FOOD ESTABLISHMENT INSPFrTinm RFPART Salem Board of Health 120 Washington Street, 4"' Floor Salem, MA 01970-3523 Tel. (978) 741_1BOB 'Fax (978) 745-0343 Address: Tel Name- S t , - u r Da - Type of Operation(s). L&-Eo•od Service LJ Retail jype of Inspection ,® Routine ❑Re -inspection -Address.^ Rik Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: [I Temporary ❑ Caterer ElPre-operation Owner _ HACCP IN s _ �s ❑ Bed 8 Breakfast ❑ Suspect Illness ❑ General Complaint Person -in -Charge (PIC) Time l ' (e\ 0 HOtth Inspector _ a Ot Permit No. CP Each violation cnSCKea requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-corrtoimnce with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Violations marked may pose an imminent health hazard and require immediate corrective action as determined by the Board of Health. FOOD PROTECTIONMANAGEMENT ' ) ❑ 1. PIC Assigned/Knowledgeable/Duties 'EMPLOYEE HEALTH ❑ 2.. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED S0URCE..... _ W ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy.of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans i 'PROTECTION FROM CONTAMINATION ❑ 8. Separation/Segregation/Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11.. Good Hygienic Practices Violations Related to Good Retail Practices- (Blue Items) Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Noncritical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C N 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4x590.005) 26. Water, Plumbing and Waste (FC5)(590.006) 27. Physical Facility (FC -6x590.007) 28. Poisonous or Toxic Materials (FCax590.00e) 29. Special Requirements (590.009) 30. Other s: o -+a doc Anti -Choking 590.009 (E) ❑ Tobacco 590.009 (F) ❑ Allergen Awareness 590.009 (G) ❑ ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities .PROTECTION FROM'CHEMICACS-. ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals ;TIME!TEMPERATURE:CONTROLS(PoterKlellyHaiardoua Foods).,. ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling - ❑ 19. Hot and Cold Holding ❑ 20. Time as a Public Health Control -j REQUIREMENTS FOR HIGHLY -SUSCEPTIBLE, POPUlATIONS(HSP) ❑ 21. Food and Food Preparation for HSP 1C64SUMERA6VIS0RW.~ ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Red Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a fight to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: Inspector's Signature: Prin . htipfi�1 Pagejof�pgges PICS Signature: Print: �� PIs- ri Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A) Asti>tmentnfRc sibil,ity* 590A03(B) Demonstration of Knowledge* 2-103.11 Person in charge dunes EMPLOYEE HEALTH 2 590.003(C) Responsibility of the person in charge to Compliance with Food Law" 3-201.12 require reporting by foot employees, and 3.201.13 Fluid Milk and Milk Products* applic:uds* Shell Eggs* 5%003(F) Responsibility Of A Food Employee Or An 3-202.16 _f Ice Made From Potable Drinkin Water* Applicant To Report To'nve Person In Drinking Water from an Approved System" 590.006(A) Char *e* 590.006(B) 590.003(C?) Reporting by Person in Charge* 3 590.003(1)) Exclusions and Resrricfions* _ 3-201.15 590.003(E) RemovafofExclusionsandResirietions 03 lin L C FOOD FROM APPROVED SOURCE .ti. Denofe5 critical item in the federal 1999 Food Code or F6 CMR 590.000. PROTECTION FROM CONTAMINATION 8 Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law" 3-201.12 Food in a Hermetically Sealed Container* 3.201.13 Fluid Milk and Milk Products* 3-202..13 Shell Eggs* 3-202.14 Ms and Milk Products, Pasteunzed'w 3-202.16 _f Ice Made From Potable Drinkin Water* 5-101.11 Drinking Water from an Approved System" 590.006(A) Bottled Drinking Watt* 590.006(B) Water Meets Standards in 310 CMR 22.0"' Washiu Fmits and Ve*etables SheAlish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caugtn Molluscan Shellfish* - _ 3-201.15 Mo1luSnm Shelffish from rNSSP listed sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Regulatory Authord 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* _ 3-701.11 Receiving/Condition 3-202.11 PHFs Receiver! at Proper Tem ratures'" 3-202.15 Package hneknit * 3-101.11 Food Safe mid Unadulterated Tags/Records: Shellstock 3-202.18 Shellstock Identification * 3-203.12 Shellstock identification Maintained* Tagsifiecords: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records. Creation and Retention* 590.0040) Labeling of Ingredients* Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* Conformance with Approved Procedures THACCP Pians 3-502.11. S ecialized Processing Methods* 3-502.12 Reduced ox en acka tin-, criteria* 8-103.12 Conformance with A roved Procedures* .ti. Denofe5 critical item in the federal 1999 Food Code or F6 CMR 590.000. PROTECTION FROM CONTAMINATION 8 Cross -contamination 3-302.1.1(A)(l) Raw Animal. Foods Separated from Corked and RTE Foods* Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.1 i(A) Foot Protection* 3-30215 Washiu Fmits and Ve*etables 3-304.11 Fund Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding.or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501.111 Manual Warewashine - Hot Water Sanitisation Tem eratures" 4-501.112 Mechanical Warewasldng- Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization- temp-, pH, concentration and hardness. * 4-601..1 I(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.1 1 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of$ ni meat* 4-703..11 Methods of Sanitization - Hot Water and. Chemical* to Proper, Adequate Handwashing 2-301.11. - Clean Condition - Hands and Arras* 301.12 Cleaning Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 40 LH Eating, Di inkimor Using Tobacco* 2401.12 Discharges From the Eyes, Nose and Mouth* 3-30'1.12 Preventing Contamination When Tasting" 12 - Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* - - 13 Handwash Facilities Conveniently Located and Accessible 5-203.11. Numbers and Capacities* acities* 5-204.1.1 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 - Handwashin Cleanser, Availability 6-301.12 Hand Drying Frovision Pager of �) Rom Code No. Referents C — Critical nem R—Red nam DESCRIPTION OF VIOLATION / PLAN�OF CORRECTION Date Verified PLEASE PPI T IEARIV r ~� (. a - c sU J c � A) JS, r `rus y ./ S S Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all inspection, to observe all conditions as described, and to violations before the next ins p comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of your food permit. f� r_�Ihl Sys Corrective Action Required: a No o Voluntary Compliance ❑ Employee Res riction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure 0 Voluntary Disposal ❑ Other: J Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 16 17 18 TIME/TEMPERATURE CONTROLS Food or Color Additives 3-202.12 Additives* 3-302.14 Protection from Unapproved Additives* 3-801,11(C) Poisonous or Toxic Substances 7-101.11 Identifying Information -Original Containers* 7-102.11 Conmron Name- Working Containers* 7-201.1 I Separation - Storage* 7-202.11 Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sanitizers, Criteria - Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 Drying Agents, Criteria* 7-205.11 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7-206.13 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Moan mg* TIME/TEMPERATURE CONTROLS * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. Proper Cooking Temperatures for Cooling Methods for PHFs PHFs 3-401.11 A(1)(2) Eggs- 155°F 15 Sec. 3-801,11(C) Eggs- immediate Service 145°F 15sec* 3-401.1 1(A)(2) Comminuted Fish, Meats & Game 3-501.16(A) Animals - 155°F l5 sec. * 3-401.11(13)(1)(2) Pork and Beef Roast- 130°F 121 min* 3-401.11(A)(2) Ratites, lnjected Meats -155°F 15 see. 26. 4 3-401.11(A)(3) Poultry, Wild Game, Stuffed PI -117s, Time as a Public Health Control* Stuffing Containing Fish, Meat, 590.004(H) Poultry orRatites-165°F 15 sec. 3-401.11(C)(3) Wlrole-muscle, Intact Beef Steaks - FC -7 145°F * 3-401.12 Raw Animal Foods Cooked in a - Microwave 165°F * 3-401.11(A)(1)(b) All Other PHFs -145°F 15 sec.* Reheating for Hol Holding 3-403.11(A)&(D) PFIFs 165°F 15 sec.* 3-403.1 1(B) Microwave- 165° F 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE Food - 140°F* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PITFs from 140°F to 70°F Within 2 Hours and From 70°F to 410F/45017 Within 4 Hours. * 3-501.14(6) Cooling PHFs Made From Ambient Temperature Ingredients to 41°F/4501' Within 4 (Tours* 3-501.14(C) PHFs Received al Temperatures According to Law Cooled to 41°F/45°F Within 4 flours. * * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 3-801.11(A) 3-501.15 Cooling Methods for PHFs 19 3-801.11(D) PHF Hot and Cold Holding 3-801,11(C) 3-501.1603) 590.004(1') Cold PHFs Maintained at or below 41°/45°F* Food and Food Protection 3-501.16(A) Hot PHFs Maintained at or above 140°F * 25. 3-501.16(A) Roasts Held at or above 130°F. 20 26. Time as a Public Health Control FC - 5 3-501.19 Time as a Public Health Control* Physical Facility 590.004(H) Variance Requirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels* 3-801.11 Use of Pasteurized Eggs* 3-801.11(D) Raw or Parially Cooked Animal Food and Raw Seed Sprouts Not Served. * 3-801,11(C) Unopened Food Package Not Re -served. CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 590.000 23. Animal Foods That are Raw, Undercooked or FC - 2 .003 Not Otherwise Processed to Eliminate Food and Food Protection FC - 3 Pathogens,* EMeL1' �n12001 25. 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited order the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. (Items 23-311) Critical and non-critical violations, which do nol relate to the foodborne illness inleoventions and risk,factors listed above, can he found in thefollowing sections of the Food Code and 105 CMR 590.000. Item Good Retail Practices FC 590.000 23. Management and Personnel FC - 2 .003 24. Food and Food Protection FC - 3 .004 25. Equipment and Utensils FC - 4 .005 26. Water, Plumbing and Waste FC - 5 .006 27. Physical Facility FC - 6 .007 28. Poisonous or Toxic Materials - FC -7 .008 29. Special Requirements - .009 30. Other S 1.ob.k 2 t a �;� .v � r z. 4. KIMBERLEY DRISCOLL MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HEAL1'1-I 120 WAST IINGI'ON SIRB.FT, 411' FLOOR Tr.'I.. (978) 741-.1800 FAX (978) 745-0343 lxamdiL1@saIem.co IV P,rutuxe Ith LARRY RAMDIN, RS/REHS, CHO, CP -FS HEAIIHI AGENT Food Establishment Permit Application (Application.must be submitted at least 30 days before the planned opening date) 1) Establishment Name: S- -, Pe/ Q ( 5 2) Establishment Address: q44, 5T, -PS'T 3) Establishment Mailing Address (if different): ' f 4) Establishment Telephone No: q 6 q - -1 4E — a.? -q I 5) Applicant Name & Title: �� , J' - f'i - 8) Applicant Address: i�--�d� 7) Applicant Telephone No _7' . ] 24 Hour Emergency No:. biz he} 8) Owner Name & TIUe (if different from applicant): g) Owner Address (if different from applicant): 10) Establishment Owned by: An association A corporation An individual A partnership Other legal entity 11) If a corporation or partnership, give name, title and home address of officers or partner. Name Title Home Address 12 Person [D)lrectly Res onsible For Daily Operations Owner, Person In Char e, Supervisor, Manager, etc Name & Titie: Address: Telephone No: 1 3 1-�- -io I Fax: Email: Emergency Telephone No: 1 -2 _ 13) District or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: Fax: Email: Check #:A _ Date: / O l �l Amount: � T J p Food Establishment Information 14) Water Source: 15) Sewage Disposal: DEP Public Water Supply No: ( if applicable) 16) Days and Hours of Operation: 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) ❑ Retail ( Sq. Ft) ❑ Caterer Permanent Structure ❑ Food Service - ( Seats) ❑ Frozen Dessert Manufacturer Mobile .17 Food Service -Takeout 13 Residential Kitchen for Retail Sale O Food Service - Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home O Food Delivery O Residential Kitchen for Bed and .Breakfast Establishments 21) Length Of Permit: (check one) RETAIL STORE RESTAURANT Annual 17 Less than 1000sq.ft. $ 70 ❑ Less than 25 seats $140 Seasonal/Dates: ❑ 1000-10,OOOsq.ft. $280 ❑ Residential Kitchens $140 0 More than 10,OOOsq.ft. $420 1325-99 seats $280 ❑ More than 99 seats $420 - ----------------------------------------------$ -100 -------- O Bed & BreakfastlChildcare Services (Nursing Home $ Temporary/Datesffime:- -------------•--•----------------------------------------------------------- ADDITIONAL PERMITS ----------------------------------------------------- O MAKE ICE CREAM, YOGURT/SOFT SERVE $25 0 PASTURIZATION $25 X.ALL NON-PROFIT* $25 *Includin , church kitchens, state funded childcare B private club 23) Food Operations: Definitions: PHF -potentially hazardous rood (time/temperature controls required) Non-PHFs - non -potentially hazardous food (no time/temperature controls required) (check all that apply): RTE- ready -to -eat foods Ex. sandwiches, salads, muffins which need no further processing - Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self -Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan (Including bare hand Service Within 4 hours contact alternative, time as public health control. Customer Self -Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured andPackaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk,Quantities To be completed by the Board of Health Retail Sale of Salvage, Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application 1, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. /7 _ 24) Signature of Applicant: Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 26) Signature of Individual or Corporate Name: A,. x s Commonwealth of Massachusetts: s' —44 City of Salem s "> �+�W Board of Health � � `PGfT1bP�12y DI1SC.011 � � 120 Washington Street; 4t1i Floor.IF flflByOr s SALEM MA 01970 � "yx-`:� •r,...a :� - '�- -e ` s q - rte' =€: `'"i - � v s� S � a 4P !.r bod/Wtail Estahhshtnent Permit DATE PRINTED 112/11/2012 si * :. .a •g x %v 'x y h ESTABLISHMENT NAME: - St Peter's Church File Number BFIF 2003 Q00017 4 $-24 St Peter Street If r� Idol 0I `y N- t Sam MA 01970 '3. 3 a sJF Al LOCATED AT .. w SALEM, MA 01970ai� n" 'psi € ,. � � Perrmt Type: m Permit No - . , Perm[ Issued �Perm�t Expires .; Fee Restrictions- /Notes j :FOOD SERVICE ;BHP 2013 0135 Jan 1, 2013 =Dec 31, 2013 -,-$25 00 '- x a ESTABLISHMENT z Total Dees fro $25 00t S V yk 1 i � ,�,',��, ' a,.r � zr " � ; - `� sem,' ✓ � a ,'� �`,+<, ol > � � � � b-� F � rte= �� - r � i x < 'e � � � �. � ro Y✓ _ i+R Y � = i* � s+` L'i' 3 3gs' $ i9� ir K :. � si. � iP £ S'" _ _ ....4. �i .. `v s✓ w b t� bq '� 6 _ `� t ez �. kYW PERMIT EXPIRES:. December 31 2013 r g� '_ sx s..£ .�'u.W. 'z` ss > .•:. xr"..'s. v`? y a "s `Boards "of Health;, . €� T. �a,}`` This Permit :is not transferable and must'be reissued upon change.of ownership or location The penmt must be posted Y. f s F in a prominent location in the Establishment:. § -In accordance with the State Sanita Code beofre au revonations im rovements or e ui meet chap es are made t ' rY Y P 9 P g all plans for such must W submitted to and appr vo ed by tt Salem"Board of Health " ,� ? e*t _ ``_- �- ss u u 3f, 'i{ - s, ib�' �,.� aY r„v yu ,•� s q � �, � {�'°"� i' a 14 KINIBERLEY DRISCOLL MAYOR. CITY OF SALEM, MASSACHUSETTS BoARu or Hr:At: TI -I 120 WASHINGTON S'111Fx I', 4:171 F1,001i Tri -(978)741-1800 FnR(978)745-0343 Iramdiii@salem.com LARRY RAIvIDIN, RS/RFFIS, CI 10, (T -FS H1 Aun-I A( ?ENI' ° ___.... Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: Q ,t y ,j `SGU Ot I ChJYt4-- 2) Establishment Address: 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: q1$ -I q S' 2 v� 5) Applicant Name & Title: 'Pall(r a y 8f, Q txr Ckuy`c1ti 6) Applicant Address: 7) Applicant Telephone No: 24 Hour Emergency No: g 31 -la mail: ?`.oGGI %i1Vh'q 8) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): 10) Establishment Owned by: An association A comer or_ata - indM ividual%cickCGi A partnership Other legal entityCh Y'C, 11) If a corporation or partnership, give name, title and home address of ..officers or partner. Name Title Home Address 1r War w of S 12 Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor, Manager, etc. Name & Title: Address: Telephone No: Fax: Email: Emergency Telephone No: 13) District or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: Fax: ' Email: Check#: Date: �`' 'Am'ount: C;Z� , Food Establishment Information Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage, Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application I, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. (� 24) Signature of Applicant: A • K �V a. phi I f.yS C , V Gly. Pursuant to MGL Ch. 62C, sec. 49A, 1 certify under the penalties of perjury that I, to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: o (4 — ca — ' -(o (0 26) Signature of Individual or Corporate Name: _s �e� LY I_SLD TZ� CLl U rC%u \ 14) Water Source: 15) Sewage Disposal: , DEP Public Water Supply No: ( if applicable) 16) Days and Hours of Operation: 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) ❑ Retail ( Sq. Ft) ❑ Caterer Permanent 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 Establishments------------------------ 21) Length Of Permit:Breakfast (check one) RETAIL STORE RESTAURANT Annual ❑ Less than 1000sq.ft. $ 70 0 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 G i iure than 99 seats $420 - - ---- -- ------ --- - -------------- --- - -- - - ❑ Bed & Breakfas-VChildcare Seryices /Nursing Home $100 Temporary/DateslTime: ------------------------------------------------ ADDITIONAL PERMITS --------------------------------------------------- - ❑ MAKE ICE CREAM, YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 13 T BACCO VENDOR $135 IOLL NON-PROFIT $25 (Including, church kitchens, state funded childcare & private clubs) 23) Food Operations: Definitions: PHF- potentially hazardous food (timeltemperature controls required) Non-PHFs- non -potentially hazardous food (no timeltemperature controls required) check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self -Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan (including bare hand Service Within 4 hours contact alternative, time as public health control. Customer Self -Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage, Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application I, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. (� 24) Signature of Applicant: A • K �V a. phi I f.yS C , V Gly. Pursuant to MGL Ch. 62C, sec. 49A, 1 certify under the penalties of perjury that I, to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: o (4 — ca — ' -(o (0 26) Signature of Individual or Corporate Name: _s �e� LY I_SLD TZ� CLl U rC%u Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA. 01970 Food/Retail Establishment Permit DATE, PRINTED: 12/28/2011 ESTABLISHMENT NAME: File Number: BHF -20034)00017 St. Peter's Church 24 St. Peter Street Salem MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued , Permlit Expires Fee Restrictions / Notes FOODSERVICE BHP -2012-0181 Jan 1, 2012 Dec31, 2012 $25.00 ESTABLISHMENT - Total Feein i Board of Health $25.00 This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with: the State Sanitary Code, beofre any revocations, improvements,:or equipment changes are made, all plans forsuch must be submitted to and approved by!the Salem Board of Health. Page 1 KINIBERLEY DRISCOLL KWOR LARRYRAW )IN, RS/RIi11S. CI to, C11-1\ Hla.u:11I ACItN'1' CITY OF SALEM, MASSACHUSETTS BOARD OF HF_kL.TH 120 WASHINGTON STREET. 4n' FLOOR TEL. (978) 741-1800 FAx (978) 745-0343 Immdinf@satem.com a %Dec282p97 ,�40 ogAo oFSgcF 2017'APPLICATION FOR PERMIT TO OPERATE A FOOD EST -A fBLISHMENT NAME OF ESTABLISHMENT PQ+CYS E�f.SGnoctl C�IVrG ]EL# Q 1�-:1 LIJ- ZZ 1 ADDRESS OF ESTABLISHMENT ,'�4 5f PCf- K Si" FAX # MAILING ADDRESS (if different) S Q ViKl e EMAIL - Business': St Rkhe V-9 2-P U V WLy\ . vi 0-1 Website: STD_P+P r r S 1 a 04 01%c . OWNER'S NAME SCI VV\ P_ /yS 4 0"..t' TEL# ADDRESS STREET11 CITY STATE ZIP CERTIFIED FOOD MANAGERS NAME(S) S 1� U)nGf Yl iP J ✓ 1 Q CERTIFlCATEtt(S)' (Required in an establishment where Potentially hazes food is preps )T - 'i^ Yom: ,. ". ..: :r• '. - ... € : EMERGENCY RESPONSE PERSON A 0 l HOME TEL # l II 3� LI —�p I TZ DAY,SOFOKRATION T; Sunday HOURS OF OPERATION Pleisewrtemtinedday. (foreumoe Item -tips) RETAIL less than 1000sq.fL =$ 70 1000-10,000sq.R X280 more than 10,000sq.ft =$420 - - -- -- --- - - -- --------------- ------- ------------------ ---.----••--•--`--------_-•-- 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 0M (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES N $25 TOBACCO VENDOR YES '$135 ALL NON-PROFff (such as church kitchens) ES $25 'Please pay total with one check payable to the City of Salem. This Permit Is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominerd location In the Establishment - In accordance with the State Sanitary Code, before any renovations, impirovements, or equipment changes are made, all pians for such must be submltted to and approved by the Salem Board of Health. Pursuam to MGL Chapter 620, Section 49A,1 certify under the pains and penalties of pe4ury that 1. to my best knowledge and belief. have filed all state tax r/�)ms and paid all state taxes required under the law. or Updated 323/11 FOODAP201 I Adm Chem & Date Number