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TABERNACLE CHURCH - ESTABLISHMENTSr �- r I _ � 3 } . } . `pNDiT City_ of Salem, Massachusetts Board of Health - 120 Washington MA 01970 T Salem 4th Floor, , , �P m Tel. . (978) 741-1800 Fax. (978) 745-0343 Pub1iCI3ealthl health@salem.com Prevent Promote. Protect. Kimberley Driscoll Larry Ramdin, MPH, REHS, CHO Mayor Health Agent FOOD ESTABLISHMENT PERMIT (must be posted on the Premises of the Food Establishment) 2017 Permit Number: FM-16-659 Permit Type: Food Establishment 25-99 seats Goods & Services: Food Service: Non-Profit Name of License Holder: Board of Trustees Tabernacle Congregational Church Name of Food Establishment Tabernacle Congregational Church Address of Food Establishment 50 Washington Street Salem MA 01970 Restrictions: Church Kitchen This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on 12/31/2017 unless sooner suspended or revoked. Permit Fee: $0.00 Effective: 12/21/2016 Larry Ramdin, MPH, REHS, CHO Health Agent KIMBERLEY DRISCOLL MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON S'1'R.EE"P, 4TM FLOOR TEL. (978) 741-1800 FAx (978) 745-0343 healthGdsalem.com LARRY RAMDIN, RS/REFIS, CHO, CP -FS HEALTH AGENT Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: -rat W, 2) Establishment Address: 5Z) 1n q-- 0) q7& 3) _ Establishment Mailing Address (if different): 4) Establishment Telephone No: - 5) Applicant Name & Title: 6) Applicant Address: 7) Applicant Telephone No: 24 Hour Emergency No: Email: S) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): 10) Establishment Owned by: An association A corporation An individual A partnership Other legal entity 11) If a corporation or partnership, give name, title and home address of officers or partner. Name Title Home Address 12 •.Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor, Manager, etc. Name & Title: korft "(A - "Te) eAar�A &,A n u �'f &r s Address: _p m 0 0 Telephone No: p 4f-7VJ--.Ls'IJ-. Fax: `Email: (Orrame bei-aia leclu Emergency Telephone No: 13) District or Regional Supervi licable) ' Name & Title: Address: Telephone No: Fax: Email: Check#: V ' 69 Date: �a.` �� ���0 Amount: �J .O .ar Food Establishment Infnrmafinn 11) Water Source: 15) Sewage Disposal: DEP Public Water Supply No: (if applicable) 16) Days and Hours of Operation: 17) No. of Food Employees: 18) Name of Person in Charge Certified in Food Protection Management: Required as of 101112001 in accordance with 105 CMR 590.003(A) 19) Person Trained in Anti -Choking Procedures ( if 25 seats or more): ❑ Yes No 20) Location: 22) Establishment Type (check all that apply) (check one) ❑ Retail ( Sq. Ft) ❑ Caterer Permanent Structure 0 Food Service - ( Seats) ❑ Frozen Dessert Manufacturer Mobile 0 Food Service - Takeout ❑ Residential Kitchen for Retail Sale 13 Food Service - Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery , ...................... ...------................................--............Breakfast ❑ Residential Kitchen for Bed and Es_tablishments..---------...--- 21) Length Of Permit: (check one) RETAIL STORE RESTAURANT Annual ❑ Less than 1000sq.ft. $ 70 ❑ Less than 25 seats $140 Seasonal/Dates: ❑ 1000-10,OOOsq.ft. $280 ❑ Residential Kitchens $140 ❑ More than 10,000sq.ft. $420 ❑ 25.99 seats $280 ❑ More than 99 seats $420 .......................................................................................................... ---.................... ❑ Bed & Breakfast/Childcare Services /Nursing Home $100 Temporary/Dates/Time: ...................... ----........ -............... ------- ................................................ ADDITIONAL PERMITS _........... .......... ❑ MAKE ICE CREAM, YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 ALL NON-PROFIT` $25 Includin , church kitchens, state funded childcare 8 private club 23) Food Operations: Definitions: PHF— potentially hazardous food(time/temperature controls required) '(check all that apply): Non-PHFs— non -potentially hazardous food (no time/temperature controls required) RTE - ready -to -eat foods Ex, sandwiches, salads,. muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PRFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self -Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan (including bare hand Service Within 4 hours contact alternative, time as public health control. Customer Self -Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale T - Animal Origin - Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares FoodlSingle IMeals for Catered Retail Sale Events or Institutional Food Service FReta rersrccrnrm tswK Quantmesil Sale of Salvage, Out of Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application I, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law: I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. r, O 24) Signature of Applicant: (C41(e Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that 1, to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: O �16 -Oco - 2 q 26) Signature of Individual or Corporate Name-.-7-0&Y/1aCJe_ f� Kimberley Driscoll Mayor City of Salem, Massachusetts lu Board of Health 120 Washington Street, 4th Floor, Salem, MA 01970 Tel. (978) 741-1800 Fax. (978) 745-0343 PublicHealth Prevent. Promote. Protect. Iramdin@salem.com Larry Ramdin, MPH, REHS, CHO Health Agent FOOD'ESTABLISHMENT PERMIT (must be posted on the Premises of the Food Establishment( 2016 Permit Number: FM -16-167 Permit Type: Food Establishment 25-99 seats Goods & Services: Food Service: Non -Profit Name of License Holder: Board of Trustees Tabernacle Congregational Church Name of Food Establishment Tabernacle Congregational Church Address of Food Establishment 50 Washington Street Salem MA 01970 Restrictions: Church Kitchen This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on 12/31/2016 unless sooner suspended or revoked. Permit Fee: $25.00 Effective: 1/1/2016 WE OO IM KIMBERLEY DRISCOLL MAYOR CITY OF SALEM, MASSACHUSETTS BOARD or Hent,'rii 120 WASHING I ON SiRui, i, 4T° Fi.00R Tra.. (978) 741-1800 FAX (978) 745-0343 IramdinQsalem.com LARRY RAn4DIN, RS/RIr.HS, CI -I0, CP -1'-S H13ALTi-I AGENT Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: Ort.lCC ((AVC 2) Establishment Address: O - �' e� S i /' 1nIC3) O 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: 0k- - _ S 6 5) Applicant Name & Title: 6) Applicant Address: 7) Applicant Telephone No: 24 Hour Emergency No: QJ aEmail: 6) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): 10) Establishment Owned by: An association A corporation An individual A partnership /� Other legal entity(?b'Ar 11) If a corporation or partnership, give name, title and home address of officers or partner. Name Title Home Address 12) Person Directly Res onsible For Daily Operations (Owner, Person in Charge, Supervisor, Manager, etc.) Name &Title: fv hL&V. Qct1/p� roto' <' dYalne S L Address: O - CeU' rail S ( t -F r{Oo`L q (Co' Telephone No: Q�f� �cIJ' �Jt/J� Fax: Email: 01,P¢rneeP— 4 Emergency Telephone No: 13) District or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: Fax: Email: Check#: _ Date: d2 Amount: !4, o"5 1-1 Food Establishment Information 14) Water Source: I 15) Sewage Disposal: DEP Public Water Supply No: ( if applicable) 16) Days and Hours of Operation: 17) No. of Food Employees: 18) Name of Person in Charge Certified in Food Protection Management: Required as of 101112001 in accordance with 105 CMR 590.003(A) 19) Person Trained in Anti -Choking Procedures ( if 25 seats or more): ❑ Yes No 20) Location: 22) Establishment Type (check all that apply) (check one) ❑ Retail ( Sq. Ft) O Caterer Permanent Structure ❑ Food Service - ( Seats) ❑ Frozen Dessert Manufacturer Mobile ❑ Food Service - Takeout ❑ Residential Kitchen for Retail Sale 13 Food Service - Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and .............................Breakfast,Establish...encs__.-___„____________. 21) Length Of Permit:--------------------------------------------- (check one) RETAIL STORE RESTAURANT Annual ❑ Less than 1000sq.ft. $ 70 ❑ Less than 25 seats $140 Seasonal/Dates: ❑ 1000-10,OOOsq.ft., $280 ❑ Residential Kitchens $140 ❑ More than 10,OOOsq.ft. $420 ❑ 25.99 seats $280 ❑ More than 99 seats $420 ------------------------------------------------------ ------------------------------------------------------- .--.----- ❑ Bed & Breakfast/Childcare Services /Nursing Home $100 Temporary/DatesMme: -- - ---- ------ --- --------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS ❑ MAKE ICE CREAM, YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 `L NON-PROFIT' �At_ $25 *Including, church kitchens, state funded childcare ivate club 23) Food Operations: Definitions: PHF- potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food (no timeltemperature controls required) (check all that apply): RTE - ready -to -eat foods Ex. sandwiches, salads, muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sate of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self -Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan (including bare hand Service Within 4 hours contact alternative, time as public health control. Customer Self -Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, Out of Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application I, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. n O 24) Signature of Applicant: 'Z /VL4� Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: Q ^/ (a - e3e)o ri J �^ I 26) Signature of Individual or Corporate Name: I O 1?21'NGcL b0Sre�;4-(ranc 1 6lupc( CC_ p Commonwealth ,f Massachusetts TotalFees o _ City of Salem , i, a.'� Board of Health e �, .Klmberley:Drlscoll �,,._ ,: - ,>_ e Mayor ,y 120 Washington Street, 4th Floor;." .: ' V fi s ^` SALEM, MA„ 01970 RNA " - « " `, F(i6d/Reta11 EstabLsh'ment Permat u j34* . �. DATE PRINTED - 12/17/2012 ns s .:. i 8 { 'w ur tjabernaele Congregational Chch ESTABLISHMENT NAME: 53f $ File Numbur BHF 2004.-000284 ' SO.Washm ton Street g ; Salem MA 01970 LOCATED AT 0050 WASHINGTON STREET x� SALEM MA x01970 r ss a 2;' -Permit Tvue e F PermitNo. "sPe'rnut IssuedYermit Expires Fee Restrictions /Notes to Jan i, 2013 -s -Dec 31' 2013: ;$25 TotalFees a $25 00r� a.'� ,y r g S .' +s 4 � (T niber 31; 2013 ' a Board Health of )e"reissued �upon change of ownership or location The permit must be posted .a ie, beofre any revonations, improvements; or equipment changes -are d`approved by the Salem Board of Health Paget K ti.�+ �J 'f 3•.-�F P +ey ` CITY OF SALEM.- 1 RECEIVED.MASSACHUSETTS .3 s� (1 2u16 BOAROOFHLALTH oE,l� L 120W.vsliuvGliou S7REGT,4ni FLoox kLiIB17tLEY nRISC ,Wj. OF SX1-E&4 Zrj_ (978) 741-1800 F,LY (978) 74so3a3 MAYOR ?6&SD OFF Ys�]xamdiu(aisalem-com LARRY RAAW1N, WRENS, CHO, (7P -F- HEALTH AGENT Food Establishment'Perrnit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: -rA (2 W kgCL C%• C • C- 2) Establishment Address: Q. S / Al G. Pb )'�-7 r TT . 2) J Ekti 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: 7 -7 77, q 31 G 5) Applicant Name&Tide: -t1¢ F02Nf}C-L[r Co�G12EG�2 [Olv L GfiU✓LC}{ IJ. G• C ti) Applicant Address: 7) Applicant Telephone No: 24 Hour Emergency No: Email: 8) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): 10) 1. Establishment Owned by: An association A corporation An individual A partnership Other legal entity 11) If a corporation or partnership, give name, title and home address of officers or partner. Name Title Home Address 12 Person Directly Responsible For Daily Operations Owner, Person in Charge, Supervisor, -Manager, etc. Name & Title: i V, kt'3016 RIPDL49- Address: Telephone No: 4'7 Sr' -74 q — 31 C 'Fax: Email: Emergency Telephone No: 13) District or Regional Supervisor (if applicable) Name & rifle: Address: Telephone No: Fax: Email: Check #._ Date: Amount: I Food Establishment Information Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, Out of Date or Reconditioned Food To be comdeted by the Board of Health Total Permit Fee: Payment is due with application 1, the undersigned, attest to the accuracy of the information provided in this application and 1 affirm that the food establishment operation will comply with 105 CMR 590.000 and a0 other applicable law. 1 have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. 24) Signature of Applicant Pursuant to MGL Ch. 62C, sec. 49A,1 codify under the penalties of perjury that 1, to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 04 6 00D 7 y -f-' 26) Signature of Individual or Corporate Name:V&13RZ k2t c -L, 47 Ca PCIRE-cAT'I 0 c HU►ZC tf 12) Water Source: .5,9L &111 G /7`j 1,4/ftrEr2_ 15) Sewage Disposal: DEP Public Water Supply No: (if applicable) 5,4i -6M 6t 5L-7,L//j,5: F 16) Days and Hours of Operation: 17) No. of Food Employees: 18) Name of Person in Charge Certified in Food Protection Management Required as of 101112001 in accordance with 105 CMR 590 003(A) 19) Person Trained in Anti -Choking Procedures ( if 25 seats or more): ❑ Yes No 20) Location: 22) Establishment7ype (check all that apply) (check one) ❑ Retail ( Sq. Ft) 0 Caterer Permanent Structure ❑ Food Service - ( . Seats) ❑ Frozen Dessert Manufachuer Mobile ❑ Food Service - Takeout ❑ Residential Kitchen for Retail Sale ❑ Food Service - Institution ❑ Residential Mchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ----------------------------------------------------------------Breakfast ❑ Residential Kitchen for Bed and Establishments---- 21) Length Of Permit (check one) RETAILSTORE RESTAURANT Annual ❑ Less than 1000sq.ft. $ 70 ❑ Less than 25 seats $140 Seasonal/Dates: ❑ 1000-10,000sq.ft. $280 ❑ Residential Kdchens $140 ❑ More than 10,000sq.8. $420 El 25-99 seats $280 - __. DMore than -99 seats -$420- ---- ----------- -------- —--------- ---------------- ------- -------- ----- ------ ❑ Bed & Breakfast/Childcere Services /Nursing Home $100 Temporary/DatesRme: -------------------------------------------------------------------- ADDITIONAL PERMITS ------------------------------------ ----- - - ❑ MAKE ICE CREAM, YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 ❑ TOBACCO VENDOR �$135 ,FALL NON-PROFIT ,/ $25 (Including, church kitchens, state funded childcare & private dubs) 23) Food Operations: Definitions: PHF-potentially hazardous rood (6meRemperature controls required} Non-PHFs - noo-potentially hazardous rood (no time/temperature controls requhedl - cheCk all that apply): RTE -ready -to -eat foods (Ez. sandwiches, salads muffins which need no rurther processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non -PRFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum PackaginglCook Chill Prepared by Consumer Reheating of Commercially Customer Self -Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan (including bare hand Service Within 4 hours contact a@ernative, time as public health control. C stonier Setf-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non PHF and Non- Retail Sale Animal Origin Perishable Foods Oniy Preparation of Non -PRFs Juice Manufactured and Packaged for Prepares FoodfSingle Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, Out of Date or Reconditioned Food To be comdeted by the Board of Health Total Permit Fee: Payment is due with application 1, the undersigned, attest to the accuracy of the information provided in this application and 1 affirm that the food establishment operation will comply with 105 CMR 590.000 and a0 other applicable law. 1 have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. 24) Signature of Applicant Pursuant to MGL Ch. 62C, sec. 49A,1 codify under the penalties of perjury that 1, to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 04 6 00D 7 y -f-' 26) Signature of Individual or Corporate Name:V&13RZ k2t c -L, 47 Ca PCIRE-cAT'I 0 c HU►ZC tf Kimberley Driscoll Mayor City of Salem, Massachusetts Board of Health 120 Washington Street, 4th Floor, Salem, MA 01970 Tel. (978) 741-1800 Fax. (978) 745-0343 Iramdin@salem.com FOOD ESTABLISHMENT PERMIT (must be posted on the Premises of the Food Establishment) 2015 Permit Number: FM -15-244 Permit Type: Food Establishment nonprofit Goods & Services: Food Service: Non -Profit Public Health Prevent. Promote, Protect. Larry Ramdin, MPH, REHS, CHO Health Agent Name of License Holder: I Board of Trustees Tabernacle Congregational Church Name of Food Establishment Tabernacle Congregational Church Address of Food Establishment 50 Washington Street Salem MA 01970 Restrictions: Church Kitchen This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on 12/31/2015 unless sooner suspended or revoked. Permit Fee: 25.00 Issued: 1/1/2015 KIMBERLEY DRISCOLL MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF Hu',im I'H 120 WASITINGTON Snare'r, 4111 Flow Tea.. (978) 741-1800 FAX (978) 745-0343 Iramdin@salem.com lu Public Health LARRY RAMDIN, RS/RtiHS, CI 10, CV -FS Hi;AL,ni AGENT Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name::TA6Ar%xJcn actlanoL t�UYtj-) 2) Establishment Address: T © d 3) . Establishment Mailing Address (if different): — 4) Establishment Telephone No: qV -31 b ty 5) Applicant Name & Title: -- 6) Applicant Address: $ 4- a., afwV v cc.-1-abOrt70Ckoho 7) Applicant Telephone No: 24 Hour Emergency No: Email: 8) Owner Name & Title (if different from applicant): g) Owner Address (if different from applicant): 10) Establishment Owned by: An association A corporation An individual A partnership Other legal entity—c. --t C4) 11) If a corporation or partnership, give name, title and home address of officers or partner. Name Title Home Address 12 Person Directly Res onsible For Daily Operations Owner, Person in char e, Supervisor, Manager, etc. Name &Title: ovra.%oe- i -O tf-.Q1ur min '1 n.%o Address: `" pi d - Cen+ral &+;ect und 0 Sa tern O 149 7 8 Telephone No: (%f- ),rqr,, Fax: Email: Orraine-e berracje Emergency Telephone No: SCI Me - 13) District or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: Fax: Email: Check #: Date: Amount: rr,h .org W4•4S Food Establishment Information 14) Water Source: 15) Sewage Disposal: DEP Public Water Supply No: (if applicable) 16) Days and Hours of Operation: 17) No. of Food Employees: 18) Name of Person in Charge Certified in Food Protection Management: Required as of 101112001 in accordance with 105 CMR 590.003(A) 19) Person Trained in Anti -Choking Procedures ( if 25 seats or more): ❑ Yes No 20) Location: 22) Establishment Type (check all that apply) (check one) ❑ Retail ( Sq. Ft) ❑ Caterer Permanent Structure 0 Food Service -( Seats) ❑ Frozen Dessert Manufacturer Mobile ❑ Food Service -Takeout ❑ Residential Kitchen for Retail Sale O Food Service - Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and _Breakfast Establishments 21) Length Of Permit: (check one) RETAIL STORE RESTAURANT Annual 17 Less than 1000sq.ft. $,70 17 Less than 25 seats $140 Seasonal/Dates: ❑ 1000-10,OOOsq.ft. ' $280 0 Residential Kitchens $140 ❑More than 10,OOOsgA $420 ❑ 25.99 seats $280 ❑ More than 99 seats $420 - ------'----------- --h ------- -------- -- ------- smn"---------------------------------------------------------- ------ ❑ Bed & BreakfastlChildcare Services /Nursing Home $100 Temporary/DatesTme: - - -------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS ❑ MAKE ICE CREAM,:YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 ALL NON-PROFIT"' *Including, church kitchens, state funded childcare & private club 23) Food Operations: Definitions: PHF- potentially hazardous food (timeltemperature controls required) (check that Non -PRFs non -potentially hazardous food (no timeltemperature controls required) - all apply): RTE -read to -eat foods Ex. sandwiches, salads, muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs.For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self -Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan (including bare hand Service Within 4 hours contact alternative, time as public health control. Customer Self -Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non.PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, Out of Date . or ReconditionedFood To be completed by the. Board of Health Total Permit Fee: Payment is due with application I, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. _ 24) Signature of Applicant: Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that 1, to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 4.1� 26) Signature of Individual or Corporate Name:) GAP-YY-4C.IL' 1`%Sre544't0Aa I rtr CITY OF SALEM, MASSACHUSETTS P irn BOARD OFHrw:ni P `; i X120 WA$IIING'fON S'17iLfi'C, 4"' FIAOli KIMBERLEY DRISCOLL ��e' T_ E1.. (978) 741-1800 FAX (978) 745-0343 LARRY IUNIDIN, RS/REI IS, CI -IO, CP -I'S MAYOR -- Icamdinasalem.com - � 1 HfsAI:1'I I AGF,N'1' v`Jnn✓ ., Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: 6P.LY�Pc �f, r �7p01at L �7 tlt 2) Establishment Address: d - aoh t, 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: 5) Applicant Name & Title: 6) Applicant Address:UJe t Anal P.QJ� J a d d refit - fer uLnQrJ 7) Applicant Telephone No: 24 Hour Emergency No: Email: 6) O an d erpack Chu mh , 0 9) Owner Address (if different from applicant): 10) Establishment Owned by: An association A corporation An individual A partnership 11 Other legal entity urGn — 11) If a corporation or partnership, give name, title and home address of officers or partner. Name Title Home Address 12 Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor, Manager, etc. Name &Title: 1�-OyKln¢ Sctid-b - sits Ctdre acAm t+r4+ar' Address: old - Cen t 4a. Sad" Telephone No: IM -2 „r- Fax: Email: 3q I b C0�7 Emergency Telephone No: rhe-- he--13) 13)District or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: Fax: Email: Check* I Cf1 i Date: Amount: rV 7 Food Establishment Information Offers RTE PHF in Bulk Quantities To be completed by the Board o(Health Retail Sale of Salvage, Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application I, the undersigned, attest to the accuracy of the information provided in this application and 1 affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 24) Signature of Applicant: Z'S . Ltx 6zv 9 PP : / r u�„c Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: og (v ` 000 - 7 l4,5- 26) FS 26) Signature of Individual or Corporate Name: 14) Water Source: 15) Sewage Disposal: DEP Public Water Supply No: ( if applicable) 16) Days and Hours of Operation: 17) No. of Food Employees: 18) Name of Person in Charge Certified In Food Protection Management: Required as of 101112001 in accordance with 105 CMR 590.003(A) 19) Person Trained in Anti -Choking Procedures (if 25 seats or more): ❑ Yes No 20) Location: 22) Establishment Type (check all that apply) (check one) O Retail ( Sq. Ft) O Caterer Permanent Structure 0 Food Service - ( Seats) 17 Frozen Dessert Manufacturer Mobile 0 Food Service - Takeout 0 Residential Kitchen for Retail Sale O Food Service - Institution 13 Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and Establishments 21) Length Of Permit:Breakfast (check one) RETASTORE IL RESTAURANT Annual ❑ Less than 1000sq.ft: $ 70 ❑ Less than 25 seats $140 Seasonal/Dates: O 1000-10,000sq.ft $280 0 Residential Kitchens $140 ❑ More than 10,000sq.ft. $420 ❑ 25-99 seats $280 ❑ More than 99 seats $420 - ---------------------•----.....-.......---.................-........................ ............. O Bed & BreakfasUChildcare Services /Nursing Home $100 Temporary/Datesrnme: ADDITIONAL PERMITS O MAKE ICE CREAM, YOGURT/SOFT SERVE $25 0 PASTURIZATION $25 ILL NON-PROFIT 25 *Including, church kitchens, state funded childc vate club 23) Food Operations: Definitions: PHF-potentially hazardous food (dmeRemperature controls required) that Non-PHFs - non -potentially hazardous food (no ome/temperature controls required) (check all apply): RTE - rea to -eat foods Ex. sandwiches, salads, muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs Ifor More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self -Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan (including bare hand Service Within 4 hours contact alternative, time as public health control. Customer Self -Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale I Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board o(Health Retail Sale of Salvage, Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application I, the undersigned, attest to the accuracy of the information provided in this application and 1 affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 24) Signature of Applicant: Z'S . Ltx 6zv 9 PP : / r u�„c Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: og (v ` 000 - 7 l4,5- 26) FS 26) Signature of Individual or Corporate Name: Commonwealth of Massachusetts • City of Salem Board of Iilealth Kiifltietiey,Driscoll 120 Washington Street, 4th,Floor Mayor SALEM, MAS 01970 Food/RetaffEstablishment Permit DATE PRINTED: 12/28/2011 ESTABLISHMENT NAME: File Number: BHF -2004-000284. LOCATED AT: 0050 WASHINGTON STREET KINI 3EIU-L1' DRISCOLL MAYOR LARRY RAINIDIN, RS/RF.I IS, (:] 10, CP -I S Hv,m iii AGiwi• CITY OF SALEM, MASSACHUSET"T'S B0,4D OF HF-kL.TH 120 WASHINGTON STREET. 4"' FLOOR TFL. (978) 741-1800 F_�x (978) 745-0343 Iramdintr salcm.com 2014 APPLICATION FOR PERMIT TOO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABII.SHNii:NT �b�fL/tiiC(� CIfU2�N -s_Lx 178'�KN-31b� ADDRESS OF ESTABLISHMENT 66 WAsh l(lgibn J'i-ee/ FAX # q7 f -'7 MAILING ADDRESS (if different) `` ` 1 EMAIL - Business': �/i�DP--LA 'P1G eAurrh,pra Website: +-Ae✓nr r.[Pd) Lr&.or9 OWNER'S NAME AS Above. TEL# ADDRESS STREET CITY - STATE CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) _ (Required in an establishment wherepotentially hazardous food is prepared):." EMERGENCY RESPONSE PERSON HOME TEL # Please write in time ZIP TYPE OF ESTABLISHMENT FEE (check only) _ RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than I0,000sq.ft: =$420 RESTAURANT YES NO (OutdwrSta`i^ na.; FaodCYrt$210) less than 25 seats =$140 -3 is =$280 more than 99 seats . =$420 ------- -YES NO ------------------------------------------------ ------------------------------ $1-0-------- BED/BREAKFAST/ 0 muvr r lwllm� rcmmt r a MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES - $135 ALL NON-PROFIT (such as church kitchens) YES NO 25 _Please pay total with one check payable to the City of Salem. z.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, 1 certify under the pains and penalties of peryury that 1, to my best knowledge and belief, have filed all state tax returpsand,paid all state taxes required under the law. / '! Date Updated 523/11 FOODAP201.Ladm Check# & Date Social Security or Federal S 6 - Commonwealth of Massachusetts ° City of Salem Board of Health Kimberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Food/Retail Establishment Perruit DATE PRINTED: 01/04/2011 ESTABLISHMENT NAME: File Number: BHF -2004-000284 Tabernacle Congregational Church 50 Washington Street Salem MA 01970 LOCATED AT: 0050 WASHINGTON STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2011-0137 Jan 1, 2011 Dec 31, 2011 $0.00 ESTABLIS14MENT Total Fees: $0.00 PERMIT EXPIRES IDecember3l,2011 Board of Health I This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 KINfBERLEY DRISCOLL MAYOR. DAVID GREENI3AuNi, RS ACTING HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HE.-,L.TH 120 WASHINGTON STREET, 4T" FLOOR TEL. (978) 741-1800 F -A. (978) 745-0343 DGReENI4dUNI(@SALEM-CONI , •2011 APPLIC__AT//ION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT / NAME OF ESTABLISHMENT lO—Leel')G- /e. r rj(.ir�r- TEL# ADDRESS OF ESTABLISHMENT, -SLI ho� kn J— r c ..., FAX# 47 L TV4 /ST7 MAILING ADDRESS (if different), EMAIL - Business': Website: OWNER'S NAME C.GS(%Y� , TEL ADDRESS STREET CITY STATE CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL # PAID �DAY5fOFQPERATION ,. ,s -'Honda li, T,uesday_a ,I�Wednesday, .,�Thursda.�: Fnday4,' Saturda '..Sunday,`'; HOURS OF OPERATION Please write in time of day. For example 11 am -11 pm I TYPE OF ESTABLISHMENT RETAIL STORE YES NO --------------------------Y-------ES ----------- RESTAURANT NO (Outdoor Stationary Food Cart $210) FEE (checkonly) less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 less than 25 seats =$140 25-99 seats =$280 more than 99 seats =$420 ------------------------------------------------------------------------------------------------------------------------------------------------------------------ BED/BREAKFAST/ YES NO $100 MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES KLO X35 ALL NON-PROFIT (such as church kitchens) YES NO 45 '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 penaltjes pf perjury that 1, to my best knowledge and belief, have filed all state tax rett^s ayrtl paid all state taxes required under the law. .1 / Revised l0n1I 1 FOODAP201 Ladm Check# & Date or If 111111