TJ MAXX 769 - ESTABLISHMENTSKimberley Driscoll
Mayor
Permit Number:
Restrictions:
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 RS/REHS, CHO, CP -FS
Health Agent
FOOD ESTABLISHMENT PERMIT
(must be posted on the Premises of the Food Establishment)
2015
FM -15-120
Permit Type: RETAIL FOOD
Goods & Services: Retail Food: 0 -1,000 sq ft
Name of License Holder: The TJ Companies, Inc.
Name of Food Establishment TJ Maxx #769
Address of Food Establishment 17 Traders Way SALEM MA 01970
This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on
12/31/2015 unless sooner suspended or revoked.
Permit Fee: 70.00
Issued: 1/1/2015
KIMBERLEY DRISCOLL
NL�YOR
CITY OF SALEM,
Ni L1SSACHUSF I"1'S
BOARD of Hl AL rl 1
120 WASlnNC MN S utu� 'r, 411� F1,00R
TEL (978) 7 41-1800 FAX (978) 745-0343
lramdinoa salcm coin
V
PublicHeatth
LARRY R,%NIDIN, IS, CHO, CP -I'S
HEMAn1A(;L.N'r
Food Establishment Permit Application
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name: 1 4- 6 9
2) Establishment Address: f-14-*—*'�
(9'/
//
�Afo� ,,ff3) Establishment Mailing Address (if different): PO soxEG)")I 4oyn r/✓ 4 017W
4) Establishment Telephone No:
5) Applicant Name & Title: jtf
6) Applicant Address: sclyhG C -r 1) /Ci t I tin
7) Applicant Telephone No:7 y -3c - 3SII 24 Hour Emergency No: 97P 7YY-SY!( Email: k • L. c
8) Owner Name & Title (if different from applicant): SCVhc,
9) Owner Address (if different from applicant): SCain'I_
10) Establishment Owned by:
An association
cor oratio
An individual
A partnership
Other legal entity
a corporation or partnership, give name, title and home address of
icers or partner.
Title Home Address
jName
►e e/Y1nCh
f _ v ��iti�!
12 Person Directly Responsible For Daily Operations Owner, Person in Charge,Supervisor, Manager, etc.
Name & Title:
C
G ✓rG
Address
/�//����G o �c
c G SG►� A "' 0
Telephone No:
q7 T t
Q7d ' 7 -S u Fax:7� — -x(74 Email: c.W _ / Ir4L/
Emergency Telephone No:
13) District or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
Fax: Email:
Check #:�
Date: / Amount: 7/)
. CCA
Food Establishment Information
14) Water Source: LII 1` L
15) Sewage Disposal: L Pt
UUUU
DEP Public Water Supply No: ( if applicable)
M°1`;�5�1 '3s," '3�
16) Days and ours of Operat!'Xn+ I�-�
17) No. of Food Employees:
IA
18) Name of Person in Charge Certified in Food Protection Management:
Required as of 10/1/2001 in accordance with 105 CMR 590.003(A)
19) Person Trained in Anti -Choking Procedures ( if 25 seats or more): ❑ Yes
No
WA
20) Location:
22) ,Establishment Type (check all that apply)
(check one)
EVRetall (tC~q. Ft)
❑ Caterer
Permanent Structure
❑ Food Service - ( Seats)
❑ Frozen Dessert Manufacturer
Mobile
❑ Food Service -Takeout
❑ Residential Kitchen for Retail Sale
❑ Food Service - Institution
❑ Residential Kitchen for Bed and
( Meals/Day)
Breakfast Home
❑ Food Delivery
❑ Residential Kitchen lot Bed and
............... .................. . .
R AIL STORE
Breakfast -Establishments,,,, ,,,,,,,,,,,,,,
RESTAURANT
21) Length Of Permit:
� (check one)
Annual
Less than 1000sq.ft. $704
❑ Less than 25 seats $140
Seasonal/Dates:
❑ 1000-10,000sq.ft. $280
❑ Residential Kitchens $140
❑ More than 10,000sq.ft. $420
❑ 25-99 seats $280
----------------i'c'e"----------•...........----.......----------.......................................
❑ Bed & Breakfast/Childcare Services Mursing
❑ More than 99 seats $420
Home $100
Temporary/Dates/Time:
.................................................................................................................
ADDITIONAL PERMITS
❑ MAKE ICE CREAM, YOGURT/SOFT SERVE
$25
0 PASTURIZATION
$25
❑ ALL NON-PROFIT`
$25
*Including, church kitchens, state funded childcare & private club
23) Food Operations:
Definitions: PHF- potentially hazardous food (timeltemperature controls required)
Non-PHFs - non -potentially hazardous food (no tlmaltemperature controls required)
(check all that apply):
RTE- read -to-eat foods Ex. sandwiches, salads, muffins which need no further processing
ale 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.
ustomer 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
I, the undersigned, attest to the accui
comply with 105 CMR 590.000 and all
590.000 and the Federal Food Code.
24) Signature of Applicant:
Offers RTE PHF in Bulk Quantities
To be completed by the Board of Health
Retail Sale of Salvage, Out of Date
or Reconditioned Food Total Permit Fee:
Payment is doe with application
of the information provided in this application and I affirm that the food establishment operation will
V.applf&lble law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR
Pursuant to MGL Ch. 62C, ec 49A, I certify under the penalties of perjury that I, to my best knowledge and belief,
Have filed all state tax ret r and paid state taxes required under law.
25) Social Security Number or Federal ID: Q W 2 2 0 7cl/
-7
26) Signature of Individual or Corporate Name:
Massachusetts Department of Public Health
Division of Food and Drugs
Salem Board of Health
120 Washington Street, 4"' Floor
Salem, MA 01970-3523
Tel. (978) 741-1800 Fax (978) 745-0343
City/Town of (;a Pe yr Address:
FOOD ESTABLISHMENT INSPECTION REPORT Te10 n G n X/"1 )V+
y - 110
Name -}^ n (-ZHACCP
at
Type of Operatron(s)
❑ d Service
Retail
Type nspectfon
outine
❑ Re -inspection
Address
isk
--- ❑ 13. Handwash Facilities
evel
❑ Residential Kitchen
❑ Mobile
Previous Inspection
Date:
Telephone
[114. Approved Food or Color Additives
❑ 3.
Personnel with Infections Restricted/Excluded
❑ 15. Toxic Chemicals
❑ Temporary
❑ Caterer
❑ Bed 8Breakfast
Permit No.
❑ Pre-operation
❑ Suspect Illness
❑ General Complaint
❑ HACCP
❑.Other
Owner
YIN
Person -in -Charge (PIC
WD
Inspector `
Z J 6.
We
ut:
eacn violation cnecked requires an explanattpn on the narrative page(s) and a citation of specific provision(s) violated.
rNon-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors_(Red
Items) - Anti -Choking 590,009(E) ❑
Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑,
Allergen Awareness 590.009 (G) ❑
corrective action as determined by the Board of Health.
'FOOD: PROTECTION MANAGEMENT.' ��
�� _ ❑ 12. Prevention of Contamination from Hands
❑ 1.
PIC Assigned/Knowledgeable/Duties
OYHEALTH -
'EMPCEE
--- ❑ 13. Handwash Facilities
....
❑ 2.
....... _ _ _ �- _-. _ _ _ _ .. -..., _ . ,PROTECTION F- -76 EMICALS"
Reporting of Diseases by Food Employee and PIC
[114. Approved Food or Color Additives
❑ 3.
Personnel with Infections Restricted/Excluded
❑ 15. Toxic Chemicals
„F.00D'FROM APPROVED SOURCE_
❑ 4. Food and Water from Approved Source
TIMEffEMPERAT.URE CONTROLSiOOtonifdlliHazardousFgods}
...
5.
Receiving/Condition (?,V rr- puQ �
E] 16. Cooking Temperatures
Z J 6.
Tags/Records/Accuracy of Ingredient Statements
E] 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans
iPROTECTION FROMCONTAMINATION
❑ 8. Separation/Segregation/Protection
❑ 9. Food Contact Surfaces Cleaning and Sanitizing
❑ 10. Proper Adequate Handwashing
❑ 11. Good Hygienic Practices
Violations Related to Good Retail Practices- (Blue
Items) Critical (C) violations marked must be corrected
immediately or within 10 days as determined by the Board
of Health. Noncritical (N) violations must be corrected
immediately or within 90 days as determined by the Board
of Health.
C N
23. Management and Personnel (FC -2)(590.003)
24. Food and Food Protection (FC -3X590.004)
25. Equipment and Utensils (FC -4X590.005)
26. Water, Plumbing and Waste (FC5)(590.006)
27. Physical Facility (FC -6X590.007)
28. Poisonous or Toxic Materials (FC -7X590.008)
29. Special Requirements (590.009)
30. Other
s e 4l
❑ 18. Cooling
❑ 19. Hot and Cold Holding
❑ 20. Time as a Public Health Control
REQUIREMENTS FOR,HIGHLYSt1SCEPTIBCE=_POPULATIONS`.(H$P) J'
❑ 21. Food and Food Preparation for HSP
,CONSUMER ADVISORY- -,
❑ 22. Posting of Consumer Advisories
Number of Violated Provisions IntRelated
To Foodborne Illnesses Interventions
and Risk Factors (Red Items 1-22):
Official Order for Correction: Based on an inspection
today, the items checked indicate violations of 105 CMR
590.000/federal Food Code. This report, when signed below
by a Board of Health member or its agent constitutes an
order of the Board of Health. Failure to correct violations
cited in this report may result in suspension or revocation of
the food establishment permit and cessation of food
establishment operations. If aggrieved by this order, you
have a right to a hearing. Your request must be in writing
and submitted to the Board of Health at the above address
within 10 days of receipt of this order.
DATE OF RE-INSPECTION:'-�
- - V -- 1 0
Violations Related to Foodborne Illness
Interventions and Risk Factors (items 1-22)
FOOD PROTECTION MANAGEMENT _
1 590,003(A) Assignment of Responsibility*
590.003(6) Demonstration of Knowledge*
2-103.11. Person in charge - duties
EMPLOYEE HEALTH
2
590.003(0)
Responsibility of the person in charge to
Compliance wi.b Food Law*
3-201.12
require reporting by food employees and
3-201.13
Fluid Milk and Milk Products*
applicants*
Shell E gs*
590.003(F)
Responsibility Of A Food Employee Or An
3-202.16
Ice Made From Potable Drinking Water*
Applicant To Report'fo The Person In
Drinking Water from an Approved S tent*
590.005(A)
Charge*
590.006(B)
590.003 Cr
Reporting by Person in Chime*
3
590.003(D)
Exclusions and Restrictions*
3-201.15
590.003(13)
Removal of Exclusions and Restrictions
fE
C
Ila
C
FOOD FROM APPROVED SOURCE
"Denotes critical new in the lateral 1999 Foixi Code or 1105 CMR 590.1 W
C
PROTFr.TION MnM tin Mee UJMAT 11M
Food and Water From Regulated Sources
590.004(A -B)
Compliance wi.b Food Law*
3-201.12
_
Food in a Hermetically Sealed Container*
3-201.13
Fluid Milk and Milk Products*
3-202.13
Shell E gs*
3-202.14
Eggs and Milk Products. Pasteurized*
3-202.16
Ice Made From Potable Drinking Water*
5-101.11
Drinking Water from an Approved S tent*
590.005(A)
Bottled Drinking Water"
590.006(B)
Water Meets Standards in 3110 0MR 22.0*
Frequency of Sanitization of Utensils and -
Food Contact Surfaces of Equipment*
Sheiftsh and Fish From an Approved Source
3-201.14
_
Fish and Recreationally Caught Molluscan'
Shellfish*
3-201.15
Molluscan Shellfish from NSSP ;:fisted
Sources"
Proper, Adequate Handwashing
_
Game and NJitd Mushrooms Approved by
Regulatory Authority
3-202.18
Shellstock Idcnrification Present*
590.004(C)
WildMusluooms*
3-201.17
Game Animals*
2-301.14
RecelvingfCondition
3-202.11
PHFs Received at Proper Temperatures*
3-202.15
Package Integrity*
3-10i.11
'Food Safe and Unadulterated
_
Tags/Recorda: Shellstock
3-202.18
Shellstock Identification *
3-203.12
Sheltstock Identification Maintained* _
TagslRecords: Fish Products -i
3-402.11
Parasite, Destruction*
3-402.12
Records Cr•ation and Retention*
590.004(J)
Labeling of Ingredients'
13
Conformance with Approved Procedures
/HACCP Plans
-502103
Specialized ProcessingMethods*
-517
Reduced oxygen ackan.criteri*
8_1 1 2
Conformance with Approved Procedures*
"Denotes critical new in the lateral 1999 Foixi Code or 1105 CMR 590.1 W
C
PROTFr.TION MnM tin Mee UJMAT 11M
9
Crass.contamination
3-302.11 (A)(1)
Raw Animal Foods Separated from
Cooked and RTE Foods*
4-501 Ht
_
Contamination from Raw Ingredients
3-302A I(A)(2)
Raw Animal Foals Separated from Each
Other`
Mechanical Warewashing- Hot Water
Sanitization Temperatures*
Contamination from the Environment
3-302.11(A)
Food Protection*
3-30215
Washing Fruits and Ve etables
3-304.11:
Food Contact with Equipment and
Utensils*
4-602.11
Contamination from the Consumer
3-306.14(A)(B)
Returned Foal and Reservice of Food*
Frequency of Sanitization of Utensils and -
Food Contact Surfaces of Equipment*
Disposition of Adulterated or Contaminated
Food
3-701_11
Discarding or Reconditioning Unsafe
Foci*
9
Food Contact surfaces
4-501 Ht
_
Manual Wazewaehing -Hot Water
Sanitization Temperatures*
4-501.112
Mechanical Warewashing- Hot Water
Sanitization Temperatures*
4501.114
Chemical Sanitization- temp., pH,
concentration and hardness. *
4-60 L 11(A)
Equipment Food Contact Surfaces and
Utensils Clean*
4-602.11
Cleaning Frequency of Equipment Food -
Contact Surfaces and Utensils*
4-702.11
Frequency of Sanitization of Utensils and -
Food Contact Surfaces of Equipment*
4-703.11
Methods of Sanitization --Hot Water and
Chemical*
16
Proper, Adequate Handwashing
2-301.11.
Clean Condition -Hands and Arms*
2-301..12
Cleaning Procedure*
2-301.14
When to Wash*
11
Good Hygienic Practices
2401.11
Eating, Drinking or UsmE Tobacco*
2-401.12
Discharges. From the Eyes, Nose and
Mouth*
3-301.12
Preventin Contamination When Tas6n *
12
Prevention of Contamination from Hands
590.004(13)
Preventing Contamination from
Employees*
13
Handwash Facilities
Conveniently Located and Accessible
5-203.11.
Numbers and Capacities*
5-204.11
Location and Placement*
5-205.11
Accessibility, Operation and Maintenance
Supplied with Soap and Hand Drying
Devices
6-301.11
Handwashing Cleanser, .Availability -
6-301.12
Hand Drying Provision
CITY OF SALEM
BOARD OF HEALTH
Establishment Name:77, nu Date: 3--r-) — Page:____rkot
DESCRIPTION OF •
PLEASE PRINT CLEARLY
EM
Me TM Vol
NOR
� � iu � i� �. _ . e Imo. _.-
-_—:7►
•
c:_ � M.
-iceM1\
.. . •- • - . • • .• - • • • •-• .•. •
OWN I
your •••
1 .- Exclusion
■ I' ■ Emergency
u Embargo El Emergency Closure
Viotat#ons Related to Foodborne illness Interventions and Risk
Factors (ftetns 1-22) (Cont.)
15
16
18
iftlslnm��
Food or Color
TIMEtTEMPERATURE CONTROLS
-
Additives
3-20212
Additives*^ --+-
3-302.14
Protection from Unapproved Addidves"
3-501.16(6)
590.004(F)
Poisonous or Toxic Substances
7-10IJI
identifying information - Original
Cantainers*
7-102.11.
Common Name - Working Containers*
7-201.11
Separation - Storage* -
7-202.11
. Restriction - Presence and Use*
7-20112
Conditions of Use*
7-203.11
Toxic Containers - Prohibitions*
7-204.11
Sanitizers. Criteria - Chemicals*
7-204.12
Chemicals fire Washing Produce, Criteria*
7-204.14
eats, Criteria°
7-205.11
Incidental Food Contact, Lubricants*
7-206.11
Restricted Use Pesticides, Criteria*
7-206.I2
Rodent Bait Stations*
7-206.13
Tracking Powders, Pest Control and
Moniturin *
TIMEtTEMPERATURE CONTROLS
-
Proper Cooking Temperatures for
3-501.15
PHP%
3-40i.11A(1)(2)
Eggs- I55°F 15 See.
3-501.16(6)
590.004(F)
Eggs. immediate Service 145'F15sec*
3-401.11(A)(2)
Comminuted Fish. Meats & Game
3-.StJ1.16tA)
Animals -155'F 15 sec. *
3401.11(8)(1)(2)
Pork and Beef Roast- 130'F 121 min*
3-401.11(A)(2)
Ratites, injected Meats - 155`F 15
590.D04(Hj
Variance Requirement
3-401.11(A)(3)
Poultry, Wild Game, Stuffed PHP's,
Stuffing Containing Fish, Meat,
Poul or Ratites -165'F 15 sec.
3.401.11((2)(,3)
Whole -muscle, Intact Beef Steaks
145T t-
3.401.12
3-401.12
Raw Animal Foods Cooked in a
Microwave 165`F *
3-40LI I(A)(1)(b)
All Other PHFs - 145°F 15 sec.
Reheating for Hot Holding
3403AI(A)&(D)
PHFs 165"F 15 we. *
3-403.11(B)
Microwave- 165'F 2 Minute Standing
Titre*
3403.11(C)
Commercially Processed RTE Food -
140°F*
3-403.11(E)
Remaining Unsticed Porticos of Beef
Roasts"
Proper Cooling of PHFs
3-501.14(A)
Cooling Cooked PHFs front I40`F to
70'F Within 2 Hours and From 70'F
to 41`F/45'F Within 4 Hours. *
3-501.14(B)
Cooling PRFs Made From Atribient
Temperature Ingredients to 41017/45°F
Within 4 Hours*
* Denotes crifical leen, in the federal 1999 Fwd Cain 01 105 CMR 590.000.
111N
3-501.14(C)
PHFs Received at Temperatures
According to law Cooled ro
41'FA5'F Within 4 Hoius.
3-501.15
Cooling Methods for PHFs
3-801.11(B}
PHF Not and Cold Holding
3-501.16(6)
590.004(F)
Cold PI117s Maintained at or below
410/45° F*
3-501,16(A)
Hot PHFs Maintained at or above
140°P.
3-.StJ1.16tA)
Roasts Held at or above 130'F.
Time as a Public Health Control
3-SD1;19
Time as a Public Health Control*
590.D04(Hj
Variance Requirement
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS (HSP)
21
3-801.11(A)
Unpasteurized Pre-packaged lmces and
Beverages with WarningLabels* _
3-801.11(B}
Use of Pasteurized Esgzs*
3-801.11(D)
_
Raw or Partially Cooked Animal Food and
Raw Seed Syruats Not Served *
3-$01.11(0)
Unopened Food Package Not Re -served.
CONSUMER ADVISORY
22
3-603.11
Consumer Advisory Posted for C"sumption of
Animal Foods That are Raw, Undercooked or
1
Not Otherwise Processed to Eliminate
Pathogens.' `r"`"*'n, r
3-302.13.
Pasteurized Eggs Substitute for Raw Shell
E
590.009(A) -(D) Violations of Section 590.009(A) -(D) in
catering, mobile food, temporary and
residential kitchen operations should be
debited under the appropriate sections
above if related to foodborne illness
interventions and risk factors. Other
590.009 violations relating to good retail
practices should be debited under #29 -
Special Requirements.
(Item 23-30)
Critical., mrd non-critical violations, which do not relate to the
foodborne illness interventions and risk factors listed above, can be
fnund in the following sections of the Food Code and 105 CMR
s:svnrmm,:±-z cc
Commonwealth of Massachusetts
` t City of Salem
Board of Health Kimberley Driscoll
120 Washington Street, 4th Floor Mayor
SALEM, MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 12/20/2011
ESTABLISHMENT NAME:
File Number: BHF -2010-000057
TJ Maxx #769
17 Traders Way
SALEM MA 01970
LOCATED AT:
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes
RETAIL FOOD BHP -2012-0104 Jan 1, 2012 Dec 31, 2012 $70.00
Total Fees: $70.00
PERMIT EXPIRES eecember 31, 2012
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted
in a prominent location in the Establishment.
In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made,
all plans for: such must be submitted to and approved by the Salem Board of Health. Page 1
KIMBERLEY DRISCOLL
MAYOR
LARRY RAMDIN, RS/RENS, CHO, CP -FS
HEALTFI AGENT
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4" F1.,00R
TEL. (978) 741-1800
FAX (978) 745-0343
LRAMDIN�%SN.EM.COM
2012 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT TJ Maxx #769
TEL # 978-744-5477
ADDRESS OF ESTABLISHMENT 17 Traders Way, Salem,
MA 01970 FAX #
508-390-4799
MAILING ADDRESS (if different) P.O. Box 9358 Framingham MA 01701
EMAIL - Business': Sales_Tax@tjx.com
Website: tix.com
OWNER'S NAME The TJX Companies Inc
TEL # 508-390-3511
ADDRESS 500 A-2 Old Connecticut Path Framingham
MA
01701
STREET
CITY STATE
ZIP
CERTIFIED FOOD MANAGER'S NAME(S) NIA
CERTIFICATE#(S)
(Required in an establishment where potentially hazardous food is prepared)
EMERGENCY RESPONSE PERSON Diane Linch
HOME TEL # 978-744-5477
DAYS OF OPERATION Monday Tuesday Wednesday
Thursday Friday
Saturday
Sunda
HOURS OF OPERATION 9:30am 9:30am- 9:30am-
9:30am 9:30am-
9:30am-
I1:00 m -
in time of day. 9:30pm 9:30pm 9:30pm
(For
9:30pm 9:30pm
9:30pm
8.0opm
example
(For example 11am-11pm)
TYPE OF ESTABLISHMENT
FEE (check only)
'
RETAIL STORE YES NO
less than 1000sci t._$
70
1000-10,000sq.ft.
280
more than 10,000sq.ft.
=$420
- ------------------------------------------- -----------.
RESTAURANT YES NO
.............. ............
less than 25 seats
......----
=$140
(Outdoor Stationary Food Cart $210)
25-99 seats
=$280
more than 99 seats
=$420
- ...... . . ... ............ .....................-------------------------.
BED/BREAKFAST/ YES NO
---------------------
------
$"100
CHILDCARE SERVICES/NURSING HOME
-
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 ter 62C, Section'49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax
returns paid =all to taxe�dunder the law.
for Vice President - Finance Date
5/23/11 FOODAP201 Ladm Checkk & Date
Security or Federal Identification Number
Commonwealth of Massachusetts
City of Salem
Board of Health Kimberley Driscoll
120 Washington Street, 4th Floor Mayor
SALEM, MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 01/03/2011
ESTABLISHMENT NAME:
File Number: BHF -2010-000057
LOCATED AT:
AJ Wright #303
17 Traders Way
SALEM MA 01970
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes
RETAIL FOOD BHP -2011-0004 Jan 1, 2011 Dec 31, 2011 $70.00
Total Fees: $70.00
PERMIT EXPIRES
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted
in a prominent location in the Establishment.
In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made,
all plans for such must be submitted to and approved by the Salem Board of Health. Page 1
KINfBERLEY DRISCOLL
MAYOR,
DAVID GREENBAum, RS
ACTING HEALTH AGENT
2011
NAME OF EST
ADDRESS OF ESTABLISHMENT
MAILING ADDRESS (if different)
PO Box 9358
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4111 FLOOR
TEL. (978) 741-1800
FAx (978) 745-0343
DGREENUAui IOSA) U.N. CONI -
PERMIT TO OPERATE A FOOD ESTABLISHMENT
P303 TEL# ?/ 6 — �q
FAX # _ Qr' 9—q 7 < Q
Frfminghaim, MA 01701
EMAIL - Business`. /�X
SQ l es --TAX C� t�`>< • Gv », Website: tJ X • c�
'S No v
OWNERS rtiQ rat_tp r�0mc.TEL# 5-W—,
ADDRESS J V (/ f1 oc VIA C—O ki)ie C41 GLt I rc / ➢1 r r l �s-r
STREET CITY STATE
CERTIFIED FOOD MANAGER'S NAME(S) _� "lam CERTIFICATE#(S)
(Required in an establishment where potentially hazardous food is prepared)
EMERGENCY RESPONSE
TEL
?So -3sl /
�r,otiai-.1-7 iul 0i20/
ZIP
_DAYS;OFOPERATION =„ . Monda': Tuesday: Wednesday ".iThursday+- ,'Fdda , , .I ..'^Saturda I :Sunil
HOURS OF OPERATION p 1n
Please write in tune of day.
(For example Ilam-11pm) 1 i
TYPE OF ESTABLISHMENT YES NO FEE (check only) (c,�t 1"- lif
RETAIL STORE less than 1000sq.ft._$ 70 gn.rc(r
1000-10,000sq.ft. 280
more than 10,000sq.ft. =$420
RESTAURANT YES NO less than 25 seats =$140
(Outdoor Stationary Food Cart $210) 25-99 seats =$280
more than 99 seats =$420
BED/BREAKFAST/ YES NO
$100
CHILDCARE SERVICES/NURSING HOME
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO
$25
TOBACCO VENDOR YES NO
$135
ALL NON-PROFIT (such as church kitchens) YES NO
$25
*Please pay total with one check payable to the City of Salem.
This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location
in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for
such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax
returns andaid all stat xes required under the law.
0,? q '6
Date 1116, //O Social Security or Federal Identification Number
C heck#
.� Commonwealth of Massachusetts
r
City of Salem
Board of Health Kimberley Driscoll
120 Washington Street, 4th Floor Mayor
SALEM, MA 01970
Food/Retail Establishment Permit
DATE PRINTED:. 09/29/2010
ESTABLISHMENT NAME:
File Number: BHF -2010-000057
LOCATED AT:
AJ Wright #303
17 Traders Way
SALEM MA 01970
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes
RETAIL FOOD BHP -2010-0558 Sep 29, 2010 Dec 31, 2010 $70.00
PERMIT EXPIRES
Total Fees: $70.00
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted
in a prominent location in the Establishment.
In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made,
all plans for such must be submitted to and approved by the Salem Board of Health. Page t
KIMBERLEY DRISCOLL
MAYOR
DAVID Gi2EENBAUNI,
ACI NG HEALTI-i AGENT
CITY OF SALEM, MASSACHUSETTS
BOARD of,, Hr AL-rH
120 WASHINGTON STREET, 4"-. FLOOR
TFL. (978) 741-1800
FAX (978) 745-0343
ncfar:rna3nuna �snr.F: 1. COM
2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT AJ WRIGHT # 303 TEL # 978-744-5477
ADDRESS OF ESTABLISHMENT 17 Traders Way, Salem, MA 01970 FAX # 508-390-4799
MAILING ADDRESS (if different) PO BOX 935.8, Framingham, MA 01701
EMAIL - Business': sales tax(a)tix.com Website: tix.com
OWNER'S NAME Concord Buying Group, Inc TEL # 508-390-3511
ADDRESS 500 A-2 Old Connecticut Path, Framingham MA 01701
STREET CITY STATE ZIP
CERTIFIED FOOD MANAGER'S NAME(S) N/A
CERTIFICATE#(S)
(Required in an establishment where potentially hazardous food is prepared)
=$ 7
1000-10,000sq.ft.
EMERGENCY RESPONSE PERSON
HOME TEL #
=$420
DAYS OF OPERATION Monday Tuesday Wednesday 1 Thursday
1 Friday 1 Saturday
Sunday
HOURS OF OPERATION 9:30am- 9:30am- 9:30am- 9:30am-
9:30am-
11:00am —
Please write in time of day.
9:30pm 9:30pm 9:30pm 9:30pm
_ 9:30am-9 30pm
9:30pm
6:00pm
(For examole 11 am -11 om1
TYPE OF ESTABLISHMENT
RETAIL STORE (DESNO
RESTAURANT YES NO
(Outdoor Stationary Food Cart $210)
BED/BREAKFAST/ YES NO
CHILDCARE SERVICES/NURSING HOME
---------------------- ------------
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE
TOBACCO VENDOR
ALL NON-PROFIT (such as church kitchens)
FEE (check only)
less than t000sq.ft.
=$ 7
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
$100
YES NO $25
YES NO $135
YES NO $25
'Please pay total with one check payable to the City of Salem.
This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location
in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for
such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax
returns and paid all state taxes required under the law.
09/10/10 02-0502486
Signature
-P VICE PRESIDENT -FINANCE
Date Social Security or Federal Identification Number
�3<'� , 76,
o
�Mfdi%
KIN BERLEY DRISCOLL
NLAYOR
DAVID GREENB:AUM,
ACTING HEALTH AGENT
Revised 4/24/07 FOODAP2008.adm Check# & Date
CITY OF SALEM, MASSACHUSETTS
BOARD OF HN AI TH
120 WASHINGTON STREET, 4p. FLOOR
'TEL. (978) 741-1800
FAx (978) 745-0343
x;iei:F:w��wmi{a)sni.r.na. CONI
KIMBERLEY DRISCOLL
MAYOR
CITY OF SALEM,
MASSACHUSETTS
BOARD or HuAI: D f
120 WASIIINGTON S7RLF; 1', 411 Ff.00R
TI•;L. (978) 741-1800 FAN (978) 745-0343
Iramdinnsalem.com
LARRY RAMDIN, RS/RF1IS, CIIO, CP -FS
Hi?AL' H Ac F,N'I'
Food Establishment Permit Application
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name: #-IIA
2) Establishment Address: MY� p j j
3) Establishment Mailing Address (if different): Qp Q:jp 9355
V::) p
4) Establishment Telephone No: G�1 - —IL"-
5) Applicant Name & Title:
6) Applicant Address: c,
7) Applicant Telephone No: 53$ 390 351N 24 Hour Emergency No: -ILM54(l Email:
VNO _Ax'ti
8) Owner Name & Title (if different from applicant): So.xv-Q
9) Owner Address (if different from applicant):
10) Establishment Owned by:
_6n -association
co atio
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
Q
V
0, rnc-C
12 Person Directly Responsible For Daily Operations Owner, Person in Charge, Supervisor, Manager,
etc.
Name & Title:
Q — g\-4X-dL-
Address:
\1 COL6 r-�- a9,d
Telephone No:
-yy 51.-\\) Fax: SO-` 390'A-jq`1 Email: kq
-1-3y'.
Emergency Telephone No:
cv-m --144 S N
13) District or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
Fax: Email:
Check #: "7 /& ' Date: Amount. O
n
Food Establishment Information
14) Water Source:
vobv\c-
15) Sewage Disposal: c-.;.
DEP Public Water Supply No:
(if applicable)
16) Days and Hours of Operation: fYfcxr-_�oA q''O 930
17) No. of Food Employees: IV WS
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 �1
20) Location:
22) Establishment Type (check all that apply)
Strrun
2f Retail ("5cc o Sq. Ft)
❑ Caterer
21mynentt urecta;'
❑ Food Service - ( Seats)
❑ Frozen Dessert Manufacturer
Mobile
❑ Food Service - Takeout
❑ Residential Kitchen for Retail Sale
❑ Food Service- Institution
❑ Residential Kitchen for Bed and
( Meals/Day)
Breakfast Home
❑ Food Delivery
❑ Residential Kitchen for Bed and
Breakfast Establishments - -----------------
21) Length Of Permit:
(check one)
RETAIL STORE
RESTAURANT
ual
Less�0sq.ft. (:$:70
❑ Less than 25 seats $140
Seasonal/Dates:
❑ 1000-10,000sq.ft. $280
❑ Residential Kitchens $140
❑ More than 10,000sq.ft. $420
0 25-99 seats $280
- ❑ More than 99 seats $420
-------- --------------------------------------------------------------------------------------------------------------------------
0 Bed & Breakfast/Childcare Services /Nursing Home $100
Temporary/Dates/Time:
-----------------------------------------------------------------------------------------------------------------------------------------
ADDITIONAL PERMITS
11 MAKE ICE CREAM, YOGURT/SOFT SERVE
$25
❑ PASTURIZATION
$25
11 TOBACCO VENDOR
$135
❑ ALL NON-PROFIT
$25
(Including, church kitchens, state funded childcare & private clubs)
23) Food Operations:
Definitions: PHF- potentially hazardous food (timeAemperature controls required)
Non-PHFs - non -potentially hazardous
food (no timekemperature controls required)
check all that a 1 :
RTE -ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing
✓ Sale of Commercially
PHF Cooked to Order
Hot PHF Cooked and Cooled or Hot Held
Pre-packaged Non-PHFs
for More Than a Single Meal Service
Sale of Commercially
Preparation of PHFs For Hot'And
PHF and RTE Foods Prepared For Highly
Pre-packaged PHFs
Cold Holding for Single Meal Service
Susceptible Population Facility
Delivery of Packaged PHFs
Sale of Raw Animal Foods Intended to be
Vacuum Packaging/Cook Chill
Prepared by Consumer
Reheating of Commercially
Customer Self -Service
Use of Process Requiring A Variance
Processed Foods for
and/or HACCP Plan (including bare hand
Service Within 4 hours
contact alternative, time as public health
control.
,Customer Self -Service of
Ice Manufactured and Packaged for
Offers Raw or Undercooked Food of
✓ Non-PHF and Non-
Retail Sale
Animal Origin
Perishable Foods Only
Preparation of Non-PHFs
Juice Manufactured and Packaged for
Prepares Food/Single Meals for Catered
Retail Sale
I Events or Institutional Food Service
1, the undersigned, attest to the accui
comply with 105 CMR 590.000 and all
590.000 and the Federal Food Code.
24) Signature of Applicant:
utters K I h PKF in bull(utlantltles
To be completed by the Board of Health
Retail Sale of Salvage, Out of Date
or Reconditioned Food Total Permit Fee:
Payment is due with application
of the information provided in this application and I affirm that the food establishment operation will
;r app"Ie law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR
Pursuant to MGL Ch. 62C, s c 49A, I certify under the penalties of perjury that I, to my best knowledge and belief,
Have filed all state tax retu and paid state taxes required under law.
25) Social Security Number or Federal ID: C)Li- aG)0_1 10V3
26) Signature of Individual or Corporate Name: T�.2 TAX COthQo�ttl\ , -Tx \C,
KIMBERLEY DRISCOLL
MAYOR
CITY OF SALEM, MASSACHUSETTS Lf
BOARD OF HEALTH
120 WASHINGTON STREET, 4t" FLOOR PablicHeaith
Prevent. Promote. Protect.
TEL. (978) 741-1800-FAx (978)_745=0343 -
kamdin sa m.com :. s
HF:Aun-i AGENT
This Form will be collected during your next Board of Health Inspection.
QUESTIONAIRE - GREASE TRAPS 2012
1. NAME OF ESTABLISHMENT: �� `rfbz-ilfl�
2. ADDRESS OF ESTABLISHMENT:0Tcc.�ar�
3. DOES YOUR ESTABLISHMENT HAVE A.GREASE TRAP? - r%
r
-4. WHAT SIZE GREASE-TRAP:DOES YOUR -ESTABLISHMENT HAVE? N Pc
CAPACITY IN GALLONS - - -
5. HOW IS THE GREASE TRAP MAINTAINED? ON A DAILY BASIS? BY AN IN-HOUSE PERSON OR
BY AN OUTSIDE CLEANING SERVICE? N\\
6. WHAT IS THE FREQUENCY THAT THE GREASE IS REMOVED FROM THE TRAP?
N Vp'
7. WHAT IS THE NAME OF THE FIRM WHO REMOVES AND/OR PICKS UP THE GREASE FROM
YOUR ESTABLISHMENT?
8. WHAT IS THE DATE OF. YOUR LAST INVOICE FROM THE REMOVAL FIRM?