The URL can be used to link to this page

SUSHI GARDEN - ESTABLISHMENTS (3)a _ I, -. } _ �� ' Foods Research (617) 442-3322 (617)427-3322 LABORATORIES, INC. FAX (617) 442-2013 ��! 130 NEWMARKET SQUARE -BOSTON, MA 02118 Report Date: November 28, 2011 Lab Code: 11327-8 Date Submitted: 11-23-11 Sushi Garden 99 North Street Salem, MA 01970 SUBJECT: Equilibrium pH Analysis of Sushi Rice validation / verification of established recipe RESULTS pH (@ 250C): 3.95 21CFR114.90 A.O.A.C., 17th edition, 2000. Respectfully submitted, Andre J. Fontaine Laboratory Director Over 50 years --Dedicated to Quafity and Se"ice KIMBERLEY DRISCOLL MAYOR LARRY RAMDIN, RS/REHS, CHO, CP -FS HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4r" FLOOR TEL. (978) 741-1800 FAX (978) 745-0343 LRAMDINQSALEM.COM 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Wenwei Lucky. Inc. d/b/a Sushi Garden TEL # 978-744-9998 ADDRESS OF ESTABLISHMENT 99 North St, Salem, MA 01970 FAX # MAILING ADDRESS (if different) EMAIL - Business': Website: TEL # 603-264-6705 ADDRESS 194 Sydney Street Dorchester MA 02125 STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) Pena Xu 10iti4 Y�nyw FarIR CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON Pna Yvc HOME TEL # d03-214- 670S DAYS OF OPERATION 1 Monday Tuesday = Wednesday Thursday Friday Saturday Sunday. HOURS OF OPERATION 11.30 am 11:30 am - 11:30 am - 11:30 am - 11:30am - i 11:30am - 12 noon - Please wdte in time of day. 1 g 30 pm 930 pm 930 pm 9:30 pm ]0:30 pm 10:3D pm 9:30 pm For example 11am-11 m TYPE OF ESTABLISHMENT RETAIL STORE YES NO RESTAURANT QYfS NO (Outdoor Stationary Food Cart $210) YES FEE (check onto) less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 .................................. ---- less than 25 seats 25-99 seats more than 99 seats =$140 =$280 =$420 ------..... $100 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 returnsd paid allstatetaxes required under the law. p 7„ him Gj X 0J11i1 �l� 4s-2Lh01-Z Signatufe l Date Social Security or Federal Identification Number Updated 5/23/11 FOODAP201 Ladm Check4 & Dat J.1 $ WENWEI LUCKY, INC. d/b/a SUSHI GARDEN 99 North Street Salem, MA 01970 Date: May 31, 2011 Board of Health City of Salem 120 Washington Street Salem, MA Dear Sir or Madam; Wenwei Lucky, Inc., d/b/a Sushi Garden at 99 North Street, Salem, Massachusetts is requesting a variance for the exemption of acidified rice (sushi rice) as a potentially hazardous food specified under § 3-502.11. The sushi rice contains vinegar as a means of food preservation in addition to flavor enhancement. The facility has a HACCP plan which is submitted to your office herewith. That planwill be maintained at the restaurant and will be made available for your review. If you have any questions, please don't hesitate to contact the undersigned. Sincerely, Peng Xu, president =61 SUSHIGARDEN 99 NORTH STREET SALEM, MA 01970 HACCP PLAN FOR THE PRODUCTION OF SUSHI RICE TABLE OF CONTENTS Page I - Signature Sheet (HACCP cover sheet) Page 2 - HACCP Plan for the Production of Sushi Rice (narrative summary) Page 3 - Flow Diagram for the Production of Sushi Rice Page 4 - HACCP Master Plan Sheet for the Production of Sushi Rice Page 5 - Standard Operating Procedure for pH Measurement Page 6 / 7 - pH Log (master sheet & sample sheet) Page 8 - Summary of Employee Training Elements for the Production of Sushi Rice Page 9 / 10 - Employee Training Log (master sheet & signed sheets) Page 11 - Laboratory Results Supplement — Guidelines for the Safe Preparation of Sushi SUSHIGARDEN 99 NORTH STREET SALEM, MA 01970 HACCP PLAN FOR THE PRODUCTION OF SUSHI RICE PURPOSE: Cooked rice maintained in the temperature danger zone (41- 140°F) is susceptible to the outgrowth of spore -forming bacteria such as Bacillus cereus. Because the functionality of sushi rice requires its use at room temperature, the rice must be acidified to a pH value below 4.6 to inhibit the growth of these spore -forming bacteria. This HACCP plan addresses proper acidification of rice for room temperature storage and use. RECIPE Equipment: 5 -gallon plastic container for vinegar mixture, measuring cups, rice cooker, shallow container for cooked rice, spoon or paddle to spread rice, rice warmer Ingredients: dry rice, water, vinegar, sugar, salt 1. Combine 3,200 grams of dry rice with 3 liters of water in the rice cooker and cook until done (approximately 30 minutes). One recipe measures approximately 200 cups of cooked rice. 2. A vinegar mixture using 12 liters Fuji Rice Vinegar (4.2% acidity), 4 liters sugar, and 16 ounces of salt is made and.stored under refrigeration in a covered, plastic container. Subsamples may be removed from the container and stored at room temperature for usage during the day. 3. Cooked rice (hot) is removed from cooker and placed in a shallow container. Using a spoon or paddle, the rice is spread to a depth of 4 inches or less. 4. 32 fluid ounces of vinegar mixture is added to one batch of cooked rice. 5. The mixture is thoroughly stirred to distribute the vinegar mixture and facilitate cooling. 6. The pH is measured immediately according to established procedures. (See: HACCP Master Plan, Standard Operating Procedures for pH Measurement of Sushi Rice, Manufacturer's pH Instruction Manual (Hanna Instruments), Summary of Training Elements for the Production of Sushi Rice) 7. Shelf -life: Same Day Use (maintained at room temperature.) Discard unused rice at the end of the day. 8. The equilibrium pH value of sushi rice, formulated according to the above listed formulation and procedures, was validated by an independent laboratory and found to be 4.1 or less (see attached). Sushi rice acidification shall be verified according to. the HACCP Master Plan. 8. This HACCP plan shall be reviewed a minimum of once per year or as needed by the PIC and shall be signed and dated to document this review. (see cover sheet). SUSHI GARDEN 99 NORTH STREET SALEM, MA 01970 I, Peng Xu, president of Wenwei Lucky, Inc. d/b/a Sushi Garden, initially present and implement this HACCP PLAN FOR THE RPODUCTION OF SUSHI RICE. marize This sheet must be signed and dated by a PIC after any reassessment or change to the HACCP Program or a minimum of once per year. Signature: Date : SUSHI GARDEN 99 NORTH STREET, SALEM, MA 01970 Vinegar Salt Sugar 4.2% Acidity Vinegar Mixture I Combining of Dry for Sushi Rice Rice with Cold Water Acidification of ------------ Cooked Rice F CSP Sub -sampling of SOP FOR pH MEASUREMENT Cooking of Rice Refrigerated i Cooling of (Rice Cooker) i Sub -sample i Storage of i I Sample Preparation Mixture Transfee of Rice to Tap Water Sub -sample) i a Shallow i pH Measurement of PH Value < 4.6 Container Acidification of ------------ Cooked Rice F CSP Sub -sampling of SOP FOR pH MEASUREMENT Sushi Rice i i Cooling of i Sub -sample i i I Sample Preparation Calibration of pH (Slurry of Tap Meter Water and Tap Water Sub -sample) i i pH Measurement of PH Value < 4.6 Slurry i i i i Rice Warmer -------------------------- i pH Value >4.6 i Holding of i Acidified Rice ------------ Discarding of Rice at End of Day SUSHI GARDEN, 99 NORTH 51 REE I, HACCP PLAN MASTER SHEET FOR THE PRODUCTION OF SUSHI RICE SALEM, MA 01970 Critical Hazard Controlled Critical Lindt(s) Monitoring Corrective Action Records Verification Control Point PRODUCTION Growth of Pathogens pH value of finished What — sushi ripe For rice made within 2 pH log 1. Calibration OF SUSHI (spore-formers sushi rice < 4.3 @ 25°C hours, if pH value is greater of pH meter RICE including if measured within 2 How - A calibrated pH than 4.3 and < 4.6, add more Corrective daily prior to Bacillus cereus) hours < 4.6 if tested meter as per Standard vinegar until a value below Action to be use. (Acidification to after 2 hours of Operating Procedures for 4.3 is achieved - Record new recorded on exempt rice as a preparation pH measurement value pH Log 2. Record PHF using a Review by validated Recipe validated at a Freauencv — each batch For rice with a pH value > PIC recipe) targeted pH < 4.1. 4.6, if made greater than Records shall performed " Who — sushi chef or one hour frommeasurement, be daily. designated employee discard rice. maintained for 30 Days 3. pH of rice To prevent recurrence: tested by a Verify use of correct recipe. food Verify proper use of pH laboratory meter, including buffer annually or integrity, electrode integrity, when daily pH and a fully charged battery levels are Verify adherence to SOP" for consistently pH measurement. higher than the laboratory validated pH measurement. 4. HACCP plan reviewed a minimum of annually or as needed by PIC (Signed and dated by PIC STANDARD OPERATING PROCEDURE FOR n77 MEASUREMENT SUSHI GARDEN, 99 NORTH STREET, SALEM, MA 01970 based upon the use of UAKTON PART I - CALIBRATION PROCEDURE 1. Switch unit on (ON/OFF button). 2. Dip electrode into chosen buffer (pH buffer 4 is suggested). DO NOT immerse above color band. 3. Press the CAL button to enter calibration mode. The "CA" flashes on the display. Then, a pH value close to the buffer value will flash. 4. After at least 30 seconds (about 30 flashes) press the HOLD/CON button to confirm calibration. The display will show "CO" and then switch to the buffer value reading. 5. Press the "CAL" button to exit. 6. Rinse the electrode in tap water. BUFFER NOTE: Make sure buffer has not passed expiration date. Keep the buffer covered and properly stored when not in use. Maintain buffer at room temperature. Keep away from bright light. Do not immerse probe into main container of buffer. Sub -sample buffer. Do not return sub -sample (used) buffer into main container. PART Z - PH MEASUREMENT OF SAMPLE 1. Place 2 tablespoons of finished sushi rice (as per formulation) into a clean container and cool to room temperature. 2. Add 2 teaspoons of room temperature tap water. 3. Mash the rice and water mixture with a clean spoon until a slurry is created. 4. Using a calibrated pH meter (see procedure above), measure the sample by dipping the electrode about 2 to 3 cm into the liquid portion of the slurry. Stir and let the reading stabilize. 5. Press HOLD/CON to freeze the reading. This is the equilibrium pH. Record this value on the pH log. (NOTE: The complete record should include the date, time, pH value and initials of the person measuring the pH). 6. Rinse the probe in tap water and blot dry with a clean, dry cloth or paper towel. 7. Tum off the meter and replace the cap on the probe tip. Store properly. NOTE: Refer to Manufacturer's instruction for troubleshooting and replacing the batteries. X14 / 1 � C SUSHIGARDEN 99 NORTH STREET SALEM, MA 01970 pH Log / Calibration Log The pH meter shall be calibrated according to established procedures and at a frequency established in the HACCP Master Plan. Follow the Standard Operating Procedure for pH Measurement Date/ Time / Initials for the performance of pH calibration Date Time pH of Sushi Rice Corrective Action (if required) Initials of person taking pH PIC Daily Record Review (Verification) Date / Initials J(� S (I P <- ;. NOTES: SUSHIGARDEN 99 NORTH STREET SALEM, MA 01970 pH Log / Calibration Log The pH meter shall be calibrated according to established procedures and at a frequency established in the HACCP Master Plan, Follow the Standard Operating Procedure for pH Measurement Date/ Time / Initials for the performance of pH calibration Date Time pH of Sushi Rice Corrective Action (if required) Initials of person taking pH PIC Daily Record Review (Verification) Date / Initials NOTES: SUSHIGARDEN 99 NORTH STREET SALEM, MA 01970 SUMMARY OF EMPLOYEE TRAINING ELEMENTS FOR THE PRODUCTION OF SUSHI RICE 1. All employees involved in the production of sushi rice shall be trained in proper personal hygiene including: • proper hand -washing (procedures and frequency) • proper hair restraints, clothing (uniform and/or use of apron) • removal of jewelry during production • proper use of gloves and no bare hand contact of ready -to -eat products 2. All employees involved in the production of sushi rice shall be informed of their responsibility to report to the PIC when they are experiencing symptoms such as nausea, vomiting, diarrhea, fever, sores, or any other symptoms that may affect the safety of food. 3. All employees involved in the production of sushi rice shall be trained in the proper use of applicable food contact surfaces including: • proper cleaning and sanitizing procedures • proper storage procedures of equipment / ingredients • proper handling procedures of equipment / ingredients • proper procedures for preventing cross -contamination. • proper use and storage of wiping cloths 4. All employees involved in the production of sushi rice shall be trained on the elements of the HACCP Plan for the Production of Sushi Rice including: • proper cooking procedures • proper formulation of sushi vinegar mixture • proper acidification of sushi rice through cooked rice to vinegar mixture ratio control and mixture distribution • proper sub -sampling procedures of sushi rice for pH measurement • proper preparation of sushi rice for pH measurement • proper storage and use of sushi rice • proper shelf -life of sushi rice 5. All employees involved in the production of sushi rice shall be trained on the Standard Operating Procedure for pH Measurement including: • proper calibration procedures • proper pH measurement of sample • proper handling procedures of buffer / pH meter • proper storage procedures of buffer / pH meter • current HACCP critical limits established in the plan • current HACCP monitoring frequency established in the plan • proper HACCP corrective actions when a deviation for a critical limit occurs • proper HACCP verification procedures / frequency • proper retention of records for 30 days (Refer to the U.S. FDA Food Code or local regulations, as applicable.) SUSHI GARDEN 99 NORTH STREET SALEM, MA 01970 EMPLOYEE TRAINING LOG The employees listed below have been properly trained in correct procedures for the production of sushi rice as per the SUMMARY OF EMPLOYEE TRAINING ELEMENTS FOR THE PRODUCTION OF SUSHI RICE (in the HA CCP PLAN) EMPLOYEES NAME EMPLOYEE SIGNATUREI TRAINING DATE This sheet must be signed and dated by the employee upon completion of training. SUSHIGARDEN 99 NORTH STREET SALEM, MA 01970 SUPPLEMENT (NOT PART OF HACCP PLAN) GUIDELINES FOR THE SAFE PREPARATION OF SUSHI 1. The HACCP Plan for the production of Sushi Rice shall be followed. (see HACCP plan including Training Elements for the Production of Sushi Rice). Proper records shall be maintained for a minimum of thirty days. 2. All food shall be obtained from an identifiable, approved sourc. All seafood shall come from a source that operates under a HACCP plan. 3. Documentation from fish supplier shall be on file regarding proper freezing of parasitic species of fish. FDA requires that fish be frozen at —4°C for 7 days or at —35°C until solid and stored at -31'F for 15hours or -4°F for 24 hours in order to ensure parasitic destruction. 4. Proper temperature control of fish and potentially hazardous ingredients during receipt and storage shall be maintained. All potentially hazardous foods shall be received at or below 41 °F. Refrigeration units shall operate to ensure food can be maintained at or below 41 °F. Frozen products shall be thawed under refrigeration at or below 41'F. All sushi and related ingredients shall be properly handled as per the "No bare hand contact with ready -to -eat foods" policy established in the Food Code. Sushi chefs shall employ the use of gloves. 5. Cross -contamination shall be prevented through separation of raw and cooked ingredients, cleaning and sanitizing of equipment and utensils between uses, and the proper covering of the bamboo mat. Plastic wrap should be changed at least every four hours or after use on raw fish if the mat is to be used again on cooked product. Ideally, a separate set-up (bamboo mat, knife and cutting board) is suggested for raw versus cooked sushi. 6. Each ingredient should be kept in a separate container and held at proper temperatures. Additionally, ensure that all ingredients and utensils are properly stored in designated locations and protected during storage. 6. Consumer Advisory statements required as per the Food Code 3-603.11 shall be properly posted to advise the consumer of increased risk of foodborne illness due to the consumption of raw fish. A PIC (Person -in -Charge) shall be present during all hours of operation during which sushi is produced. 49'-9" 25' _ _ Ewsrowewa wµ,.ronEww EXIST STOREFR P•1 :. tee.-_��--,.9 . KITCHEN `��'°'� t?� *F�� '� puLL. Cb .94y(au 9 Ery,, ffT „• P Ewsr .' I -• — — — I iNEW co,wrEn I ` EX. 716 \'I^.�_'--�Ij EXIST 5u� I A I VV�u I' RM ACLESSIBIE COUNIEq Elisa. I n.� B LIcbT I aeN C e� 1I 1P I IMIT OF WORK oo'ROPOSED FLOOR PLAN 1 SCALE: 1/4” = 1'-0" .M 7'-S" I Gam' 4 ®eNQubn r M Bo ..—_ - .�...,.- EXIST OTHROOM Eweroa,�eeewurro rtaww ,r EQUIPMENT LEGEND HAND SINK SUSHICOUNTER SUSHI DISPLAY CASE ELEC RICE COOKER UNDERCOUNTER REFRI WASTE RECEPTICLE PENDANT LIGHTS W/SCATTER PROOF LIGHT BLUBS P.O S. BY CLIENT CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name Date of Date The above-named person is hereby issued this certificate for completing an alleigen awareness training program recognized by the Massachusetts Department of Public Health in accordance with 105 CMR 590.009(G)(3)(a). This certfcate will be valid for fve (S).years from date of completion. M OF 7j7'°. No mp Issued By: IIIIIa NATIONAL 4� RESTAURANT ASSOCIATION, Massachusetts Restaurant Association 800.765.2122 333 Turnpike Road; Suite 102 eR ..restaurant.org Southborough, MA 01772 508-303-9905 w .marestaurantassoc.org v*� Table Number 2 Pieces Nigiri Kappa (Cucumber) Roll (Seaweed Outside) Sashimi f- pieces Add $1.50 Item Prices Sushi Sashimi Tamago (Egg) 2.95 Vegetable Dragon Roll 5.75 *Maguro 3.50 Vegetable Tempura Rall (5 pcs (Tuna) Deep fried vegetable. Veggie Roll (5 pCs) Avocado, lettuce, cucumber & yellow pickle. *Sake 3.50 Maki is cut in 6 pts • Hand roU is in ice cream cone shape. (Salmon) Add Cucumber 504 • Add Avocado 50¢ • Add flying fish lice 504 • Spicy Salmon Maki Hamachi 3.50 4.50 • Crab Roll (Yellowtail) • Negihama Maki Yellowtail w. station 3.95 • Spicy Scallop Maki *Kanikama 2.95 4.50 Spider Maki Soft shell crab tobiko,avocado (Crab Stick) Crazy Maki Shrimp tempura, tobiko, avocado 4.50 • Spicy Tuna Maki Ebi (Shrimp) 2.95 4.50 • California Maki w. Tobiko Unagi (Eel) 2.95 4.25 Una-Kyu Maki eel & cucumber *Tako 2.95 3.95 • Sake Maki Salmon roll (Octopus) •Futo Maki cucumber, avocado, kani, tamago, sp nach, tobiko 3.95 Boston Maki Eb., cucumber, lettuce, asparagus, mayo ant avocado. Smoked 2.95 4.50 • Tuna Mango Maki Salmon Mango Shrimp Maki 3.95 Shrimp w. Avocado Maki * Tobiko 3.95 4.50 Alaskan Maki rooked salmon &avocado (Flying Fish • California DeluxeTuna, Cucumber, avocado, tobiko 4.50 Roe) *White Tuna 2.95 *Tai (Red 2.50 Snapper) Inari (Tofu 2.50 Skin) A El Wmztabl4z Roll Avocado Roll (Seaweed Outside) 2.75 Kappa (Cucumber) Roll (Seaweed Outside) 2.75 Avocado and Cream Cheese Roll 2.95 Avocado and Cucumber Roll 2.95 Sweet Potato Roll (Tempura Sweet Potato) 2.75 Vegetable Dragon Roll 5.75 Avocado, cucumber and yamagoba, topped w. avocado, spici mayo and sesame seed. Vegetable Tempura Rall (5 pcs 3.95 Deep fried vegetable. Veggie Roll (5 pCs) Avocado, lettuce, cucumber & yellow pickle. 3.95 Maki ,& Mand Rolls Maki is cut in 6 pts • Hand roU is in ice cream cone shape. Add Cucumber 504 • Add Avocado 50¢ • Add flying fish lice 504 • Spicy Salmon Maki 4.50 • Spicy Yellowtail Maki 4.50 • Crab Roll 3.50 • Negihama Maki Yellowtail w. station 3.95 • Spicy Scallop Maki 4.50 Salmon Tempura Cucumber, Avocado, Tobiko 4.50 Spider Maki Soft shell crab tobiko,avocado 5.95 Crazy Maki Shrimp tempura, tobiko, avocado 4.50 • Spicy Tuna Maki 4.50 California Maki Crabstick, Cucumber, Avocado 4.50 • California Maki w. Tobiko 3.95 Una -Avocado Maki eet & avocado 4.25 Una-Kyu Maki eel & cucumber 4.25 • Tekka Maki Tuna rat 3.95 • Sake Maki Salmon roll 3.95 •Futo Maki cucumber, avocado, kani, tamago, sp nach, tobiko 3.95 Boston Maki Eb., cucumber, lettuce, asparagus, mayo ant avocado. 4.50 Philly Maki ON, cucumber, lettuce, asparagus, mayo and avocado. 4.50 • Tuna Mango Maki 4.25 Mango Shrimp Maki 3.95 Shrimp w. Avocado Maki 3.95 Shrimp Tempura Maki 4.50 Alaskan Maki rooked salmon &avocado 3.95 • California DeluxeTuna, Cucumber, avocado, tobiko 4.50 §p�7,Cial Mbk'i Dragon Maki 6.95 California mold w. eel, avocado on top. • Rainbow Maki 6.95 Kari, ebi, tobiko w. fish on top. Caterpillar Maki 6.95. Eel, cucumber, tobiko w. avocado on top. _ Scorpion Maki 6.95 Eel, cucumber, avocado, tobiko, shrimp on top. ; • Volcano Maki � d 6.95 Crab meat, avocado, caviar, eel, spicy mayo and spiry tuna on top. Crispy Eel Roll 7.75 Eel, avocado, cucumber, tobiko and tempura bitsw. mayc. A boston favorite. Crazy Dragon a 8.95 Kanikama, shrimp tempura, tobiko, mango and Team cteese topped w.F avmado and house spiry honey sauce. • Seaweed Maki 8.9 - Spicy salmon w. seaweed on top. • 007 Maki9.9E. Spicy crunch tuna topped w. salmon and eel spiry mayo, eel sauce, and sesame seed. • Crary Salmon Maki ` ® '• ,9.95 SpicyCrunch salmon w. avocado topped w.satmorispiq mayo, and j sesame seed. • Sakura Maki 9.9s �.. Shrimp tempura avocado topped w. salmon, tuna, tooiko art sesame seed. .s. All dishes served w choice of ONE appetaer and one an of soda. Japany,6�z `flppztiz�zr6 Chc ice of Pork Fried Rice or While Rice BONELESS SPARERoss, CnAB RANGOON, CHICKEN TERIYAKI, Add an Appel¢erfrom helowfor an aiditional $1, two appetite, max. (Lunch Time Only) EG3 ROLL, CHICKEN WING, CRICEEN FINGER, BEEF TERIYAKI, BONELESS SPARER®s, CRAB RANGOON, CHI:EEN Tasorxr L SPRING ROLL SC 1. • General Gau's Cticken (7 Drys A Week 1130am. 0:00 pm Except Christmas Eve, Chdstmae, 4ew Year Eve and New Year Day) After 3:00pm, Extra $2.00 7.95 LM 1. Lo Merl, Chicken or Beef 5.95 LM 2. Chow Mein, Chicken or Beef 5.95 LM 3. -Curry, Chicken or Beef 5.95 LM 4. Walnut Shrimp 6.95 LM 5. Cashew Shrimp w. Pineapple 6.95 LM 6. Lobster Sauce w. Shrimp 6.2 5 LM 7.- General Gau's Chicken 6.25 LM B. Beef or Chicken Broccoli 5.95 LM 9. Mixed Vegetable, Ct cken or Bee' 5.95 LM 10. Chicken w. Sesame 6205 LM11. Moo Goo Gai Pan 5.95 LM 12.- Orange Flavored Beef or Chicken 6.25 LM13. Pork Fred Rice w. 2 Appetizer 6.25 LM' 4.- Szechuan Spiced Chicken or Beet 5.95 LM 15. Beef w. Mushroom 5 .�5 IS FREE CALIFORNIA ROTI W. ANY $TO PURCHASE LUNCH TIME ONLY COMBINATION Served Al Day Pick Any Three Appelizels, Served w One Can of Soda, Pak Fnad Rice or Polk Lo Mein EGG ROLL, CHICKEN WING, CEICKEN FINGER, BEEF TERIYAKI, BONE- LESS SPARERIES, CR.11I RANGOON, CHICICN TERIYAKI, SPRING BOLL, FRIED SHRIMP, SWEEI' & SOUR CHIC12N OYSO All D'¢has Served w Choice of On: Appetizer and One an of sada Japany,6�z `flppztiz�zr6 EGG ROLL, CHICKEN WING, CHICKEN FINGER, BEEF TERIYAKI, BONELESS SPARERoss, CnAB RANGOON, CHICKEN TERIYAKI, Gyoza ` SPRING ROLL, FRIED SHRDRP. SWEET Sr SOUR CHICKEN Sat. SC 1. • General Gau's Cticken 7.95 SC 2. Sesame Chicken 7.95 SC 3.- Kung Pao Chicken, Beef, or Shrimp 7.95 SC 4.- Szechuan Spicy Chicken, Beef or Shrimp 7.95 SC 5. Chicken w. CashEW Nuts 7.95 SC 6. Baby Shrimp w. Tofu 7.95 SC 7. Beef w. String Bean 7.95 KIDS MEAL (SERYID W. ONE CAN Of fODA) Spicy Naruto RM1. Mini Pork Dumplings w. Chicken Wings & Fries 5.00 RM2 4Chicken Fingers & Chicken Wings w. Fries 5.00 RM3. Crab Rangoon, Boneless Spareribs 8 =ries 5.00 salad Sal. Japany,6�z `flppztiz�zr6 3.75 Al. Gyoza ` 3.50 Sat. Meat and vegetable dumpling served steamed or pan fried. 3.75 A2. Kani Shumai 3.53 style mayonnaise. Crab meat do mpling served steam=_d or pan fried. Sa3. A3. Edamame 3.50 ' Boiled greErsoy beans, lightly salted. Sao. A4. Spicy Naruto 4.50 Fresh seaweed w. spicy crispy tuna 5 pieces of crab stick, shrimp tobiko, avocado & spicy mayo. Rolled w. Sa5. Seaweed w Spicy Salmon thinly sliced :ucumber roll. salad Sal. Ika Salad 3.75 Blended squid with seaweed. 1 Sat. Avocado Salad 3.75 Avocado salad! w. flying fish roe, cucumber and crab stick in Japanese style mayonnaise. Sa3. 'Seaweed Salad 3.75 :Fresh seaweed seasoned in sesame. Sao. Seaweed Salad w. Spiry Tuna 4.50 Fresh seaweed w. spicy crispy tuna Sa5. Seaweed w Spicy Salmon 4.5C Fresh seaweed w. spicy crispy salmon. Sa6. Side Salad 1.95 3reen garder salad w. homemade special ginger sauce. Sal. Seaweed w. Spicy Hamachi 4.50 =resh seaweed w spiry crispy yellowtail. Japan�zn, Noodl, Jrl. Chicken, beef or vegetable Udon Soup 7.75 Jr2. Seafood Ucon 7.95 ' Jarawn entrzQs All served w. soup, salad, White rice. . Tender meats dipped in a light bread crumb batter, and then deep fried to perfection. El. Tonkatsu (Fork) 9.95 E2. Chicken Katsu 9.95 T9,rivaki. Fresh tender meat trilled to perfection, then smothered in our own 1 specialteriyaki sauce. E3. Japanese TEriyaki Chicken 9.95 E4. Japanese TEriyakiBeef (New York Sirloin) 11.95 f+ /" For I •Y�Y ¢F CHINESE APPETIZERS Sm. U. 4 Spring Roll, Fried Shrimp & Chicken Fingers ;6 CA 1. Egg Roll 1.95 3:95 1- >4 f CA 2. Spring Roll 1.95 395 0 Chicken Teriyaki, Crab Rangoon, M1 CA 3. Chicken Wings 4.95 '95 Mfr S 4. -Hot and Sour Soup 44 CA 4. Chicken Fingers 4.25 695 xt S 5. _ CA 5. Fried Shrimp 4.25 .7.95 ik idr iW CA 6. Scallion Pancake 1.95 3.95 = * I � CA 8. Chicken Teriyaki 4.25 7.95 3.75 *AAT* 'fi # CA 9. Beef Teriyaki 4.50 7.95 xt Sushi Garden Delight 11.95 4th CA10. French Fries 1.95 3.53 A t CA11. Boneless Spare Rib 4.25 6.95 I N1 *t*RN14 ~Singapore Rice Noocle * CA12. Barbecued Spareribs 4.25 7.25 * k * RN15. M CA13. Peking Ravioli 4.25 3.25 Pan Fried Noodle 2.2E 3.95 (Steamed or Pan Fried) CA14. Crab Rangoon 4.25 5.95 PU PU PLATTER W W • FOR 1 8.95 • FOR 2 13.95 IUDI13 (EACH SUBSTITUTION $1.00 MOBS) T 1. Egg Roll, Chicken Fingers & Chicken Wings 7.25 T 2. Spring Roll, Fried Shrimp & Chicken Fingers 7.50 T 3. Beef Teriyaki, Boneless Spare Ribs, S 2. Egg Drop Soup Chicken Wings & Crab Rangoon 8.115 T 4. Beef Teriyaki, Chicken Wings & Chicken Fingers 7.'5 T 5. Chicken Teriyaki, Crab Rangoon, 1.95 3.75 Boneless Spareribs, Chicken Fingers 8.25 L4,iffx3 S 1. Mini Dumpling Soup 2.50 4.00 3.75 di; xy ikRN 3. S 2. Egg Drop Soup 1.95 3.75 F t 695 S 3. Wonotn Soup 1.95 3.75 A� Sushi Rice 150 S 4. -Hot and Sour Soup 1.95 3.75 # 4 i S 5. Chicken Noodle Soup 1.95 3.75 SX ik i S 6. Chicken Rice Soup 1.95 3.75 * I ;b S 7. Miso Soup 1.35 3.75 *AAT* 'fi S 8. Seafood Miso Soup 3.35 6.95 RICE & NOODLES Sm. U (Choice of chicken, Beef, Pork or Vegetables) -Tor Shrimp Is Add i0onal $1) 4a ° icy R RN 1 -Curry Fried Rice 3.95 5.95 icy R RN 2. Fried Rice 3.75 595 xy ikRN 3. Pineapple Fried Rice 3.50 575 X} iK RN 4. House Fried Rice 4.75 695 V� *L RN 5. Steamed White Rice 1.00 2.00 <� K RN 6. Sushi Rice 150 2.75 vha vN 4 14 RN 7. -Curry Lo Mein 4.95 695 RN 8. Lo Mein 425 6.50 t- A icy 4-4 RN 9. Chow Mein 4.50 6.75 SW Sy0 RN10. Chicago or Subgum Chow Mein 4.95 7.50 4 4 RN 11. House Lo Mein 5.25 7.95 IN 4 -fu RN12. Pad Thai 9z Al 4M H14. 7.95 40 it H15. Thai flat noodle wok fried w. cioice of meat, egg, White meat chicken Med w. light egg batter, topped w. peanuts and bean sprouts. H16. Sushi Garden Delight 11.95 RN13 -Sa Shia Chicken Lo Mein Chicken, beal shdrryand inted vegetadeshined w bloom sauce, 7.95 Chef Specialty 10.95 Sliced chicken, pea pods, mushroom & bamboo shoot wok tossed in a Chinese BBQ sauce & Lo Meir. I N1 *t*RN14 ~Singapore Rice Noocle 7.50 Wok fried shrimp, pork and otieem, thin nice noodle k * RN15. w. cony sauce. Rice Noodle 7.50 A a * RN16. Pan Fried Noodle 2.2E 3.95 zq- ENTREES PLATES Sm. L0. Select Your Favorite Meatand Vegetables: Choice of Chicken "Bed. Shrimp isAddidonal $1 All Vegetarian dishes listed below: Sm 4.50 Lg. 6.50 a es nl >W M 1.-Szechuan Spicy Chicken 8.50 5.25 es 111 + M 2 -Szechuan Spicy Beef 9.25 8.75 rs 111 #i M 3 •Szechuan Spicy Shrimp 9.95 8.7E s 4f *,i€ M 4. -Kung Pao Chicken 8.50 8.75 s % + M 5. -Kung Pao Beef 9.25 8.7: s 4* <M 6. -Kung Pao Shrimp 9.95 8.7E Gal Poo !II j- A M 7-Szechuan Spicy Tofu 7.50 ENTREES PLATES Sm. L0. Select Your Favorite Meatand Vegetables: Choice of Chicken "Bed. Shrimp isAddidonal $1 All Vegetarian dishes listed below: Sm 4.50 Lg. 6.50 a ;T-, EP1. Cashew and Pineapple 5.25 8.7E K SE2. Sweet and Sour t- EP2.-Garlic Sauce 5.25 8.75 at JX EP3. Mixed Vegetables 5.25 8.7E TQ A EP4. String Beans 5.25 8.75 garlic in a spicy sweet & sour sauce. M EP5. Broccoli 5.25 8.7: - s EP6. Fresh Snow Peas 5.25 8.7E Gal Poo -9 EP7. Mushroom 5.25 8.7'. st %t EP8. Black Bean Sauce 5.25 8.7E SIDE ENTREES Select Your Favorite Meat and Vegetables: Choice of Chicken or Beef. Shrimp is Additional $1 t * SE1. Egg Foo Young 6.25 0 K SE2. Sweet and Sour 7.95 vpn °)R SE3.-Curry 8.50 * �ffl SE4. Moo Shi 7.50 STEAMED HEALTHY DISHES(spedalSam OnThe Siae) Kfi A* ST1. Steamed Chicken w. Mixed Veg 8.25 X ST2. Steamed Mixed Vegetables 7.95 >� 40 ST3. Steamed Jumbo Shrimp w. Mix Veg 9.95 4,* fA 0 ST4. Steamed Chicken w. Broccoli 8.25 i*J ,, t, M A ST5. Steamed Shrimp w. Broccoli 9.95 *fik XX # H 1. Sweet & Sour Pineapple Chicken 9.95 All white meat chicken w. onion, green pepper & pineapple in light sweet & sour st!r fry. # 4d6 A H 2. Jumbo Shrimp w. Walnuts 14.95 Crispy jumbo shrimp in creamy sauce. A Must Try! 9 4f J,� H 3. Kung Pao Three Delight 10.95 Shrimp, dtidcen, beef sauteed w. peanuts in hatsaicy sauce. A =1L H 4. Moo Goo Gal Pan 9.95 449v' &A H 5. -House Special Crispy Chicken 10.95 Crispy fried sliced chicken wok tossed w. ginger & garlic in a spicy sweet & sour sauce. % fl H 6. -Gen Gao Chicken 10.95 X 0 A Wx H 7. Mango Chicken or Shrimp 10.95 P* &$* _v�+ H 8 -Orange Flavored Chicken or Beef 10.95 X A H 9. Chicken w. Sesame 10.95 *, 4dx.{ I H10. -Black Pepper Steak w. Onion 9.95 t AA 0 H11. Gal Poo Lo Mein 13.95 Bahrfindd spedafymoped&sautaedw. onsipyleletables, pod4drirpwa sideorderdpenfigd noode.Ag�dmerkatvu. k H12. Dragon & Phoenix 10.95 Jumbo shrimp, chicken, broccoli and Chinese cabbage, straw caret and mushroom. - nA H13. Lobster Sauce (Sm) 4.25 (Lg) 6.50 9z Al 4M H14. Shrimp w. Lobster Sc(Sm) 5.95 (Lg) 9.95 40 it H15. Lemon Chicken 9.95 White meat chicken Med w. light egg batter, topped w. fish lemon sauce. H16. Sushi Garden Delight 11.95 Chicken, beal shdrryand inted vegetadeshined w bloom sauce, I H17. Chef Specialty 10.95 Jumbo Sump, beef aril nix Tegehde strfrell w dove sauce. E2 1�7 OO %P,EEI D� Iv L 1 PARTY PLATTER Sunday 12 Noon — 9:30 p.m. AVAILABLE Mon. — Thurs. 11:30 a.m. — 9:30 p.m. GIFT Fri. & Sat. 11:30 a.m. —10:30 Midnight CERTIFICATE AVAILABLE • Before Placing Your Order, Please- Inform `I V n to to n P O Ci` O P S p d N � N _ E E E & CE N t a tit .o _ W ME .� o C w C OE J n� E E' p O J'c t ti.F T u tp J u m a in d in .n Ln J J PRSRT $TP US POSTAGE 6 Gehe✓-d &ao Ckicke� or-f:7f+,r e. R/✓cha$e ' PAID 4 , w. Purchase of $30.00 or More SALEM, MA r Please Mention Coupon When Ordering Please Mention Coupon When OMenng� + PERMIT#263 4oiiv offC✓ab ClvckeH 5pv,w 5p/,wSalmoh Qoll . r �'4 4 rw�ee i ov,J ovwa 9011 ov ti, I ( w. Purchase of $20.00 or More of ' I w Purchase o $25.00 or More * , ?P---Manfnn---,WI. n�Jeiniy rieeSC MCntI0n t;0upon When Urdenrg�'� � f�./ 1AtEM P"00OY I �$lJ SO �HARGE� (* If A Person in Your Party Has a Food Allergy • :x r O O O 1l1 V� 4L1 ll1 Ln 4!� l!1 V1 4A 4/� P P U C1� M. P ti N a • L r,(3 A 2 OO o E f.°�� O a - - n o V 3 w V a N" V M a ct d .o c q o �'- E �e E �0� x E, 4v '" '-c' �r c a a o t E on a v1 v ce E o.e i (a ;m a'� wmv � ,o N m c Ece s�E�E�io�o.'�9.•.n_rn • N o^^ 6 �y !O .` Y LA E N F� ~ u C u y N p N Q )C ¢ E (/) ?rn111 V1m v1`r N�uL¢H�i�Vlin �wtnm Nm Hm �mVl�Vlv+i�r a0 �_ Vi U J J J J 7 l D J J J J J J J J / V) VI VI V) V) VI N V) V1 N N 0 VI N VI • R ��oND11;�o in =i �,it ATE / 2— r-// 9`�C/r11NE RECEIVED OF IN PAYMENT OF TICKET # �SO(I t� pecJA [ [ choose to contest this matter within 21 days of the date of this notice and request in writing a noncriminal hearing. Enclose a copy of this citation and mail h to the Clerk Magistrate, Salem District Court, 65 Washington Street, Salem, MA 01970. The Court will schedule a hearing. FAILURE TO OBEY THIS NOTICE WITHIN 21 DAYS OF THE DATE OF THIS NOTICE WILL RESULT IN THE CITY OF SALEM APPLYING FOR THE ISSUANCE OF A CRIMINAL COMPLAINT AGAINST YOU AND THE DENIAL OR REVOCATION OF ANY CITY OF SALEM PERMITS OR LICENSES YOU APPLY FOR OR THAT YOU HAVE BEEN GRANTED, INCLUDING BUILDING PERMITS. City of Salem, City Clerk's Office, 93 Washington Street, Salem, MA 01970 (978) 745-9595, ext. 5610. SEE OTHER SIDE FOR FURTHER INSTRUCTIONS ENCLOSE PAYMENT IN THIS ENVELOPE, PEEL AND SEAL Nil 3AOw321 3AIS3HOV 3SOCX3 01 TO EXPOSE ADHESIVE, REMOVE LINE 3 01 TO EXPOSE ADHESIVE. REMOVE LINER 831,41 3AOiN38 '3AIS31-11 THE AMOUNT OF IN (CASH) (CHECK) U CITY CLERK ISSUED FOR A VIOLATION. M KIMBERLEY DRISCOLL MAYOR LARRY RAMDIN, RS/RENS, CHO, CP -FS HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4"' FLOOR TEL. (978) 741-1800 FAx (978) 745-0343 LRnMDIN@SAI,EM COM THE SALEM BOARD of HEALTH HEREBY GRANTS A VARIANCE AS REQUIRED BY 105 CMR 590 AND 1999 FEDERAL FOOD CODE §3-502.11 IN ACCORDANCE WITH 1999 FOOD CODE § 8.103.10, TO: NAME: Guang Ke Lai Group Inc D/b/a Sushi Garden ADDRESS: 99 North Street, Salem, MA 01970 The establishment is permitted to use vinegar as a method of food preservation rather than as a method of flavor enhancement for SUSHI RICE. This variance is granted subject to the following conditions: 1. The facility will strictly adhere to all procedures as set forth in the HACCP Plan and maintain all necessary records. 2. The monitoring records must be reviewed and signed at least once per day by the person in charge (PIC) of the facility and maintain on site for at least thirty( 30)days for the Salem Board of Health inspections. 3. The HACCP Plan must be reviewed and signed by an individual who is HACCP Certified, at least once annually and maintained on site at all times for the Board of Health inspections. 4. Laboratory testing at least once every twelve (12) months must validate the pH of the rice. These test results must be forwarded to the Salem Board of Health. This variance is effective only after the initial test results have been received by the Salem Board of Health. 5. This variance shall be specific to the location and process as set forth in your application and is NOT TRANSFERABLE. 6. The PIC must demonstrate that the employee (s) performing pH measurement has been adequately trained to use the pH meter / pH test papers and measurement of the pH of the rice. 7. Any changes to the process or HACCP Plan as submitted will render this variance null and void. This includes changes in the raw material such as rice vinegar concentration. (The brand of vinegar may change but not the concentration). 1 HAVE READ THE REQUIREMENTS OF THIS VARIANCE AND UNDERSTAND THEM. I AGREE TO COMPLY WITH THESE REQUIREMENTS; 1 UNDERSTAND THAT I MUST COMPLY WITH ALL APPLICABLE PROVISIONS OF 105 CMR 590. THE LEGAL OWNERS OF THIS ESTABLISHMENT ASSUME ANY AND ALL LIABLILITY FOR ANY INJURY RESULTING FROM USING VINEGAR AS A METHOD OF PRESERVING SUSHI RICE. DATE: PRINT:—�%6"!/ LEGAL OWNER I AGENT SIGNATURE: DATE GRANTED: 12 �'' Larry Ra Health Agent CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient's Keuetmall Z�leilg CertiEate7Number _C 1 S1 Date of Coinpletlon11 .. 11!40$/2011 Date of Expiatlon. Y1�❑bL2016 The above-named persons hereby issued this certifcate for completing an allergen awareness training program recognized by the Massachusetts Department of Public Health in accordance with 105 CMR 590.009(G)(3)(a). This certificate will be valid for five (5) years from date of completion. Issued Sy: Go Compuworks CompuWorks Systems, Inc 591 North Avenue, Door 2 Wakefield, MA 01880 P:791-224-1113 F: 781-2?.4-0504 Wwwcompuworks.com N Cil N m N N W M m 11/25/2011 12:33 6173503188 Christopher E. Coleman, Esq.% PC 128 Lincoln Street, Suite 103, Boston, MA 02111 Date: November 25, 2011 To: Board of Health Attn.: Mr. Larry Ramdin From: Andrea Kor, paralegal PAGE 01/02 Tel: 617-350-6188, Fax: 617-350-3188 E-mail: attomeycoleman@gmail.com FAX TRANSMITTAL PAGES INCLUDING THIS COVER 2 Re: Change of ownership / Application for permit to Operate a Food Establishment Guang Ke Lai Group, Inc. d/b/a Sushi Garden 99 North St., Salem, MA Dear Larry; In connection with the above referenced application, enclosed please find a copy of the Certificate of Allergen Awareness Training of the applicant for your review. The applicant had sent the rice sample to the Foods Research Laboratories, Inc. for testing on Wednesday and is expecting a report on Monday. The applicant will be looking forward to meet you for a pre -opening inspection at the restaurant on 11 /28/2011 (Monday) at 2:00p.m. Please don't hesitate to contact me if you have any questions. Thank you 1.,,..._ - 1 paralegal If there are any problems with this transmittal, please call us at 617-350-6188, or fax to 617-350-3188. Statement of Confidentiality The documents included with this facsimile transmittal sheet contain information, which is confidential and/or privileged. This information is intended to be for the use of the addressee named on this transmittal sheet. If you are not the addressce, note that any disclosure, photocopying, distribution or use of the contents of this Wed information is prohibited. if you have received this facsimile in error, please notify us by telephone immediately so that we can arrange for the retrieval of the original documents at no cost to you. Commonwealth otf Massachusetts ` City of Salem Board of Health Kimberley Driscou 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Foo"etail Establishment Permit DATE PRINTED: 12/08/2011 ESTABLISHMENT NAME: File Number: BHF -2004-000279 Sushi Garden 99 North Street Salem MA 01970 LOCATED AT: 0099 NORTH STREET. U I SALEM, MA 01970 Permit Type Permit No. Permit Issued Permir. Expires Fee Restrictions / Notes FOOD SERVICE BHP -2011-0665 Dec 1, 2011 Dec 31, 2012 $140.00 ESTABLISHMENT PERMIT EXPIRES Total Fees: $140:00 Board of Health N' This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approvedby the Salem Board of Health. Page 1 KIMBERLEY DRISCOLL MAYOR LARRY RAMDfN, RS/REHS, CHO, CP -FS HEALTH AGENT 2011 NAME OF ESTABLISHMEN-i ADDRESS OF ESTABLISHM MAILING ADDRESS (if different) EMAIL - Business': CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4T FLOOR TEL. (978) 741-1800 Fax (978) 745-0343 / LRAM )IN&ALEM COhf lZ��G""sol TO OPERATE A FOOD ESTABLISHMENT (�n�(� TEL # s FAX # Website: OWNER'S NAME / TEL # ADDRESS 6(Q STREETCITY do /l� �N STALE .J� �Z Z® 80s CERTIFIED FOOD MANAGER'S NAME(S) / CERTIl kTEE## S) Q (Required in an establishment where potentially hazardous food is prel ed) (�.Q EMERGENCY RESPONSE PERSON HOME TEL #��Y)�c3l00 DAYS OF OPERATION 1 Monday- Tuesday-,.,, W nesda i "Thursda i Friday Saturday Sunda HOURS OF OPERATION Please in time day. l l z oaf41 I //>.`�0wyL—, //' 3QayY�— //-N3J'a M1'L 1 /P-3 Oaf l //=3WJ 1-- l� n0o32— write of For example 11am-11 m ! I i rD.Dr�nntl r/�©v =om i .,3 nom TYPE OF ESTABLISHMENT FEE (check only RETAIL STORE YESNO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 (ry ........................................... ---- ------------------------------------------ RESTAURANT YES NO �jless than 25 seats =$140 Outdoor Stations Food Cart $2 25-99 seats =$280 ------------------ -------...--- BEDIBREAKFAST/ YES NO CHILDCARE SERVICES/NURSING HOME --------------------------------- ADDITIONAL PERMITS MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE TOBACCO VENDOR ALL NON-PROFIT (such as church kitchens) more than 99 seats =$420 $100 YES N $25 YES $135 YES 0 $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 lax returns and paid all state taxes required under the law. Signature Updated 52Pn FOOQAP201 l.adm Check4 & A171.7 -15 f ab.1aJ Date / / �� O / I Social Security or Federal Identification Number CITY OF SALEM 12 1 8 . 1 zatl 16,10 19 06(Z,T1t Sr2EE i NAMEOFOFFENDER 6.0 te [e Eil 1bla susN►IG `1`11Jo�TH St. 5{iLEri Ill 0113p 1 hereby acknowledge receipt of-therforegoing citation . Jr „ f ,-, -[-] Unable to obtain signature of offender [_] Date Mailed [ ] Posting Advertisements, Notices on City Property _ S004-2 [ ] Illegal Signs - [ ] Violation of State Building Code SCD 4-39 and 4-47 SCO 12-1 ] ] Removal of Unsightly.Condhions I.] Violation of BOCA Nat. Fire Prey. Code FA BCD 12-56 SCO 20-111 [ ] Keeping of Trailers, Comm. and Red. Vehicles, etc. C) SCO 24-21.1 [ ] Removal of Snow/Ice from Sidewalks SCO 38-13 and 38-14 [ ] ZoningZ0 § Ord0ma,ce § [y} Other citation: OQE&t47tuL aEcea(-"rwb43W i.2f4a 17T14ottT W&Iltt Signature off.•Eoforc`in l g-P-erson 1 Department A E7A L -r ;it Amount of Fine: [ ] Warning [ ] $25.00 [ ] $50.00 [] $100.00 [ ] $200.00 [ ] $300.00 [X]Other tra You have the following. alternatives in this matter within 21 days of the date of this notice: [ ] choose to pay the fine within 21 days of the date of this notice. Enclose a check or money order payable to the City of Salem and return it in this envelope or by delivering in hand to the City Clerk's Office, City Hall, 93 Washington Street, Salem, MA 01970. If delivering in hand, please note the hours of City Hall operation; Monday through Wednesday from 8:00 a.m. to 4:00 p.m, Thursday from 8:00 a.m. to 7:00 p.m. and Friday from 8.00 a.m. to 12:00 p.m. [ [ choose to contest this matter within 21 days of the date of this notice and request in writing . a noncriminal hearing. Enclose a copy of this citation and mail it to the Clerk Magistrate, Salem District Court, 65 Washington Street, Salem, MA 01970. The Court will schedule a hearing. FAILURE TO OBEY THIS NOTICE WITHIN 21 DAYS OF THE DATE OF THIS NOTICE WILL RESULT IN THE CITY OF SALEM APPLYING FOR THE ISSUANCE OF A CRIMINAL COMPLAINT AGAINST YOU AND THE DENIAL OR REVOCATION OF ANY CITY OF SALEM PERMITS OR LICENSES YOU APPLY FOR OR THAT YOU HAVE BEEN GRANTED, INCLUDING BUILDING PERMITS. City of Salem, City Clerk's Off ice, 93 Washington Street, Salem, MA 01970 (978) 745-9595, ext. 5610. SEE OTHER SIDE FOR FURTHER INSTRUCTIONS ENCLOSE PAYMENT IN THIS ENVELOPE, PEEL AND SEAL 12/01/2011 18:05 6173503188 Christopher E. Coleman, Esq., PC ------------- 128 Lincoln Street, Suite 103, Boston, MA 0211 i Date; December 1, 2011 To: Health Department Attn.: Larry From: Yuki Re: Sushi Garden Dear Larry ; PAGE 01/03 Tel: 617-350-6188, Fax: 617-350-3188 E-mail: attomeycoleman@gmail.com FAX TRANSMITTAL PAGES INCLUDING THIS COVER _3_ Attached please find the Closing Statement and Bill of Sale for the above business. The previous owner still operating the restaurant until Your approval for the Food Permit so our client can start to operate the business for Chinese food and sushi. Please let us know when the Food Permit can be issue. Thank you in advance for your help, and please do not hesitate to contact our office if You have any questions regarding this matter. Thanks Yuki Wong If there are any problems with this transmittal, please callus at 617-350-6188, or fax to 617-350-3188. Statement of Confadentiality, The documents included with this facsimile transmittal sheet contain information, which is confidential and/or privileged. This information is intended to be for the use of the addressee named on this transtnittal sheet. Tf you are not the addressee, note that any disclosure, photocopying, distribution or use of the contents of this faxed information is prohibited. if you have received this facsimile in error, please notify us by telephone immediately so that we can arrange for the retrieval of the original documents at no cost to you. 12/01/2011 18:05 6173503188 PAGE 02/03 CLOSING STATEMENT Sale of Restaurant Assets 99 North Street, Salem, MA Seller: Wenwei Lucky, Inc. Buyer: Guang Ke Lai Group, Inc. Date: November 29, 2011 Purchase Price Deposit -Paid and being held by Christopher E. Coleman, Esq., PC Adjustment: nems have not been paid by Seller None Adjustment: items have been paid by Seller -Security deposit -Last month rent Holdback Fund shall to be held by Christopher E, Coleman, Esq., PC for 60 days as per the purchase and sale agreement dated November 4, 2011 FUNDING FROM BUYER DURING CLOSING FUNDING TO SELLER DURING CLOSING BUYER Guang Ke Lai Group, In By! Keller an J Its director, duly authorized Buyer Seller $ 20,000.00 $ 20,000.00 $ (5,000.00) $ 2,500.00 $ 2,500.00 $ 1,800.00 $ 1,800.00 $ (5,000.00) $ 19,300.00 SELLER Wenwei Lucky, Inc. By:Pen�&u - Its treasurer, duly authorized $ 19,800.00 12/01/2011 18:05 6173503188 PAGE 03103 RHI OF SALE I{Now ALL PERSONS By TIMSE PRESENTS that Wenwei Lucky, &M, a Massachusetts Corporation, EIN 45-2401299, ("Grantor'), in consideration of Twenty Thousand Dollars ($20,000.00) and other valuable consideration paid by Guang % Lai Group, Inc., a Massachusetts Corporation ("Grantee"), the receipt whereof is hereby acknowledged, do hereby grant, sell, transfer, and deliver unto the said Grantee the following assets of the Grantors, namely: All of its right, title and interest in the business known as the Sushi Garden with a principal place of business located at 99 North Street, Salern, Massachusetts, including (i) all tangible personale property, fixed assets, all restaurant furnishings, tables, dishes, silverware, cooldng equipment and utensils, telephone systems, furniture, fixtures and all machinery in connection with the business, list of equipment as per the attached Exhibit "A" and (ii) goodwill and the trade name of the Sushi Garden, to have and to hold all and singular the said goods and chattels to the said Grantee and its successors and assigns to its own use forever. Grantor hereby covenants with the Grantee that the Grantor is the lawful owner of the said goods and chattels; that all such assets are free from all encumbrances; liens, claims, demands and security interests, that the Grantor has good right, power, and authority to sell the same as aforesaid. EXECUTED as a sealed instrument as of this 29" of November, 2011. Signed in the prgsence of: GRANTOR Wenwei Lucky, Inc, BY: Peng u, Ir urer Duly authorized 11/29/2011 12:08 6173503188 Christopher E. Coleman, Esq., PC 128 Lincoln Street, Suite 103, Boston, MA 02111 Date: November 29, 2011 To: Board of Health Attn.: Mr. Larry Ramdin From: Andrea Kor, paralegal Re: Sushi Garden 99 North Street, Salem, MA Dear Larry; PAGE 01/02 Tel : 617-350-6188, Fax: 617-350-3188 E-mail : attomeycoleman@gmall.com FAX TRANSMITTAL PAGES INCLUDING THIS COVER 2 Please be informed that both of Mr. Peng Xu and Kellerman Jason Zheng have been trained by the Foods Research Laboratories, Inc. in the use of a pH meter and the measurement of pH of sushi rice today. Enclosed please find a confirmation letter from Andrea Fontaine of the Foods Research Laboratories, Inc. for your review. Please advise when you will be available to do a re -inspection. Your kind co-operation is much appreciated. Yours S' or, aralegal If there are any problems with this transmittal, please callus at 617-350-6188, or fax to 617-350-3188. Statement of Confidentiality The documents included with this facsimile transmittal sheet contain information, which is confidential and/or privileged. This information is intended to be for the use of the addressee named on this transmittal sheet. If you are not the addressee, note that any disclosure, photocopying, distribution or use of the contents of this faxed information is prohibited. If you have received this facsimile in error, please notify us by telephone immediately so that we can arrange for the retrieval of the original documents at no cost to you. 11/29/2011 12:08 6173503188 PAGE 02/02 Foods Research (617) 442-3322 LABORATORIES, INC. (617) 427-3322 FAX (617) 442-2013 •� 130 NEWMARKET SQUARE - BOSTON, MA 02118 November 29, 2011 City of Salem Board of Health 120 Washington Street 4'b Floor Salem, NIA 01970 To Whom It May Concern: Sushi Garden, located at 99 North Sreet, Salem, is requesting a variance for the exemption of acidified rice (sushi rice) as a potentially hazardous food requiring temperature control for safety. The sushi rice contains vinegar as a means of food preservation in addition to flavor enhancement. Peng Xu and Kellerman Jason Zheng have been trained in the use of a pH meter and the measurement of pH of sushi rice. It is our understanding that a HACCP plan was already in existence. Please contact me if you require further information. Sincer l� An Fontaine �1` L abo ory Director O'm'so years--Dedicatedto qty and Service The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 u,p www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leeibly Business/Organization Name City/State/Zip: q'Phone #: «%ti) - '/ft f' Are you an employer? Check the appropriate box: Business Type (required): 1. I am a employer with 5 employees (full and/ 5. ❑ Retail or part-time).* 6. [j�'Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] g. ❑ Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10 El Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑Health Care with no emulovees. fNo workers' coma. insurance reo.l 12.0 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **If the corporate officer; have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box M. I am an employer that isproviding workers' compensation insurancefor my employees. _Below is thepolicy information. Insurance Company Name: 09 %e YLle / lfGer?/Jfll tnU k�/0 /) Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. Expiration 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 maybe forwarded to the Office of Investigations of the )OIA for insurance coverage verification. I do hereby cerdfyf n h and penalties ofperjury that the information provided above is true and correct. S; narP• i I llabo I/ 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 Person: Phone #: 11=0OOc0/I Hours of Operation: Sun _ g"Motr Thurs L -LOO 1 10=001n1 Mon Tues V - We /0=00 n1 Number of Seats: Number of Staff: _. (Maximum per shift) Fri Sat 11=S0QM—//:00IWO Total Square Feet of Facility: Jr o zSq O. Number of Floors on which operations are conducted Maximum Meals to be Served: Breakfast 1.51 (approximate number) Lunch So Dinner 100 Projected Date for Start of Project: Projected Date for Completion of Project: Type of Service: (check all that apply) Sit Down Meds _ Take Caterer Mobile Vendor Other Please enclose the following documents: Proposed Menu (including seasonal, off-site and banquet menus) Manufacturer Specification sheets for each piece of equipment shown on the plan Site plan showing location of business in building; location of building on site including alleys, streets; and location of any outside equipment (dumpsters, well, septic system - if applicable) Plan drawn to scale of food establishment showing location of equipment, plumbing, electrical services and mechanical ventilation Equipment schedule CONTENTS AND FORMAT OF PLANS AND SPECIFICATIONS 1. Provide plans that are a minimum of 11 x 14 inches in size including the layout of the floor plan accurately drawn to a minimum scale of 1/4 inch = 1 foot. This is to allow for ease in reading plans. 2. Include: proposed menu, seating capacity, and projected daily meal volume for food service operations. 3. Show the location and when requested, elevated drawings of all food equipment. Each piece of equipment must be clearly labeled on the plan with its common name. Submit drawings of self- service hot and cold holding units with sneeze guards. 4. Designate clearly on the plan equipment for adequate rapid cooling, including ice baths and refrigeration, and for hot -holding potentially hazardous foods. 5. Label and locate separate food preparation sinks when the menu dictates to preclude contamination and cross -contamination of raw and ready -to -eat foods. 6. Clearly designate adequate hand washing lavatories for each toilet fixture and in the immediate area of food preparation. 7. Provide the room size, aisle space, space between and behind equipment and the placement of the equipment on the floor plan. 8. On the plan represent auxiliary areas such as storage rooms, garbage rooms, toilets, basements and/or cellars used for storage or food preparation. Show all features of these rooms as required by this guidance manual. 9. Include and provide specifications for: a. Entrances, exits, loadinglunloading areas and docks; b. Complete finish schedules for each room including floors, walls, ceilings and coved juncture bases; c. Plumbing schedule including location of floor drains, floor sinks, water supply lines, overhead waste -water lines, hot water generating equipment with capacity and recovery rate, backflow prevention, and wastewater line connections; d. Lighting schedule with protectors; (1) At least 110 lux (10 foot candles) at a distance of 75 cm (30 inches) above the floor, in walk-in refrigeration units and dry food storage areas and in other areas and rooms during periods of cleaning; (2) At least 220 lux (20 foot candles): (a) At a surface where food is provided for consumer self-service such as buffets and salad bars or where fresh produce or packaged foods are sold or offered for consumption; (b) Inside equipment such as reach -in and under -counter refrigerators; KIMBERLEY DRISCOLL MAYOR LARRY RAMDIN, RS/REHS, CHO, CP -FS HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 \W'ASIIINGTON STREET, 4"' FLOOR TEL. (978) 741-1800 FAX (978) 745-0343 Iramdin@salem.com Fees: New Establishment: $180.00 Remodel: $90.00 Make Checks payable to: The City of Salem No cash is accepted FOOD ESTABLISHMENT PLAN REVIEW APPLICATION _NEW _REMODEL _CONVERSION Date: / I Ac, c, cJl Name of Establishment: JJIA �J lki�L A_ 0 Category: Restaurant, Institution _, Daycare _, Retail Market Other Address: Phone if available: �%g)7�4 1999 7c'l Name of Owner: Mailing Address:, �G I(L4p/1�0 �/2 p0, ,�Q12(%1/� V Telephone: Applicant's Name: Title (owner, manager, architect, etc.):�W&1/(,2424 Mailing Address: &U c L a's' Q/JITVPa J Telephone: �L )&H 31SR I have submitted plans/applications to the following authorities on the following dates: Licensing Board Zoning Planning Building Conservation Plumbing Electric Police Fire Other ( ) (c) At a distance of 75 cm (30 inches) above the floor in areas used for hand washing, ware washing, and equipment and utensil storage, and in toilet rooms; and (3) At least 540 lux (50 foot candles) at a surface where a food employee is working with food or working with utensils or equipment such as knives, slicers, grinders, or saws where employee safety is a factor. e. Food Equipment schedule to include make and model numbers and listing of equipment that is certified or classified for sanitation by an ANSI accredited certification program (when applicable). f. Source of water supply and method of sewage disposal. Provide the location of these facilities and submit evidence that state and local regulations are complied with; g. A color coded flow chart demonstrating flow patterns for: -food (receiving, storage, preparation, service); -food and dishes (portioning, transport, service); -dishes (clean, soiled, cleaning, storage); -utensil (storage, use, cleaning); -trash and garbage (service area, holding, storage); h. Ventilation schedule for each room; i. A mop sink or curbed cleaning facility with facilities for hanging wet mops; j. Garbage can washing area/facility; k. Cabinets for storing toxic chemicals; 1. Dressing rooms, locker areas, employee rest areas, and/or coat rack as required; in. Completed Section 1; n. Site plan (plot plan) FOOD PREPARATION REVIEW Check categories of Potentially Hazardous Foods (PHF's) to be handled, prepared and served CATEGORY* YESNCO) 1. Thin meats, poultry, fish, eggs (hamburger; sliced meats; fillets) (. ?' ( ) 2. Thick meats, whole poultry (roast beef; whole turkey, chickens, hams) ( ) V 3. Cold processed foods (salads, sandwiches, vegetables) V ( ) 4. Hot processed foods (soups, stews, rice/noodles, gravy, chowders, casseroles) (✓� ( ) 5. Bakery goods (pies, custards, cream fillings & toppings) ( ) A * A generic HACCP plan for each category of food may be available from the regulatory authority for reference. PLEASE CIRCLE/ANSWER THE FOLLOWING QUESTIONS FOOD SUPPLIES: 1. Are all food supplies from inspected and approved sources?( / NO 2. What are the projected frequencies of deliveries for frozen foods Refrigerated foods j& 4 cue< , and Dry goods /Wa- 2 i,)&.ki 3. Provide information on the amount of space (in cubic feet) allocated for: Dry storage l Refrigerated Storage (� " -in -oolP/ and Frozen storage TreeZP.P 4. How will dry goods be stored off the floor? ( from tie floor COLD STORAGE: 1. Is adequate and approved freezer and refrigeration vailable to store frozen foods frozen and refrigerated foods at 41'F (5°C) and below?(D/NO Provide the method used to calculate cold storage requirements. 2. Will raw meats, poultry and seafood be stored in the same refrigerators and freezers with cooked/ready-to-eat foods? YES If yes, how will cross -contamination be prevented? 3. Does each refrigerator/freezer have a thermometer`o / NO Number of refrigeration units: l% �� Number of freezer units: 1 4. Is there a bulk ice machine available? YES /0 THAWING FROZEN POTENTIALLY HAZARDOUS FOOD: Please indicate by checking the appropriate boxes how frozen potentially hazardous foods (PHF's) in each category will be thawed. More than one method may apply. Also, indicate where thawing will take place. Thawing Method *THICK FROZEN *THIN FROZEN FOODS FOODS Refrigeration 01A Running Water Less than 70°F(21°C) Microwave (as part of g1A cooking process) Cooked from Frozen state /A / \/ Other (describe) duce _Side *Frozen foods: approximately one inch or less = thin, and more than an inch = thick. COOKING: 1. Will fog4product thermometers be used to measure final cooking/reheating temperatures of PHF's?S NO pp What type of temperature measuring device: Minimum cooking time and temperatures of product utilizing convection and conduction heating equipment. beef roasts 130°F (121 min) solid seafood pieces 145°F (15 sec) other PHF's 145°F (15 sec) eggs: Immediate service 145°F (15 sec) pooled* 155°F (15 sec) (*pasteurized eggs must be served to a highly susceptible population) pork 145°F (15 sec) comminuted meats/fish 155°F (15 sec) poultry 165°F (15 sec) reheated PHF's 165°F (15 sec) 2. List types of cooking equipment. HOT/COLD HOLDING: 1. How will hot PHF's be maintained at 140°F (60°C) or above during holding for service? Indicate type and number LLof hot holding units. = 2. How will cold PHF's be maintained at 41'F (5°C) or below during holding for service? Indicate type and number of cold holding units. COOLING: Please indicate by checking the appropriate boxes how PHF's will be cooled to 41°F (5°C) within 6 hours (140°F to 70°F in 2 hours and 70°F to 41°F in 4 hours). Also, indicate where the cooling will take place. COOLING THICK THIN THIN THICK RICE/ METHOD MEATS MEATS SOUPS/ SOUPS/ NOODLES GRAVY GRAVY Shallow Pans fj A V Ice Baths r Reduce Volume or nj % ✓ ✓ ✓ Size / Rapid Chill Other (describe) REHEATING: 1. How will PHF's that are cooked, cooled, and reheated for hot holding be reheated so that all parts of the food reach a temperature of at least 165°F for 15 seconds. Indicate type and number of units used for reheating foods. 2. How will reheating food to 165°F for hot holding be done rapidly and within 2 hours? PREPARATION: 1. Please list categories of foods prepared more than 12 hours in advance of service. a 2. Will food employees be trained in good food sanitation practices? 6 NO Method of training: Number(s) of employees: Dates of completion: 3. Will disposable gl and/or utensils and/or food grade paper be used to prevent handling of ready -to -eat foods( YEY/ NO 4. Is there a written policy to exclude or restrict food workers who are sick or have infected cuts and lesions / NO Please describe briefly: Will employees have paid sick leave? YES / NO 5. How will cooking equipment, cutting boards, counter tops and other food contact surfaces which cannot be submerged in sinks or put through a dishwasher be sanitized? Chemical Type:' /!? �e Concentration:A7 Test KitV/ NO 6. Will ingredients for cold ready -to -eat foods such as tuna, mayonna se and eggs for salads and sandwiches be pre -chilled before being mixed and/or assembled? 0 If not, how will ready -to -eat foods be cooled to 41°F? 7. Will all produce be washed on-site prior to use? l`.:y' NO Is there a planned location used for washing produce? V/ NO If not, describe the procedure for cleaning and sanitizing multiple use sinks between uses. 8. Describe the procedure used for minimizing the length of time PHF's will be kept in the temperature danger zone (41 °F - 140°F) during preparation. 9. Provide a HACCP plan for specialized processing methods such as vacuum packaged food items prepared on-site or otherwise required by the regulatory authority. 10. Will the facility be serving food to a highly susceptible population? YES /e If yes, how will the temperature of foods is maintained while being transferred between the kitchen and service area? A. FINISH SCHEDULE Applicant must indicate which materials (quarry tile, stainless steel, 4" plastic coved molding, etc.) will be used in the following areas. Kitchen FLOOR COVING WALLS CEILING Bar N/H Food Storage 5& le 0 n%t Other Storage Tie %l e P,via& Toilet Rooms C�in�vlm 2s' ) -file �Uw-ar Aywj imp Dressing Rooms _ I� IV Garbage & Refuse Storage _ Mop Service Basin Area / fit Ware washing Area Walk-in Refrigerators(l�SG_,Q Freezers 7^ f�CGe and B. INSECT AND RODENT CONTROL APPLICANT: Please check appropriate boxes. YE N N S O A 1. Will all outside doors be self-closing and rodent proof? 2. Are screen doors provided on all entrances left open to the outside? 3. Do all openable windows have a minimum #16 mesh screening? 4. Is the placement of electrocution devices identified on the plan? 5. Will all pipes & electrical conduit chases be sealed; ventilation systems ( () ( ) exhaust and intakes protected? 6. Is area around building clear of unnecessary brush, litter, boxes and other harborage? 7. Will air curtains be used? If yes, where? C. GARBAGE AND REFUSE Inside <> <> <> 8. Do all containers have lids? 9. Will refuse be stored inside? () (ff ( ) If so, where? 10. Is there an area designated for garbage can or floor mat cleaning? O O (✓)� Outside / 11. Will a dumpster be used? Number I Size —! l- l Frequency of pickup hrlee LI Wee� �g(j1Cll Contractor im wJI 12. Will a compactor be used? �d Number Size Frequency of pick up Contractor 13. Will garbage cans be stored outside? () ( ( ) 14. Describe surface and location where dumpster/compactor/garbage cans are to be stored 15. Describe location of grease storage receptacle 1 L L c 4 eP .ra c7 (ity�l 71 16. Is there an area to store recycled containers? Indicate what materials are required to be recycled; ( ) Glass (vf Metal ( ) Paper ( ) Cardboard ( ) Plastic 17. Is there any area to store returnable damaged goods? D. PLUMBING CONNECTIONS O O (-K AIR AIR *INTEGRAL *"P" VACUUM CONDENSATE GAP BREAK TRAP TRAP BREAKER PUMP 18. Toilet 19. Urinals / 20. Dishwasher f g 21. Garbage IV / Grinder 22. Ice machines 1 Pr 23. Ice storage bin Nirt 24. Sinks a. Mop b. Janitor c. Hand washTOM d.3 4- Compartment J NA — 1 I� e. 2 Compartment L1 - Compartment g. Water 0 Station 25. Steam s tables 26. Dipper wells J �( V 27. Refrigeration condensate/ drain lines 28. Hose \' connection N 29. Potato ` peeler 30. Beverage Dispenser w/carbonator 31. Other * TRAP: A fitting or device which provides a liquid seal to prevent the emission of sewer gases without materially affecting the flow of sewage or waste water through it. An integral trap is one that is built directly into the fixture, e.g., a toilet fixture. A ?P? trap is a fixture trap that provides a liquid seal in the shape of the letter ?P.? Full ?S? traps are prohibited. 32. Are floor drains providedl& easily cleanable, if so, indicate location: r) flbbf drd(4 ;0 Krtc)W4 E. WATER SUPPLY 33. Is water supply public (4or private ( )? 34. If private, has source been approved? YES ( ) NO ( ) PENDING ( ) Please attach copy of written approval and/or permit. 35. Is ice made on premises ( ) or purchased commercially ( )? A11A If made on premise, are specifications for the ice machine provided? YES ( ) NO ( ) Describe provision for ice scoop storage: Provide location of ice maker or bagging operation 'j LP 36. What is the capacity of the hot 37. Is the hot water generator sufficient for the needs of the establishment? Provide calculations for necessary hot water (see Part 5 & Part 9 Under Section III in this manual) 38. Is there a water treatment device? YES ( ) NO (/ If yes, how will the device be inspected & serviced? 39. How are backflow prevention devices inspected & serviced? F. SEWAGE DISPOSAL 40. Is building connected to a municipal sewer? YES (`�NO ( ) 41. If no, is private disposal system approved? YES ( ) NO ( ) PENDING ( ) Please attach copy of written approval and/or permit. 42. Are grease traps provided? YES (✓) NO ( ) If so, where? Provide schedule for cleaning & maintenancesI�M & 11MM J' Q/%l G. DRESSING ROOMS 43. Are dressing rooms provided? YES () NO (Vr 44. Describe storage facilities for employees' personal belongings (i.e., purse, coats, boots, umbrellas, etc.) & GENERAL 45. Are insecticides/rodenticides stored separately from cleaning & sanitizing agents? YES VNO ( ) Indicate location: 46. Are all toxics for use on the premise or for retail sale (this i cludes personal medications), stored away from food preparation and storage areas? YES (- O ( ) 47. Are all containers of toxics including sanitizing spray bottles clearly labeled? YES (/NO ( ) 48. Will linens be laundered on site? YES ( ) NO (/f If yes, what will be laundered and where? If no, how will linens be cleaned? &26 hZM C;V1W1r2 49. Is a laundry dryer available? YES ( ) NO (14-1, 50. Location of clean linen storage: 51. Location of dirty linen storage: I - 52. Are containers constructed of safe materials to store bulk food products? YES f )NO (V Indicate type: 53. Indicate all areas where exhaust hoods are installed: LOCATION OI'ef FILTERS WOR EXTRACTION DEVICES 11�P�S SQUARE FEET 24 Tit FIRE PROTECTION '' esslp1'Gf 14 AIR CAPACITY CFM AIR MAKEUP CFM 54. How is each listed ventilation hood system cleaned? I. SINKS 55. Is a mop sink present? YES (vj NO ( ) If no, please describe facility for cleaning of mops and other equipment: 56. If the menu dictates, is a food preparation sink present? YES (/NO ( ) J. DISHWASHING FACILITIES 57. Will sinks or a dishwasher be used for ware washing? Dishwasher( ) Two compartment sink ( ) Three compartment sink (Jr 58. Dishwasher Type of sanitization used: Hot water (temp. provided) Booster heater Chemical type Is ventilation provided? YES ( ) NO ( ) 59. Do all dish machines have templates with operating instructions? YES ( ) NO ( ) 60. Do all dish machines have temperature/pressure gauges as required that are accurately working? YES ( ) NO ( ) 61. Does the largest pot and pan fit into each compartment of the pot sink? YESJ/NO ( ) If no, what is the procedure for manual cleaning and sanitizing? 62. Are there drain boards on both ends of the pot sink? YES (V� NO( ) 63. What type of sanitizer is used? Ch1 Iodine ) Quaternary ammonium ) Hot Water Other ) 64. Are test papers and/or kits available for checking sanitizer concentration? YES ) NO K. HANDWASHING/TOILET FACILITIES 65. Is there a hand washing sink in each food preparation and ware washing area? YES (-<NO 66. Do all hand washing sinks, ' cluding those in the restrooms, have a mixing valve or combination faucet? YES (,.) NO ( ) 67. Do self-closing metering faucets provide a ow of water for at least 15 seconds without the need to reactivate the faucet? YES ( ) NO 68. Is hand cleanser available at all hand washing sinks? YES (-41NO ( ) 69. Are hand dr>ifig facilities (paper towels, air blowers, etc.) available at all hand washing sinks? YES ( NO ( ) 70. Are covered waste receptacles available in each restroom? YES�/) NO ( ) 71. Is hot and cold running water under pressure available at each hand washing sink? YES NO() 72. Are all toilet room doors self-closing? YES () NO (� 73. Are all toilet rooms equipped with adequate ventilation? YES �O ( ) 74. Is a hand washing sign posted in each employee restroom? YES �O ( ) L. SMALL EQUIPMENT REQUIREMENTS 75. Please specify the number, location, and types of each of the following: Slicers I NI kwow Cutting boards 6 Uow sas-lu bar,aWprliA .5'eefio a &7a #ree Oil /mJ lYwa� Can openers I %/I KltCt12/1 Mixers I Ill ki-�d eA Floor mats MA Other STATEMENT: I hereby certify that the above information is correct, and I fully understand that any deviation from the above without prior permission from the Salem Board of Health may nullify final appyval. Signature(s) owner(s) or responsible representative(s) Date:_.. Approval of these plans and specifications by the Salem Board of Health does not indicate compliance with any other code, law or regulation that may be required --federal, state, or local. It further does not constitute endorsement or acceptance of the completed establishment (structure or equipment). A preopening inspection of the establishment with equipment in place & operational will be necessary to determine if it complies with the local and state laws governing food service establishments. 49'-r 25' 7'-S' FF rT iull OO IL_y onus l l ww w EXIST t✓ •—'_� ^ �--� --- t� .—� STOREFRONT P•1 . .va -. Q��;-¢ ;. -� . KITCHEN a' FUIL nut 4 N �UZI- f EXIST %�''6 I - �� YtlLr64�T TJSl E.LIC.1jJ S o�oo�n STOliEF I V A 4 t a _ - En�a. B couoFn 0 o LIGbT _- -•��`. _.' EXIST H - �.� .' . BATHROOM 3Ga d 44 - u-,o- ,zr V----LIMIT OF WORK ROPOSED FLOOR PLAN SCALE: 1/4" = 1'-0" EQUIPMENT LE EG ND HAND SINK SUSHI COUNTER SUSHI DISPLAY CASE ELEC RICE COOKER UNDERCOUNTER REFRI WASTE RECEPTICLE PENDANT LIGHTS W/ SCATTER PROOF LIGHT BLUBS P•O.S. BY CLIENT I W 4 ... ........ �,(jOD S MI W R A uo �.�00D,S MTYPAOFES' IONALSM), `yy A �v W. ,CERTIFKTIMJ qf r tw PENGXU" lv t t I, , I I � � ;.,-e c 'd W P HO,�6 U CERM IED -THE 'REi TV OR P - REQUIREMENTS NUM THE D; SAFETY �R, ETY. MA14AGE s -C CAM 1� ON ERTIFf AMINA"O -P `..1r`,„ V, -�Z �Y F sidWil -A, N AS 6, 204 I �ll "iLQC' Y4, TEST FORM W!NRF Le]Ls i o hg I s F 7 John T.Szet.0 (Adi q�p tr- 78_1 26765 Pest Control Service Agreement DENNIS THE MENNIS PEST CONTROL CO., INC. 1562 TERMITE & CARPENTER ANT SPECIALISTS 1-800-649-3028 WOBURN LOWELL BOSTON LYNN PEABODY NEWTON LAWRENCE 935-DEAD 459-2950 576-1038 592-0023 532-3443 332-5853 689-0697 CUSTOMER �sJ SE LOCATION SL\ a2 STREET � \ OF\ CITY, STATE aSd ZIP PERSON TO BE CONTACTED SERVICE PHONE PHONE TYPE OF PROPERTY Tp BE SERVICED DATE SERVICE BEGINS EXPIRATION DATE RENEWAL SERVICE TO BE PERFORMED ❑ ❑ MONTHLY ❑ QUARTERLY ❑ OTHER PESTS TO BE CONTROLLED Z�o SPECIAL INSTRUCTIONS _.:_.:. 1 1` - r1 tl Z P C-o Ij c- lye V�ot�6 �5., 1 e t C TERMS AND CONDITIONS: �1 (\ 512' 3 \ 12j SERVICE GUARANTEE: We agree to apply chemicals to control above-named pests in accordance with terms and conditions of this Service Agreement. All labor and materials will be furnished to provide the most efficient pest control and maximum safety required by federal, state and city regulations. ANNUAL AGREEMENTCHARGE $ BY COMPANY DATE SERVICE CHARGE $ tnurHD ZEUSIGNATUPE) t1,, MONTHLY/QUARTERLY PAYMENTS $ Lac '3�U� FOR CUSTOMER DATE _ (AUTHORIZED SIGNATURE) $ GUANG KE LAI GROUP, INC: d/b/a SUSHI GARDEN 99 North Street Salem, MA 01970 Date : November 14, 2011 Board of Health City of Salem 120 Washington Street Salem, MA Dear Sir or Madam; Guang Ke Lai Group, Inc., d/b/a Sushi Garden at 99 North Street, Salem, Massachusetts is requesting a variance for the exemption of acidified rice (sushi rice) as a potentially hazardous food specified under § 3-502.11. The sushi rice contains vinegar as a means of food preservation in addition to flavor enhancement. The facility has a HACCP plan which is submitted to your office herewith. The plan will be maintained at the restaurant and will be made available for your review. If you have any questions, please don't hesitate to contact the undersigned. Sin ,ate' rrr JUJMI UANUEN 99 NORTH STREET SALEM, MA 01970 HACCP PLAN FOR THE PRODUCTION OF SUSHI RICE TABLE OF CONTENTS Page I - Signature Sheet (HACCP cover sheet) Page 2 - HACCP Plan for the Production of Sushi Rice (narrative summary) Page 3 - Flow Diagram for the Production of Sushi Rice Page 4 - HACCP Master Plan Sheet for the Production of Sushi Rice Page 5 - Standard Operating Procedure for pH Measurement Page 6 / 7 - pH Log (master sheet & sample sheet) Page 8 - Summary of Employee Training Elements for the Production of Sushi Rice Page 9 / 10 - Employee Training Log (master sheet & signed sheets) Page 11 - Laboratory Results Supplement — Guidelines for the Safe Preparation of Sushi SUSHIGARDEN 99 NORTH STREET SALEM, MA 01970 HACCP PLAN FOR THE PRODUCTION OF SUSHI RICE PURPOSE: Cooked rice maintained in the temperature danger zone (41- 140°F) is susceptible to the outgrowth of spore -forming bacteria such as Bacillus cereus. Because the functionality of sushi rice requires its use at room temperature, the rice must be acidified to a pH value below 4.6 to inhibit the growth of these spore -forming bacteria. This HACCP plan addresses proper acidification of rice for room temperature storage and use. RECIPE Equipment: 5 -gallon plastic container for vinegar mixture, measuring cups, rice cooker, shallow container for cooked rice, spoon or paddle to spread rice, rice warmer Ingredients: dry rice, water, vinegar, sugar, salt 1. Combine 3,200 gams of dry rice with 3 liters of water in the rice cooker and cook until done (approximately 30 minutes). One recipe measures approximately 200 cups of cooked rice. 2. A vinegar mixture using 12 liters Fuji Rice Vinegar (4.2% acidity), 4 liters sugar, and 16 ounces of salt is made andstored under refrigeration in a covered, plastic container. Sulosamples may be removed from the, container and stored at room temperature for usage during the day. 3. Cooked rice (hot) is removed from cooker and placed in a shallow container. Using a spoon or paddle, the rice is spread to a depth of 4 inches or less. 4. 32 fluid ounces of vinegar mixture is added to one batch of cooked rice. 5. The mixture is thoroughly stirred to distribute the vinegar mixture and facilitate cooling. 6. The pH is measured immediately according to established procedures. (See: HACCP Master Plan, Standard Operating Procedures for pH Measurement of Sushi Rice, Manufacturer's pH Instruction Manual (Hanna Instruments), Summary of Training Elements for the Production of Sushi Rice) 7. Shelf -life: Same Day Use (maintained at room temperature.) Discard unused rice at the end of the day. The equilibrium pH value of sushi rice, formulated according to the above listed formulation and procedures, was validated by an independent laboratory and found to be 4.1 or less (see attached). Sushi rice acidification shall be verified according to the HACCP Master Plan. 8. This HACCP plan shall be reviewed a minimum of once per year or as needed by the PIC and shall be signed and dated to document this review. (see cover sheet). SUSHI GARDEN 99 NORTH STREET, SALEM, MA 01970 FkQR01AGRAMOF THE PRUDUCT7lON;OF,S ISHI,RICE Vinegar Salt 4.2% Acidity Vinegar Mixture for Sushi Rice Refrigerated Storage of Mixture Sugar Acidification of ------------ ��' ► Cooked Rice i i Combining of Dry Rice with Cold Water Cooking of Rice (Rice Cooker) Transfer of Rice to a Shallow Container Sub -sampling of i SOP FOR pH ME,4SUREMENT Sushi Rice t i Cooling of Sub -sample i i Sample Preparation Calibration of pH (Slurry of Tap Meter Water and Ta Water p i Sub -sample) i i PH Measurement of pH Value < 4.6 Slurry i ------i i t i Rice Warmer --------------------------- pH Value >4.6 1 Holding of ------------' Acidified Rice Discarding of Rice at End of Day SUSHI GARDEN, 99 NOW IH S I REE 1, HACCP PLAN MASTER SHEET FOR THE PRODUCTION OF SUSHI RICE SALEM, MA 01970 Critical Hazard Controlled Critical Litnit(s) Monitoring Corrective Action Records Verification Control Point PRODUCTION Growth of Pathogens pH value of finished What — sushi rice For rice made within 2 pH log 1. Calibration OF SUSHI (spore -formers sushi rice < 4.3 cr 25°C hours, if pH value is greater of pH meter RICE including if measured within 2 HOW - A calibrated pH than 4.3 and < 4.6, add more Corrective daily prior to Bacillus cereus) hours < 4.6 if tested meter as per Standard vinegar until a value below Action to be use. (Acidification to after 2 hours of Operating Procedures for 4.3 is achieved - Record new recorded on exempt rice as a preparation pH measurement: - value pH Log 2. Record PHF using a Review by validated Recipe validated at a Frequency — each batch For rice with a pH value > PIC recipe) targeted pH < 4.1. - 4.6, if made greater than Records shall performed - Who — sushi chef or one hour from measurement, be daily. designated employee discard rice. maintained for 30 Days 3. pH of rice To prevent recurrence: tested by a Verify use of correct recipe. food Verify proper use of pH laboratory meter, including buffer annually or integrity, electrode integrity, when daily pH and a fully charged battery levels are Verify adherence to SOP for consistently PH measurement. higher than the - laboratory validated PH measurement. 4. HACCP plan reviewed a minimum of annually or as needed by PIC (Signed and dated by PIC STAIVDARD OPERATING PROCEDURE FOR PH MEASUREMENT' SUSHI GARDEN, 99 NORTH STREET, SALEM, MA 01970 based upon the use of OAKTON PART I - CALIBRATIONPROCEDURE 1. Switch unit on (ON/OFF button). 2. Dip electrode into chosen buffer (pH buffer 4 is suggested). DO NOT immerse above color band. 3. Press the CAL button to enter calibration mode. The "CA" flashes on the display. Then, a pH value close to the buffer value will flash. 4. After at least 30 seconds (about 30 flashes) press the HOLD/CON button to confirm calibration. The display will show "CO" and then switch to the buffer value reading. 5. Press the "CAL" button to exit. 6. Rinse the electrode in tap water. BUFFER NOTE: Make sure buffer has not passed expiration date. Keep the buffer covered and properly stored when not in use. Maintain buffer at room temperature. Keep away from bright light. Do not immerse probe into main container of buffer. Sub -sample buffer. Do not return sub -sample (used) buffer into main container. PART 2 - pHMEASUREMENT OF SAMPLE 1. Place 2 tablespoons of finished sushi rice (as per formulation) into a clean container and cool to room temperature. 2. Add 2 teaspoons of room temperature tap water. 3. Mash the rice and water mixture with a clean spoon until a slurry is created. 4. Using a calibrated pH meter (see procedure above), measure the sample by dipping the electrode about 2 to 3 cm into the liquid portion of the slurry. Stir and let the reading stabilize. 5. Press HOLD/CON to freeze the reading. This is the equilibrium pH. Record this value on the pH log. (NOTE: The complete record should include the date, time, pH value and initials of the person measuring the pH). 6. Rinse the probe in tap water and blot dry with a clean, dry cloth or paper towel. 7. Tum off the meter and replace the cap on the probe tip. Store properly. NOTE: Refer to Manufacturer's instruction for troubleshooting and replacing the batteries. SUSHIGARDEN 99 NORTH STREET SALEM, MA 01970 pH Log / Calibration Log The pH meter shall be calibrated according to established procedures and at a frequency established in the HACCP Master Plan. Follow the Standard Operating Procedure for pH Measurement Date/ Time / Initials for the performance of PH calibration Date Time pH of Sushi Rice Corrective Action (if required) Initials of person taking PH PIC Daily Record Review (Verification) Date / Initials i1 Gid ie c lei 'v C1 2 V klP 11 D ' U V(Y NOTES: SUSHiGARDEN 99 NORTH STREET SALEM, MA 01970 pH Log / Calibration Log The pH meter shall be calibrated according to established procedures and at a frequency established in the HACCP Master Plan, Follow the Standard Operating Procedure for pH Measurement Date/ Time / Initials for the performance of pH calibration Date Time pH of Sushi Rice Corrective Action (if required) Initials of person taking pH PIC Daily Record Review (Verification) Date / Initials NOTES: SUSHIGARDEN 99 NORTH STREET SALEM, MA 01970 SUMMARY OF EMPLOYEE TRAINING ELEMENTS FOR THE PRODUCTION OF SUSHI RICE 1. All employees involved in the production of sushi rice shall be trained in proper personal hygiene including: • proper hand -washing (procedures and frequency) • proper hair restraints, clothing (uniform and/or use of apron) • removal of jewelry during production • proper use of gloves and no bare hand contact of ready -to -eat products 2. All employees involved in the production of sushi rice shall be informed of their responsibility to report to the PIC when they are experiencing symptoms such as nausea, vomiting, diarrhea, fever, sores, or any other symptoms that may affect the safety of food. 3. All employees involved in the production of sushi rice shall be trained in the proper use of applicable food contact surfaces including: • proper cleaning and sanitizing procedures • proper storage procedures of equipment / ingredients • proper handling procedures of equipment / ingredients • proper procedures for preventing cross -contamination • proper use and storage of wiping cloths 4. All employees involved in the production of sushi rice shall be trained on the elements of the HA CCP Plan for the Production of Sushi Rice including: • proper cooking procedures • proper formulation of sushi vinegar mixture • proper acidification of sushi rice through cooked rice to vinegar mixture ratio control and mixture distribution • proper sub -sampling procedures of sushi rice for pH measurement • proper preparation of sushi rice for pH measurement • proper storage and use of sushi rice • proper shelf -life of sushi rice 5. All employees involved in the production of sushi rice shall be trained on the Standard Operating Procedure for pH Measurement including: • proper calibration procedures • proper pH measurement of sample • proper handling procedures of buffer / pH meter • proper storage procedures of buffer / pH meter • current HACCP critical limits established in the plan • current HACCP monitoring frequency established in the plan • proper HACCP corrective actions when a deviation for a critical limit occurs • proper HACCP verification procedures / frequency • proper retention of records for 30 days (Refer to the U.S. FDA Food Code or local regulations, as applicable.) SUSHIGARDEN 99 NORTH STREET SALEM, MA 01970 EMPLOYEE TRAINING LOG The employees listed below have been properly trained in correct procedures for the production of sushi rice as per the SUMMARY OF EMPLOYEE TRAINING ELEMENTS FOR THE PRODUCTION OF SUSHI RICE (in the HA CCP PLAN) EMPLOYEES NAMEI EMPLOYEE SIGNATURE TRAINING DATE This sheet must be signed and dated by the employee upon completion of training. SUSHI GARDEN 99 NORTH STREET SALEM, MA 01970 REVIEW / REVISION TO HACCP I SIGNED BY: I Date This sheet must be signed and dated by a PIC after any reassessment or change to the HACCP Program or a minimum of once per year. Signature: Date : SUSHIGARDEN 99 NORTH STREET SALEM, MA 01970 SUPPLEMENT (NOT PART OF HACCP PLAN) GUIDELINES FOR THE SAFE PREPARATION OFSUSHI The HACCP Plan for the production of Sushi Rice shall be followed. (see HACCP plan including Training Elements for the Production of Sushi Rice). Proper records shall be maintained for a minimum of thirty days. 2. All food shall be obtained from an identifiable, approved sourc. All seafood shall come from a source that operates under a HACCP plan. 3. Documentation from fish supplier shall be on file regarding proper freezing of parasitic species of fish. FDA requires that fish be frozen at -4°C for 7 days or at -35°C until solid and stored at -31 °F for 15hours or -4°F for 24 hours in order to ensure parasitic destruction. 4. Proper temperature control of fish and potentially hazardous ingredients during receipt and storage shall be maintained. All potentially hazardous foods shall be received at or below 41 °F. Refrigeration units shall operate to ensure food can be maintained at or below 41 °F. Frozen products shall be thawed under refrigeration at or below 41'F. 4. All sushi and related ingredients shall be properly handled as per the "No bare hand contact with ready -to -eat foods" policy established in the Food Code. Sushi chefs shall employ the use of gloves. 5. Cross -contamination shall be prevented through separation of raw and cooked ingredients, cleaning and sanitizing of equipment and utensils between uses, and the proper covering of the bamboo mat. Plastic wrap should be changed at least every four hours or after use on raw fish if the mat is to be used again on cooked product. Ideally, a separate set-up (bamboo mat, knife and cutting board) is suggested for raw versus cooked sushi. 6. Each ingredient should be kept in a separate container and held at proper temperatures. Additionally, ensure that all ingredients and utensils are properly stored in designated locations and protected during storage. 6. Consumer Advisory statements required as per the Food Code 3-603.11 shall be properly posted to advise the consumer of increased risk of foodborne illness due to the consumption of raw fish. 7. A PIC (Person -in -Charge) shall be present during all hours of operation during which sushi is produced. The purpose of this agreement is to ensure that Food Employees and Applicants who have received a conditional offer of employment notify the Person in Charge when they experience any of the conditions listed so that the Person in Charge can take appropriate steps to preclude the transmission of foodborne illness. I AGREE TO REPORT TO THE PERSON IN CHARGE: SYMPTOMS 1. Diarrhea 2. Fever 3. Vomiting 4. Jaundice 5. Sore throat with fever 6. Lesions containing pus on the hand, wrist, or an exposed body part (such as boils and infected wounds, however small) MEDICAL DIAGNOSIS Whenever diagnosed as being ill with Salmonella Typhi (typhoid fever), Shigella spp. (shigellosis), Escherichia coli 0157:H7, hepatitis A virus, Entamoeba histolytica, Campylobacter spp., Vibrio cholera spp., Cryptosporidium parvum, Giardia lamblia, Hemolytic Uremic Syndrome, Salmonella spp. (non -typhi), Yersinia enterocolitica, or Cyclospora cayetanensis. PAST ATEDICAL DIAGNOSIS Have you ever been diagnosed as being ill with one of the diseases listed above? If you have, what was the date of the diagnosis? HIGH-RISK CONDITIONS 1. Exposure to or suspicion of causing any confirmed outbreak of typhoid fever, shigellosis, E. coli 0157:H7 infection, or hepatitis A 2. A household member diagnosed with typhoid fever, shigellosis, illness due to E. coli 0157:H7, or hepatitis A 3. A household member attending or working in a setting experiencing a confirmed outbreak of typhoid fever, shigellosis, E. coli 0157:H7 infection, or hepatitis A I have read (or had explained to me) and understand the requirements concerning my responsibilities under 105 CMR 59011999 Food Code and this agreement to comply with the reporting requirements specified above involving symptoms, diagnoses, and high-risk conditions specified. I also understand that should I experience one of the above symptoms or high-risk conditions, or should I be diagnosed with one of the above illnesses, I may be asked to change my job or to stop working altogether until such symptorns or illnesses have resolved. I understand that failure to comply with the terms of this agreement could lead to action by the food establishment or the food regulatory authority that may jeopardize my employment and may involve legal action against me. Applicant or Food Employee Dame (please print) Signature of Applicant or Food Employee Date Signature of Permit Holder or Representative Date This is a model form created by MA Dept, of Public Health which is offered as a tool for Industry to use to aid in compliance with 105 CMR 590.003(C) and Food Code 2-201.11 The use of this form is voluntary and is not required by state regulation. Revised5/8/2001 IMPORTANT MESSAGE FOR DATE �t/Q/ TIME P.M. M AAAreeA t� }' OF r VI 1 `S PHONE AREA CODE UMBER EXTENSION ❑ FAX ❑ MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED CAME TO SEE YOU PLEASE CALL _ WILL CALL AGAIN WANTS TO SEE YDU RUSH , RETURNED YOUR CALL WILL FAX TO YOU MESSAGE SIGNED 48005 / MADE IN U.S.A. DATE S,IL-TIME -G P. M. KA S u s h � � rden OF ©r^ PHONE AREA CODE NUMBER EXTENSION ❑ FAX ❑ MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED CAME. TO SEE YOU PLEASE CALL ILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU M SSAGE SIGNED Su�hi'�rden CHINESE & JAPANESE CUISINE For Delivery &Take Out T.: 978.744.9998 978.744.9995 99 North Street Salem, MA 01970 Open Daily Sun. 12 noon - 9:30 pm We Deliver Mon. - Thurs.: 11:30 am -10:00 pm Salem -Peabody FriA Sat.:11:30 am -11:00 pm ($1.50 Charge) Party Platter Gift Certificate Available Available * Before Placing Your Order; please inform your server if a person in your party has a food allergy. J .-- '�F R "E E General Tso's Chicken W. Purchase of $35 or More !F R E E Crabi� Rangoon or Chkken unser ; w. Purchase of $20 or More .y salmon Ran or sphy Rma Ron w. Purchase of $25 or More 15%OFF` Entire Purchase oiler or on Gnrt@tm 1 eve do New Year eve d u, wD Win' JAPANESE APPETIZERS SPECIAL MAKI Crispy Eel Maki ; 8.25 Sakura Maki 9.95 • Spider Maki 6.95 eel, avocado, cucumber;topped with spicy Shrimp tempura, avocado 1. G oza 3.50 5. Tuna Tatar 5.95 G, mfr he,[ abard"'aQa beg atnu tea crab meat, tobiko, scallion, tempuraflake topped w. salmon, tuna, tobiko Crazy Dragon Maki 8.95 Iowa Maki 9.95 2. Kani Shumai 3,50 6. Vegetables Dr a on Maki 7.25 3. Edamame 3.50 Tempura 4.95 cau}�ornia makt wee[, avocado on top Shrimp tempura, mango, cream cheese Eel, cream cheese, avocado, crab meat, topped w avocado, honey wasabi sauce spiry tuna, deep fried topped with tobiko, 4. Spicy Naruto 4.50 Rainbow Maki 7.25 Holy Tuna 9.25 scallions. spiry mayo, eel sauce Kani, ebi, tobiko w. topped with tuna, salmon, red snapper Spicy tuna, avocado, battered and Alaskan King 10.95 SALADCaterpillar Maki 7.25 deep fried topped with spicy eel sauce special chili sauce mayo, Tempura shrimp, Alaskan king crab meat, tobiko, scallion, spicy mayo & eel sauce 1. Ika Salad 4.50 4. Garden Salad 1.95 Eel, cucumber, tobiko, stallions with avocado on the top 007 Maki 9.95 Jumping Halapino 10.95 2. Ava Salad 4.25 5. Seaweed Salad Scorpion Maki 7.25 Spicy crunch, tuna topped w salmon and eel, Tempuras mp topped over tuna grilled with spiry mayo, eel sante I black pepper and house special halopino sauce 3. Seaweed w. Spicy Tuna / Eel, cucumber, tobiko, shrimp Crazy mon SalMaki 9.95 Red Don Maki 11.95 Dragon g Salad 3.75 Spicy Salmon4.75 p Y and avocado on the top Volcano Maki 7.75 Topped salmoSpicy n, salmon, spicy mayo, tempura flake. with fresh salmon f� avocado spicynch ma on w,avocflake.pped w. Spicy lobstermeat& avocado UDONCrab meaC at -ado, lettere eel v ppedwdhspicy tuna Thick White Wheat Noodles VEGETABLE ROLL SUSHI REGULAR 1. Tempura Udon7.95 3. Seafood Udon8.25 Avocado Roll 2.75 Served w Miso Soup 2. Chicken Udon7.75 4. Vegs. Udon 7.50 Kappa Roll (Cucumber Roll) 2.75 1. Sash! Regular 14.95 Avocado w, Cream Cheese Roll 2.95 8pcs of nigiri susbi and 6pieces of tuna roll TEMPURA Avocado w. Cucumber Roll 2.95 2. Sushi Deluxe 16.95 Served w. Sou P Sweet Potato Roll 2.95 l0 pts ojnigtrisusbi and Gpcs tuna roll 3. Sushi Super r2 pct sushi and 6pcs tuna roll 18.95 Lightly battered and deep fried fresh seafood and vegetable Vegetable Dragon Roll 5.95 4. Chlrash! Assorted tier o f offish over bed of rice 14.95 1. Vegetables 7.50 3. Shrimp & Uegs. 9.95 Ooshiko, cucumber, and yamagoba Aped to avocado spiry mayo 5. Unag! Don Eel over a bed of rice 12.95 2. Shrimp 10.95 Vegetable Tempura Roll 3.95 6. Vegetarian Platter 7.95 Deep fried sweet potato and string beans Avocado roll, cucumber roll, osbiko roll KAT SU Veggie Roll Avocado, lettuce, cucumber &yellowpickle 3.95 7. Makimono Combination 12.95 Tender meats dipped in a light bread crumb batter MAKI (HAND ROLLS) Spicy tuna, Alaskan, shrimp tempura 8. Salmon Combo 7.95 and then deep fried to perfection Tonkatsu Fork 9.95 Chicken Katsu 9.95 Maki is culled in S t0 6 PCs Hand roll is in ice cream cone shape 3 pts salmon sushi & salmon avocado roll 9. Tuna Combo3p�tn aaahthi tanaac,.nve ron 7.95 TE PPANYAKI Add cucumber $0.50, add avocado $0.50, add flying fish roe $0.50 10. Sashimi Regular 8pcs assorted rawpsb 9.95 California Mak! Crabmeat, cucumber, avocado 3.75 11. Sashimi Deluxe 15pcs assorted rawfsh 14.95 Fresh tender meat grilled to perfection, then smothered California Maki w. Tobiko 3.95 12. Sushi and Sashimi Combo 15.95 in our own special teriyaki sauce Spicy Salmon Maki 4.50 6pcsauartedsushi,6p"assortedraw Chicken 9.95 Shrimp 11.95 Tempuraflake, salmon, scallion, cucumber fish and Ca[ffornia roll 13. Sushi Platter for 2 29.95 Beef 10.95 Salmon 12.95 Spicy Yellowtail Maki 4.50 l0 pcs assorted sushi, 9 pct assorted raw fish, Tempura flake, yellowtail, scallions, cucumber Neglhama Maki 4.00 crazy dragon and spicy tuna roll Y Yenowtaaand scallions 14. Sushi Garden Party Trait 45.95 Spicy Scallop Mak! Rmpuraftaw,,scallions, Cucumber 4.75 l5pcssusbi. l2pcssashimi, 3cbefsspecial roil ,: '�,, +. • �. - ... - Samon Tempura Mak! T,-p,,-snJmnn, ntn,mbcfi avocado, tobiko 4.75 JAPANESE LUNCH SPECIAL Crazy Maki shrimp tempura, tobiko, avocado &sbuy mays 4,75 Served w Miso Soup / 7 Days A Week 11:30am - 3:00pm SUSHI & SASHIMI Spicy Tuna Mak! Temmanftake, tura,, cucumber, scat[1ons4.50 Except Christmas Eve, Christmas Day, New Year Eve and New Year Day Una-Ava Mak! Eel, avocado 4.50 1. Sushi Lunch #1 4ptsa tmsbi&Caxjbrma Qa 6.95 Sushi 2 pcs per order, sashimi 3 pcs per order Una-Kyu Maki Eel, cucumber 4.25 2. Sushi Lunch #2 6p" assorted susbi & tuna roll 7.95 sa Maguro (Tuna) 3.75 5.00 Tekka Maki 3.95 3. Sashimi Lunch #1 apcsassorted 8.50 Sake (salmon) 3.50 5.00 Sake Maki 3.95 4. Sashimi Lunch #2 IOP" assorted 9.95 Hamachi (Yenowtau) 3.75 5.00 Futo Maki 4.50 5. Sushi & Sashimi Combo 12.95 '• Ebi (Shrimp) 2.95 4.50 Cucumber, avocado, kam, tobiko, tamago, shrimp, yamagoba 4 pcs susbi, 6pcs sashimi, California roll r Boston Mak! Shrimp, cucumber, lettuce, scallions, p ma 4.50 MAKI LUNCH: Kanikama (crab stick) 2.95 4.50 Philadelphia Maki.3.00 `•�� 4.95 Any 2 Rolls 7.50 /Any 3 Rolls 9.95 Tal (Red Snapper) 3.00 4.50 Smoke salmon, cucumber, cream cheese, scallions t. Unag! (Eel) 3.50 5.00 r r Mango Shrimp Maki " 3.95 California , Alaskan Ebi Kyu Tamago (Egg cake) 2.95 4.50 ? mangmango, nds shrimp ke ectal e- ;, ,, , Tuna, Y Sweet,potato Avocado ;j Tako (octopus) 3.25 4.75 y Shrimp Avocado Maki 3.95 �Salmon-.,. eTuna Avocado -,Cucumber' ' Tobiko (FiymgFishRoe) 3.95 5.50' P p Shrimp Tempura Maki 4.50 Spic y'Tuna>,.e Una Avocado'Osh nko'r I White Tuna 3.75 , 5.00 Alaskan Mak! Salmon, avocado, cucumber 4.25 Spicy Salmon Una Kyu ShrimpTempura Inarlgg(rofaskin) 2.75 ` "" California Deluxe Tuna, Cucumber avocado, tobiko 4.75 Avocado Kyu Ebi Avocado Negihama * ti fL"`�7 • Consuming raw or P. 11 �V under cooked meats, poultry, seafood shel#ish or eggs may increase f your rl4k orfoodborne illness, especially if you have certain medical conditions Su�hi'�rden CHINESE & JAPANESE CUISINE For Delivery &Take Out T.: 978.744.9998 978.744.9995 99 North Street Salem, MA 01970 Open Daily Sun. 12 noon - 9:30 pm We Deliver Mon. - Thurs.: 11:30 am -10:00 pm Salem -Peabody FriA Sat.:11:30 am -11:00 pm ($1.50 Charge) Party Platter Gift Certificate Available Available * Before Placing Your Order; please inform your server if a person in your party has a food allergy. J .-- '�F R "E E General Tso's Chicken W. Purchase of $35 or More !F R E E Crabi� Rangoon or Chkken unser ; w. Purchase of $20 or More .y salmon Ran or sphy Rma Ron w. Purchase of $25 or More 15%OFF` Entire Purchase oiler or on Gnrt@tm 1 eve do New Year eve d u, wD Win' TIBITS CHINESE APPETIZERS Each Substitution $1.00 More: H 1. T 1. Egg Roll, Chicken Sm. Lg. 1. Egg Roll 1.95 3.95 2. Spring Roll 1.95 3.95 3. Chicken Wings 4.95 7.95 4. Chicken Fingers 4.25 6.95 5. Fried Jumbo Shrimps 4.25 7.95 6. Chicken Teriyaki 4.25 7.95 7. Beef Teriyaki 4.50 7.95 8. Boneless Spare Ribs 4.25 6.95 9. Crab Rangoon 4.25 6.95 10. Scallion Pancakes 7.95 3.95 11. Dumplings (Pried or Steamed) 4.25 6.25 12. French Fries 1.95 3.50 TIBITS RICE & NOODLES Each Substitution $1.00 More: H 1. T 1. Egg Roll, Chicken 8.75 Fingers & Chicken Wing 7.50 T 2. Spring Roll, Fried Shrimp Lg. & Chicken Fingers 7.75 T 3. Beef Teriyaki, Boneless Spare Ribs, 5.95 Chicken Wings & Crab Rangoon 8.50 T 4. Beef Teriyaki, Chicken Wings 5.95 & Chicken Fingers 7.75 T 5. Chicken Teriyaki, Crab Rangoon, 6.95 Boneless Spareribs, Chicken Fingers 8.25 SOUP 3.50 Sm. Lg. S 1. Mini Dumpling Soup 2.50 4.00 S 2. Egg Drop Soup 1.95 3,75 S 3. Wonton Soup 1.95 3.75 S 4. t Hot & Sour Soup 1.95 3.75 S 5. Chicken Noodle Soup 1.95 3.75 S 6. Chicken Rice Soup 1.95 3.75 S 7. Miso Soup ' 1.95 3.75 S 8. t Seafood Hot & Sour Soup 6.95 ft CHICKEN / VEGETABLE Sm. RICE & NOODLES Broccoli w. Chicken 5.25 H 1. Choice of Chicken, Beef, Pork, or Vegetables: 8.75 H 2. For Shrimp is Additional $1.00 Sm. Lg. R 1. t Curry Fried Rice 3.95 5.95 R 2. Fried Rice 3.95 5.95 R 3. House Fried Rice 4.75 6.95 R 4. Pineapple Fried Rice 3.50 5.75 R 5. Steamed White Rice 1.00 2.00 R 6. Sushi Rice 1.50 2.75 R 7. t Curry Lo Mein 4.95 6.95 R 8. Lo Mein 4.25 6.50 R 9. House Lo Mein 5.25 7.95 R 10. Chow Mein 4.50 6.75 R 11. Chicago or Subgum Chow Mein 4.95 7.50 R 12. t Pad Thai �. 7.95 cabbage, straw carrot and mushroom Thai flat noodles wok fried w. choice of HI 1. Lobster Sauce (Sm) 4.25 (Lg) 6.50 t Szechuan Spicy Shrimp 6.25 meat, egg, peanuts and bean sprouts Shrimp w. Lobster (Sm) 5.95 (Lg) 9.95 9.75 R 13. Sa Shia Lo Mein Sweet & Sour Shrimp 7.95 White meat chicken fried w. light egg Choice of meat, pea pods, mushroom, bamboo Egg Foo Young w. Shrimp batter topped w fresh lemon sauce shoots wok tossed in Chinese BBQ sauce H 14. t Hunan Delight of Three 11.95 R 14. Rice Noodle Sauteed Jumbo shrimp, beef, cbicken, flesh 7.50 R 15. Singapore Rice Noodle Egg Roll Crab Rangoon, 7.95 R 16. Pan Fried Noodles 2.25 3.95 I CHICKEN / VEGETABLE Sm. HOUSE SPECIALTIES Broccoli w. Chicken 5.25 H 1. t General Gau's Chicken 10.95 8.75 H 2. Sesame Chicken or Beef 10.95 Cashew Nuts w, Chicken 5.25 H 3. t Orange Flavored Chicken or Beef 11.95 8.75 H 4. t Kung Pao Three Delight 10.95 String Beans w. Chicken 5.25 8.75 Jumbo shrimp, chicken, beef sauteed w 8.75 Mushroom w. Chicken 5.25 mixed vegs and peanuts in hot spicy sauce Black Bean Sauce w. Chicken 5.25 H 5. Moo Goo Gal Pan 9.95 7.95 H 6. t House Special Crispy Chicken 10.95 Egg Foo Young w. Chicken or Veg. 6.25 Crispy fried sliced chicken wok tossed w. ginger Sm. & garlic in a spicy sweet & sour sauce Broccoli w. Beef or Pork 5.25 H 7. Mango Chicken or Shrimp 11.95 8.75 H 8. Pepper Steak w. Onion 9.95 Szechuan Spicy Beef or Pork 5.25 H 9. Go! Poo Lo Mein 13.95 8.75 Mushroom w. Beef or Pork 5.25 Batter fried chicken, specially cooked & sauteed Black Bean Sauce w. Beef or Pork 5.25 8.75 w. crispy vegetables, pork, shrimp w. a side 6.25 SHRIMP order of pan fried noodles Sm. H10. Dragon & Phoenix 10.95 9.75 Mixed Vegetables w. Shrimp 6.25 Jumbo shrimp, chicken, broccoli and Chinese �. 9.75 cabbage, straw carrot and mushroom 9.75 HI 1. Lobster Sauce (Sm) 4.25 (Lg) 6.50 t Szechuan Spicy Shrimp 6.25 H12. Shrimp w. Lobster (Sm) 5.95 (Lg) 9.95 9.75 H13. Lemon Chicken 9.95 Sweet & Sour Shrimp 8.95 White meat chicken fried w. light egg 9.50 Egg Foo Young w. Shrimp batter topped w fresh lemon sauce CHOOSE YOUR OWN H 14. t Hunan Delight of Three 11.95 Served All Day Sauteed Jumbo shrimp, beef, cbicken, flesh Pick Any Three Appetizers, Served w. Pork Fried Rice, or Pork Lo Mein $7.95 vegetables served in spicy black bean sauce Egg Roll Crab Rangoon, H15, Happy Family 13.95 Jumbo shrimp, sea scallops, sliced pork, chicken & beef W. mixed vegetables in a tasty -brown sauce ""10.95 1-116. Mongolian Beef Beej w1ul onion & sra/itons sameed w H17. Four Happiness 10.95 Cub •s of Gbaresc roastpork, with sliced beef shrimp, H18. chicken with fresh mixed vegetables in an exotic sauce Chet's Iriple Crowns ' ' 11 �" ''14.95 /urrlbo shrimp, sea scallops. sliced tender beef selected nixed vegetables cooked in oyster sauce 4' CHICKEN / VEGETABLE Sm. Lg. Broccoli w. Chicken 5.25 8.75 Mixed Vegetable w. Chicken 5.25 8.75 t Kung Pao w. Chicken 5.25 8.75 Cashew Nuts w, Chicken 5.25 8.75 i Garlic Sauce w. Chicken or Veg.5.25 8.75 t Szechuan Spicy Chicken or Veg. 5.25 8.75 String Beans w. Chicken 5.25 8.75 Fresh Snow Peas w. Chicken 5.25 8.75 Mushroom w. Chicken 5.25 8.75 Black Bean Sauce w. Chicken 5.25 8.75 Sweet & Sour Chicken 7.95 t Curry Chicken 8.50 Egg Foo Young w. Chicken or Veg. 6.25 BEEF / PORK Sm. Lg. Broccoli w. Beef or Pork 5.25 8.75 Mixed Veg. w. Beef or Pork 5.25 8.75 t Garlic Sauce w. Beef or Pork 5.25 8.75 Szechuan Spicy Beef or Pork 5.25 8.75 String Beans w. Beef or Pork 5.25 8.75 Mushroom w. Beef or Pork 5.25 8.75 Black Bean Sauce w. Beef or Pork 5.25 8.75 Egg Foo Young w. Beef or Pork 6.25 SHRIMP Sm. Lg. Broccoli w. Shrimp 6.25 9.75 Mixed Vegetables w. Shrimp 6.25 9.75 t Kung Pao w. Shrimp 6.25 9.75 Cashew Nuts w. Shrimp 6.25 9.75 t Garlic Sauce w. Shrimp 6.25 9.75 t Szechuan Spicy Shrimp 6.25 9.75 String Beans w. Shrimp 6.25 9.75 Fresh Snow Peas w. Shrimp 6.25 9.75 Sweet & Sour Shrimp 8.95 t Curry Shrimp 9.50 Egg Foo Young w. Shrimp 7.25 CHOOSE YOUR OWN COMBINATION Served All Day Pick Any Three Appetizers, Served w. Pork Fried Rice, or Pork Lo Mein $7.95 Egg Roll Crab Rangoon, Chicken Wings Chicken Teriyaki i ..` CHINESE COMBINATION PLANT All Combination Plant Served w. Choice of one appetizers and pork fried rice or white rice Egg Roll. Chicken Wings, Chicken Fingers, Beef Teriyaki, Boneless Spareribs, Crab Rangoons, Chicken Teriyaki, Spring Roll Chinese Combination Plant served all day, except Christmas Eve, Christmas Day, New Year Eve and New Year Day Lintel, Dinner D 1. Lo Mein with Chicken, Pork or Beef 5.95 7.95 D 2. Chow Mein w. Chicken, Pork or Beef 5.95 7.95 D 3. t Garlic Sauce with Chicken or Beef 6.95 7.95 D 4. Fresh Snow Peas with Chicken or Beef 5.95 7.95 D 5, Cashew Chicken 5.95 7.95 D 6. Lobster Sauce with Shrimp 6.25 8.25 D 7. t General Gau's Chicken 6.25 7.95 D 8. Broccoli w. Chicken or Beef 5.95 7.95 D 9. Mixed Vegetable Chicken, Pork or Beef 5.95 7.95 D10. Sesame Chicken or Beef 6.25 8.25 D11. Moo Goo Gal Pan 5.95 7.95 D12. t Orange Flavored Chicken or Beef 6.25 8.25 D13. t Szechuan Spicy Chicken, Pork or Beef 5.95 7.95 D14. Sweet & Sour Chicken 5.95 7.95 D15. Mushroom Chicken or Beef 5.95 7.95 D16. t Kung Pao Chicken or Beef 5.95 7.95 D17. String Bean with Chicken, Pork or Beef 5.95 7.95 D18. Egg Foo Young with Pork or Chicken 5.95 7.95 D19, Broccoli Shrimp 6.50 8.50 D20. t Kung Pao Shrimp 6.50 8.50• Chicken FingerSpring Roll 7, Beef=Ter'I' Fried Shrimp ©,t� v 1r � s " r Berpareri v.� P q 12/05/2011 15:12 6173503188 Christopher E. Coleman, Esq., PC 128 Lincoln Street, Suite 103, Boston, MA 02111 Date: December 5, 2011 To: Health Department AM.: Larry From: Yuki PAGE 01/02 Tel: 617-350-6188, Fax: 617-350-3188 E -mall : attomeyeoleman@gmail.com FAX TRANSMITTAL Re: Servsafe Certificate—Sushi Garden Dear Larry ; PAGES INCLUDING THIS COVER 2 Please find attached food safety manager training certificate for the business owner of Sushi Garden. Thank you in advance for your help, and please do not hesitate to contact our office if you have any questions regarding this matter. Thanks Yuki Wong If there are any problems with this transmittal, please call us at 617-35Ml8$, or fax to 617.350-3188. Statement of Confidentiality The documents included with this facsimile transmittal sheet contain information, which is confidential and/or privileged. This information is intended to be for the use of the addressee named on this transmittal sheet. If you are not the addressee, note that any disclosure, photocopying, distribution or use of the contents of this faxed information is prohibited. If you have received this facsimile in error, please notify us by telephone immediately so that we can arrange for the retrieval of the original documents at no cost to you. John P. Szeto (Administrator ) 781-267-6580.(cell) 4.. [ssUE DATE: NOVEMBER 22, 201 S wi CoffMCATE NO: EZ206929B i T 9MSfi TEST FORM: EZC i 1 t OD�. s •. - .. - L- £ THE NATIONAL .RECIS'TKYOF , FOOD SAF'" E'MRROFESSIONAL.SO IM �. � t KEI I ERMAN ZHENG ;. HAS SUCCESSFULLY SATU3PIED M REQU[REME,NTS FOR p_- "� THE F000 SAFETY MANAGER x C-:ERTIFICATIOrI'EXAIiH1INATlON -ems . gg*vhk LawrenceJ,Lynch ; CAIS John P. Szeto (Administrator ) 781-267-6580.(cell) 4.. [ssUE DATE: NOVEMBER 22, 201 S i9 CoffMCATE NO: EZ206929B i T 9MSfi TEST FORM: EZC i 1 Bfq e� �, -. T�gdpyFi.3I81& •. - .. - P{80�4,¢6d�446 �VAVif�5eCf1 1"�2 --uertlfl®teo(refdiorm rr Tfii Ihflrl fll'C ditt Oil .c" i;SafrZ.fr3F. egi .. °Lp ]r(fTO John P. Szeto (Administrator ) 781-267-6580.(cell)