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STEPPING STONE INN-BB - ESTABLISHMENTSS r P/AlG SrtcaE / 9 Wash .Nq 7v -yl V, -11"17;` 6/B 41 ANN aws ra PPIN6 S*wc 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 :PublicHealth( 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 -16-597 Permit Type: Food Establishment 25-99 seats Goods & Services: Food Service: Incidental Name of License Holder: Stepping Stone Inn- Matt Baldassari Name of Food Establishment Stepping Stone Inn Address of Food Establishment 19 Washington Square North Salem MA 01970 Restrictions: Bed & Breakfast 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: 12/15/2016 Larry Ramdin, MPH, REHS, CHO Health Agent CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON SIREET, 4- FLOOR KIMBERLEY DRISCOLL TEL. (978) 741-1800 FAx (978) 745-0343 MAYOR health a salem.com lu rubttexeatth LARRY RAMDIN, RS/REHS, CHO, CP -FS HEALTH AGENT Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: 6Q iin(P'STO , (� G /y� 2) Establishment Address: �- W06f lnrToy) UGC 1Ioi-A'L. ,J(llenirrtIA O�q7VT 3) Establishment Mailing Address (if different): -6 d I� lent): 4) Establishment Telephone No: 9 -4 3 ' qL, I ' q q O V 5) Applicant Name & Title: FO of r ox I S a 6sovit e 'I o O W Vj. e i2 6) Applicant Address: P i h � RCJo h -hn Stvw2e norit, Sti,I.evr,.� �q b►h i5 ��tl� �� IOz-163'6,12% retie«G, 1oA5 7) Applicant Telephone No: 24 Hour Emergency No: mai . h ;1- 8) Owner Name & Title (if different from applicant): `501"U 9) Owner Address (if different from applicant): sown -C 10) Establishment Owned by: An association A c oration Indivi ua A partners Ip Other legal entity 11) If a corporation or partnership, give name, title and home address of officers or partner. Name Title Home Address fl /CA 12 Person Directly Res onsiyb'le)Forr Dail Operations Owner, Person in e, Supervisor, Manager, etc. Name &Title: ,Char y I r a i 01 * 53 Cil. 2 I- ow n e 12 Address: (� 1i Ja. 6:1ern I, Telephone No: 11 �rt� S. le ff �' l�,tJtJ Fax: Emaila-64 of; erved On Coaq Emergency Telephone No: 2.0 L V S' 2-q 13) District or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: Fax: Email: Check #:- Date: -� Amount: �Jdn-S ' `3a Aootstablishment Information 14) Water Source: / n r 15) Sewage Disposal: y� I� I ' DEP Public Water Supply No: (if applicable) �+ AA 2 r ajq-S r) l of 16) Days and Hours of Operatiol -5 17) No. of Food Employees: 18) Name of Person in Charge Certified in Food Protection Management: Toil n' 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 n' 20) Location: 22) Establishment Type (check all that apply) (check one) O Retail ( Sq. Ft) 13 Caterer Permanent Structure 0 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 Cl Food Delivery ❑ Residential Kitchen for Bed and Establishments..................... 21) Length Of Permit:Breakfast (c ck one) RETAIL STORE RESTAURANT Annual ❑ Less than 1000sq.ft. $ 70 ❑ Less than 25 seats $140 Seasonal/Dates: 13 1000-10,OOOsq.ft. $280 O Residential Kitchens $140 ❑ More than 10,OOOsq.ft. $420 O 25-99 seats $280 O More than 99 seats $420 Bed & Breakfast/Childcare Services%Nursing Home $100 Temporary/Dates/Time:--------------------------------------------------------------------- ---------•----------- -----------------------------------------------•---------------------------------.....---------------- ADDITIONAL PERMITS ❑ MAKE ICE CREAM, YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 ❑ ALL NON-PROFT" $25 *Including, church kitchens, state funded childcare 8 private club 23) Food Operations: Definitions: PHF- potentially hazardous food (time/temperature controls required) (check all that apply): Non-PHFs - non -potentially hazardous food (no timeltemperature controls required) RTE - read -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. stomer Self -Service of Ice Manufactured and Packaged for . Offers Raw or Undercooked Food of VIP'Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only /reparation 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 howto obtain copies of 105 CMR 590.000 and the Federal Food Code. 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 N QUESTIONAIRE - GREASE TRAPS 2013 1. NAME OF ESTABLISHMENT:4s+P )/)G S4vne I on 2. ADDRESS OF ESTABLISHMENT: L-1 Wv�'S��n � n oc,.v YIM, 3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP?I 0 4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT HAVE? CAPACITY IN GALLONS 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? >' The Commonwealth of Massachusetts rrAt arm; , Department of Industrial Accidents Office of Investigations Wj I Congress Street, Suite 100 Boston, MA 02114-2017 www mass gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information t ( Please Print Legibly Business/Organization Name: G(J i YL& cG -6 he b {1 V1 Address: City/State/Zip: Are you an employer? Check the appropriate box: L ❑ I am a employer with _ employees (full and/ or part-time). * 2.,)K I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]' 4. ❑ We are a non-profit organization, staffed by volunteers, with no emnlovees. rNo workers' como. insurance rea.] Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 11.❑ Health Care 12'0 Other Z7n r *My applicant that checks box #I most also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #l. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's City/State/Zip: Policy # or Self -ins. Lic. # Expiration Date: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penalties ofperjury that the information provided above is true and correct �Z�Mo Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact www.mass.gov/dia Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Form Revised 7/2010 Kimberley Driscoll Mayor City of Salem, Massachusetts lu Board of Health 120 Washington Street, 4th Floor, Salem, MA 01970 Tel. (978) 741-1800 Fax. (978) 745-0343 PablicHealth Prevent. Promote. Protect. Iramdin@salem,com Larry Ramdin, MPH, RENS, CHO Health Agent FOOD ESTABLISHMENT PERMIT (must be posted on the Premises of the Food Establishment) 2016 Permit Number: FM -16-161 Permit Type: Food Establishment 25-99 seats Goods & Services: Food Service: Incidental Name of License Holder: Stepping Stone Inn- Matt Baldassari Name of Food Establishment Stepping Stone Inn Address of Food Establishment 19 Washington Square North Salem MA 01970 Restrictions: Bed & Breakfast This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on 12/31/2016 unless sooner suspended or revoked. Permit Fee: $100.00 Effective: 1/1/2016 KIMBERLEY DRISCOLL MAYOR CTIY OF SALEM, MASSACHUSETTS BOARD orHi;m. rl-I I'20 WASI LING ION S'IlUu-, r, 4111 Flom Tia.. (978) 741-1800 FAX (978) 745-0343 lramdin@salem.com PubHcl3eattL LARRY RAMDIN, RS/RIiHS, CI 10, CP -FS HuAI: I I AGE'N'T Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: JSfeFf,ino,4dYie I 2) Establishment Address: a6h 1 n A -0n L7 I I 0'A fe o h 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: CI1-- qL4 I- 900 5) Applicant Name & Tltle: m A iI VIII, I 4 . f I - V 00 e" ansa 2 6) Applicant Address: I gW a h s a� f/A/t,P no ff�. I` jf -soh ,"+o 7) Applicant Telephone Nor G1I l b FH I "4 1W4 Hour Emergency No b 3 r ZEmail: RQScrJ�t}IonS�Y6e5 8) Owner Name & Title (if different from applicant): h 9) Owner Address (if different from applicant): h ICA 10) Establishment Owned by: An association ore An individual A partnership Other legal entity i 11) If a corporation or partnership, give name, title and home address of officers or partner. Name Title Home Address 0 12 Person Directly Res onsible-For Daily Operations Owner, Person in Charge, Supervisor, Manager, etc. Name & Title:(� G -SS -A Y& R- I -19-A I Address: ash r 6 S /'P I vl Telephone No: P Fax: mail: �, i '�y �- �b 7f-�� j(,�E rQ5PfJtH 01)5 1hf q,7 Emergency Telephone No: ' N - SGOh 13) District or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: Fax: Email: Check #: Date: � � Amount: ne rn) COn. 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. I - 24) Signature of Applicant: 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 retuins and paid state taxes required under law. 25) Social Security Number or Federal ID: n JJG�%,�-J i`] LI ---C 3l `® ( n 26) Signature of Individual or Corporate Name/ ///� 14) Water Source: DEP Public '� 15) Sewage Disposal: �� Water Supply No: ( if applicable) Pob I I I C 6 (-1 t 1- 16) Days and Hours of Operation: J 17) No. of Food Employees: 18) Name of Person in Charge Certified in Food Protection Management: �Q II�7 RQ I Required as of 101112001 in accordance with 105 CMR 590.003(A) 55a C'�IZ 1 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 13 Food Service - ( Seats) ❑ Frozen Dessert Manufacturer Mobile ❑ Food Service - Takeout D Residential Kitchen for Retail Sale ❑ Food Service - Institution ViResidential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and Breakfast Establishments---------------„ 21) Length Of Permit: (cl eck one) RETAIL STORE RESTAURANT Annual V1 ❑ 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 Temporary/DatesMme: $100 ------------------------------------------------------- ADDITIONAL PERMITS --- ------ --------... ❑ MAKE ICE CREAM, YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 ❑ ALL NON-PROFIT' $25 *Including, church kitchens, state funded childcare 6 private club 23) Food Operations: Definitions: PHF- potentially hazardous food (time/temperature controls required) (check all that apply): Non-PHFs - non -potentially hazardous food (no time/temperature controls required) 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 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,1 certify under the penalties of perjury that I, to my best knowledge and belief, Have filed all state tax retuins and paid state taxes required under law. 25) Social Security Number or Federal ID: n JJG�%,�-J i`] LI ---C 3l `® ( n 26) Signature of Individual or Corporate Name/ ///� June 3, 2015 Stepping Stone Inn 19 Washington Square No Salem, MA 01970 SALEM FIRE DEPARTMENT 48 LAFAYETTE ST SALEM, MA 01970 (978) 744-1235 Congratulations, an inspection of your facility on Jun 3, 2015 revealed no violations. Inspection Note No sprinkler system r 01367 (Lt.) Peter Schaeublin Matthew baldassarri Inspector 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 Iramdin@salem,com Permit Number: FM -15-222 Permit Type: FOOD ESTABLISHMENT PERMIT (must be posted on the Premises of the Food Establishment) 2015 Food Establishment 25-99 seats Goods & Services: Food Service: Incidental 1V PublicHealth Prevent Promote. Protect. Larry Ramdin RS/REHS, CHO, CP -FS Health Agent Name of License Holder: Stepping Stone Inn- Matt Baldassari Name of Food Establishment . Stepping Stone Inn Address of Food Establishment 19 Washington Square North Salem MA 01970 Restrictions: Bed & Breakfast 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: $100.00 Issued: 1/1/2015 KIMBERLEY DRISCOLL MAYOR CITY OF SALEM, MASSACHUSETTS Bb RD or HEALTH 120 WASHINGTON S'ntr:Lrr, 4TH FI.oOic Ti;i- (978) 741-1800 F kx (978) 745-0343 Iramdin t(i salem corn LARRY RAMDIN, RS/REJ IS, CI 10, CP -FS HEAL'n-I AGEN'P - Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: e n 2) Establishment Address:A6VIN'Wguh 3) Establishment Mailing Address (if different): 4) Establishment Telephone NG: — ' `Tq ('� 5) Applicant Name & Title: & � 65a V'I ` V( Ii n t '(L 6) Applicant Address; WIs � 1 n S Va t t f %0 P �l 7) Applicant Telephone No: q Q-�4 � 24 Hour Emergency No. 9 S .NSeI'rA. Oh Email: Sfe Iy4SibrvQ 8) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): 10) Establishment Owned by: An association A individual A pa ners ip Other legal entity 11) If a corporation or partnership, give name, title and home address of officers or partner. Name Title Home Address 12) Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor, Manager, etc. Name &Title: �� _�OC�Qi1 " C1wyler- Address: i l4t Telephone Ni �(-1 l - Fax: Email: 1 �I t e$PfV011 h$ '1neJ-� Emergency Telephone No: 13) District or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: Fax: Email: Check#: I k Date:--�� Amount: / 0 l Food Establishment Information 1'4) Water Source: 15) Sewage Disposal: C) DEP Public Water Supply Not ( if applicable) � 16) Days and Hours of Operation: 2 LA 17) No. of Food Employees: 2- 18) Name of Person in Charge Certified in Food Protection Management: Required as of 101112001 in accordance with 105 CMR 590.003(A) ��j (ZQL 19) Person Trained in Anti -Choking Procedures ( if 25 seats or more): ❑ Yes /Flo 20) Location: 22) Establishment Type (check all that apply) (check one)0 Retail ( Sq. Ft) 0 Caterer Permanent Structure 0 Food Service -( Seats) O Frozen Dessert Manufacturer Mobile 0 food Service -Takeout O Residential Kitchen for Retail Sale 0 Food Service -Institution XResidential Kitchen for Bed and ( Meals/Dey) Breakfast Home 0 Food Delivery O Residential Kitchen for Bed and ........... . Establishments 21) Length Of Permit:,Breakfast (check one) RETAIL STORE RES TAURA NT Annual. 0 Less than 1000sq.ft. $ 70 0 Less than 25 seats $140 Seasonal/Dates: 01000-10,000sq.ft. $280 O Residential Kitchens $140 O More than 10,000sq.ft. $420 O 25-99 seats $280 Ock r„... 0 More than 99 seats $420 . .. ....... ................ .. ... - .... Fd Bed & Breakfast/Childcare Seryices /Nursing . - Home $100 TemporarylDatesmme: -------------------------------- ----- -................................................. ADDITIONAL PERMITS --------------------------- ...--------- 0 MAKE ICE CREAM, YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 0 ALL NON-PROFIT" $25 *Including, church kitchens, state funded childcare 8 private club 23) Food Operations: Definitions: PHF- potentially hazardous food (time/temperature controls required) that Non-PHFs-non-potentially hazardous food (no time/temperature controls required) (check all apply): . RTE - ready -to -eat roods 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 Said Animal Origin Perishable Foods Only /reparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered V 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 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 Pursuant to MGL Ch. 62C, sec. 49A,1 certify under the penalties of perjury that 1, 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 26) Signature of Individual or Corporate Name: 4420 /9F <: KIMBERLEY DRISCOLL MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HEAL111 120 WAST- INGTON STRHET, 4- ftooR TEI.. (978) 741-1800 FAx (978) 745-0343 h�din@salem.com PublicHeatth LARRY RAMDIN, RS/REHS, CHO, CP -FS HEALTH AGENT Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name:—^ n }� 2) Establishment Address: (t I q 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: - /V - &P6 5) Applicant Name & Title: a �4 d 1/ I ssal F f /rJj2 6) Applicant Address: 7) Applicant Telephone No: % - r(/• f$4 Hour Emergency No:a0A BF'(a'S$y Email:M4 j4j7e �+�{� 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 t/ 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 Directly Res onsible For Daily O erationsOwnero,,P,errsson in Charge, Supervisor, Manager, etc. Name & Title: Q t 1' �QQF Qi hlAs ,e Address: 19 Telephone No:q7e - 741 • Mo Fax: Email: ma +LOtma ec4+. Emergency Telephone No: 11 e�15 13) District or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: Fax: Email: , Check #: Date: Food Establishment Information 14) Water Source: PublIG 15) Sewage Disposal: 0, 4 DEP Public Water Supply No: ( if applicable) 16) Days and Hours of Operation: Sen/ain 5 $30- lo3o&vA 17) No. of Food Employees: a 18) Name of Person in Charge Certified in Fo6d Protection Management: V�16- 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 v\ -j r 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 O Residential Kitchen for Bed and ( Meals/Day) Breakfas ome ❑ Food Delivery ErResidential Kitchen for Bed and --------------------- - Breakfast Establishments 21) Length Of Permit: (ch�ckone) 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 I0,000sq.ft. $420 ❑ 25.99 seats $280 ❑ More than 99 seats $420 - - -- - - Bed & Breakfastlt hildcare Services !Nursing -- ----- Home $100 T---- emporary/Dates�me: ------------------------------------------------------------------- --------------------------------------------------------------------- ADDITIONAL PERMITS 0 MAKE ICE CREAM, YOGURT/SOFT SERVE $25 13 PASTURIZATION, $25 ❑ ALL NON-PROFIT" $25 *Including, church, kitchens, state funded childcare & private club 23) Food Operations: Definitions: PHF-potentially hazardous food(timetemperature 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. Siustomer Self -Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of V 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 I, the undersigned, attest to the accw comply with 105 CMR 590.000 and all 590.000 and the Federal Food Code„ 24) Signature of Applicant: 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 of the information provided in this application and I affirm that the food establishment operation will ar applicable Javf. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 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 IC 26) Signature of Individual or Corporate Massachusetts Department of. Public Health Division of Food and Drugs City/Town of 13-n Lz, . . FOOD ESTARLISHMFNT INSPFCTInN RFPnRT Salem Board of Health 120 Washington Street, 0 Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Address: Tnl Name - - )N6NI Date I Type of Operations) 'M Food Service ❑ Retail Type of Inspection ❑ Routine El Re -inspection Address 14 SQ Risk Page ) of Pages Level ❑ Residential Kitchen Previous Inspection TelephoneG� 9 -2 ?-4-7 y )- Vcn6 ❑ Mobile Date: / ❑ Temporary ❑ Caterer ❑ Bed & Breakfast JR Pre-operation ❑ Suspect Illness - ❑ General Complaint Ownerd KILL 6a to Psi MA.1 HACCP YM Person -in -Charge (PIC) So-, n.3 Time In: - - - - ElHACCP - Ins ector P 7 raR-�E a��r�vrti. - Out: Permit No. I ❑. Other Each vioiaaon cneCKea requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. . Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) - - ' - - Anti -Choking 590.009 (E) [I Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009 (F) E] Allergen Awareness .590.009 (G) ❑ corrective action as determined by the Board of Health: FOOD PROTECTI0-N "AGEMENT ❑ 1. PIC Assigned/Knowledgeable/Duties lffiMPLOYEE HEALTH ❑- 2. Reporting of Diseases by Food Employee and PIC - ❑ 3. Personnel with Infections Restricted/Excluded- F.00D'FROM_APPRovED SOURCE �'4. Food and Water from Approved Source ❑ 5. Receiving/Condition _. ❑ 6. Tags/Records/Accuracy. of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans C- PROTECTION FROM CONTAMINATION -- ------ I ❑ 8.Separation/Segregation/Protection E19, 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 -2X590.003) 24. Food and Food Protection (FC -3X590.004) 25. Equipment and Utensils (FC -4X590.005) 26. Water, Plumbing and Waste (FCsX59o.006) 27. Physical Facility - (FC -6X590.007) 28. Poisonous or Toxic Materials (FC -7X590.008) 29. Special Requirements (590.009) 30. Other S d�cdoc 11 s ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities [PROTECTIONF,ROM'CHEMICACS_ [114. Approved Food or Color Additives - - ❑ 15. Toxic Chemicals TIMFITEMPERATURE_.CONTROLS (1?otentlalty Fia¢ardousF.oals) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding - - - ❑ 20. Time as a Public Health Control REQUIREMENTS PO -71 El 21. Food and Food Preparation for HSP CONSUMERADVISORY ❑ 22. Posting of Consumer Advisories - - Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Red Items 1-22)t 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 right 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 Signatur • Print: PICS Signature: Print: �2 i - Page ) of Pages Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A) AssigtmentofResponsibility* 590.003(B) Demonstration of Knowledge" 2-103.11 Person in charge - duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the person in charge to Compliance with Food Law* 3-201.12 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shell Eggs* 590.003(F) Responsibility Of A Fail Employee Or An 3-202.16 ice Made From Potable Drinking Water* Applicant To Report To ThePerson In Drinking Water from an Approved System* 590.006(A) Charge* 590.006(B) 590.003(0) Reporting by Person in Cbaree* 3 590.003(D) Exclusions and Restrictions* 3-201.I5 ji 590.003(E) Removal of Exclusions and'Restr ct gas Lat In In 7 FOOD FROM APPROVED SOURCE * Denotes critical item inrhe federal 1999 Paid Code or 105 CMR 590.0011. 8 PROTECTION FROM CONTAMINATION Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermetically Seated Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 Eggs and %4ilk Products, P, steurzed* 3-202.16 ice Made From Potable Drinking Water* 5-101..11 Drinking Water from an Approved System* 590.006(A) Bottled Drinibng Water' 590.006(B) Water Meets Standards in 31.0 CMR 229* Frequency of Sanitization of Utensils and - Food Contact Surfaces of Equipment* Shoidish and Fish From an Approved Source 3-201.14 Fish and Ren'eahonaliy Caught Molluscan Shell:ish* 3-201.I5 _ Molluscan Shellfish from NSSF lasted Sources* Proper, Adequate Handwashing Game and Wild Mushrooms Approved by Requiatory Authority 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 GameAtdmals'r -. 2-301.14 Re.ceiving(Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.1.5 Package Integrity* 3-1()l.I i F x d Safe and Unadulterated TagstRecmds: Shellstock 3-202.18 - Shellstock Identificatinn 3-203.12 Shellstock Identification Maintained* 12 Tags/Records: Fish Products 3=402.11 Parasite Dcstrucdo0 3-402.12 Records,Creation and Retention* 590.004(.f) Labeling of Ingredients' Handwash Facilities Conformance with Approved Procedures fHACCP Plans 3-502.11. Specialized Processing Methods* 3-502:1.2 Reduced ox gen packaging, criteria* 8-103.12 Conformance with A roved Procedures* * Denotes critical item inrhe federal 1999 Paid Code or 105 CMR 590.0011. 8 PROTECTION FROM CONTAMINATION 9 Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* 4501_ I.11. Contamination from Raw Ingredients 3-302.11(A)(2) Raw Aminal Foals Separated from Each Other* Mechanical Warewashing- Hot Water Sanitization Tem eratures*. Contamination from the Environment 3-302.11(A) Food Protection* 3-302.15 Washing Fruits and Vegetables 3-:304.11 Food Contact with Equipment and Utensils* 4-602.11 Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Frequency of Sanitization of Utensils and - Food Contact Surfaces of Equipment* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4501_ I.11. Manual Warewasbing - Hot Water Sanitization Temperatures# 4-501.112 Mechanical Warewashing- Hot Water Sanitization Tem eratures*. 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. * 4-60 LI I(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils"' 4-702.11. Frequency of Sanitization of Utensils and - Food Contact Surfaces of Equipment* - 4-703.11 Methods of Sanitization - Hot Water and - Chemical* t0 Proper, Adequate Handwashing 2-301.1.1. - Clean Condition - Hands and Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2-401.11 Eating, Drinking or Using Tobacco* 2-401.12 Discharges. From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(F.) Preventing Contamination. from Em plo es* 13 Handwash Facilities _ Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 - Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser, Availability 6-30t.12 Hand Drying Provision CITY OF SALEM BOARD OF HEALTH Establishment Name: S71e-PP1,.-1 Lj STaNt 1r -j W Date: --3-t6 -A Page: of? Item No. Code Reference c-crtneai nem R - Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION PLEASE PRINT CLEARLY Date- Verified "' cS5Ta6�,uSH�6� 1 Llr..a'17�,� `3 tat{a CtS' }=6W1 J piZ�- R (a ►'aLL ffJ'11E+n, � V\Cizra. a�> a � t HD.J` 1 b � Su�J I` Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to P comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of tweet -five dollars; or suspension/revocation of your food permit. T Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance CI Employee Restriction Emersion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo L3Emergency Closure 0 Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness. Interventions and Risk Factors (items 1-22) (Cont.) 15 16 17 or Color Rdditives 3-202.12 Additives* 3-302.14 Protection from (?ua roved Additives* Poisonous or Toxic Substances 7-101,11 identifying Information - Original Containers* 7-102.11. Common Nance - Working Containers'* 7-201.11 Separation - Storae* - 7-202.11 . Restriction - Presence and -Use* 7-202.12 1 Conditions of Use' 7-203.11 Toxic Containers - Prohibitions* 7-204.11. Sanidzers. Criteria - Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria' 7-204.14 Drying Agent& Criteria* 7-205.11 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides,' Criteria* 7-206.12 Rodent Bait Stati--* 7-206.13 Tracking Powders, Pest Control and F�7 Monimrin * Food r 'r - 3-501..15 PRFs 340LIIA(1)(2) Eggs- 155V15 Sec. 3-501.16(B) 590.004(Fl Eggs- Immediate Service 145'Fl5sec* 3401.11(A)(2) - Comminuted Fish. Meats & Game 3 -SOI . i 6(A) Animals -155'F 15 sec. * 340IAI(B)(I)2) Pork and Beef Roast- 130'F 121 min* 3-401.11(A)(2) Ratites, Injected Meats -155°F 15 590.004(H) see. * 3-401.1l(A)(3) Poultry, Wild Game, Stuffed PHFs, Stuffing Containing Fish, Meat, Poultry or Ratites -365°F 15 see. 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks 145°F 3401.12 Raw Animal Foils Cooked in a Microwave 165'F * 3-40LI I(A)(1)(b) All Other PHFs -- 145'F 15 sec. Food r 'r * Dew+tes critical =4111 in the fe&ml 1999 Foal Cede wIV Qmk X90.000. 19 I� 21 3-501.14(C) Proper Cooking Temperatures for . 3-501..15 PRFs 340LIIA(1)(2) Eggs- 155V15 Sec. 3-501.16(B) 590.004(Fl Eggs- Immediate Service 145'Fl5sec* 3401.11(A)(2) - Comminuted Fish. Meats & Game 3 -SOI . i 6(A) Animals -155'F 15 sec. * 340IAI(B)(I)2) Pork and Beef Roast- 130'F 121 min* 3-401.11(A)(2) Ratites, Injected Meats -155°F 15 590.004(H) see. * 3-401.1l(A)(3) Poultry, Wild Game, Stuffed PHFs, Stuffing Containing Fish, Meat, Poultry or Ratites -365°F 15 see. 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks 145°F 3401.12 Raw Animal Foils Cooked in a Microwave 165'F * 3-40LI I(A)(1)(b) All Other PHFs -- 145'F 15 sec. Retreating for Hot Holding 3403AI(A)&(D) PHFs 165"F 15 see. * 3-403.11(6) Microwave -165' P 2 Minute Standing Time* 3403.11(C) Commercially PrccessedRTE Food - 140'F 3-4)3.11(E) - Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140`F to 70oF Within 2 Hours and From 70`F to 4FF145'F Within 4 Hours. * 3-501.14(6) Cooling PHFs Made From Ambient Temperature Ingredients to 41'Ft45'F Within 4 Hours* * Dew+tes critical =4111 in the fe&ml 1999 Foal Cede wIV Qmk X90.000. 19 I� 21 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 41'F1457 Within 4 Houm 3-501..15 Coolin _ Methods for PAPS 3-801.1 I (D) PHF Not and Cold Holding 3-501.16(B) 590.004(Fl Cold PHFs Maintained at or below 41'(45° F* 3-501,16(A) Hot PHFs Maintained at or above 140'F. 3 -SOI . i 6(A) Roasts Field at or above 130'F. Time as a Public Health Control 3-501:19 - Time as a Public Health Cnntrvi' 590.004(H) Variance Requirement r a` 3-801.11(A) Unpasteuti7ed Pre-packaged Juices and Beverages with Warning lAbels*� 3-801.11(6 Use of Pasteurized Ergs* 3-801.1 I (D) Raw or Partially Cooked Animal Foci and Raw Seed Sprouts Not Served * 3-801.11 C Unopened Food Package Not Re -served. 22 3-603.11 Consumer Adviscra Pasted fur Consumption of Animal Foods That are Raw-. Undercooked or 1 Not Othercvise.Processed to Eliminate Pathogens 3302.13 1 Pasteurized Eggs Substitute for Raw Shell E Violations of Section 590.009(A) -(D) in catering, mobile fore=, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to goal retail practices should be debited under #29 - Special Requirements. (Items 23-34) Critical and non-critical violations, which do not relate to the foodborne illness haerventitms and risk,factors listed above, can -be found in thefollowing sectionsofthe Food Code and 105 CMR snn nnn 659�f �mc2�tc r'y Commonwealth of Massachusetts City of Salem Board of Health ` Kimbedey DtiScoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/13/2011 ESTABLISHMENT NAME: Stepping Stone Inn File Number: BHF -2004-000326 19 Washington Square North Salem LOCATED AT: 0019 WASHINGTON SQUARE.NO SALEM, MA 01970 Permit Type Permit No. ` - Permit Issued Permit Expires ' Fee Restrictions / Notes FOOD SERVICE BHP2o1z OOt2 Jan 1, 2012 Dec 31, 2012 $100:00 ESTABLISHMENT Total Fees: $100.00 PERMIT EXPIRES IDecember 31, 2012 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.promment 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 • r'7sp KINIBEXLEY DRISCOLL MAYOR LAItItY RANWIN, Its/RI{I IS, 0 I0, CP-FS- I-IFAl iii A(;FN,r CITY OF SALEM, MASSACHUSETTS BOARD OF HEArri-I 120 WASH]NGTON STREET, 4'°' Fwolz TL''— (978) 741-1800 FAX (978) 745-0343 - IsamdinQr salem com 201 APPLICA I N FOR PERMIT TO OPERATE�A FRPD ESTA LISHMENT NAME -OF ESTABLI.SHMEMT_ alz?_ TEL # ADDRESS OF ESTABLISHMENT (A /rA -,4e FAX # MAILING ADDRESS (if different) EMAIL, Business': OWNER'S NAME ADDRESS Website: CITY TEL# %%y 7Ai( $ 1Ql40 STATE CERTIFIED FOOD MANAGER'S NAME(S) I CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL # ZIP ,,DAYS OF -OPERATION -! `Monda <Tuesd s,Wediesd �xThursda w Fdd-='Saturda Sund HOURS OF OPERATION Please write in time of day j For example Ilam -11 pm) _TYPE OF ESTABLISHMENT FEE (checkonlvl RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000SI ft. =$280 more than 10,000sq.ft. =$420 --------------------------------------------- ---------------------- -------- ------`---- RESTAURANT" YES NO (Outdoor Stationary Food Cart $210) NO less than 25 seats =$140 25-99 seats =$280 more than 99 seats =$420 ADDITIONAL PERMITS ----------- MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT (such as church kitchens) YES NO $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 prominent location 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 certify under the pains and penalties of perjury that I, to mybest knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Date {1)A,, i n Updated 5234YFOODAP201 Ladm Check# & or 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: 01/03/2011 ESTABLISHMENT NAME: File Number: BtiF-2004-000326 Stepping Stone Inn 19 Washington Square North Salem MA 01970 LOCATED AT: 0019 WASHINGTON SQUARE NO SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2011-0114 Jan 1, 2011 Dec 31, 2011 $100.00 ESTABLISHMENT PERMIT EXPIRES Total Fees: $100.00 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 KIMBERLEY DRISCOLL MAYOR DANTID GREENB SUM, RS ACTING HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HE.NLTH 120 WASHINGTON STREET, 4` FLOOR TEL. (978) 741-1800 FAX (978) 745-0343 DGRF,ENBAU,b1@SALEM. CONI 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT TEL # 7 �I CY Jl/� ef6'0 ADDRESS OF ESTABLISHMENT_1, FAX#___,_, MAILING ADDRESS (if different) `�(/ — A n EMAIL -Business': CJeC .111 &77/ Website: OWNER'S NAME 06M-e� uy &Zth ADDRESS ,6,A Aa " -4; /, CERTIFIED FOOD MANAGER'S NAME(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE TEL STATE CERTIFICATE#(S) TEL # D'AYS'OF`OPERATIQN ,F. ;,, '>,'Manday ' 'n R Tuesday;?. ; .Wednesday ..�.., Thu sit Fnday' 'Saturdays HOURS OF OPERATION Please write in time of day. - (For examoe 11 am -11 pm) TYPE OF ESTABLISHMENT FEE (checkonly) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 1 0,000sq.ft. =$420 -----------------------------------------------------------------------------------------------------------------------------------a'is" RESTAURANT YES NO .--------------------- less than 25 seats' =$140 (Outdoor Stationary Food Cart $210) 25-99 seats =$280 more than 99 seats =$420 - ------------------- ---- ----- ---------------------------..- -------------------------------------------------------------- BED/BREAKFAST/ S NO $100 CHILDCARE SERVICES/NURSING------_E--_--------_ ------------------------------------------------------------------------------------------ ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT (such as church kitchens) YES NO $25 `Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid -all state taxes required under the law. - Signature ZDy1 — Date 6 Social Security or Federal Identification Number -------- —"� ----_----�-- ------------,-�I,J—�—` ---------------- Revised lo/7 1 FOODAP2011.adm Check# &Date -� -$.v Commonwealth of Massachusetts i 6 City of Salem Board of Health Kimberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/05/2010 ESTABLISHMENT NAME: File Number: BHF -2004-000326 Stepping Stone Inn 19 Washington Square North Salem MA 01970 LOCATED AT: 0019 WASHINGTON SQUARE NO SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2010-0130 Jan 4,2010' Dec 31, 2010 $100.00 ESTABLISHMENT PERMIT EXPIRES Total Fees: $100.00 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 I understand that by enrolling my account for Easy Pay, all future invoices sent to me by Terminix for services performed pursuant to my contract will automatically be paid by a deduction from my checking, savings or credit card account as indicated. If Easy Pay is selected — a copy of agreement must be sent to Corporate at 860 Ridge Lake Boulevard, Memphis, TN 38120 Mailstop C2-4092 THE TERMS AND CONDITIONS SET FORTH BELOW. INCLUDING THE MANDATORY AGREEMENT AND ANY ADDITIONAL PROVISIONS ATTACHED HERETO, AND IF APPLICABLE TO SERVICE, THE INSPECTION GRAPH, ARE PART OF THIS AGREEMENT. Customer Acceptance Date Terminix Authorization Prepared By Ron Sheppard Date 1. EFFECTIVE DATElTERMITERMINATION. The Effective Date of this Agreement is defined as the date of execution by both parties. The parties agree thatthe initial Term of this agreement is one (1) year commencing on the Effective Date and that the Agreement will continue in successive year to year Terms thereafter unless one of the parties provides written notice to the other at least thirty (30) days prior to the end of the then -current Term. 2. MATERIALS. - A. The materials used in Terminix's pest control service will comply with federal, state, and local laws, and shall be reasonably acceptable to Purchaser. B. All pest control service shall be performed in accordance with pest control procedures recognized in the pest control industry and scientific community as effective against target pests. C. Should Terminix perform treatment on this property, Terminix will make available, upon request to the Purchaser, a copy of the manufacturer's specimen label and other state required documents for the pesticide(s)Itermiticide(s) which will be used to treat the above-named property. 3. PURCHASER'S COOPERATION. A. The Purchaser's cooperation is important to ensure the most effective results from Terminix service. Whenever conditions conducive to the breeding and harborage of pests covered by this contract are reported in writing by Terminix to the Purchaser, and are not corrected by Purchaser, Terminix cannot ensure satisfactory service. B. If the conditions noted by Terminix are not corrected by Purchaser as required, all guarantees in this agreement shall automatically terminate and be cancelled. Further, additional treatments in areas of such conditions that are not corrected as required shall be paid for by Purchaser as an extra charge. 4. INSURANCE. Terminix will furnish a Certificate of Insurance upon request. 5. TERMS OF AGREEMENT. If Terminix fails to comply with the terms of this Agreement, Terminix shall be given thirty (30) days after receipt of written notice from Purchaser to correct the problem. If, at the expiration of such thirty (30) days, the unsatisfactory conditions have not been corrected, Purchaser reserves the right to cancel this Agreement. Terminix is not responsible for insect or rodent damage to products or other contents at the premises. This agreement does not provide for control of termites, other wood destroying organisms, or any other pests not specified herein. 6. NOTICE OF CLAIMS, ACCESS TO PROPERTY. Any claim under the terms of this agreement must be made immediately in writing to any Terminix Service Center. Purchaser must allow Terminix access to the structures for any purpose contemplated by this Agreement, including but not limited to reinspections, whether the inspections were requested by the Purchaser or considered necessary by Terminix. The failure to allow Terminix such access, including to the interior of Structures, will terminate Terminix s obligations under this Agreement without further notice. 7: LIMITATION OF LIABILITY, LIMITED WARRANTY. EXCEPT AS PROHIBITED BY LAW, TERMINIX DISCLAIMS AND IS NOT LIABLE TO PURCHASER FOR ANY SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, EXEMPLARY, OR PUNITIVE DAMAGE, REGARDLESS OF THE BASIS FOR THE CLAIM. THE WARRANTIES OF TERMINIX SPECIFICALLY STATED IN THIS AGREEMENT ARE TERMINIX'S EXCLUSIVE WARRANTIES. TERMINIX MAKES NO WARRANTIES NOT EXPLICITLY STATED HEREIN, AND TO THE GREATEST EXTENT PERMITTED BY LAW SPECIFICALLY DISCLAIMS ANY AND ALL OTHER WARRANTIES, INCLUDING, BUT NOT LIMITED TO, IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE. 8. WATER LEAKAGE. Purchaser is responsible for making timely repairs as necessary to stop water leakage in interior areas or through the roof or exterior walls of the Structure as it occurs. Purchaser understands that such leakage may destroy the effectiveness of treatment rendered by Terminix and is conducive to new infestation. Purchaser's failure to make timely repairs will terminate this Agreement automatically without further notice. Terminix shall have no responsibility for infestation or damage in any way associated with water leakage. 9. ADDITIONS, ALTERATIONS. This Agreement covers the Structures described on the Inspection Graph as of the date of initial inspection. In the event the premises are structurally modified, altered, or otherwise changed, or if soil is removed or added around the foundation, Purchaser will notify Terminix prior to such event and will arrange for an additional inspection. Failure to do so will terminate the Agreement automatically without further notice. In the event of any such change. Terminix reserves the right to adjust the annual renewal charge. The failure of Terminix to notice any such changes does not relieve Purchaser of the obligations set forth in this paragraph. 10. EXISTING DAMAGE. - Terminix is not responsible for the repair of either visible damage or hidden damage existing as of the date of this Agreement or occurring prior to the Effective Date of this Agreement. Damage discovered after the Effective Date of this Agreement with no verified live and active infestation present shall be deemed to have been caused before the date. Because damage may be present in areas which are inaccessible to visual inspection, Terminix does not guarantee that the damage disclosed on the Inspection Graph represents all of the existing damage as of the date of this Agreement. 11. DISCLAIMER. This Agreement does not cover and Terminix will not be responsible for damage resulting from, or services required, for: (1) any and all damage resulting from termites and/or any other wood destroying organisms except as specifically provided herein. (2) moisture conditions, including but not limited to fungus and/or water leakage caused by faulty plumbing, roofs, gutters, downspouts and/or poor drainage. (3) masonry failure or grade alterations. (4) inherent structural problems, including but not limited to, wood to ground contacts. (5) termites entering any rigid foam, wooden or cellulose containing component in contact with the earth and the Structures regardless of whether the component is part of the Structures. (6) the failure of Purchaser upon notice from Terminix to properly cure at Purchaser's expense any condition which prevents proper treatment or inspection or is conducive to termite infestation. (7) any other damage cause not specifically covered herein. This plan does not guarantee, and Terminix does not represent, that pests will not return. 12. LIMITED ASSIGNABILITY. This Agreement is assignable by Purchaser to a new owner of the property for a period of one year after the Effective Date of this Agreement. Thereafter, Purchaser may only assign this Agreement upon written permission from Terminix after its inspection of the property. 13. FORCE MAJEURE. , Terminix's obligations under this agreement will be terminated if Terminix is prevented from fulfilling its responsibilities under the terms of this agreement by reason of delays in transportation, shortages of fuel and/or materials, strikes, embargoes, fire, Floods, quarantine restrictions, earthquakes, hurricanes, or any other act of God or circumstances or other cause beyond the control of Terminix. 14. CHANGE IN LAW. Terminix performs its services in accordance with the requirements of law. In the event of a change in existing law as it pertains to the services herein, Terminix reserves the right to revise the monthly service charge or terminate this agreement, at Purchaser's option. If Terminix is unable to comply with a change in law, Terminix reserves the right to terminate this Agreement upon notice to Purchaser. 15. CHANGE IN TERMS. At the time of any renewal of this agreement, Terminix may change this agreement by adding, deleting or modifying any provisions, including the annual renewal charge. Terminix will notify the Purchaser in advance of any such change, and Purchaser may decline to accept such a change by declining to renew this agreement. Renewal of this agreement will constitute acceptance of any Terminix -proposed changes. 16. NON-PAYMENT, DEFAULT. In case of non-payment or default by the Purchaser, Terminix has the right to terminate this agreement and reasonable attorney fees and costs of collection shall be paid by the Purchaser, if Purchaser fails to correct the problem within ten (10) days after Terminix's notice of same. 17. ENTIRE AGREEMENT/SEVERABILITY/CHOICE OF LAW. This agreement constitutes the entire agreement between the parties and no other representations or statements, oral or written, will be binding upon the parties. If any part of this agreement is held to be invalid or unenforceable for any reason, the remaining terms and conditions of this agreement shall remain in full force and effect. This agreement shall be governed by and construed in accordance with the laws of the State of Tennessee without regard to its conflict of laws rules. Venue for arbitration hereunder shall lie in Memphis, TN. 18. MANDATORY ARBITRATION. Any claim, dispute or controversy, regarding any contract, tort, statute, or otherwise ("Claim"), arising out of or relating to this agreement or the relationships among the parties hereto shall be resolved by one arbitrator through binding arbitration administered by the American Arbitration Association ("AAA"), under the AAA Commercial or Consumer, as applicable, Rules in effect at the time the Claim is filed ('AAA Rules'). Copies of the AAA Rules and forms can be located at www.adr.org, or by calling 1-800-778-7879. The arbitrators decision shall be final, binding, and non -appealable. Judgment upon the award may be entered and enforced in any court having jurisdiction. This clause is made pursuant to a transaction involving interstate commerce and shall be governed by the Federal Arbitration Act. Neither party shall sue the other party other than as. provided herein or for enforcement of this clause or of the arbitrator's award;. any such suit may be brought only in Federal District Court for the District or, if any such court lacks jurisdiction, in any state court that has jurisdiction. The arbitrator, and not any federal, state, or local court, shall have exclusive authority to resolve any dispute relating to the interpretation, applicability, unconscionability, arbitrability, enforceability or formation of this Agreement including any claim that all or any part of the Agreement is void or voidable. However, the preceding sentence shall not apply to the clause entitled "Class Action Waiver." 19. CLASS ACTION WAIVER. ' Any Claim must be brought in the parties' individual capacity, and not as a plaintiff or class member in any purported class, collective, representative, multiple plaintiff, or similar proceeding ("Class Action"). The parties expressly waive any ability to maintain any Class Action in any forum. The arbitrator shall not have authority to combine or aggregate similar claims or conduct any Class Action nor make an award to any person or entity not a party to the arbitration. Any claim that all or part of this Class Action Waiver is unenforceable, unconscionable, void, or voidable may be determined only by a court of competent jurisdiction and not by an arbitrator. THE PARTIES UNDERSTAND THAT THEY WOULD HAVE HAD A RIGHT TO LITIGATE THROUGH A COURT, TO HAVE A JUDGE OR JURY DECIDE THEIR CASE AND TO BE PARTY TO A CLASS OR REPRESENTATIVE ACTION, HOWEVER, THEY UNDERSTAND AND CHOOSE TO HAVE ANY CLAIMS DECIDED INDIVIDUALLY, THROUGH ARBITRATION. - 20. EASY PAY AGREEMENT. In payment for services performed by Terminix I (we) hereby authorize you to initiate debit entries to my specified account, within five (5) business days after my (our) account has been charged, as indicated in the Sales Agreement, at the depository financial institution named herein and to debit the same to such account. I (we) acknowledge that the amount may increase subsequent to the Sales Agreement's second anniversary date. This authorization will remain in effect until I (we) notify you in writing to cancel it in such time as to afford the financial institution a reasonable opportunity to act upon that notification. I (we) understand that cancellation of this authorization does not cancel my (our)service agreement or my responsibilities there under. 21. TERMINIX MANAGEMENT APPROVAL. Contracts are subject to approval by Terminix management at the branch that will perform the service. 22. STATE SPECIFIC CONDITIONS. CA: Notice to OwnedTenant (long form) GA: The Georgia Structural Pest Control Act requires all pest control companies to maintain insurance coverage. Information about this coverage is available from this pest control company. TX: Licensed and regulated by: Texas Department of Agriculture, Structural Pest Control Service, PO Box 12847, Austin, TX 78711-2847 Phone 866-918-4481 Fax 888-232-2567. Signature: r'� Bat�rassa eA, Kelry a Oes (Mar 9, 2011) Email: mattthecat@mattthecat.com CITY OF SALEM, MASSACHUSETTS ` BOARD OF HEALTH 120 WASHINGTON STREET, 4: ' FLOOR TEL: (978) 741-1800 KRNMERLEY DRISCOLL FAX (978) 745-0343 MAYOR DGREENBAUM(iOe SALEM. COM DAVID GREENBAum, ACTING HEALTH AGENT 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT TEL # 9 7 rk PY 1 9, 9490 ADDRESS OF ESTABLISHMENT FAX # . MAILING ADDRESS (if different) EMAIL - Business': /9,1 C Website: P L OWNER'S NAME 4061) Illi ' /Q _TErq ADDRESS % R "491974 STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL # �®AYSR�F +PEitA710N -Mpn'day" *,' iluesd°';��Wednesday',.. ,� Thursday Friday HOURS OF OPERATION less than 1000sq.ft. =$ 70 Please write in time 1000-10,000sq.ft. =$280 For example 11 ai - , TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES - NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 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 MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE TOBACCO VENDOR ALL NON-PROFIT (such as church kitchens) YES NO $25 YES NO $135 YES NO $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 prominent location 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 certify under the pains and penalties of perjury that 1, to my best knowledge and belief, have filed all state tax return nd p3id all state taxes required y�der the law. ,.U__ f�. ,. L/ Yl.e a_ Q -aro\ �iic Date Revised 424/07 FOODAP2008.adm Check# & Date Social Security or Federal Identification Number. CITY OF SALEM, FiECEIVED MASSACHUSETTS q BOARD or HEA1:I7-i INGTON KIMBERLEY DRISCOLL NOV 2 4 2013 .'Ii3t0..978)t741-1800 FAX (978) 745-0343 MAYOR GIlY OF SALEM 1mmdin@sa1em.com BOARD OF HEALTH 0 1?ublicHeattlt LARRY RAMDIN, RS/REHS, CHO, CP -FS 14mi,'H A(,E.N'I' Food Establishment Permit Application (Application.must be submitted at least 30 days before the planned opening date) 1) Establishment Name: uU 67 2) Establishment Address: / (,{' 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: _Lf '7� -7,41 g g Q® 5) Applicant Name & Title: 6) Applicant Address: 7) Applicant Telephone No: 24 Hour Emergency No: Email: T ip G 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 11) If a corporation or partnership, give name, title and home address of officers or partner. Name Title Home Address 12 Person Directl .Res onsible For Daily Operations Owner, Person in Char e, Su ervisor, 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: �m Check #: Date: I ( 13 Amount: / r J CERTIFICATE OF ALLERGEN AWARENESS TRAINING A Name RlciN,cnt-Matthew`Bal&ssarri Certificate bert1335127 -Num_ E Date of Cohn}Action 3L5/3014 Date of xpiration. 3/5/2019 ., _ - Issued 13r: /be rpbry nnna Arertou is be, l v issued lbis t rr,/'urre p1.�=--=—1,—j NATIONAL' far,;nnrphrrn unnl(rpa:,rn •mvamstnanrineP,asirnn ��R . � RESTAURANT " _ ,;.crfrlrrd1,ydJr YIN:�srnhns�arsP.pmtmenrr/'PnLLrHealr, ASSO&_noN 1 .•"�'�°' _ - in arnrpdanei. with J05 CAIM 5,90 00J(FIJ(J)(it). )La .aduu�rt, R<stawam \sgo iatiun h00 ^[,>:_2122 ,. 333Tumpike ap:id,$nitc 102 wwwrestauraai.on, %hit teYt1 ,ate gill Jl L'ffiill rl ,Ve 5 Vears Yovi dare q romp lellon. 1� J J (l. l l. P Saiu'd rnugh..b1A 01772 509-305-9905 XM . w„�c.mxrrsrur, ,m:tssrx.or� TERN11(11IX® PEST CQNTRQL: �S,ERyVI «�E, F?�ROP:QSsA�L; Proposal developed for Stepping Stone Inn MW /NK /CQMMERC1AL Ron Sheppard rsheppard2@tenninix.com 781-760-0516 THANK YOU FOR LOOKING TO TERMINIX. YOU'RE IN GOOD COMPANY. - "- Terminix has been in business for more than 85 years. Over that time, we have gained -- a depth of experience to offer specialized =,I services to a range of business types and be a Proactive partner for businesses of all I'} Kinds. We eliminate problems with pests and with your pest control process. With our guaranteed results and customer -focused approach, Terminix has become the #1 PEST _ CONTROL COMPANY IN THE WORLD. What We Heard Owners of inn need general pest service What We Saw Inspected What We Recommend General pest control. monthly service interior and exterior to control all invading pest. WE KNOW HOW TO HELP YOUR BUSINESS. When It comes to pest control, every business faces Its own Issues. For some, the stakes are particularly high. Some are strictly �i regulated or have especially sensitive environments. Terminix. Commercial works closely with your business to create a customized program that fits your needs and facilities. WHAT IT MEANS FOR YOUR BUSINESS • We guarantee a fast response to any pest report to keep your property pest free • We'll work with you to maintain compliance with any regulatory guidelines that apply to your business • If your business Is assessed a fine by a regulatory agency because of a covered pest Infestation, Terminix will reimburse you for the amount of the fine, plus an additional 10% ULTIMATE PROTECTION® The Terminix Commercial FastTrack 2 -Hour Solution guarantees that we will provide a solution to your pest problem within two hours of your call, 24 hours a day, seven days a week. NO WAIT: See a pest and get a solution right away NO DOUBT: Total satisfaction or your money back NO LIMIT' Yourbusiness Is covered at any cosi NOT JUST APPLYING PEST CONTROL. ADVANCING IT. Terminix does more than lust spray for pests. We continually raise the bar for pest control both In effectiveness and In convenience for our customers. Below are lust a few examples. INTEGRATED PEST MANAGEMENT (IPM) We partner with your business to eliminate conducive conditions for pests In the first place Instead of lust piling on more and more treatments. ONLINE ACCOUNT MANAGEMENT Your personalized account center is available around the clock at Te rminixCom me rclal.com SCANMASTER® TRACKING This exclusive computerized system automatically tracks and posts real-time data from your treatments to a database you can access anytime via your online account. - NATIONAL ACCOUNTS Whether you have single storefront location or operations all across the country. Terminix Commercial has the resources to provide the same high standard of expertise and service at every location. Your problem will be solved by a trained professional, backed by the resources of the most respected technical team in the industry. We proudly protect more businesses than any other pest management provider, and we've done so since 1927. We would love to protect you, too. Our business is protecting yours. Call us 2417 at 1-866.319.5967. Service Location Bill To 19 Washington Sq 19 Washington Sq Salem. Me 01970 Salem, Me 01970 USA USA Target Pest(s) General Pest Standard Covered Ants,. Mice, Rats, Roaches, Non -Dangerous Spiders, Social Wasps (only nests within 8' from the ground), Common Pests` Occasional Invaders (earwigs, millipedes, centipedes, sowbugs, pillbugs, crickets, ground beetles, springtails) Call Backs Call backs for covered pests between regularly scheduled service visits are included at no extra charge. `Carpenter. Fire, Crary and Pharaoh Ants, Bed Bugs, Brown Recluse or Black Widow Spiders, Flies, Honey Bees, Stored Product Pests, Termites -and other wood -destroying organisms are not covered unless specifically identified as the Target Pest. Terminix will provide a proposal for additional services to treat non -covered pests upon their identification by our Service Professional. DetaiP (7ctlges 4 " Stepping Stone Inn 19 Washington Sq Initial Charge 1.00 j $180.00 $180.00 cr,..,° i.,., `" ° ' 10 lNasninnfnn"Sn. Service. Phce..60.00.0 11. services � {:....�„ 1.00 `'- .,,,; $660.00 ... $660,06 First year total service amount includes the price of the initial service, equipment and one year of service. 3% discount when annual investment is paid in advance. 1st Year Total $840.00 Service Amount Tax $0.00 1 st Year Total $840.00 2nd Year Total $720.00 Service Amount N11 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Are you an employer? Check the aPer 1. I.am a employer with 2.X employees (full and/or part-time)." I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. Q 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t CJ 6 riste box: 4. [] I am a general contractor and I have hired the sub -contractors listed on the attached sbeeL These subcontractors have employees and have workers'- , comp... insurance.; 5. [] We are a cbrporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), andwehave no employees. [No workers' tomo. insurance required.) 0b Type of project (required): 6. F New construction 7. ❑ Remodeling. 8. [J Demolition - 9. ❑ Building. addition 10.❑ Electrical repairs or additions 1 LQ Plumbing repairs or additions 12.[J Roof repaus 7 13.�JOtherOf `t• GMu el -Any applicant that cbecks box BI must also till out the section below slowing their wvikers' compensation policy infonnatiaa I llomww who submit this atndevrt indicating they am doing an work and Wen hue outaide coam; must submit a am affidavit indicating such. 10ormactors Witt check this box must attached an additional shad slowing the name of the sub•ccnbactms and state whethu or act those entities have employees. If the subconhacmrs have employcw, they rmet provide Weir wo&=' comp. pohcy numbm. I am an employer that is providing workers' compensation insurance foamy employees Below is the policy and job site informahom Insurance Company Name: _ Policy # or Self -ins. Lic: #:.. Expiration Date Job Site Address: City/NtawLip: Attach a copy of the workers' compensation Polley declaration page (showing the polity number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofpedwy that the informadonnprovided above is true and correct Official use only. Do not write in this area,, to be completed by city or town ofrcial. City or Town: Permit/License Issuing Authority (circle one): II 1. Board of Health' 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.6they Contact Person: - Phone The Commonwealth of Massachusetts '{ Deportment of IndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 ww6mass-govIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Are you an employer? Check the aPer 1. I.am a employer with 2.X employees (full and/or part-time)." I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. Q 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t CJ 6 riste box: 4. [] I am a general contractor and I have hired the sub -contractors listed on the attached sbeeL These subcontractors have employees and have workers'- , comp... insurance.; 5. [] We are a cbrporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), andwehave no employees. [No workers' tomo. insurance required.) 0b Type of project (required): 6. F New construction 7. ❑ Remodeling. 8. [J Demolition - 9. ❑ Building. addition 10.❑ Electrical repairs or additions 1 LQ Plumbing repairs or additions 12.[J Roof repaus 7 13.�JOtherOf `t• GMu el -Any applicant that cbecks box BI must also till out the section below slowing their wvikers' compensation policy infonnatiaa I llomww who submit this atndevrt indicating they am doing an work and Wen hue outaide coam; must submit a am affidavit indicating such. 10ormactors Witt check this box must attached an additional shad slowing the name of the sub•ccnbactms and state whethu or act those entities have employees. If the subconhacmrs have employcw, they rmet provide Weir wo&=' comp. pohcy numbm. I am an employer that is providing workers' compensation insurance foamy employees Below is the policy and job site informahom Insurance Company Name: _ Policy # or Self -ins. Lic: #:.. Expiration Date Job Site Address: City/NtawLip: Attach a copy of the workers' compensation Polley declaration page (showing the polity number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofpedwy that the informadonnprovided above is true and correct Official use only. Do not write in this area,, to be completed by city or town ofrcial. City or Town: Permit/License Issuing Authority (circle one): II 1. Board of Health' 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.6they Contact Person: - Phone Larry Ramdin From: Matt The Cat <mattthecat@mattthecat.com> Sent: Monday, March 03, 2014 1:09 AM To: Larry Ramdin Subject: Stepping Stone Inn Menu, Workman's Comp Waiver, etc Attachments: Stepping Stone Inn Workers Comp Waiver Form.pdf Hi Mr. Ramdin, Thanks once again for your help with obtaining a health permit. Attached, please find the Mass Workman's Comp Waiver Form. Below is the menu you requested for our bed and breakfast. Sfelipini' Stonelnn Bed & Breakfast Menu: Whole fruit (apples, pears, bananas, oranges) Individual yogurt cups Individual cereals and milks Individually and professionally -wrapped meats and cheeses Bakery -bought muffins, Danishes, breads Individually packaged butter, jams and jellies Individual coffee, tea, hot chocolate via Keurig single cup brewer Shelf stable creamers and packets of sugar/Equal/Sweet n' Low, etc. Individual juice cups (orange, apple, cranberry) Individual bottled waters We have been in touch with and will obtain a pest control contract with: Terminex of Woburn 84 Cummings Park Woburn, MA 01801 617-969-0038 We are going to watch the video and obtain a Mass Allergen Certificate today. I will send that along as soon as I have it. Can you think of anything else that we are missing, before having a health inspector out to the inn for the evaluation? We are hoping to close on March 11`". Do you think there is any way we can have a health inspector out before that date? Will the health inspector expect to see all the foods we will be serving or will he/she be evaluating our kitchen/dining room and space? Thanks again, Mr. Ramdin. Sincerely, Matt & Kelly Baldassarri Stepping Stone Inn 19 Washington Square North Salem, MA 01970 A, Z Al 1 IM Aw iFl lk cofilmonwi kikof Massaehusett c S4 Ly V1 SRIUi1a III- wpl R lUVW1, 0,,',,-F6od/,Retqff EoibHshi'efit WrmIt.l. ATF PRINTED - 0 13- k �W W, X -�A c - ij ? Ni T' :�Wpping Stone Inn.' 44ESTABIL1911 PoleNumber-19-Washington Square North U. n M_ v, , _15 :SiIla'V'€c A -1- -1 Ok V LOC)WASHINGTON SQUARE NO W 10W i', A 70 W EMWA".--#7610 gl , � � - i�, % X A_ AV, W _ �74 + W % TermitIs - Fie Restrictions /Aotes��. ikn,,f�rnut Type, 1UNw,, -B� ermit-Expire 9 �;i D.6c,3 1 2013 A,Jan L 2013 - 100 -so6- p�p, $ -4;4FOOD SERVICE ,�"-#OHR-2013-b328'!��t-, V ABLISID413 EST 4 W, ell IW I 61, % 'pqjV, Total Fees-.'- $1 _4 x KA M� IS, k -7-4 Q qRs" p -Z n, A _i A V, W A -W ;q M, P f Mr, -ZO 4 M A AV A % Wi 4; Wj, t PERMITsEXPIRES 1,01 �v Oitrd 6 HMO P w "!W A tv 0.00 N11 g-, X Owiell W� 'R v, - -, R1W. 1VIX 'N"i Nw �7E: 4.'nA2 WYR� l. - Awe issued upon,change-6foWneishil). -01 posted- �417 This 'Permit is n transferable � location permit must ea -prominent icie;iion iii_tv�`Nfibl in a I accor a -SA d improvements, or equipmentehanges ire ffiiade; net with -the State, nitary Code; b9offe any.revonationi, d to and animi6ved b, _d -of Health :4 I lans- rs such must be submitted Boa id Al� 0g, ^k,7 7p X& K a 0 U A- g� M M, KIDIBERLEY DRISCOLL MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HBA111 f 120 WASE[1NG1'0N Sa u-u:.r, 411' FLOOR Tea.. (978) 741-1800 FAx (978) 745-0343 Iramdiu(a�.salcm.com �,mtcxeatta LARRY RAMDIN, RS/RFI-LS, CIIO, CP -FS H IIdALri-f AF EN'F Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: 2) Establishment Address: "n 3) Establishment Mailing Address (if different): ) �' 4) Establishment Telephone No: 4 7v —7 L 5) Applicant Name & Title: ') I /r 6) Applicant Address: V 7) Applicant Telephone No: 24 Hour Emergency No: Email: /3/t 1 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 act 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 Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor, Manager, etc. Name & Title: Address: V C Telephone No: 6Z Lj Fax: &)V Email: Emergency Telephone No: 7 -7q( c ) 13) District or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: Fax: Email: Check Date: /,;L / Amount: V4/C>? 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) 0 Retail ( Sq. Ft) 0 Caterer Permanent Structure 0 Food Service - ( Seats) 0 Frozen Dessert Manufacturer Mobile 0 Food Service - Takeout 0 Residential Kitchen for Retail Sale 0 Food Service - Institution 0 Residential Kitchen for Bed and ( Meals/Day) Breakfast Home 0 Food Delivery -------------------------------------------------Breakfast 0 Residential Kitchen for Bed and Es tablishments------------------------- 21) Length Of Permit: (check one) RETAIL TORE S TAANT RESTAURANT Annual Annual 0 Less than 1000sq.ft. $ 70 0 Less than 25 seats $140 Seasonal/Dates: 0 1000-10,000sq.ft. $280 0 Residential Kitchens $140 0 More than 10,000sq.ft. $420 0 25-99 seats $280 ❑ More than 99 seats $420 -- --- - -- -------------- - ---- - -- --- -- - - ❑ Bed & BreakfasUChildcare Seryices /Nursing Home $100 TemporarylDates/Time: ------------------------------------------------ ADDITIONAL PERMITS 0 MAKE ICE CREAM, YOGURT/SOFT SERVE $25 0 PASTURIZATION $25 0 TOBACCO VENDOR $135 0 ALL NON-PROFIT $25 (Including, church kitchens, state funded childcare 8 private clubs) 23) Food Operations: Definitions: PHF- potentially hazardous food (timeRemperature 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 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 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. 24) Signature of Applicant: Pursuant to MGL Ch. 62C, sec. 49VI 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: 4 a 2 � d 14157 26) Signature of Individual or Corporate Name: KIMBERLEY DRISCOLL NfAYOR 4/27/2012 CITY OF SALF-,M, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4... FLOOR (978) 741-9.800 FAX (978) 745-0343 haindin e salein.com Stepping Stone Inn 19 Washington Square N. Salem MA 01970 19 Washington Square N. Dear Owner: ]Publioiiealtla Prevrnl. Vfnmorc. Vrrrlrr�l. LARM' RANIDIN, ILS/RliHS, Cr10, CP -IFS HFiAI:ITI AGISN'I' The Salem Board of Health, Building and Fire Departments are scheduling yearly inspection of all establishments licensed as lodging houses. The Salem Licensing Board will review inspection and re -inspection reports in accordance with its license renewal procedures. The inspection will include dwelling units and common areas, therefore each tenant must be present or he/she must sign the enclosed release form which will allow the inspectors to enter the unit. Your Lodging House at 19 Washington Square N. has been scheduled to be inspected on Wednesday 6/6/2012 at 10:00:00 AM Thank your for your anticipated cooperation. Sincerely„ L—, Larry Ramdin Health Agent cc: Michael Lutrzykowski, Assistant Inspector of Buildings Lt. Erin Griffin, Fire Prevention Robert St. Pierre, Chairman, Salem Licensing Board KIMBERLEY DRISCOLL MAYOR DAVID GREENBAUM, RS ACTING HF.AL'IH AGI'.NT 5/9/2011 Stepping Stone Inn 19 Washington Square N. Salem MA 01970 19 Washington Square N Dear Owner: CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4'N FLOOR TEL. (978) 741-1800 FAX (978) 745-0343 Dcxci NBAUMQSAI.F:M.COM The Salem Board of Health, Building and Fire Departments are scheduling yearly inspection of all establishments licensed as lodging houses. The Salem Licensing Board will review inspection and re -inspection reports in accordance with its license renewal procedures. The inspection will include dwelling units and common areas, therefore each tenant must be present or he/she must sign the enclosed release form which will allow the inspectors to enter the unit. Your Lodging House at 19 Washington Square N. has been scheduled to be inspected on Wednesday 6/8/2011 at 10:00:00 AM Thank your for your anticipated cooperation. David Greenbaum, Acting Health Agent cc: Tom McGrath, Assistant Inspector of Buildings Erin Griffin; Fire Prevention Robert St. Pierre, Chairman, Salem Licensing Board KIMBERLEY DRISCOLL MAYOR DAVID GREENBAUM ACTING HL:AIm-i AGFN T 4/27/2010 Stepping Stone Inn 19 Washington Square N. Salem MA 01970 19 Washington Square N. Dear Owner: CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4" FLOOR TEL. (978) 741-1800 FAX (978) 745-0343 DGRL,LNBAUM@SALPM COM The Salem Board of Health, Building and Fire Departments are scheduling yearly inspection of all establishments licensed as lodging houses. The Salem Licensing Board will review inspection and re -inspection reports in accordance with its license renewal procedures. The inspection will include dwelling units and common areas, therefore each tenant must be present or he/she must sign the. enclosed release form which will allow the inspectors to enter the unit. Your Lodging House at 19 Washington Square N. has been scheduled to be inspected on Tuesday 6/29/2010 at 10:00:00 AM Thank your for your anticipated cooperation. Sincerely, David Green um, ing Health Agent cc: Tom McGrath, Assistant Inspector of Buildings Erin Griffin, Fire Prevention Robert St. Pierre, Chairman, Salem Licensing Board IQMBERLEY DRISCOLL MAYOR JANETMANCINI - AcI ING H'E:ALTI-I AGI:'.Nr 3/25/09 Stepping Stone Inn 19 Washington Square N. Salem MA 01970 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, .4'"FLOOR TEL. (978) 741-1800 Fax (978) 745-0343 IMAN(7]NI@SAJ.i'Ni.com 19 Washington Square N. Dear Owner: The Salem Board of Health, Building and Fire Departments are scheduling yearly inspection of all establishments licensed as lodging houses. The Salem Licensing Board will review inspection and re -inspection reports in accordance with its license renewal procedures. The inspection will include dwelling units and common areas, therefore each tenant must be present or he/she must sign the enclosed release form which will allow the inspectors to enter the unit. Your Lodging House at 19 Washington Square N. has been scheduled to be inspected on Wednesday 4/22/2009 at 9:00:00 AM Thank your for your anticipated cooperation. Sincerely, net Mancini, Acting Health Agent cc: Edgar Paquin, Assistant Inspector of Buildings Erin Griffin, Fire Prevention David Shea, Chairman, Salem Licensing Board i3 Commonwealthof Massachusetts ` r City of Salem Board of Health IQmberiey Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/18/2008 ESTABLISHMENT NAME: File Number: BHF -2004-000326 Stepping Stone Inn 19 Washington Square North Salem MA 01970 LOCATED AT: 0019 WASHINGTON SQUARE NO SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2009-0007 Dec 18, 2008 Dec 31, 2009 $100.00 ESTABLISHMENT PERMIT EXPIRES Total Fees: $100.00 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 KIMBERLEY DRISCOLL NLkYOR JANET DIONNE, ACTING HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET"4" FLOOR TEL. (978) 741-1800 FAx (978) 745-0343 IDIONNFO-SA1.86I. COAL 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF, ESTABLISHMENT_ � ja L�„��/�-._ TEL #_-�241 L _c U ADDRESS OF ESTABLISHMENT CI ({ FAX# MAILING ADDRESS (if different) EMAIL -Business': Website: OWNER'S NAME /WM its Ia/T/ir TEL# 71//%� D6 ADDRESSZ!q bila _/y% ` M'T 01170 STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL # D'AYSOF.OFERATION .. Suesda' ' '--Honda .,ri, ”` "rWetlnesda ° Ix Thursda }'_;' ?Fridiy =SatuMa Sunday,,,"3 HOURS OF OPERATION Please write in time of day. I (For example Ilam -11 pm TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than I 0,000sq.ft. =$420 _DCCTAI RANT —YES-- NIO - .:- t-..-=• «. �--..�la£g than,25 seats _ -.. _-. $1.40 (Outdoor Stationary Food Cart $210) 25-99 seats =$280 more than 99 seats =$420 BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES --------ff6i --------------------------- ---------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO, $135 ALL NON-PROFIT (such as church kitchens) YES NO $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 prominent location 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 certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all slate tax returns and paid all state taxes required un4er the law. I . W q KIMBERLEY DRISCOLL MAYOR JOANNE SCOTT HEALTH AGENT 2/25/08 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 Stepping Stone Inn 19 Washington Square N. Salem MA 01970 19 Washington Square N. Dear Owner: JSCOTT@SALEM.COM The Salem Board of Health, Building and Fire Departments are scheduling yearly inspection of all establishments licensed as rooming houses. The Salem Licensing Board will review inspection and re -inspection reports in accordance with its license renewal procedures. The inspection will include dwelling units and common areas, therefore each tenant must be present or he/she must sign the enclosed release form which will allow the inspectors to enter the unit. Your Rooming House at 19 Washington Square N. has been scheduled to be inspected on Wednesday 4/2/2008 at 11:00:00 AM Thank your for your anticipated cooperation. Sincerely, L Joa�J� t, Health Agent JS/mfp cc: Joseph Barbeau, Inspector of Buildings Erin Griffin, Fire Prevention David Shea, Chairman, Salem Licensing Board V 6/28/2007 Stepping Stone Inn 19 Washington Square N. Salem MA 01970 19 Washington Square N. Dear Owner: The Salem Board of Health, Building and Fire Departments are scheduling yearly inspection of all establishments licensed as rooming houses. The Salem Licensing Board will review inspection and re -inspection reports in accordance with its license renewal procedures. The inspection will include dwelling units and common areas, therefore each tenant must be present or he/she must sign the enclosed release form which will allow the inspectors to enter the unit. Your Rooming House at 19 Washington Square N. has been scheduled to be inspected on Wednesday 8/8/2007 at 11:00:00 AM Thank your for your anticipated cooperation. Sincerely, Joanne Scott, Health Agent JS/mfp cc: Joseph Barbeau, Inspector of Buildings Erin Griffin, Fire Prevention David Shea, Chairman, Salem Licensing Board CIN OF SALEM, MASSACHUSETTS BOARD OF HEALTH s 1.20 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAx 978-745-0343 Kimberley Driscoll WWW.SALEM.COM JOANNE SCOTT, MPH, RS, CHO Mayor HEALTH AGENT 6/28/2007 Stepping Stone Inn 19 Washington Square N. Salem MA 01970 19 Washington Square N. Dear Owner: The Salem Board of Health, Building and Fire Departments are scheduling yearly inspection of all establishments licensed as rooming houses. The Salem Licensing Board will review inspection and re -inspection reports in accordance with its license renewal procedures. The inspection will include dwelling units and common areas, therefore each tenant must be present or he/she must sign the enclosed release form which will allow the inspectors to enter the unit. Your Rooming House at 19 Washington Square N. has been scheduled to be inspected on Wednesday 8/8/2007 at 11:00:00 AM Thank your for your anticipated cooperation. Sincerely, Joanne Scott, Health Agent JS/mfp cc: Joseph Barbeau, Inspector of Buildings Erin Griffin, Fire Prevention David Shea, Chairman, Salem Licensing Board •L . `•'�' ' +i � '"t L'M:+ z r..... 4'a v x ,v,i=a*e% ., -. s. . Commonwealth of Massachusetts City of Salem Board of Health Iftberley Driscoll 120 Washington Street, 4th Floor Mayor VW SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2008 ESTABLISHMENT NAME: File Number: BHF -2004-000326 Stepping Stone Inn 19 Washington Square North Salem MA 01970 LOCATED AT: 0019 WASHINGTON SQUARE NO SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2008-0166 Jan 3; 2008 Dec 31, 2008 $100.00 ESTABLISHMENT Total Fees: $100.00 PERMIT EXPIRES December 31, 2008 Board of Health This Permit is not transferable and must be reissued upon changeof ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements; or equipment changes are made, all plans for such must be submitted to. and approved by the Salem Board of Health. - . Page 7 of 9 I s ! 1 KIMBERLEY DRISCOLL MAYOR JOANNE SCOTT, HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4' FLOOR Tf.L. (978) 741-1800 FAx (978) 745-0343 ISCOTTna SALENL COM 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT_ n/navy 7YVl/ TEL # / i � 7N Q�%LiL ADDRESS OF ESTABLISHMENT FAX # MAILING ADDRESS (if different) EMAIL - Business': gAr4r OWNER'S _rI:- Website:i � . PA—,JM Cyri JNAIE CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is -prepared) EMERGENCY RESPONSE PERSON HOME TEL # DAYS OF OPERATION Monday Tuesday Wednesday Thursday Friday Saturday Sunda Please write TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES less than 1000sq.ft. =$ 70 ANO 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 '---'------------'-----------------------`------ IE ......-O--------------------------------------------'---'.....-------------------------'---...... RESTAURANT YES NO less than 25 seats =$140 rnr�rd�.,.Statienar;,Ede.Cact-z^,n.)_.._--�`— 25-99 seats =$290 _ more than 99 seats =$420 ..------'-'--'-----'--'----'-------------------------...... -------------------`----------------------------------------------------.-...... BED/BREAKFASTI � NO $100 CHILDCARE SERVICES— - - ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT (such as church kitchens) YES NO $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 prominent location 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 certify under the pains and penalties of perjury that I, to my best knowledge and belief, have fled all state tax returns and paid all state taxes required under the law. Signature Date Revised 4/23/07 FOODAP2008.adm Check# & Date or Federal Identification Number SALEM FIRE DEPARTMEN7%� Inspec. Date: / INSPECTION AND VIOLATION REP(pTRT ( Insp. Number r (0 s,OJ Reinsp. Date: i Occupancy Name �A -/ Occupancy T�yip(eJ _�"t"LfQ Address �1 Bldg. #'s , Floor/Section Phone 3 i9 Wtl ja. 4S4t S(P N Yes fZ No ;•� Inspector Name y+/t Company# Notifications / � /, , ` I (" 1 n ❑ Health ❑ Bldg. ❑ Electrical ❑ Police 1. Exterior�� 6. HeatinglSystems ❑ N/A fire escapes/decks 'Pass Ll Fail r Warn ❑ N/A combustibles ❑1 Pass 11 Fail ❑ Warn ❑ N/A proper storage Pass [I Fail F71am ❑ N/A within 5 feet proper access I Pass ❑ Fail ❑ Warn ❑ N/A defective chimney Q Pass ❑ Fail ❑ Warn ❑ N/A KNOX BOX ❑ Pass ❑ Fail ❑ Warn ❑ N/A defective system 0 Pass ❑ Fail ❑ Warn ❑ N/A 2. Exits other ❑ Pass ❑ Fail ❑ Warn ❑ N/A open properly Pass ❑ Fail ❑ Warn ❑ N/A 7. Electrical exit blocked Q Pass ❑ Fail ❑ Warn ❑ N/A defective wiring Pass ❑ Fail ❑ Warn ❑ N/A exit signs working Q Pass ❑ Fail ❑ Warn ❑ N/A panels accessible Pass ❑ Fail ❑ Warn ❑ N/A adequate lighting ® Pass ❑ Fail ❑ Warn ❑ N/A extension cords: door(s) locked Lt7 Pass ❑ Fail ❑ Warn ❑ N/A proper use IV Pass ❑ Fail ❑ Warn ❑ N/A signs needed r Pass ❑ Fail ❑ Warn ❑ N/A cover plate missing N Pass ❑ Fail ❑ Warn ❑ N/A in need of repair P Pass ❑ Fail ❑ Warn ❑ N/A proper fusing [5 Pass ❑ Fail ❑ Warn ❑ N/A emergency lights F Pass ❑ Fail ❑ Warn ❑ N/A other ❑ Pass ❑ Fail ❑ Warn ❑ N/A otherfFt] Pass ElFail El Warn ❑ N/A 8. Fire Extinguishers ❑ N/A 3. Fire Alarm System ❑ N/A signs needed . Pass LlFail El Warn El N/A operative © Pass 1-1Fail El Warn El N/A properly mounted Pass ❑ Fail ❑ Warn ❑ N/A properly labeled 17 Pass 11 Fail [I Warn ❑ N/A proper type 8,] Pass ❑ Fail ❑ Warn ❑ N/A accessiblei❑ Pass ❑ Fail ❑ Warn ❑ N/A obstructed 1 Pass ❑ Fail ❑ Warn ❑ N/A trouble indication Pass ❑ Fail ❑ Warn ❑ N/A need recharging ]J Pass ❑ Fail ❑ Warn ❑ N/A defective devices IV Pass ❑ Fail ❑ Warn ❑ N/A other ❑ Pass ❑ Fail ❑ Warn ❑ N/A •s missing devices Pass ❑ Fail ❑ Warn ❑ N/A ` other D Pass ❑ Fail ❑ Warn ❑ N/A 9. Sprinkler & Standpipe System\ / 4. Kitchens `C7\ N—/A I valves labeled 1-1Pass L1 Fail L1Warn �J N/A at 10 ABC extinguisher El Pass El Fail [I Warn ®N/A valves accessible El Pass El Fail El Warn El N/A at hazard pressure reading EJ Pass L1 Fail El Warn El N/A ext. system operat. [I Pass ❑Fail El Warn N/A roof collect. clean ❑ Pass ❑ Fail ❑ Warn 4 N/A FDC clear/capped ❑ Pass ❑ Fail ❑ Warn ❑ N/A system inspected ❑ Pass ❑ Fail ❑ Warn [11 N/A valves open ❑ Pass ❑ Fail ❑ Warn ❑ N/A hood/duct clean ❑ Pass ❑ Fail ❑ Warn ® N/A valves secured ❑ Pass ❑ Fail ❑ Warn ❑ N/A other Ll Pass ❑ Fail ❑ Warn © N/A spare head avail. ❑ Pass ❑ Fail ❑ Warn ❑ N/A heads obstructed ❑ Pass ❑ Fail ❑ Warn ❑ N/A 5. Storage other ❑ Pass ❑ Fail ❑ Warn ❑ N/A proper labeling E Pass ❑ Fail ❑ Warn ❑ N/A proper storage 'k Pass ❑ Fail ❑ Warn ❑ N/A PTN Form #84 - Completed Yes ❑ No ❑ legal storage ❑ Pass ❑ Fail ❑ Warn ❑ WA Form #58 -Filed Yes El No Ll LEI Pass Ll Fail El Warn ❑ N/A 10. Violations Found i�� I or �)�cl to Sul�rti(t-{ re P lu raw, vu0L),'(<- I , t—i re �'�(fA t J0,J- %r �� (A,-,4 I-- (b1 C()P Y t Al Form #16 - (Rev. 11/93) Copies: White- Fire Prevention Yellow- Inspecting Company Pink- Building Owner/Manager R&'Ao r :34iO M UNITED STATES POSTAL SERVICE First -Class Mail rst.g .. � F USPS Permit No. G -If 0 Sender: Please print your name, address, and ZIP+4 in this box 0 BOARD OF HFiP� ➢ O SALEM, MA 0110 JUL 7 - 2006 CITY OF SALEM BOARD. OF HEALT L ■ Complete items 1, 2, and -3..Also complete item A if Restricted Delivery is desired. f ■ Pdnt'your name and address on the reverse so th S we can return the card to. you. ■ Attac � this card to the back of the mailpiece, or on fie front if space permits. 1. Article Addressed. to: John W. Brick I19 Washington Square Nor tt Salem, MA 01970 \ Lqa 9OUC A. tu .. _ X ❑ Agent W ❑ddressee B ceiw d by (Pnnted Name) C. DSU of Delivery 'fill .e D. y6elivery address different from item 17 U Yes YES, enter delivery address below: ❑ No 3. Service Type ❑ Certified Mail ❑ Express Mail ❑ Registered ❑ Return Receipt for Merchandise - [ . sured Mail ❑ C.O.D. 4. Restricted Delivery? (Extra Fee) ❑ Yes 2. Article er r/rom damp'# 7RE 133 3JW3AQO5 1992 2643 Domestic Return Receipt 102595-02-M-1540 information visit our website at PS Certified Mail Provides: ■ A mailing receipt (asienea) zooz eunrpose =0:1 se ■ A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders. ■ Certified Mail may ONLY be combined with First -Class Mail® or Priority Mail, ■ Certified Mail is not available for any class of International mail. in NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables, please consider Insured or Registered Mail. ■ For an additional fee, a Return Receipt m% be requested to provide proof of delivery. To obtain Return Receipt service, please complete antl attach a Return Receipt (PS Form 3811) to the article and add applicable postage to cover the fee. Endorse mailpiece "Return Receipt Requested". To receive afee waiver for a duplicate return receipt, a USPS® postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent. Advise the clerk or mark the mailplece with the endorsement "Restricted Delivery. ■ If a postmark on the Certified Mail receipt is desired, please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed, detach and affix label with postage and mail. IMPORTANT: Save this receipt andpresent it when making an Inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH s 120 WASHINGTON STREET, 4TH FLOOR �antNe SALEM, MA 01970 TEL. 978-741-1800 FAx 978-745-0343 W W W.SALEM.COM Kimberley Driscoll JOANNE SCOTT, MPH, RS, CHO Mayor HEALTH AGENT July 3, 2006 John W. Brick 19 Washington Square North Salem, MA 01970 Dear Sir/Madam: In accordance with Chapter III, Sections 127A and 127B of the Massachusetts General Laws, 105 CMR 400.00; State Sanitary Code, Chapter 1: General Administrative Procedures and 105 CMR 410.00: State Sanitary Code, Chapter 11: Minimum Standards of Fitness for Human Habitation, an inspection was conducted of the property at 19 Washington Square North conducted by David Greenbaum, Sanitarian, Tuesday, June 20, 2006. Notice: if this rental unit is occupied by a child or children under the age of 6 years, it is the property owner's responsibility to notify tenants of lead related reports and tests, and to ensure that this unit complies fully with 105 CMR 460:000: Regulations for Lead Poisoning Prevention and Control. For further information or to request an inspection, contact the Salem Board of Health at 978-741-1800. You are hereby ORDERED to make a good -faith effort to correct the violations listed on the enclosed inspection report. Failure on your part to comply within the time specified on the enclosed inspection report will result in a complaint being sought against you in Salem District Court. Time for compliance begins with receipt of this Order. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for said hearing'must be received in writing in the office of the Board of Health within 7 days of receipt of this Order. At said hearing, you will be given an opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. An attorney may represent you. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection in investigation reports, orders and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. Please be advised that the conditions noted may enable the occupant(s) to use one or more of the statutory remedies available to them as outlined in the enclosed inspection report form. For the Board of Health Reply to: anne Scott David Greenbaum Health Agent Sanitarian HL Sent certified mail — 7003 3110 0005 1992 2643 0019 WASHINGTON SQUARE NO John W. Brick 19 Washington Square North Salem, MA 01970 Area To Inspect:: All Areas no- to Iccne Certificate T City of Salem Mass Housing (Health) - Inspection Stepping Stone Inn ( Rev. Jun 26,2006 ) Item: Status: Nature of problem or correction: Owners Responsibility to Maintain Struc Not Done Windows, floors, doors, ceilings, roof In FAIL There is a crack in the ceiling in the front hall. Repair and seal crack. NO V V VyV vV Vv V good condition (410.500) There is chipping/peeling paint on the wall above the back stair case. Scrape Building Layout The Same ?: and repaint all chipping/peeling paint. Yes Inspector: David Greenbaum Date & Time Requested: at Date of Inspection: Tuesday, June 20, 2006 ,Reinspect By:: Certificate Number: Certificate Expires On: Status: OPEN Notes: Cc: Building Fire Prevention Licensing Weathertight Elements Not Done Windows are weathertight (410.501(A)) FAIL There is a cracked window behind the bed in the Goode room. Repair the window. 120 Washington Street, 4th Floor : SALEM, MA' Phone:(978) 741-1800 * Fax:(978) 745-0343 GeoTMS® 2006 Des Loaners Municipal Solutio Page 1 of 1 Commonwealth of Massachusetts s r City of Salem Board of Health 120 Washington Street, 4th Floor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2006 WHO'S PLACE OF BUSINESS IS.- File S: File Number: BHF -2004-0326 Stepping Stone Inn 19 Washington Square North Salem MA 01970 LOCATED AT: 0019 WASHINGTON SQUARE NO SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2006-0213 Jan 3, 2006 Dee 31, 2006 $100.00 ESTABLISHMENT Total Fees: $100.00 PERMIT EXPIRES December 31, 2006 � Board of Health 10 4 This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. _ In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 9 of 10 ei'^It" ccm STANLEY J. USOVICZ, JR. MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAx 978-745-0343 W W W.SALEM.COM JOANNE SCOTT, MPH, RS, CHO ' HEALTH AGENT 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT 110% F-11 A,l:1115ely:9/_1=3461:1A1:01NII Vcr.'; ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different) OWNER'S ADDRESS ✓ ', CITY :5a om 1 ST CERTIFIED FOOD MANAGER'S NAME(S) (required in an establishment where potentially hazardous food is prepared.) ZIP TEL # EMERGENCY RESPONSE PERSON HOME TEL # HOURS OF OPERATION: Mon.—Tue.—Wed.—Thu.—Fri.—Sat.—Sun.— TYPE on.Tue.Wed.Thu.Fri.Sat.Sun. TYPE OF ESTABLISHMENT RETAIL STORE YES NO RESTA-URAN--------------YES ---- �---------------------------- B- ED../.B...R..E..A...K..F..A..S..T....YES NO ------------------------ ------ 0 ----- 013-0 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE TOBACCO VENDOR ALL NON-PROFIT (such as church kitchens) FEE (check only) less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 --------------------------------------- $100 --------------------------- I.......... ............. YES NO $5 YES NO $50 YES NO $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 prominent location 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 certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Revised 11/03/05 FOODAP2.adm Check#& -61-OS— Revised 6('O5 ) o0 or 7 i Number x"k�h`"�5„w} S }4��; .iia a`�.K3�✓� aA''� r'�,,"�+s -� '",i .-c .ras�gi s-:, n:e+ +,+�^ .e'k�aV.ii'.'9 r¢rck'*,�'v`e'+k3y�':4.kn �+"?µw'w wwn+eR 1".i s . �".' .r. N a s. ,yxo h � ' „E .: & �tL° 'F f ick -t w''+ u a{�H. �3 �soJ"w •^ � F ag {,� t. u� i s .. {CITY OF SALEM MASSACHUSETTS fr �. �• BOARD OF.HEALTH -� - :9 - 120 WASHINGTON STREET, 4TH FLOOR g _ SALEM, MA 01970 -' .� TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE -SCOTT, 'MPH, RS, CHO -. MAYOR HEALTH AGENT " COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a'Food Establishment in the City of Salem is hereby granted to: Type of Establishment: Bed and Breakfast Name of Establishment: Stepping Stone Inn Address of Establishment: 19 Washington Square North Owner's Name: John W. Brick Restrictions: Application Date: 11/18/04 Permit for Food Establishment' 27-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2005 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, 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. VEzALTHENT�«,mac_ STANLEY J. LISOVICZ, JR. CITY OF SALEM9 MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM,. MA O 1970 TEL. 978-741-1800 FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different) OWNER'S C!TYj O STATE Wd ZIP a f y /p CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME TEL # HOURS OF OPERATION: Mon.—Tue.—Wed.—Thu.—Fri.—Sat.—Sun. TYPE OF ESTABLISHMENT RETAIL STORE YES RESTAURANT YES C� BED/BREAKFAST Lam' NO ' OZ 77'0s ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE TOBACCO VENDOR ALL NON-PROFIT (such as ch:., ch .kitchens). FEE check only less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 $100 YES $5 YES $50 YES M $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 prominent location 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 certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. ft) HLZor— Date//– iS – Social Security or Federal Identification Number Revised 1 n03/03 FOODAP2.adm Check# & Date 4-E30 //—/S- 0;< STANLEY J. USOVICZ, JR. MAYOR CITY OF SALEM, MASSACHUSETTS -BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT April 28, 2004 John Brick 19 Washington Square North Salem, MA 01970 Dear Sir/Madam: In accordance with Chapter III, Sections 127A and 127B of the Massachusetts General Laws, 105 CMR 400.00; State Sanitary Code, Chapter 1: General Administrative Procedures and 105 CMR 410.00: State Sanitary Code, Chapter 11: Minimum Standards of Fitness for Human Habitation, an inspection was conducted of the property 19 Washington Square North occupied by (Bed & Breakfast) conducted by Virginia Moustakis & David Greenbaum, Sanitarians on Tuesday April 27, 2004 @ 9:30 a.m. Notice: if this rental unit is occupied by a child or children under the age of 6 years, it is the property owner's responsibility to notify tenants of lead related reports and tests, and to ensure that this unit complies fully with 105 CMR 460:000: Regulations for Lead Poisoning Prevention and Control. For further information onto request an inspection,.contact the Salem Board of Health at 978-741-1800. You are hereby ORDERED to make a good -faith effort to correct the violations listed on the enclosed inspection report. Failure on your part to comply within the time specified on the enclosed inspection report will result in a complaint being sought against you in Salem District Court. Time for compliance begins with receipt of this Order., Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for said hearing must be received in writing in the office of the Board of Health within 7 days of receipt of this Order. At said hearing, you will be given an opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection in investigation reports, orders and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. Please be advised that the conditions' noted may enable the occupant(s) to use one or more of the statutory remedies available to them as outlined in the enclosed inspection report form. For the Board of Health Reply to: anne Scott Virginia Moustakis & David Greenbaum Health Agent Sanitarians cc: Licensing Building Inspector 'Fire Prevention Councillor Michael Sosnowski CITY OF SALEM, MASSACHUSETTS BOARD OF -HEALTH • i ,w I� 120 WASHINGTON STREET. 4TH FLOOR " SALEM. MA 01970 �r TEL. 978-74 1 -1 BOO - FAX 978-745-0343 Page 1 of.1_ STANLEY USOVICZ. JP JOANNE SCOTT. MPH. RS. CHO MAYOR ,HEALTH AGENT State SanitaryCode, Chapter II: 105 CMR 410.000 Minimum Standards of Fitness for Human Habitation Occupant �2co Phoneky 7W-8900 _ Address: 1 �ri� fiT an So. �n eru Apt.# vu,{s Floor ata Owner-.— 0&&/ )?eye k Address:A&wl Si/le42 , %YJit 171920 Inspection Date: 11-a7-0 4 Time: q.-golv-7 Conducted By'y�/,,,xsrukrs .nti&wWjz, 7 Accompanied By: f .SZ' � Ce (�� ef•� Anticipated Reinspection Date: A0,41,r ,I-0<�Pia�Ye, i fle iJeEt/ -1111 n One ior more of the above violations may endanger or materially impair the health safety, and well being of the occupant(s) Code Enforcement Inspector l',/ Este es documento legal importante. Puede que afecte sus derechos. ein....nneenrin Ilmmnr 71 fPlnfnnn 7A1-1Rn01 Appendix II (14) Legal Remedies for Tenants of Residential Housing The following is a brief summary of some of the legal remedies tenants may use in order to get housing code violations corrected : 1. Rent Withholding (Massachusetts General Laws, Chapter 239, section 8A): If Code Violations Are Not Being Corrected you may be entitled to hold back your rent payments. You can do this without being evicted if You can prove that your dwelling unit or common areas contain code violations which are serious enough to endanger or materially impair your health of safety and that your landlord knew about the violations before you were behind in your rent. You did not cause the violations and they can be repaired while you continue to live in the building. You are prepared to pay any portion of the rent into court if a judge orders you to pay it. ( For this it is best to put the rent money aside in a safe place) 2. Repair and Deduct (Massachusetts General Laws, Chapter III, section 127L): The law sometimes allows you to use your rent money to make the repairs yourself. If your local code enforcement agency certifies that there are code violations which may endanger or materially impair your health, safety, or well-being, and your landlord has received written notice of the violations, you may be able to use this remedy. If the owner fails to begin necessary repairs (or to enter into a written contract to have them made) within five days after the notice or to complete repairs within 14 days after notice, you can use up to four months rent in any year to make repairs. ....V,.L ■ucrcases or rvrcuons Prohibited (Massachusetts General Laws, Chapter 186, section 18, and Chapter 239, Section 2A): The owner may not increase your rent or evict you in retaliation for making a complaint to your local code enforcement agency about code violations. If the owner raises your rent to try to evict within six months after you have made the complaint, he or she will have to show a good reason for the increase or eviction which is unrelated to your complaint. You may be able to sue the landlord for damages or if he or she hies this. 4. Rent Receivership (Massachusetts General Laws Chapter II, section 127 C -H): The occupants and/or the Board of Health may petition the District or Superior Court to allow rent to be paid into court rather than to the owner. The court may then appoint a "receiver" who may spend as much of the rent money as is needed to correct the violation. The receiver is not subject to a spending limitation of four months'rent. 5. Breach of Warranty of Habitability You may be entitled to sue your landlord to have all or some of your rent returned if your dwelling unit does not meet minimum standards of habitability. 6. Unfair & Deceptive Practices (Massachusetts General Laws, Chapter 93A) : Renting an apartment with code violations is a violation of the consumer protection act and regulations, for which you may sue an owner. The information presented above is only a summary of the law. Before you decide to withhold rent or take anv other legal action, it is advisable that you consult an attorney. If you can not afford to consult an attorney, you should contact the nearest legal services office, which is North Shore Community Action Northeast Housing Court Programs Inc. 2 Appleton Street 98 Main Street Lawrence, MA. 01840 Peabody, MA. 01960 (978) 689-7833 (978) 531-0767 STANLEY J. USOVICZ, JR. MAYOR CITY OF SALEM, MASSACHUSETTS " BOARD•OF HEALTH ' •' - 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA O 1970 TEL. 978.741-1800 - FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: Bed and Breakfast Name of Establishment: Stepping Stone Inn Address of Establishment: 19 Washington Square North Owner's Name: John W. Brick Restrictions: Application Date: 1/15/2004 Permit for Food Establishment 260-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2004 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, 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. HEALTH AGENT i STANLEY USOVICZ, JR. MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT ADDRESS OF ESTABLISHM MAILING ADDRESS (if different) OWNER'S NAME 5U'eW CITY CERTIFIED F TEL # I LI I MCO STATE ZIP CERTIFICATE#(s) I (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON O HOME TEL # 2H (5V 9.0'0 HOURS OF OPERATION: Mon. ue. Wed.—Thu.—Fri.—Sat.—Sun.— TYPE ed.Thu.Fri.Sat.Sun. TYPE OF ESTABLISHMENT RETAIL STORE YES RESTAURANT YES 10 BED/BREAKFAST YES NO FEE check only less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 $100 ADDITIONAL PERMITS ' MAKE (notjust serve) ICE CREAM, YOGURT, SOFT SERVE YES $5 TOBACCO VENDOR YES $50 ALL NON-PROFIT (such as church kitchens) YES $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 prominent location 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, best krAwledRle and 4elie"av Revised 11/03/03 FOODAP2.adm 49A, I certify under the pains and penalties of perjury that 1, to my sta=11H e 11 returns and paid all state ta61 �s�&ire15 Z) r t�/� % Check# & Social Security or 0-6 Number IMPORTANT MESSAGE PHONE 9 zj-- AREA CODE NUMBER EXiEN510N ❑ FAX O MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAXTO YOU OAF ' SIGNED z 0 rMTw l,. COURT DOCKET NO. Q CITATION NO. CITY OF SALEM PCI 1096 VIOLATION NOTICE NAME (LAST, FIRST, INITIAL) S rAW1011yr5 Alf- /✓ n A STREEERETADDR€SS CCITYOWN STATE ZIP ' �l � "ii-4 LICENSE NO. L .EXP. DATE DAT ATH ., n OWNER'S NAME (LAST, FIRST, INITIAL) STREETADDRESS I CI /TOWN STA E ZIP REGISTRATION NO. TATE P AT AKID"PE YEAR COLOR DATE OF VIOLATION TIME DATE CITATION WRITTEN PERSONAL R'uRb ❑ AM El Pm YES [I NO LOCATION OF VIOLATION OR IN DEPT �w � N C7r1 OFFE E CHAP. SECT. FINES A P /✓ O B vsC� C OFFICER I.D. NO. TOTAL 00 FINE @ W ail+ O DUE OFFICER CERTIFIES COPY GIVEN TO VIOLATOR /� yam-- El IN HAND X //i '� ❑ BY MAIL DO NOT MAIL CASH - PAY ONLY BY POSTAL NOTE, MONEY ORDER OR BY CHECK MADE PAYABLE TO: CITY CLERK CITY HALL 93 WASHINGTON STREET SALEM, MA 01970 TEL. (508) 745-9595 X 251 1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON REVERSE, CONFESS TO THE OFFENSE CHARGED, AND ENCLOSE PAYMENT IN THE AMOUNT OF $ CASE # SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE, PEEL AND SEAL CITATION NO. CITY. OF SALEM VIOLATION NOTICE PD 109fi NAME (LAST FIRST, INITIAL) _ ' 5r 1,411T -o /J STREETADDRESS CITY/TOWN STATE ZIPCY'77?j � 's1f1,.r S • ir6er6i .�/�s jf'�. LICENSE LIC. EXP. DATE DATE OF BIRTH a f OWNER'S IfAME (LAS��Tpp,''FIRST, INITIAL)) N�ilC� ue� ffAi +tet/ STREETADDRESS CITY(TOWN STATE ZIP f9 w45%1f 9 7 Sd? AO I REGISTRATION NO. STATE EXP.i1ATE MAKE/IYPE YEAR COLOR DATE OF VIOLATION TIME 13 Pp DATE CITATION WRITTEN- PERSONAL iWURYEIVES f+1 G7 7 P []NO LOCATION OF VIOLATIONENF,ORCINP�.�� OFFENSE Sr. FINES A v ;fL rx,f ,ee oB r c?od r' c OFFICER I.D. NO. f ` TOTAL FINE 00 $ atj ✓ !`�OGCS•�I'J! ( DUE OFFICER CERTIFIES COPY GIVEN TO VIOLATOR 'jy7 .�y�/ - El IN HAND x /, /i'f AGGURI, Q[ f ❑ BY MAIL - DO NOT MAIL CASH - PAY ONLY BY POSTAL NOTE, MONEY ORDER OR BY CHECK MADE PAYABLE TO: - CITY CLERK CITY HALL 93 WASHINGTON STREET SALEM, MA 01970 TEL. (508) 745-9595 X 251 1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON REVERSE, CONFESS TO THE OFFENSE CHARGED, AND ENCLOSE PAYMENT IN THE AMOUNT OF $ CASE # SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT INTHIS ENVELOPE, PEEL AND SEAL An Ll to LU <� R Z v o i J a -. .Ll. COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Owner's Name: John W. Brick Name of Establishment: Stepping Stone Inn Address of Establishment: 19 Washington Square North Type of Establishment: Bed L Breakfast Application Date: 12/03/2002 Restrictions: Permit for Food Establishment 2-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2003 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, 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. HEALTH AGENT f CITY OF SALEM, MASSACHUSETTS �oxwr BOARD OF HEALTH n 120 WASHINGTON STREET, 4TH FLOOR � SALEM, MA 01970 �. TEL. 978-741 -1 800 FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT. MPH. RS. CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Owner's Name: John W. Brick Name of Establishment: Stepping Stone Inn Address of Establishment: 19 Washington Square North Type of Establishment: Bed L Breakfast Application Date: 12/03/2002 Restrictions: Permit for Food Establishment 2-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2003 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, 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. HEALTH AGENT I* CITY OF SALEM, MASSACHUSETTS �v� � BOARD OF HEALTH )7 > 120 WASHINGTON STREET, 4TH FLOOR lll/// 'SALEM, MA 01970 TEL. 978-741 -1800 FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2003 APPLICATION FOR PERMIT TO OPERATEA FOOD ESTABLISHMENT NAME OF ESTABLISHMENT. TEL #) X -114 1 & 90 0 ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different) Sa= p OWNER'S TEL #_ 917 Z 74/,'? 0 ADDRESS CITY " _ STATE_ ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME TEL HOURS OF OPERATION: Mon.—Tue.—Wed.—Thu.—Fri.—Sat.—Sun. TYPE OF ESTABLISHMENT RETAIL STORE YES NO RESTAURANT YES NO BED/BREAKFAST YES NO ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVE YES NO TOBACCO VENDOR YES NO ALL NON-PROFIT (such as church kitchens) YES NO FEE check only less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 less than 25 seats =$100 25-99 seats =$150 more than 99 seats = $100. $5 $50 $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 prominent location in the Establishment. In accordance with the State Sanitay 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 certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. r s 1i C/ L/1_1/%L �7 Date j'2 Cl Social Security or Federal Identification Number Revised ",125/02 FOODAP2.adm Check# & II CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WAS STREET, 4TH FLOOR SALEM, MA 01970 SEL. 978-741 -1800 FAX 978-745-0343 STANLEY USOVICZ, JR. MAYOR Stepping Stone Inn-Bed/Breakfast C/o John Brick 19 Washington Square North Salem, MA. 01970 Dear Mr. Brick: JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT April 11, 2003 In accordance with Chapter III, Sections 127A and 1276 of the Massachusetts General Laws, 105 CMR 400.00; State Sanitary Code, Chapter I: General Administrative Procedures and 105 CMR 410.00: State Sanitary Code, Chapter II Minimum Standards of Fitness for Human Habitation, an inspection was conducted of the property 19 Washington Square North (8 room bed & breakfast) conducted by Virginia Moustakis, Sanitarian on Tuesday, April 8, 2003 at 10:00 A.M.. Notice: If this rental unit is occupied by a child or children under the age of 6 years, it is the property owner's responsibility to notify tenants of lead related reports and tests, and to ensure that this unit complies fully with 105 CMR 460.000 : Regulations for Lead Poisoning Prevention and Control. For further information or to request an inspection, contact the Salem Health Department at 741-1800. You are hereby ORDERED to make a good -faith effort to correct the violations listed on the enclosed inspection report. Failure on your part to comply within the time specified on the enclosed inspection report will result in a complaint being sought against you in Salem District Court. Time for compliance begins with receipt of this Order. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for said hearing must be received in writing in the office of the Board of Health within 7 days of receipt of this Order. At said hearing, you will be given an opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports, orders and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. Please be advised that the conditions noted may enable the occupant(s) to use one or more of the statutory remedies available to them as outlined in the enclosed inspection report form. For the Board of Health: , Reply to: Joanne Scott Virginia Moustakis Health Agent Sanitarian Cc: Councillor Flynn, Licensing Board, Fire Prevention, Building Department violet I ,; CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR ' SALEM, MA 01970 TEL. 978-74 1 -1800 FAX 978-745-0343 JOANNE SCOTT, MPH, RS. CHO HEALTH AGENT State Sanitary Code, Chapter Ik 105 CMR 410.000 Page 1 of / Minimum Standards of Fitness for Human Habitation Occupant rjyw &,u -&n4z � Phone -97f) yvl Address: Apt.# zen,j�c Floor - s Owner: v, -,,y v l5Q, ,I, Address: ,� /�,v%-„ 4,bzz-x Sa/,n. �✓b ai97� Inspection Date: rir_ F -o,3 Time: <;c psi ecce @lai �Jv� Conducted By: ✓„u k Accompanied By: Pu +@f Anticipated Reinspection Date: pf�g„ ,�•T�/ie .�e,Sc//eme..9-.DvyuGY /Z-&Sk't Specified Time Reg.#410.. Violation(s) cru�l/2C One or more of the above violations may endanger or materially impair the health safety, and well being of the occupant(s) Code Enforcement Inspector Este es documento leqal importante. Puede que afecte sus dereehos. Puede ndauirir una traduccion de esta forma sies necesario Ilamar at telefono 741-1800. e- x ' +de CS F i rA, ' .E'iUG' c�iYL dG N q2 4 4 ald xe Z JL e v F ;✓ s FtfS L- -d C' y One or more of the above violations may endanger or materially impair the health safety, and well being of the occupant(s) Code Enforcement Inspector Este es documento leqal importante. Puede que afecte sus dereehos. Puede ndauirir una traduccion de esta forma sies necesario Ilamar at telefono 741-1800. t Appendix II (14) Legal Remedies for Tenants of Residential Housing The following is a brief summary of some of the legal remedies tenants may use in order to get housing code violations corrected : L Rent Withholdin (Massachusetts General Laws, Chapter 239, section 8A): 1f Code Violations Are Not Being Corrected you may be entitled to hold back your rent payments. You can do this without being evicted if You can prove that your dwelling unit or common areas contain code violations which are serious enough to endanger or materially impair your health of safety and that your landlord knew about the violations before you were behind in your rent. You did not cause the violations and they can be repaired while you continue to live in the building. You are prepared to pay any portion of the rent into court if a judge orders you to pay it. ( For this it is best to put the rent money aside in a safe place) 2. Repair and Deduct (Massachusetts General Laws, Chapter III, section 127L): The law sometimes allows you to use your rent money to make the repairs yourself. If your local code enforcement agency certifies that there are code violations which_ may endanger or materially impair your health, safety, or well-being, and your landlord has received written notice of the violations, you may be able to use this remedy. If the owner fails to begin necessary repairs (or to enter into a written contract to have them made) within five days after the notice or to complete repairs within 14 days after notice, you can use up to four months rent in any year to make repairs. 3. Retaliatory Rent Increases or Evictions Prohibited (Massachusetts General Laws, Chapter 186, section 18, and Chapter 239, Section 2A): The owner may not increase your rent or evict you in retaliation for making a complaint to your local code enforcement agency about code violations. If the owner raises your rent to try to evict within six months after you have made the complaint, he or she will have to show a good reason for the increase or eviction which is unrelated to your complaint. You may be able to sue the landlord for damages or if he or she tries this. 4. Rent Receivership (Massachusetts General Laws Chapter II, section 127 C -H): The occupants and/or the Board of Health may petition the District or Superior Court to allow rent to be paid into court rather than to the owner. The court may then appoint a "receiver" who may spend as much of the rent money as is needed to correct the violation. The receiver is not subject to a spending limitation of four months'rent. 5. Breach of Warranty of Habitability You may be entitled to sue your landlord to have all or some of your rent returned if your dwelling unit does not meet minimum standards of habitability. 6. Unfair & Deceptive Practices (Massachusetts General Laws, Chapter 93A) : Renting an apartment with code violations is a violation of the consumer protection act and regulations, for which you may sue an owner. The information presented above is only a summary of the law. Before you decide to withhold rent or take anv other legal action, it is advisable that you consult an attorney. If you can not afford to consult an attorney, you should contact the nearest legal services office, which is North Shore Community Action Northeast Housing Court Programs Inc. 2 Appleton Street 98 Main Street Lawrence, MA. 01840 Peabody, MA. 01960 (978) 689-7833 (978) 531-0767 o„ � a STANLEY USOVICZ, JR. MAYOR CITY OF'SALEM, MASSACHUSETTS BOARD OF HEALTH .120WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter ,94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to:. Owner's Name: John W. Brick Name of Establishment: Stepping Stone Inn Address of Establishment: 19 Washington Square North Type of Establishment: Bed & Breakfast Application Date: 12/17/2001 Restrictions: ,-:Permit for Food Establishment 201-02 Frozen Desserts/Ice Cream - Permit for the Sale of Tobacco Products These'Permits Expire December 31, 2002 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, 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. : A v HEALTH AGENT n a 1 ,-0 s s STANLEY USOVICZ, JR. MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT DEC 1 7 2001 CITY OF SALEM HEALTH DEPT. 2002 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT. ADDRESS OF ESTABLISHM MAILING ADDRESS (if different) Ovv'NE^n'S NAME TEL ADDRESS CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME TEL # DAYS / HOURS OF OPERATION: Mon. i Tue.- Wed.-Thu.-Fri.-Sat.-Sun.-TYPE OF ESTABLISHMENT , FEE check only RETAIL STORE YES�$40 RESTAURANT YES $40 BED & BREAKFAST ?rfD NO $40 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT SOFT SERVE YES $5 TOBACCO VENDOR YES O 10 NO CHARGE FOR NON-PROFIT (such as church kitchens) PLEASE INCLUDE COPY OF TAX EXEMPT FORM Please pay total with one check payable to the City of Salem iii This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location 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 certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. SignatureDate /2- 4S Social Security or Federal Identification number _r -- 7 ------- Revised 11/1/01 foodapZadm Check# & O It, 0 Ln M1 M M r .D U.S. Postal Service CERTIFIED MAIL RECEIPT N (Domestic Mail Only; No Insurance coverage Provided) ; Postage Certified Fee O Restdcled Delivery Fee C3 (Endorsemert Required) Total Postage 6 Fees S ,a I Sent To a pC3 r I A L U Postrnark Hera I Prdvides: ■ A mailing receipt ■ A unique identifier for your mailpiece ■ A signature upon delivery ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First -Class Mail or Priority Mail. ■ Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables, please consider Insured or Registered Mail. ■ For an additional fee, a Return Receipt may be requested to provide proof of delivery. To obtain Return Receipt service, please complete and attach a Return Receipt (PS Form 3811! to the article and add applicable postage to cover the fee. Endorse mailpiece 'Return Receipt Requested". To receive a fee waiver for a duplicate return receipt, a USPS postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent. Advise the clerk or mark the mailpiece with the endorsement "Restricted Delivery". ■ If a postmark on the Certified Mall receipt is desired, please present the ard- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed, detach and affix label with postage and mail. j `IMPORTANT. Save ttiis receipt and present It when making an inquiry. PS Farm 386, January 2001 UNITED STATES POSTAL M ^` �'�""�-�• -Frst=Class Mait---- Postage & Fees,Paid USPS Permit No. G-10 • Sender: Please print yoaGglome, address, and ZIP+4 in this box Ill% f Health APR 2 6 2002 Sco , Joanne, Health Agent d 120 Washington Street —4th Floor 111Salem, MA 01970-3523 B0fIIR0 OFHEALTH ■ Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. ■ Print your name and address on the reverse so that we can return the card to you. ■ Attach this card to the back of the mailpiece, or on the front if space. permits. 1. Article Addressed to: sfePP/"9 .S*77e XNA /q Cvastii�a � ,q 77o,4- A. oe A. Received by (Please Print Clearly) IB. C. X ❑ Agent 1delivery address "Pe—mnt from rtem 19 ❑ Vee VES, enter delivery address below: ❑ No 3. Service Type fA Certified Mail ❑ Express Mail ❑ Registered ❑ Return Receipt for Merchandise ❑ Insured Mail ❑ C.O.D. 4. Restricted Delivery? (Extra Fee) ❑ yes 12. Article Number (Copy from service label) I{ . I 700/ //yo 0000 6 733 7509 PS Form 3811, July 1999 Domestic Return Receipt n STANLEY USOVICZ, JR. MAYOR Mr. John Brick Stepping Stone Inn 19 Washington Sq. North Salem, Ma 01970 Dear Mr. Brick: CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-74 1 -1800 FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT April 16, 2002 In accordance with Chapter 11, Sections 127A and 127B of the Massachusetts General Laws, 105 CMR 400.00; State Sanitary Code, Chapter 1: General Administrative Procedures and 105 CMR 410.00: State Sanitary Code, Chapter It: Minimum Standards of Fitness for Human Habitation, an inspection was conducted of the property at 19 Washington Sq. North conducted by Virginia Moustakis, Sanitarian on Tuesday, April 16, 2002 at 10.30 A.M. Notice: If this rental unit is occupied by a child or children under the age of 6 years, it is the property owner's responsibility to notify tenants of lead related reports and tests, and to ensure that this unit complies fully with 105 CMR 460.000: Regulations for Lead Poisoning Prevention and Control. For further information or to request an inspection, contact the Salem Health Department at 741-1800. You are hereby ORDERED to make a good -faith effort to correct the violations listed on the enclosed inspection report. Failure on your part to comply within the time specified on the enclosed inspection report will result in a complaint being sought against you in Salem District Court. Time for compliance begins with receipt of this Order. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for said hearing must be received in writing in the office of the Board of Health within 7 days of receipt of this Order. At said hearing, you will be given an opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You maybe represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports, orders and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. Please be advised that the conditions noted may enable the occupant(s) to use one or more of the statutory remedies available to them as outlined in the enclosed inspection report form. Fo the Board of Health: Reply to: oanne Scot Virginia Moustakis Health Agent Sanitarian cc: Councillor Regina Flynn,Licensing Board, Fire Prevention, & Building Inspector Certified Mail #7001 1140 0000 6733 7509 JS/ vm c -h -violet y CITY OF SALEM HEALTH DEPARTMENT 120 WASHINGTON STREET 4TH FLOOR Salem, Massacnusetts 01970 Pagel of /. State Sanitary Code, Chapter ll: 105 CMR 410.000 Minimum Standards of Fitness for Human Habitation occupant: s; An. T nP -rti,u Phone: 7111-F9od ` Address: 1A 6p Apt.#S,� s Flooa Owner: sd/e,) ;gx;i:4 Address: /9 G(iAr/f/,�/9r4rrr 4 A"771 Inspection, Date: ; Time /e:'3o /,'-m ..• Conducted By ✓/1�,�,� �� Accompanied By[,�;�;,ur'aaer/.in/� t " r- Anticipated Reinspection Date:�Xe 7y��asfxt� .F/AQP Ei/G7.776�'1 �rl LQ. Specified Time Reg.#410.. Violabon(s)40 IAI ci` rt. ..N.S;s Lt.. e-. y w v..ti� #,, v]`✓-mJei�[n �„ t ?',. •'!t a ,:...vt i .t;s R'" r vvCl �F � "--i"' ':.-..., b- 4 . , :.. /'• \ A.i f, }a o r.-.i-.AO;��i//tJ�� .. :. i ....,/Y'a >.,...x :. _}-,t3 .. ,/@i .e, iuiP 4 � ... • .-'S# ' j1i.ht - A& (:, i., sr�., ,s e• .�,'A,-..�' 5 Ji. "' �! �. B...t - .5... y c ..C(/ ��` .(I Tu,- .'..,, -p17- sir;. ,. $ �.;. .•. "y: x.+ x T r1% exon Z F t,F�" Si" �'�. P•^� 'A:43-f�4gj`.n' ' fi'rt i e' e Y 6 ee :pit{J-;�;x.,,g._t�.=�_,{: ,.` ,rtfix� r-•,. ,. 'i2i: v a •3�.,r�<�.. 1,,�' {��.,:.aa� *'./,u Y - _ � 'C� . Ste! U - it 14 e£�,:.;n.e `+�C. ini u... k'"'a `.; '�£ a .;':i- r. ay ;,is _+..-t r�.n � ..�.g � rt.�� • r , v i-. .f '��' �"Yi - , x ` R.*F-.s -0' . .'' LJ�}ih +:''31 Cid '�"YI ^k ��xt S`� t`.i 4- .i a'F`{ �"_-. rut`:5>ti u a,-s.�siF w.+ .. .. r •. _ ti� Y -. A,. One or more of the above violations may endanger or materially impair the health . an safety; and well being of the occupant(s) w ; i i _ , �yy�&C'Ja4e Code Enforcement Inspector `%/ /y1��o�[�i Este es documento legal importante. Puede que afecte'sus derechos rraductu n c p Psta'forma sie's necesario Ilamar al�telefono 741-1800. t R1 U— Postage $' E:3 S Certified Fee Postmark t'( Return Receipt Fee (Endomement Requlretl) Here O C3 ResrsDelivery Fee C3 (Endorsement Required) .C3 Total Postage 8 Fees $ O I m Name le�/as'e fpAnt IeaAy like completed b mailer /r/t/ t7�7 P Y 1 ----------------------------- Speeq AP o. r Po Box No I W "W"17 -ails. 5Q ��eC�off �O_city, � tete. ZIP+ -- ----------------------------------- �' 1 M4. :rr ____------..._______________-__ C770 Certified Mail Provides:• ■ A in ling receipt ■ A unique identifier for your mailpiece ■ A signature upon delivery ■ Atecord of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First -Class Mail or Priority Mail. ■ Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables, please consider Insured or Registered Mail. ■ For an additional fee, a Return Receipt may be requested to provide proof of delivery. To obtain Return Receipt service, please complete and attach a Return Receipt (PS Fonn 3a11� to the article and add applicable postage to cover the fee. Endorse mailpiece 'Return Receipt Requested". To receive a fee waiver for a duplicate return receipt, a USPS postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent. Advise the clerk or mark the mailpiece with the endorsement "Restricted Delivery". ■ If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed, detach and affix label with postage and mail. IMPORTANT: Save this receipt and present it when making�an inquiry. PS Form 3800, July 1999 (Reverse) 102595-99-M-2087 CITY OF�SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT April 5, 2001 John Brick 19 Washington Square North Salem, MA 01970 Dear Mr. Brick : NINE NORTH STREET Tel: (978) 741-1800 Fax: (978) 740-9705 In accordance with Chapter III, Sections 127A and 1276 of the Massachusetts General Laws, 105 CMR 400.00. State Sanitary Code, Chapter I: General Administrative Procedures and 105 CMR 410.00: State Sanitary Code, Chapter II Minimum Standards of Fitness for Human Habitation, an inspection was conducted of the property 19 Washington Square North occupied by (Stepping Stone Inn) conducted Virginia Moustakis, Sanitarian on Wednesday, April 4, 2001 at 11:30 A.M.. Notice: If this rental unit is occupied by a child or children under the age of 6 years, it is the property owner's responsibility to notify tenants of lead related reports and tests, and to ensure that this unit complies fully with 105 CMR 460.000 : Regulations for Lead Poisoning Prevention and Control. For further information or to request an inspection, contact the Salem Health Department at 741-1800. You are hereby ORDERED to make a good -faith effort to correct the violations listed on the enclosed inspection report. Failure on your part to comply within the time specified on the enclosed inspection report will result in a complaint being sought against you in Salem District Court. Time for compliance begins with receipt of this Order. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for said hearing must be received in writing in the office of the Board of Health within 7 days of receipt of this Order. At said hearing, you will be given an opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports, orders and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. Please be advised that the conditions noted may enable the occupant(s) to use one or more of the statutory remedies available to them as outlined in the enclosed inspection report form. For the Board of Health Reply to: Joanne Scott Virginia Moustakis Health AgentSanitarian cc: Counalsor Regina Flynn, Licensing'Board, Fire Prevention, & Building Department Certified Mail # 7099 3400 0009 4093 2515 JS/ sjk c -h -violet CITY OF SALEM HEALTH DEPARTMENT R Nine North Street Salem, Massachusetts 01970 Page 1 of State Sanitary Code, Chapter 11: 105 CMR 410.000 Minimum Standards of Fitness for Human Habitation Occupant ��pet,vc sjntiF z',vAl Phone:_7gi-S9oo Address: /9 //iasf,,ti � m�� ,� M-10 yy Apt.# X ,P-mz Floor,_ ,,, Owner:,Address: SAC�'n✓/ /L%a/9 %U Inspection Date:_ y-q-oo/ Time: i4-jaA.7, Conducted By: ✓.i^%a.rS�aftts Accompanied By:,ee G/Gc^A/N. ET, /7�A�oLO OLAKE Anticipated Reinspection Date:,,L„� h,�� f f,�E y✓%!/�sti</c �� f<Aeces /ofrrLOC � ,��OiNG :ZrLCSPECTpR FRf3ti/e D/�AeG< Specified Time Reg.# 410.. Violation(s) One or more of the above violations may endanger or materially impair the health safety, and well being of the occupant(s) Code Enforcement Inspector Este es documento legal importante. Puede que afecte sus derechos. Puede adquirir una traduccion de esta forma sies necesario Ilamar al telefono 741-1800. /./CvNst� NC! Fk'E !'/REUFMT7U1V ,EiGo6. l7�� Gi r'/ GoUNG/��-r'f �. r4yN/✓ •1090"11 109 i M'MAN WE /al ff Li I /1. I L ®-/►IML♦/SI+� ' ' ' ! ♦ / / - : - I/ i /J rd/ • / " ' /.moi i 'I One or more of the above violations may endanger or materially impair the health safety, and well being of the occupant(s) Code Enforcement Inspector Este es documento legal importante. Puede que afecte sus derechos. Puede adquirir una traduccion de esta forma sies necesario Ilamar al telefono 741-1800. /./CvNst� NC! Fk'E !'/REUFMT7U1V ,EiGo6. l7�� Gi r'/ GoUNG/��-r'f �. r4yN/✓ Appendix II (14) Legal Remedies for Tenants of Residential Housing The following is a brief summary of some of the legal remedies tenants may use in order to get housing code violations corrected : 1. Rent Withholding (Massachusetts General Laws, Chapter 239, section 8A): If Code Violations Are Not Being Corrected you may be entitled to hold back your rent payments. You can do this without being evicted if: You can prove that your dwelling unit or common areas contain code violations which are serious enough to endanger or materially impair your health of safety and that your landlord knew about the violations before you were behind in your rent. You did not cause the violations and they can be repaired while you continue to live in the building. You are prepared to pay any portion of the rent into court if a judge orders you to pay it. ( For this, it is best to put the rent money aside in a safe place) 2. Repair and Deduct (Massachusetts General Laws, Chapter III, section 127L): The law sometimes allows you to use your rent money to make the repairs yourself. If your local code enforcement agency certifies that there are code violations which may endanger or materially impair your health, safety, or well-being, and your landlord has received written notice of the violations, you may be able to use this remedy. If the owner fails to begin necessary. repairs (or to enter into a written contract to have them made) within five days after the notice or to complete repairs within 14 days after notice, you can use up to four months rent in any year to make repairs. 3. Retaliatory Rent Increases or Evictions Prohibited (Massachusetts General Laws, Chapter 186, section 18, and Chapter 239, Section 2A): The owner may not increase your rent or evict you in retaliation for making a complaint to your local code enforcement agency about code violations. If the owner raises your rent to try to evict within six months after you have made the complaint, he or she will have to show a good reason for the increase or eviction which is unrelated to your complaint. You may be able to sue the landlord for damages or if he or she tries this. 4. Rent Receivership (Massachusetts General Laws Chapter II, section 127 C -H): The occupants and/or the Board of Health may petition the District or Superior Court to allow rent to be paid into court rather than to the owner. The court may then appoint a "receiver" who may spend as much of the rent money as is needed to correct the violation. The receiver is not subject to a spending limitation of four months'rent. 5. Breach of Warranty of Habitability: You may be entitled to sue your landlord to have all or some of your rent returned if your dwelling unit does not meet minimum standards of habitability. 6. Unfair & Deceptive Practices (Massachusetts General Laws, Chapter 93A) : Renting an apartment with code violations is a violation of the consumer protection act and regulations, for which you may sue an owner. The information presented above is only a summary of the law. Before you decide to withhold rent or take any other legal action, it is advisable that you consult an attorney. If you can not afford to consult an attorney, you should contact the nearest legal services office, which is Neighborhood Legal Services 37 Friend Street Lynn, MA. 01902 (781)-599-7730 h Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. Print your name and address on the reverse so that we can return the card to you. Attach this card to the back of the mailpiece, or on the front if space permits. . Article Addressed to: John Brick 19 Washington Square North Salem, MA 01970 r A. Received by (Please Print Clearly) I B. ❑'Agent Is delivery address different from item 17 LI Yes If VES, enter delivery address below: ❑ No 3. Service Type Y& Certified Mail ❑ Express Mail ❑ Registered ❑ Return Receipt for Merchandise ❑ Insured Mail ❑ C.O.D. - (19 Washington Sq N ) VM 4. Restricted Delivery? (Extra Fee) ❑ Yes . Article Number (Copy from service labei)i r i - -' _ I 1 +' i + i 7099 3400 0009 4093-2515i;Elt, +E .i1I��111I�I ' I S Form 3811, July 1999 Domestic Return Receipt 102595-00-M-0952 4� UNITED STATES POSTAL J • Sender: Please APR l -1 601 CITYHER TH DELPTM .{ - E SS'c� A First-Eiass.Mail PM "`"'-� - o &Eeesaaa o cm Ua G-10. i;t 2p�\ e, address, and ZIP; -4 in this box BOARD OF HEALTH SALEM, MA 01970 1!' Salem Health Departrnent AA 9 Noith St. Sa;em, Mess. 01970 -39z8 r -.' �{{ruui{{{,lnhiillhnulhl�Ieml�llrtlrlhnitlnn IMPORTANX MESSAGE FOR .�c.//,sLsLLi �OZ �� A. M. DATE TIME P. M. M OF yr PHONE AREA CODE NUMBER EXTENSION D FAX Cl MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU SIGNED, Mr. John Brick Stepping Stone Inn 19 Washington Sq. N. Salem, MA 01970 LOCATION: 19 Washington Sq. N. CITY OF SALEM HEALTH DEPT. ALONG WITH THE BUILDING DEPARTMENT AND THE HEALTH DEPARTMENT, THE LICENSING BOARD HAS SCHEDULED THE YEARLY INSPECTION OF YOUR LODGING HOUSE FOR April 4, 2001 THEY WILL ARRIVE AT 11:15 a.m. — 11:45 a.m. ENCLOSED YOU WILL FIND RELEASE FORMS FOR YOUR TENANT TO SIGN WHICH WILL ALLOW THE INSPECTORS ENTRANCE INTO THEIR AREA. PLEASE MAKE EVERY EFFORT TO HAVE THESE RELEASE FORMS SIGNED PRIOR TO INSPECTION TIME. FULL WINDOW SCREENS ARE REQUIRED FOR ALL WINDOWS THAT OPEN. EXPANDABLE SCREENS ARE NOT ACCEPTED. IF YOU HAVE ANY QUESTIONS PLEASE CONTACT THE LICENSING BOARD AT THE NUMBER LISTED ABOVE. SALEM LICENSING BOARD cc: Health Dept. Bldg. Dept. Fire Prev. lodging inspn otif CITY OF SALEM, MASSACHUSETTS LICENSING BOARD �s .95 MARGIN STREET, P.O. BOX 1042 TEL.,(978) 744-0171 EXT. 130 CLERK Chairman, Harold F. Blake, Jr. JUDY DAVENPORT James M. Fleming Johhnn H. Casey March 20, 2001 11 MAR 2 '1 2001 Mr. John Brick Stepping Stone Inn 19 Washington Sq. N. Salem, MA 01970 LOCATION: 19 Washington Sq. N. CITY OF SALEM HEALTH DEPT. ALONG WITH THE BUILDING DEPARTMENT AND THE HEALTH DEPARTMENT, THE LICENSING BOARD HAS SCHEDULED THE YEARLY INSPECTION OF YOUR LODGING HOUSE FOR April 4, 2001 THEY WILL ARRIVE AT 11:15 a.m. — 11:45 a.m. ENCLOSED YOU WILL FIND RELEASE FORMS FOR YOUR TENANT TO SIGN WHICH WILL ALLOW THE INSPECTORS ENTRANCE INTO THEIR AREA. PLEASE MAKE EVERY EFFORT TO HAVE THESE RELEASE FORMS SIGNED PRIOR TO INSPECTION TIME. FULL WINDOW SCREENS ARE REQUIRED FOR ALL WINDOWS THAT OPEN. EXPANDABLE SCREENS ARE NOT ACCEPTED. IF YOU HAVE ANY QUESTIONS PLEASE CONTACT THE LICENSING BOARD AT THE NUMBER LISTED ABOVE. SALEM LICENSING BOARD cc: Health Dept. Bldg. Dept. Fire Prev. lodging inspn otif JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT NINE NORTH STREET Tel: (978) 741-1800 Fax: (978) 740-9705 In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Owner's Name: John W. Brick Name of Establishment: Stepping Stone Inn Address of Establishment: 19 Washington Square North Type of Establishment: Bed & Breakfast Application Date: 12/28/2000 Restrictions: Permit for Food Establishment 190-01 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2001 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, 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. HEALTH AGENT CITY, OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 M ?9814W ITY OF SftL� H 814 DEPT, JOANNE SCOTT, MPH, RS, CHO NINE NORTH STREET HEALTH AGENT Tel: (978) 741-1800 Fax: (978) 740-9705 2001 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT / NAME OF ESTABLISHMENT_0Qyly�� 14nXs-, 2 TEL # �I7Y %� ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different) OWNER'S TEL # CITY CERTIFIED FOOD MANAG (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME TEL # TYPE OF ESTABLISHMENT "l v "d / FEE check only RETAIL STORE YES 40) $40 RESTAURANT Y NO # seats_ # nonsmoking ✓ $40 BED & BREAKFAST ES NO $40 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT SOFT SERVE YES $5 TOBACCO VENDOR YES 10 NO CHARGE FOR NON-PROFIT (sugas,hurch kitchens) PLEASE INCLUDE COPY OF TAX EXEMPT FORM 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 location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such'mustbe submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief ave filed all state tax returns and paid all state taxes required under the law. f)6 -.V^ 0 ell SCS L�7) 1-1/57 Social Securitv or Federal Identification Number ----------------------------------------------------------49-1 _ _ --------------------------------- Revised 11/21/00 foodap2.adm Check# &Date C57i 4L9' 1 7 w a CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH, RS, CHO May 11, 2000 ` HEALTH AGENT Stepping Stone Inn c/o John Brick 19 Washington Square North Salem, MA 01970 Dear Sir/Madam: NINE NORTH STREET Tel: (978) 741-1800 Fan: (978) 740-9705 In accordance with Chapter 111 Sections 127A and 1276 of the Massachusetts General Laws, 105 CMR 400.00; . State Sanitary Code, Chapter 1: General Administrative Procedures and 105 CMR 410.00: State Sanitary Code, Chapter 11: Minimum Standards of Fitness for Human Habitation, a inspection was conducted of your property located at 19 Washington Square North (Bed/Breakfast) conducted Virginia Moustakis, Sanitarian on May 10, 2000 @ 10:30 a.m. Notice: If this rental unit is occupied by a child or children under the age of 6 years, it is the property owner's responsibility to notify tenants of lead related, reports and tests, and to ensure that this unit complies fully with 105 CMR 460.000: Regulations for Lead Poisoning Prevention and Control. For further information or to request an inspection, contact the Salem Board of Health at 741-1800. You are hereby ORDERED to make a good -faith effort to correct the violations listed on the enclosed inspection s:u. report. Failure on your part to comply within the time specified on the enclosed inspection report will result in a complaint being sought against you in Salem District Court. Time for compliance begins with receipt of this Order. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for said hearing must be received in writing in the office of the Board of Health within 7 days of receipt of this Order. At said hearing, you will be given an opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also' be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports, orders and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. Please be advised that the conditions noted may enable the occupant(s) to use one or more of the statutory remedies available to them as outlined in the enclosed inspection report form. For the Board of Health Reply to oanne Scott Health Agent - Enclosure JS/mfp cc: Frank Preczewski, Fire Prevention Licensing Board Virginia Moustakis Sanitarian Frank DiPaolo, Building Department Harold Blake, Chairman, =`177"-'�77"M 77 77 SALEM HEALTH DEPARTMENT (a , 9 N8rth Sitee i Salem. MA 01970 State Sanitary Code Chapter 11: 105 CMR 410 000 0" J Specified Violation X7 2 Time Minimum Standar&6i AM6 MFku6an Habitation Occupant: V �Ielliil�lllz�, Phone: 7,41- 51cl6 Addresst� �� 4� it 4s'•n I j n' �4j� i[ +N„0. Apt 5 Wr Owner. \/*L Address: Ab M:w 4�s 71 7 -4 *1"" Insp to Timid, Conducted By: 1z 111611fs /,e SIS AccoTpanied By: rl (V O CP PL�F) e v 4fici�patW'Rei'tn spectto'n' Date:' "Aiie" 5 iw P 111 10'4 0" J Specified Violation X7 2 Time ", , , or ,� One or more of the above violations may endanger &materially impair the health, safety and well-being or the occupants(s) Code Enfor6ement Inspector Este es un documento legal imporlante- Puede q I ue Afecte sus derechos. Puede adquiriruna traduccion de esta forma.' V;!., f L fT PL�F) e v Az 40 T- Zz 0. �',UiAt s j. 0. U f, _'k-1 yzde� C2 'Ag A ", , , or ,� One or more of the above violations may endanger &materially impair the health, safety and well-being or the occupants(s) Code Enfor6ement Inspector Este es un documento legal imporlante- Puede q I ue Afecte sus derechos. Puede adquiriruna traduccion de esta forma.' /; SOPS.MADE MESSAGE FO(IMPORTANT` 2 A. DATE %-a 7'fl0 TIME =0U OF PHONE AREA CODE NUMBER EXTENSION ❑ FAX ❑ MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL. WILL FAX TO YOU CAME TO SEE YOU WILL CALL AGAIN WANTS TO MESSAGE fiJ2,p C Q� • '�/ vM ice 1? SIGNED SOPS.MADE SEE YOU RUSH RETURNED YOUR C L WILL FAX TO YOU IN UOOS A. FOR --ktA- 41,-'L pp M DATE P, 16' TIME 8; N5 A.P. M.. �c�M OF IA) PHONE / AREA CODE NUMBER EXTENSION • FAX • MOBILE AREA COCE SUMBER TIMETO CAL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU SIGNED 0m. FORM 4000 MAGE IN U.S.A. Y 's CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT August 10, 2000 John Brick 19 Washington Square North Salem, MA 01970 Dear Mr. Brick: NINE NORTH STREET Tel: (978) 741-1800 Fax: (978) 740-9705 In accordance with Chapter 111, Sections 127A and 127B of the Massachusetts General laws, 105 CMR 400.00: State Sanitary Code, Chapter I: General Administrative Procedures and 105 CMR 410.000: State Sanitary Code, Chapter Il: Minimum Standards of Fitness for Human Habitation, an inspection was conducted of your property 19 Washington Square North in the City of Salem, Massachusetts, Mark Tolman, Sanitarian of the Salem Board of Health on Monday, August 7, 2000 at 2:00 P.M.. The following violations of the State Sanitary Code were noted, as checked ; X CMR 410:600 Storage of Rubbish and Garbage CMR 410:601 Collection of Rubbish and Garbage CMR 410:602 Maintenance of Areas Free From Garbage and Rubbish (A through D) BOH Regulation #7 Description of Violations: See Enclosure(s) 410.600: Storage of Rubbish and Garbage (A) Garbage or mixed garbage and rubbish shall be stored in watertight receptacles with tight -fitting covers. Said receptacles and covers shall be of metal or other durable, rodent -proof material. Rubbish shall be stored in receptacles of metal or other durable, rodent -proof material. Garbage and rubbish shall be put out for collection no earlier than the day of collection. (B)- Plastic bags shall be used to store garbage or mixed rubbish and garbage only if used as a liner in watertight receptacles with tight-fiting covers asrequiredin 105 CMR 410.600(A) provided that the plastic bags may be put out for collection except in those places where such practice is prohibited by local rule or ordinance, or except in those cases where the Department of Public Health determines that such practice constitutes a health problem. For purposes of the preceding sentence, in making its determination, the Department shall consider, among other evidence of strewn garbage, torn garbage bags, or evidence of rodents. (C ) The owner of any dwelling that contains three or more dwelling units, the owner of any rooming house, and the occupant of any other dwelling place shall be responsible for providing as many receptacles for the storage of garbage and rubbish as are sufficient to contain the accumulationbefore final collection or ultimate disposal, and shall so locate them to be convenient to the tenant that no objectionable odors enter any dwelling (D) The occupants of each dwelling, dwelling unit, and rooming unit shall be responsible for the proper placement of her or his garbage and rubbish in the receptacles required in 105 CMR 410.600(C)or at the point of collection by the owner. 410.601: Collection of Garbage and Rubbish The owner of any dwelling that contains three or more dwelling units, the owner of any rooming house, and the occupant of any other dwelling place shall be responsible for the final collection or ultimatedisposal or incineration of garbage and rubbish by means of: (A) The regular municipal collection system; or (B) Any other collection system approved by the Board of Health; or (C) When otherwise lawful, a garbage grinder which grinds garbage into the kitchen sink drain finely enough to ensure its free passage, and is otherwise maintained so as not to create a safety or health hazard; or (D) When otherwise lawful, a garbage or rubbish incinerator located within the dwelling which is properly installed and which is maintained so as not to create a safety or health hazard; or (E) Any other method of disposal which does not endanger any person and which is approved in writing by the Board of Health (see 10410.840) t 1 4DCITY OF SALEM HEALTH DEPARTMENT S, . y/ Nine North Street '�.,!,•% ° Salem, Massachusetts 01970 410.602: Maintenance of Areas Free From Garbage and Rubbish (A) Land: The owner of any parcel of land, vacant or otherwise, shall be responsible for maintaining such parcel of land in a clean and sanitary condition and free from garbage, rubbish, or other refuse. The owner of such parcel of land shall correct any condition caused by or on such parcel or its appurtenance which affects the health or safety and well-being of the occupants of any dwelling or of the general public. (B) Dwelling Units: The occupant of any dwelling unit shall be responsible for maintaining in a clean and sanitary condition and free of garbage, rubbish, other filth or causes of sickness that part of the dwelling which s/he exclusively occupies or controls. (C) Dwellings Containing Fewer Than Three Dwelling Units: In a dwelling that contains fewer than three dwelling units, the occupant shall be responsible for maintaining in a clean and sanitary condition free of garbage, rubbish, other filth or causes of sickness the stairs or stairways leading to her or his dwelling unit and the landing adjacent to her or his dwelling unit if the stairs, stairways, or landing are not used by another occupant. (D) Common Areas: In any dwelling, the owner shall be responsible for maintaining in a clean and sanitary condition free of garbage, rubbish, other filth or causes of sickness that part of the dwelling which is used in common by the occupants and which is not occupied or controlled by the occupant exclusively. (1) The owner of any dwelling abutting a private passageway or right-of-way owned or used in common with other dwellings or which the owner or occupants under her or his control have the right to use or are in tact using shall be responsible for maintaining in a clean and sanitary condition free from garbage, rubbish, other filth or cause of sickness that part of the passageway or right-of-way which abuts her or his property and which s/he or the occupants under her or his control have the right to use, are in fact using, or which s/he owns. Board of Health Regulation #7 Section 3.10: Containers or Bundles of Household and Ordinary Commercial Waste. Garden and Lawn Waste: These shall be placed at the outer edge of the sidewalk appurtenant to the premises of the owner not later than 7:00 a.m. on the day of collection and not before 6:00 p.m. on the day preceding the day of collection, and shall be removed from the sidewalk on the same day as emptied. No commercial establishment shall place or cause to be placed more than four barrels or other containers of ordinary commercial wastes or any extraordinary commercial or industrial wastes or tree waste upon any sidewalk or way for disposal. You are hereby Ordered to make a good faith effort to correct these violations within 24 (twenty four) hours of receipt of this notice. Failure on your part to comply within the specified time will result in a complaint being sought against you in Salem District Court. Should you be aggrieved by this order, you have the right to, request.a hearing before the Board of Health. A request for said hearing must be received in writing in the office of the Board of Health within 7 Days of receipt of this order. At said hearing, you will be given an opportunity to be heard and to present witness and documentary evidence as to why this order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports, orders, and other documentary information in the possession of this Board, and that any adverse parry has the right to be present at the hearing. One or more of the above violations constitutes a condition which may endanger or materially impair the health or safety and well-being of the occupant(s) or the general public. If you have any questions, kindly contact this office at (508) 741-1800. For a Board of Health Reply to: iJoanne Scott tt�—1 Mark Tolman Health Agent Sanitarian Cc: Councillor R. Flynn JS/sjk c -g -trash �Q CITY OF SALEM HEALTH DEPARTMENT Nine North Street Salem, Massachusetts 01970 Trash Letter Violations To: Tolnr Address: i9gSti,n= ppe Aer+F City / State: �a►e rna o,9,o Property At: ry uASh +en so :are 'nor+Ik Date: s�u� Time: Violation Numbers: ✓ 600: Storage of Rubbish and Garbage 601: Collection of Rubbish and Garbage 602: Maintenance of Areas From Rubbish and Garbage B.O.H. Regulation #7 Complaint -,Due tn5na f cn x' ?eAecl /IuMereus -#a<i b9s 1w rircvx/ d ed,� 1 / /w -/ y ras{ tds MSS i!60/PeN ei FieP++ e12Viy n.x erlJ Spore of ,p All t/AS� w si• die 5kee/cri Aorre& wd-1 Cowers c.w� nit Oji• Foe Ae- n• L% de6ee picly. A Menel4r� c; iz z oa l r: cc: Mayor's Office Fire Prevention Building Inspector Ward CouncillorRpqing i%jin N.I.T.F _ Other_ CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH, RS, CHO NINE NORTH STREET HEALTH AGENT Tel: (978) 741-1800 Fax: (978) 740-9705 COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to:, Owner's Name: John W. Brick Name of Establishment: Stepping Stone Inn Address of Establishment: 19 Washington Square North Type•of Establishment: Bed & Breakfast. Application Date:_.09/06/2000 Restrictions: Permit for Food Establishment 289-00 Frozen Desserts/Ice Cream Permit for'the Sale of Tobacco Products These Permits Expire December 31, 2000 Thisrpermit is not transferable and must be reissued upon change of ownership or location. In accordance with the State Sanitary Code, all plans of renovations, improvements, equipment changes must be approved by the Health Department: HEALTH AGENT CITY OF SALEM BOARD OF HEALTH Salem,. Massachusetts 01970-3928 JOANNE SCOTT, MPH, RS, CHO NINE NORTH STREET HEALTH AGENT Tel: (978) 741-1800 Fax: (978) 740-9705 2000 APPLICATION FOR PERMIT TOp OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT cAA—te'l q . rzg TEL# J�7Y741/W900 ADDRESS OF ESTABLISHMENT f/CQ1 A/ )-,AA 16 Vh MAILING ADDRESS (if different) OWNER'S NAMEqcm TEL#. ADDRESS CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON TEL ESTABLISHMENT'S DAYS &HOURS OF OPERATION TYPE OF ESTABLISHMENT RETAIL STORE YES RESTAURANT YES ADDITIONAL PERMITS MAKE FROZEN DESSERTS YES TOBACCO VENDOR YES NO NO # seats_ # nonsmoking_ NO NO FEE check only $40 $40 $5 $10 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. 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 certify under the pains and penalties of perjury that I, to my best knowledge and belief,�Pve filed all state tax returns and paid all state taxes required under the law. FFR_s Social Security or Revised 10/20/98 foodap2, adm Check#8 Dati SEP' 5 2000 CITY OF SALEM HEALTH DEPT. CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH„RS, CHO HEALTH AGENT April 21, 2000 Stepping Stone Inn 19 Washington Square North Salem, MA 01970 Dear Owner/Manager: The Board of Health, Building and Fire Departments are scheduling yearly inspection of all establishments licensed as rooming houses. The Salem Licensing Board will review inspection and reinspection reports in accordance with its license renewal procedures. NINE NORTH STREET Tel: (978) 741-1800 Fax: (978) 740-9705 The inspection will include dwelling units and common areas, therefore each tenant must be present or he/she must sign the enclosed release form which will allow the inspectors to enter the unit. Your establishment at 19 Washington Square North has been scheduled to be inspected on Wednesday May 10, 2000 at 11:00 am. Thank you for your anticipated cooperation. Sincerely, For the BoardofHealth oan9 ne Scott Health Agent cc: Frank DiPaolo, Inspector of Buildings Charles Latulippe, Fire Prevention Harold Blake, Chairman, Salem Licensing Board CITY OF SALEM, MASSACHUSETTS EFF o BOARD OF HEALTH e 6 ,��V ®� 120 WASHINGTON STREET, 4TH FLOOR 0 SALEM, MA 01970 DEC. , 1 ZQQB TEL. 978-741-1800 n 7 FAx978-745-0343C'JAF,nFSAI M Kimberley Driscoll www.SALEM.COM ` uF H Mayor JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT`/ IGA_ ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different) W:E? EMAIL -- Business':- vwnel s -IA. OWNER'S NAMENI W R/2!C K TEL# -)W I 4?uo ADDRESS 19 ll n bT do rYl '/JLYhwn bYl a 40/ 9 70 / ciTY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL #. DAYS OF OPERATION Monday Tuesday Wednesday ThursdaY Friday Saturday Sunday HOURS OF OPERATION Please write in time of day. IFer example Ilam llpml TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 - -------- ---------------------- - RESTAU-RAN-- T YES NO - - ---------- -- less than 25 seats -- ---------- =$100 25-99 seats =$150 more than 99 seats =$200 - ----------- --- -- ---- BED/BREAKFAST YES NO $100 ------ -- --------------- - - ------------------------- ----- ------- -`---- ... ----- ADDITIONAL PERMITS ------ --------- -------- ------------ MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT (such as church kitchens) YES NO $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 prominent location in the Establishment. In accordance with the State Sanitary Code,lbefore 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 certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filet.] all state tax retu,n�Jand paid all state taxes'required under the law. r /A� 1' 1�r &C l — Ole H k�q— 5U — N1,907 aliire Date Social Security or Federal Identification Number -------- ------------------------ -- Revised 11/13/06 FOODAP2007.adm d Check# & Date 3.065 12 Lor O $ Food/Retail Establishment Permit DATE PRINTED: 12/20/2006 ESTABLISHMENT NAME: File Number: BHF -2004-000326 Stepping Stone Inn 19 Washington Square North Salem MA 01970 LOCATED AT: 0019 WASHINGTON SQUARE NO SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2007-0131 Dec 20, 2006 Dec 31, 2007 $100.00 ESTABLISHMENT PERMIT EXPIRES Total Fees: $100.00 31, 2007 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 6 of 8