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WARD EIGHT CAFE - ESTABLISHMENTSWARD EIGHT 3-5 Ward Street ca No. 2-15OLGN HASTINGS. MN -LOS ANGELES LAGAN, ON - McGREGOR. TX U. S. A y r, r t No. 2-15OLGN HASTINGS. MN -LOS ANGELES LAGAN, ON - McGREGOR. TX U. S. A I I HP Fax Series 900 Plain Paper Fax/Copier .Last Fiat Date. Time. Type. Sep 18 2:33pm Sent Result: OK - black and white fax Identification_ 914137479650 Fax History Report for Joanne Scott Salem, BOH 978 745 0343 Sep 18-2006.2:34pm Duration. Pages Resul 0:57 3 OK CITY OF SALEM, MASSACHUSETTS m BOARD OF HEALTH s 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAx 978-745-0343 W W W.SALEM.COM Kimberley Driscoll ,JOANNE SCOTT, MPH, RS, CHO Mayor HEALTH AGENT Facsimile Transmittal To: Fax # (/) 3 ') q i q� h / RE: C�Orn, �5 P/00)f / a�T-d X ei Date / �3-1e)6 Page(s): including this cover #3-- OFFICE HOURS: Monday, Tuesday, & Wednesday 8:00 AM to 4:00 PM Thursday 8:00 AM to 7:00 PM Friday 8:00 AM to 12:00 Noon Do Salem Residents Know ? — Applications for a permit to remove exterior paint are required by the Salem Board of Health. No fee for permit and electric sanding is not permitted. Regulations for home owners and painting contractors are available. v ,- r� CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH, RS, CHO - NINE NORTH STREET HEALTH AGENT Tel: (978) 741.1800 _ Fax: (978) 740.9705 COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with. .regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Owner's Name: Lawrence R. Thibodeau Name of Establishment: Salem Ward Eight Cafe Address of Establishment: 109 Lafayette Street Type of Establishment' FOOD SERVICE Application Date: 02/12/98 Restrictions: Permit for Establishment 226-98 Frozen Desserts/Ice Cream .Permit for the Sale of Tobacco Products These Permits Expire December 31, 1998 This permit is not transferable and must be reissued upon change of ownership or location. In accordance with the State Sanitary Code, all plans of renovations, improvements, equipment changes must be approved by the Health Department. HEALTH AGENT CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT NINE NORTH STREET Tel: (978) 741-1800 Fax: (978) 740-9705 1998 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different) n OWNER'SNAME A.aWA, /UP,�% i�`l3od�/�c- TEL#9'96'?�9!�V?0 ADDRESS 109 1006BOw kO EMERGENCY RESPONSE PERSON r D/I/A/ 1L-�- TEL 4_1, ,5-L "3 i 4 ir7 M ESTABLISHMENT'S DAYS & HOURS OF OPERATIONS�� 'TYPE OF ESTABLISHMENT /(� p2 o v ` 0 FEE check only RETAIL STORE YES NO $40 RESTAURANT NO #seats #nonsmoking $40 MOBILE UNIT YES NO Please fill out additional form $40 TEMPORARY YES NO Please fill out additional form $40 OTHER YES NO S ADDITIONAL PERMITS MAKE FROZEN DESSERTS YES NO $5 TOBACCO VENDOR YES NO $10 Please pay total with one check This permit is not transferable and must be reissued upon change of ownership. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Health Department. 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 Al state tax returns and paid all state taxes required under the law. Date Social Security or Federal Identification Number modan'- nm„ 6IL//�Ur:I� • • • � �m. lu OF . PLEASE CALL _ _... PHONE CAMETOSEE YOU WANTS TO SEE YOU'.. WILL CALL .MIN RUSH AREA CODE NUMBER EXTENSION O FAX WILL FAX TO YOU O MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED -... . PLEASE CALL _ _... CAMETOSEE YOU WANTS TO SEE YOU'.. WILL CALL .MIN RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE '� 4008 1 U.S.A. NOTES Sep 18 06 11:44a Gold 4 Vanaria 413 747 OG50 p.l GOLD & VANARIA P.C. ATTORNEYSATLAIV 121NGR4ILIbITERRACE SPRINGFIELD, MASSACHUSETTS oil$$ TELEPIlONE (413) 747-7700 FAX (4l5) 747-9650 MEBSITE VGLDVANARUCOM 1l YERS OOM/GOL D& VANA&A FACSIMILE COVER SHEET To: o' S Your FaxNo.: 999— IY4'=p3 93 From: � Date: �9/—p (—r — Time: //,m; Total Pages:` (includes cover shear) I I Original Documents will be mailed. I j Azw at Downbmts will NOT be =aged -atthis time. A- ��20��,. �' Tifil�l�4'eg1! G�cor�L. . v 7 oz THE INFORMATION CONTAINED IN THIS TRANSMISSION IS ATTORNEY PRIVILEGED, IS OTHERWISE CONFIDENTIAL, AND IS INTENDED ONLY FOR THE USE OF THE INDIVIDUAL.. OR ENTITY NAMED ABOVE, DISSEMINATION, DISTRIBUTION OR COPYING OF THIS COMMUNICATION IS STRICTLY PROHIBITED..IS YOU HAVE RECEIVED THIS COMMUNICATION IN ERROR, PLEASE IMMEDIATELY NOTIFY US BY TELEPHONE, AND RETURN THE ORIGINAL MESSAGE TO US AT THE ABOVE ADDRESS VIA TRE UNITED STATES POSTAL SERVICE, THANK YOUI IF YOU DO NOT RECEIVE ALL OF THE PAGES, SE PLEACALL POSSIBLE. AS SOON AS COURT DOCKET NO. Q CITATION NC CITY OF SALEM VIOLATION NOTICE !'r,6 NAME (LAST, FIRST, INITIAL) ts9,uJ to a� �+Fe STREETADDRESS CITY/TOWN STATE ZIP LICENSE NO. LIC. EXP. DATE DATE OF BIRTH OWNER'S NAME (LAST, FIRST, INITIAL) STREET ADDRESS CITY/TOWN STATE ZIP /G� ctt rr ST"5r4 -n "".v evy7e REGISTRATION NO. STATE EXP. DATE MAKE/TYPE YEAR COLOF DATE OF VIOLATION TIME 26AM DATE CITATION WRITTEN PERSONAL 1141111 / El Pm O7/.�//F ❑NOS LOCATION OF VIOLATION ENFORCING DEPT. OFFENSE/ /i9r �/I.i 7-cl 00777>>~+ fid CHAP SECT. FINES A B "Ads - OFFICER I.D. NO. TOTAL FINE Is �� . i=iL ir�iTrs a'Ci e7/ DUE OFFICE`R CERTIFIES COPY GIVEN TO VIOLATOR // ❑ IN RANI X/� F�rBY MAII DO IL,QASH - PAY ONLY BYTPOSTAL NOTE, MONEY PRD R OR BY CHECK MADE PAYABLE TO: CITY CLERK CITY HALL 93 WASHINGTON STREET SALEM, MA 01970 TEL. (508) 745-9595 X 251 1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED OI REVERSE, CONFESS TO THE OFFENSE CHARGED, AND ENCLOSI PAYMENT IN THE AMOUNT OF CASE # SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN. THIS ENVELOPE, PEEL AND SEAL THE COMMONWEALTH OF MASSACHUSETTS City of Salem BOARD OF HEALTH FOOD ESTABLISHMENT INSPECTION REPORT Establishment Name Date 7/31/47 Toxics 47. Address /a9 Time: In Out sAd 30 Telephone Type of Establishment: Service Retail Food Purpose: Routine Owner's NameFood 44 r _ Residential Kitchen Follow-up Person in Charge LA Unit Complaint C.C.Mobile Temporary Food Service investigation 34. Inspector's Name Catering Other U Based on an Inspection today, the Items checked below indicate the violated provisions of 105 CMR 590.000. Each item is followed by the applicable section of the Massachusetts regulation. Non-critical violations are marked under column ••N•• and critical violations are marked under column "C". Descriptions of each item appear on the back of this form. Each violation checked requires an explanation on the narrative page(s):. This report serves as official notice of violated provisions and official notice to correct said violations. Food 1. Food Supply 2. Food Containers Food Protection 3. PHF Temperatures 4. Facilities. Hot b Cold Storage 5. PHF Re -service 6: Spoiled/Damaged Foods 7. Food Protected S. Food Thermometers 9. Cross Contamination 10. PH Fs thawed, cooked d cooled 11. Food Handling 12. Dispensing Utensils Personnel 13. Employee Infections 14. Employee Hygiene 15. Employee Clothing Equipment & Utensils 16. Equipment/Utensil Clean d Sanitized 17. Food Contact Surfaces 18. Non -Food Contact Surfaces 19. Food Contact Surfaces Clean 20. Non -Food Contact Surfaces Clean 21. Wiping Cloths 22. Dish/Warewashing Facilities 23, Pre -Scraped, Soaked 24. Wash/Rinse Water 25. Thermometers/Test Kits 26. Equipment/Utensil Storage 27, Single Service Articles 28. Single Service Re -Use 0 0 46. Toxics 47. Sanitary Facilities .0021F 29, Water Source .002 30.. Sewage Bulk Foods 31. • 'Cross -Connections 32. Toilets/Handwashing .004 33. Insects/Rodents .004 34. Plumbing .006 35. Toilet Rooms .003 &. Handwashing Areas .003 37. Garbage/Refuse •004 38. Outside Disposal .005 39. Outer Openings .005 40, Pesticide/Rodenticide Application .005 .006 Physical Facilities Q Floors 42. Walls, Ceiling .008 43, Lighting .009 44, Ventilation .010 45. Dressing Rooms .013 .013 .013 .013 .013 .013 .013 .013 .013 .013 .014 .014 .012 Other 46. Toxics 47. Premises 48. Living Areas 49. Linen 50. Pets 51r Bulk Foods 52, Salad Bars .015 016 .017 .018 &.019 .021 .017 .018 .019 .020 .020 .021 021 022E .022 �J .023 .024 .025 .026 .027 .027 .027 .027 .031 .032 INo. of 13 Critical Items Violated -I These items require immediate attention. ln�pe tg��y. SMOKING LAW COMPLIANCE_YES_NO_NA Reinspection of Critical Items FORM 734A (HA)HOBBSA WARREN TR CHOKE SAVER COMPLIANCE -YES -NO -NA Reinspection of Noncritical Items THE COMMONWEALTH OF MASSACHUSETTS City of Salem Establishment Name Date1S//-V,' S F Address Page a of 3 /09 a f% Item No. In the space below describe all violations checked on front page. A(n) ed"4i., e. inspection of this establishment was conducted in accordance with the State Sanitary Code for Food Establishments, Chapter X, 105 CMR 590.000. The following violations were observed: JAJa,.4cw e o t e G aiSe' S s e S 7&%4S a E i s 6e,;,r- Discussion with Management 'fe.,,Ai Ar,.o� I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to comply with all mandates of Chapter X. I understand that noncompliance may result in daily fines of twenty-five dollars. gWjGINS �J THE COMMONWEALTH OF MASSACHUSETTS .. •s City of Salem BOARD OF HEALTH FOOD ESTABLISHMENT INSPECTION REPORT Establishment Name Date .1/2/98 0 C Sanitary Facilities Address Time: In Out �/ O M Telephone 740,V- 9;a 9 Type of Establishment: Food Service Retail Food Purpose: Routine Owner's Name 30. Residential Kitchen Mobile Unit Follow-up Complaint - Person in Charge W (c�elt' I'�a �� , Temporary Food Service Investigation Food Inspectoes Name Catering Other AW k 4 3. PHF Temperatures t) Based on an Inspection today, the Items checked below indicate the violated provisions of 105 CMR 590.000. Each item is followed by the applicable section of the Massachusetts regulation. Non-critical violations are marked under column"N" and critical violations are marked under column "C". Descriptions of each Item appear on the back of this form. Each violation checked requires an explanation.on the narrative page(s). This report serves as official notice of violated provisions and official notice to correct said violations. Food 0 C Sanitary Facilities 1. Food Supply .00229. Water Source 2. Food Containers .00211' 30. Sewage 31. Cross -Connections Food Protection 32. Toilets/Handwashing 3. PHF Temperatures .004 33, Insects/Rodents 4. Facilities. Hot d Cold Storage .004 34. Plumbing 5. PHF Re -service .006 35. Toilet Rooms 6. Spoiled/Damaged Foods .003 36. Handwashing Areas 7. Food Protected .003 37. Garbage/Refuse S. Food Thermometers .004 38. Outside Disposal 9. Cross Contamination .005 39, Outer Openings 10. PHFs thawed, cooked d cooled .005 40. Pesticide/Rodenticide Application 11. Food Handling .005 12. Dispensing Utensils .006 Physical Facilities 41. Floors Personnel 42, Walls, Ceiling 13. Employee Infections .008 43, Lighting 14. Employee Hygiene .009 44. Ventilation 15. Employee Clothing .010 45. Dressing Rooms Equipment i Utensils Other 16. Equipment/Utensil Clean 8 Sanitized .013 46. Toxics 0. Food Contact Surfaces .013 47. Premises 18. Non -Food Contact Surfaces .013 48. Living Areas 19. Food Contact Surfaces Clean .013 49. Linen 20. Non -Food Contact Surfaces Clean .013 50. Pets 21. Wiping Cloths .013 51. Bulk Foods 22. Dish/Warewashing Facilities .013 52. Salad Bars 23. Pre -Scraped. Soaked .013 24. Wash/Rinse Water .013 No. of 13 Critical Items Violated 25, Thermometers/Test Kits .013T hese items require i mediate attention. 26. Equipment/Utensil Storage .014 Re a Gad by: Ins 27. Single Service Articles .014 28, Single Service Re-Uie .012 _ FORM 734A H&W Homs P. WARREN TM 14114I:1 SMOKING LAW COMPLIANCE_YES_NONA Reinspection of Critical Items .022 .022 .023 .024 .025 .026 .027 .027 .027 .027 .031 .032 CHOKE SAVER COMPLIANCEYESNONA Reinspection of Noncritical Items THE COMMONWEALTH OF MASSACHUSETTS City of Salem Establishment Name Date ,A/A/98 Address Page I of 3 0 v Item No. In the space below describe all violations checked on front page. Ain) jr4tAfte inspection of this establishment was conducted in accordance with the State Sanitary Code for Food Establishments, Chapter X, 105 CMR 590.000. The following violations were observed: f Discussion with Management 1 have read this report, have had the opportunity to ask questions and agree to correct all violations before the nett inspection, to observe all conditions as described, and to comply with all mandates of Chapter X. I understand that noncompliance may result in daily fines of twenty-five dollars. S tCiT - OF L) _ a rla t^; n°Salem, Massachusetts0l N JOANNE 'SCOTT MPH RS CHO,, st ^ti ., n_y t• i,HEALTH AGENT° �+-rv-icg''""r"g�aeq„�'"t : ^ #Y F.. h OF HEALTH , 970-3928 NINE NORTH STREET -T61.(508)-74Y=1600 "§ .. ,.F= (508)740.9705 COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94 Section 305A`and"Chapter'III, Section 5 of the General Laws, to operate a Food„Establishment in the City of Salem is hereby granted to: Owner's Name: Lawrence R. Thibodeau Name of.Establishment: Salem Ward Eight Cafe Address of Establishment: 109 Lafayette Street Type of Establishment: FOOD SEEVICE Application Date: 01/09/91 Restrictions: Permit for Establishment 201-97 Frozen Desserts/Ice Cream I Permit for the Sale of'Tobacco Products These Permits Expire December 31, 1997 This permit is not transferable and must be reissued upon change of ownership. In accordance with the State Sanitary Code, all plans of renovations, improvements, equipment changes must be approved by the Health Department. qv- ,x,4'c,i HEALTH AGENT KA CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH, RS, CHO NINE NORTH STREET HEALTH AGENT Tel: (508) 741-1800 Fax: (508) 740-9705 199" -'APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLIS'-IMENTS'A-i 4/0 WORD I�6 a_(,_Wn TEL #__J ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different QV'NER'S NAME" L(% Al C ADDRESSZ0 A.G 66W EMERGENCY RESPONSE; PERSON , TEL # ESTABLISHMENT'S DAYS 6< HOURS OF OPERATION -_-___9 TYPE OF ESTABLISHMENT a6 / ' FEE check only RETAIL STORE y FS NO RESTAURANT YES NO MOBILE UNIT YES NO TEMPORARY YES NO OTHER YES NO $40 # seas']-- - # nonsmoking $40 Please till out additional form $46 Please fill out additional forn $40 ADDITIONAL PERMITS MAKE FROZEN DESSERTS YES NO $5 TOBACCO VENDOR YES NO $10 Please pay total with one check 'This permit is not transferable and must be reissued upon change of ownership. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Health Department. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of pefjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Date foodapi adm � - 2n-qiL D(- 913r) Social Security or Federal Identification Number THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM HEALTH DEPARTMENT - 9 NORTH STREET, SALEM, MASS. 01970 FOOD ESTABLISHMENT INSPECTION REPORT Based on an inspection today, the items checked below indicate the violated provisions of 105 CMR 590.000. Each item is followed by the applicable section of the Massachusetts regulation. Non-critical violations are marked under column "N"and critical violations are marked under column "C". Descriptions of each item appear on the back of this form. Each violation checked requires an explanation on the narrative page(s). This report serves as official notice of violated provisions and official notice to correct said violations. Food N C Sanitary Facilities N C 1. Establishment Name �' .015 Date Address 0021�1 30. Sewage Time: In Out 31. Cross -Connections .017 Telephone �y�j, 9 79 Type of Establishment: Food Service Retail Food X Purpose: Routine Owner shame / T/. ��,-.�eav PHF Temperatures C .r tiv.P Residential Kitchen Follow-up 4. Person in Charge .004 " Mobile Unit Complaint 5. PHF Re -service .006 Temporary Food Service 35. Toilet Rooms Investigation .018 Inspector's Name TF«ilL, w. //�,�� Catering 1111111110 Other Based on an inspection today, the items checked below indicate the violated provisions of 105 CMR 590.000. Each item is followed by the applicable section of the Massachusetts regulation. Non-critical violations are marked under column "N"and critical violations are marked under column "C". Descriptions of each item appear on the back of this form. Each violation checked requires an explanation on the narrative page(s). This report serves as official notice of violated provisions and official notice to correct said violations. Food N C Sanitary Facilities N C 1. Food Supply .00229_ Water Source .015 2. Food Containers 0021�1 30. Sewage .016 31. Cross -Connections .017 Food Protection 32. Toilets/Handwashing .018 & .019 3. PHF Temperatures .004 33. Insects/Rodents .021 4. Facilities, Hot & Cold Storage .004 34, Plumbing .017 5. PHF Re -service .006 35. Toilet Rooms .018 6. Spoiled/Damaged Foods 003 36.;, Handwashing Areas .019 )� 7. Food Protected .00337.' Garbage/Refuse .020 8. Food Thermometers .004 �38. Outside Disposal .020 9. Cross Contamination .005 39. Outer Openings .021 10. PHF's thawed, cooked & cooled .005 40, Pesticide/Rodenticide Application .021 11. Food Handling .005 12. Dispensing Utensils .006 Physical Facilities 41. Floors .022 Personnel 42. Walls, Ceiling .022 13. Employee Infections .008 43. Lighting .023 14. Employee Hygiene .009 44. Ventilation .024 15. Employee Clothing .010 45. Dressing Rooms .025 Equipment & Utensils Other 16. Equipment/Utensil Clean & Sanitized .013 46. Toxics .026 17. Food Contact Surfaces .013 47. Premises .027 18. Non -Food Contact Surfaces .013 48. Living Areas .027 19. Food Contact Surfaces Clean .013 49. Linen .027 20. Non -Food Contact Surfaces Clean .013 50. Pets .027 21. Wiping Cloths .013 51. Bulk Foods .031 22. Dish/Warewashing Facilities .013 52. Salad Bars .032 23. Pre -Scraped, Soaked .013 24. Wash/Rinse Water .013 No. of 13 Critical Items Violated 25. Thermometers/Test Kits .013 These items require immediate attention. _ 26. Equipment/Utensil Storage 014 27. Single Service Articles .014 R ceived by: n Inspected by: r� 26 Single Service Re -Use 012 C �A(7rs NYO�ti � FORM 73 A HOBSS & WARREN, INC. 1985 r Full Item Descriptions Food C1 Food Source, approved, wholesome 2 Containers, properly labelled Food Protection C3 Potentially hazardous foods at proper temperatures: 140OF or above, 450F or below, OOF; rapid cooling of cooked foods •within 4 hours C4 Facilities to maintain product temperature C5 Unwrapped and potentially hazardous foods not re -served 6 Damaged, spoiled,_ returned foods segregated 7 Food protected during storage, preparation, display, dispensing, service, transportation 8 Thermometers provided, conspicuous, accurate 9 No cross -contamination 10 Potentially hazardous foods properly thawed, cooked, and cooled 11 Food handling minimized 12 Dispensing utensils stored Personnel C13 Employees with infections restricted C14 Hands washed and clean; good hygienic practices 15 Clean clothes, hair restraints Equipment 8 Utensils C16 Equipment, utensils sanitized (automatic and manual methods) 17 Food contact surfaces: design, constructed, installed, maintained, located 18 Non-food contact surfaces: design, constructed, installed, maintained, located 19 Food contact surfaces clean, free of all cleansers 20 Non-food contact surfaces clean, free of all cleansers 21 Wiping cloths; clean, use restricted 22 Dish/Warewashing facilities: designed, constructed, maintained, installed, located, operated 23 Pre -flushed, scraped, soaked 24 Wash/Rinse water clean, temperature 25 Accurate thermometers, chemical test kits provided; instructions posted 26 Storage, handling of clean equipment/utensils 27 Single service articles, storage, dispensing 28 No re -use of single service articles Sanitary Facilities C29 Water source; approved, hot&cold under pressure C30 Sewage and waste water disposal - C31 No cross -connections, back siphonage, backflow C32 Toilets t, Handwashing: number, accessible, design, installed C33 No insects or rodents; harborage prevented 34 Plumbing; installed, maintained 35 Toilet rooms enclosed, self-closing doors, fixtures good repair; clean, signs 36 Handwashing areas supplied with soap and towel dispensers, proper waste receptacles 37 Garbage and refuse: containers covered, adequate number, insect/rodent resistant, frequency, clean 38 Outside area: dumpster covered, construction, clean 39 Outer openings protected 40 Pesticides and rodenticides, proper application Physical Facilities 41 Floors constructed, maintained, clean 42 Walls, ceiling, attached equipment; constructed, maintained, clean 43 Lighting provided as required, fixtures shielded 44 Rooms and equipment vented as required 45 Dressing, locker areas provided used, clean Other C46 Toxics properly stored, labelled, used 47 Premises litter -free, unnecessary articles, cleaning maintenance equipment properly stored. Authorized personnel 48 Living/sleeping quarters and laundry separate 49 Linen properly stored 50 No pets or ether live animals except guide dogs 51 Bulk foods stored, labelled, dispensed 52 Salad bar operations prepared, refrigerated, displayed, protected THE COMMONWEALTH OF MASSACHUSETTS City of Salem Establishment Name Date Address Page _.2 of /o • t S�- Item No. In the space below describe all violations checked on front page. A(n) waiinspection of this establishment was conducted in accordance with the State Sanitary Code for Food Establishments, Chapter X, 105 CMR 590.000. The following violations were observed: 3(v 's el Ged A Gama+ O O<T u C L Cm �.(7.0 B T /rAl •.•/Je o Discussion with Management I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to comply with all mandates of Chapter X. I understand that noncompliance may result in daily fines of twenty-five dollars. r CITY OF SALEM BOARD OF HEALTH - Salemi-Massachusetts 01970-3928 JOANNE SCOTT, MPH, AS, CHO HEALTH AGENT OF MASSACHUSETTS NINE NORTH STREET Tel: (508) 741-1800 Fax: (508) 740-9705 PERMIT TO OPERATE A FOOD ESTABLISHMENT In. accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Owner's Name: Lonnie Thibodeau . Name of Establishment: Salem Ward Eight Cafe Address of Establishment: 109 Lafayette Street Type of Establishment: FOOD SERVICE Application Date: 03/04/96 Restrictions: Permit for Establishment Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 1996 232-96 (� HEALTH AGENT CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT NINE NORTH STREET Tel: (508) 741-1800 Fax: (508) 740-9705 1996 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT atX M W/p tiX Ecjtfi- itle TEL # I% 0-f S"3 / ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different) _n OWNER'S NAME ViEGr�D IJL TEL # EMERGENCY RESPONSE TYPE OF ESTABLISHMENT RETAIL STORE tYE NO RESTAURANT YES NO MOBILE UNIT YES NO TEMPORARY YES NO OTHER YES NO ADDITIONAL PERMITS `IanufactureFROZEN DESSERTS YES NO TOBACCO VENDOR YES NO I/ VkQC-) FEE check only $25 # seats # nonsmoking_ $25 Please fill out additional form $25 Please fill out additional form $25 $5 $10 Please pay total with one check This permit is not transferable and must be reissued upon change of ownership. In accordance with the State Sanitary Code, all plans of renovations, improvements, equipment changes must be approved by the Health Department. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Signature fo .p d., Social Security or Federal Identification Number TO DATE TIME AM H' FROM l fLdW !C-2 AREA CODE �Q OF EXT. ',1 FAX # ;E M M s d -- ;.,E G 1 M' 2- E SIGNED (t(O;. iP. PHONED CALL RETURNED WANTS TO WAS IN ,❑N LL, URGENT �¢ _, SAON CALL SEE YOU a`Se a' pvo b (amu.._. . kq-� THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM HEALTH DEPARTMENT - 9 NORTH STREET, SALEM, MASS. 01970 FOOD ESTABLISHMENT INSPECTION REPORT Establishment Name ScAc wv . rl e ; 1�t �f Date ?/Giys Address 3 4o-rc� S3 Time: In Out Telephone w,4 - `75311 Type of Establishment: Food Service Retail Food Residential Kitchen Mobile Unit Temporary Food Service Catering Purpose: Routine x Follow-up Complaint p Investigation Other Owner's Name • c 't �tl`f Person in Charge Inspector's Name rnn2 r ku\,-� Based on an inspection today, the items checked below indicate the violated provisions of 105 CMR 590.000. Each item is followed by the applicable section of the Massachusetts regulation. Non-critical violations are marked under column" N" and critical violations are marked under column "C'. Descriptions of each item appear on the back of this form. Each violation checked requires an explanation on the narrative page(s). This report serves as official notice of violated provisions and official notice to correct said violations. Food N C Sanitary Facilities N C 1. Food Supply .00229. Water Source 015 2. Food Containers .00211' 30. Sewage .016 31. Cross-Connertions .017 Food Protection32. Toilets/Handwashing .018 & .019 3. PHF Temperatures .004 33. Insects/Rodents .021 4. Facilities. Hot & Cold Storage .004 34. Plumbing .017 5. PHF Re -service .006 35.. Toilet Rooms .018 6. Spoiled/Damaged Foods .003 36. Handwashing Areas .019 7. Food Protected .003 37., Garbage/Refuse .020 8. Food Thermometers .004 38. Outside Disposal .020 9. Cross Contamination .005 39. Outer Openings .021 10. PHFs thawed, cooked & cooled .005 40. Pesticide/Rodenticide Application .021 11. Food Handling .005 12. Dispensing Utensils 006 Physical Facilities 41. Floors .022 Personnel 42. Walls, Ceiling .022 13. Employee Infections .008 43. Lighting .023 14. Employee Hygiene .009 1p 44. Ventilation .024 15. Employee Clothing .010 45. Dressing (dooms .025 Equipment & Utensils Other 16. Equipment/Utensil Clean & Sanitized .013 46. Toxics .026 17. Food Contact Surfaces .013 47. Premises .027 18. Non -Food Contact Surfaces .013 48. Living Areas .027 19. Food Contact Surfaces Clean .013 49. Linen .027 20. Non -Food Contact Surfaces Clean .013 50. Pets 027' 21. Wiping Cloths .013 51. Bulk Foods .031 22. Dish/Warewashing Facilities 013 52. Salad Bars .032 23. Pre -Scraped, Soaked .013 24. Wash/Rinse Water .013 No. of 13 Critical Items Violated 25. Thermometers/Test Kits .013 These items require immediate attention. _ 26. Equipment/Utensil Storage .014 27. Single Service Articles .014 rj Received by: ��I/ n__ Inspected by. 28 Single Service Re Use 012 O / f/G4 I �(IiJ!u ,,, ✓° ij; FORM 734A HOBBS & WARREN, INC. 1985 Full Item Descriptions Food C1 Food Source, approved, wholesome 2 Containers, properly labelled Food Protection C3 Potentially hazardous foods at proper temperatures: 140OF or above, 450F or below, OOF; rapid cooling of cooked foods within 4 hours C4 Facilities to maintain product temperature C5 Unwrappedandpotentially hazardous foods not re -served 6 Damaged, spoiled, returned foods segregated 7 Food protected during storage, preparation, display, dispensing, service, transportation 8 Thermometers provided, conspicuous, accurate 9 No cross -contamination 10 Potentially hazardous foods properly thawed, cooked, and cooled 11 Food handling minimized 12 Dispensing utensils stored Personnel C13 Employees with infections restricted C14 Hands washed and clean; good hygienic practices 15 Clean clothes, hair restraints Equipment & Utensils - C16 Equipment, utensils sanitized (automaticand manual methods) 17 Food contact surfaces: design, constructed, installed, maintained, located 18 Non-food contact surfaces: design, constructed, installed, maintained, located 19 Food contact surfaces clean, free of .all. cleansers 20 Non-food contact surfaces clean, free ofall cleansers 21 Wiping cloths; clean, use restricted 22 Dish/Warewashing facilities: designed, constructed, maintained, installed, located, operated 23 Pre -flushed, scraped, soaked ' 24 Wash/Rinse water clean, temperature 25 Accurate thermometers, chemical test kits provided; instructions posted 26 Storage, handling of clean equipment/utensils 27 Single service articles, storage, dispensing 28 No re -use of single service articles . Sanitary Facilities C29 Water source; approved, hot&cold under pressure ' C30 Sewage and waste water disposal C31 No cross -connections, back siphonage, backflow C32 Toilets & Handwashing: number, accessible, design, installed , C33 No insects or rodents; harborage prevented, 34 Plumbing; installed, maintained 35 Toilet rooms enclosed, self-closing-doors,'fixtures good repair, clean, signs 36 Handwashing areas supplied with soap and towel dispensers, proper waste receptacles 37 Garbage and refuse: containerscovered, adequate number, insect/rodent resistant, frequency, clear, 38 Outside area: dumpster covered, construction, clean 39 Outer openings protected 40 Pesticides and rodenticides, proper application - Physical Facilities 41 Floors constructed, maintained, clean 42 Walls, ceiling, attached equipment; constructed, maintained, clean 43 Lighting provided as required, fixtures shielded 44 Rooms and equipment vented as required 45 Dressing, locker areas provided used, clean. Other C46 Toxics properly stored, labelled, used 4'1 Premises litter -free, unnecessary articles, cleaning maintenance equipment properly stored. Authorized personnel " 48 Living/sleeping quarters and laundry separate 49 Linen properly stored ' 50 No pets or other live animals except guide dogs 51 Bulk foods stored, labelled, dispensed y. .52 ,Salad bar operations prepared, refrigerated, displayed, protected THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM HEALTH DEPARTMENT - 9 NORTH STREET, SALEM, MASS. 01970 Establishment Name SrJcw, wovj ekY4.t c'C-c Date 71`/r5 - Address 3 wurA S t Page 2 of Z Item No. In the space below describe all violations checked on front page. Til accC r / oce WcLaAe.`C� nF S4r 4c. Sa.,... fay CaAe 16s --CN 4 syo rFIJ Fr-.. i' SCwrc�. Discussion with Management 0;►, THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM HEALTH DEPARTMENT - 9 NORTH STREET, SALEM, MASS. 01970 FOOD ESTABLISHMENT INSPECTION REPORT Establishment Name S C4 Date Q ' Address Time: In Out Telephone Type of Establishment: Purpose: .00229. Food Serviced Water Source .015 Owner s Name Retail Food Routine 21Y-113 u/ Residential Kitchen Folli ersonECharge 6t 11 Mobile UnitTemporary Complaint Linsoecup Food Service Investigation Protection tme Catering Other Based on an inspection today, the items checked below indicate the violated provisions of 105 CMR 590.000. Each item is followed by the applicable section of the Massachusetts regulation. Non-critical violations are marked under column" N" and critical violations are marked under column "C". Descriptions of each item appear on the back of this form. Each violation checked requires an explanation on the narrative page(s). This report serves as official notice of violated provisions and official notice to correct said violations. Food N C Sanitary Facilities N C 1. Food Supply .00229. Water Source .015 2. Food Containers 0021�1 30. Sewage .016 - 31. Cross -Connections .017 Food Protection 32. Toilets/Handwashing .018 & .019 3. PHF Temperatures .004 33. Insects/Rodents .021 4. Facilities, Hot & Cold Storage .004 34, Plumbing .017 5. PHF Re -service .006 <g> Toilet Rooms .018 6. Spoiled/Damaged Foods .003 36. Handwashing Areas '19 7. Food Protected .003 37. Garbage/Refuse .020 Food Thermometers .004 38_ Outside Disposal .020 Cross Contamination .005 39. Outer Openings .021 10. PHF's thawed, cooked & cooled .005 40. Pesticide/Rodenticide Application .021 11. Food Handling .005 _ 12. Dispensing Utensils .006 Physical Facilities 41. Floors .022 Personnel 42. Walls, Ceiling .022 13. Employee Infections .008 43. Lighting .023 14. Employee Hygiene .009 44. Ventilation .024 15. Employee Clothing .010 45. Dressing (dooms .025 rA%uipment & Utensils Other 16. Equipment/Utensil Clean & Sanitized .013 46. Toxics 026 Food Contact Surfaces .013 47. Premises .027 18. Non -Food Contact Surfaces .013 48. Living Areas .027 19. Food Contact Surfaces Clean .013 49. Linen .027 20. Non -Food Contact Surfaces Clean .013,50. Pets .027 21. Wiping Cloths .013,9 51. Bulk Foods .031 Dish/Warewashing Facilities .013 52. Salad Bars 032 23. Pre -Scraped, Soaked .013 24. Wash/Rinse Water .013 No. of 13 Critical Items Violated 25. Thermometers/Test Kits .013 These items require immediate attention. 26. Equipment/Utensil Storage 014 27. Single Service Articles .014 ceivedby: 28. Single Service Re -Use .012 Jlnspecteby FORM 7NA HOBBS & WARREN. INC. 1985 is Full Stem Descriptions Food C1 Food Source, approved, wholesome 2 Containers, properly labelled Food Protection C3 Potentially hazardous foods at proper temperatures: 140OF or above, 450F or below, OOF; rapid cooling of cooked foods within 4 hours C4 Facilities to maintain product temperature C5 Unwrapped and potentially hazardous foods not re -served 6 Damaged, spoiled, returned foods segregated 7 Food protected during storage, preparation, display, dispensing, service, transportation 8 Thermometers provided, conspicuous, accurate 9 No cross -contamination 10 Potentially hazardous foods properly thawed, cooked, and cooled 11 Food handling minimized 12 Dispensing utensils stored Personnel C13 Employees with infections restricted C14 Hands sashed and clean; good hygienic practices 15 Clean clothes, hair restraints Equipment u UtenS113 C16 Equipment, utensils sanitized (automatic and manual methods) 17 Food contact surfaces: design, constructed, installed, maintained, located 18 Non-food contact surfaces: design, constructed, installed, maintained, located 19 Food contact surfaces clean, free of all, cleansers 20 Non-food contact surfaces clean, free of all cleansers 21 Wiping cloths; clean, use restricted 22 Dish/Warewashing facilities: designed, constructed, maintained, installed, located, operated 23 Pre -flushed, scraped, soaked 24 ',lash/Rinse water clean, temperature 25 Accurate thermometers, chemical test kits provided; instructions posted 26 Storage, handling of clean equipment/utensils 27 Single service articles, storage, dispensing 28 No re -use of single service articles Sanitary Facilities C29 Water source; approved, hot&cold under pressure C30 Sewage and waste water disposal C31 No cross -connections, back siphonage, backflow C32 Toilets & Handwashing: number, accessible, design, installed C33 No insects or rodents; harborage prevented 34 Plumbing; installed, maintained 35 Toilet rooms enclosed, self-closing doors, fixtures good repair, clean, signs 36 Handwashing areas supplied with soap and towel dispensers, proper waste receptacles 37 Garbage and refuse: containers covered, adequate number, insect/rodent resistant, frequency, clean 38 Outside area: dumpster covered, construction, clean 39 Outer openings protected 40 Pesticides -and rodenticides, proper application r Physical Facilities 41 Floors constructed,,maintained, clean 42 Walls, ceiling, attached equipment; constructed, maintained, clean 43 Lighting provided as required, fixtures shielded 44 Rooms and equipment vented as required 45 Dressing, locker areas provided used, clean Other C46 Toxics properly stored, labelled, used 47 Premises litter -free, unnecessary -articles, cleaning maintenance equipment properly stored. Authorized personnel 48 Living/sleeping quarters and laundry separate 49 Linen properly stored 50 No pets or ether live animals except guide dogs 51 Bulk foods stored, labelled, dispensed 52 Salad bar operations prepared, refrigerated, displayed, protected 1r/ THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM HEALTH DEPARTMENT - 9 NORTH STREET, SALEM, MASS. 01970 FOOD ESTABLISHMENT INSPECTION REPORT Establishment Name Date Address I 1,1111112d (17 -Telephone !/Oe In Out �y Type of Establishment: Food Service Retail Food Purpose: Routine Owner's Name � Residential Kitchen Follow up Pets Person in Charge it N Mobile Unit Complaint 36. Temporary Food Service Investigation Garbage/Refuse Inspector's NameCa rin Other v•J1 40, Pesticide/Rodenticide Application Based on an inspection today, the items checked below indicate the violated provisions of 105 CMR 590.000. Each item is followed by the applicable section of the Massachusetts regulation. Non-critical violations are marked under column "N" and critical violations are marked under column •'C". Descriptions of each item appear on the back of this form. Each violation checked requires an explanation on the narrative page(s). This report serves as official notice of violated provisions and official notice to correct said violations. Food Food Supply Food Containers Food Protection 3. PHF Temperatures 4. Facilities, Hot & Cold Storage 5. PHF Re -service 6. Spoiled/Damaged Foods 7. Food Protected 8. Food Thermometers 9. Cross Contamination 10. PHF's thawed, cooked & cooled 11. Food Handling 12. Dispensing Utensils Personnel 13. Employee Infections 14, Employee Hygiene 15. Employee Clothing Equipment & Utensils 16, Equipment/Utensil Clean & Sanitized 17. Food Contact Surfaces 18, Non -Food Contact Surfaces 19. Food Contact Surfaces Clean 0 Non -Food Contact Surfaces Clean 21 Wiping Cloths 22, Dish/Warewashing Facilities 23. Pre -Scraped, Soaked 24, Wash/Rinse Water 25. Thermometers/Test Kits 26. Equipment/Utensil Storage 27, Single Service Articles 28 Single Service Re -Use FORM 734A HOBBS & WARREN, INC. 1985 N C 002 .002 SUN .013 .013 .013 .013 .013 013 .013 .013 .013 .013 014 .014 .012 Sanitary Facilities 29. Water Source 30. Sewage 31, Cross -Connections 32. Toilets%Handwashing 33. Insects/Rodents Pets Plumbing 35. Toilet Rooms 36. Handwashing Areas Garbage/Refuse 38. Outside Disposal 39. Outer Openings 40, Pesticide/Rodenticide Application Physical Facilities 41. Floors 42. Walls, Ceiling 43, Lighting 44. Ventilation 45. Dressing Rooms Other 46. Toxics 47. Premises 48. Living Areas 49. Linen 50, Pets 51, Bulk Foods 52. Salad Bars .022 .022 .023 .024 .025 .026 .027 .027 .027 .027 .031 .032 No. of 13 Critical Items Violated _ These items require immediate attention. 1. /.{ .I1:. 104 .lili.L Full Stem Descriptions Food C1 Food Source, approved, wholesome 2 Containers, properly labelled Food Protection C3 Potentially hazardous foods at proper temperatures: 140OF or above, 450F or below, OOF; rapid cooling or cooked foods within 4 hours C4 Facilities to maintain product temperature C5 Unwrapped and potentially hazardous foods not re -served 6 Damaged, spoiled, returned foods segregated 7 Food protected during storage, preparation, display, dispensing, service, transportation 8 Thermometers provided, conspicuous, accurate 9 No cross -contamination 10 Potentially hazardous foods properly thawed, cooked, and cooled 11 Food handling minimized 12 Dispensing utensils stored Personnel C13 Employees with infections restricted C14 Hands washed and clean; good hygienic practices 15 Clean clothes. hair restraints Equipment & Utensils C16 Equipment, utensils sanitized (automatic and manual methods) 17 Food contact surfaces: design, constructed, installed, maintained, located 18 Non-food contact surfaces: design, constructed, installed, maintained, located 19 Food contact surfaces clean, free of all cleansers 20 Non-food contact surfaces clean, free of all cleansers 21 Wiping cloths; clean, use restricted 22 Dish/Warewashing facilities: designed, constructed, maintained, installed, located, operated 23 Pre -flushed, scraped, soaked 24 dash/Rinse water clean, temperature 25 Accurate thermometers, chemical test kits provided; instructions posted 26 Storage, handling of clean equipment/utensils 27 Single service articles, storage, dispensing 28 No re -use of single service articles Sanitary Facilities C29 Water source; approved, hot&cold under pressure C30 Sewage and waste water dxsoosal C31 No cross -connections, back siphonage, backflow C32 Toilets & Handwashing: number, accessible, design, installed C33 No insects or rodents; harborage prevented 34 Plumbing; installed. maintained 35 Toilet rooms enclosed, self-closing doors, fixtures good repair, clean, signs 36 Handwashing areas supplied with soap and towel dispensers, proper waste receptacles 37 Garbage and refuse: containers covered, adequate number, insect/rodent resistant, frequency, clean 38 Outside area: dumpster covered. construction, clean 39 Outer openings protected 40 Pesticides and rodenticidesi proper application Physical Facilities 41 Floors constructed, maintained, clean 42 Walls, ceiling, attached equipment; constructed, maintained, clean 43 Lighting provided as required, fixtures shielded 44 Rooms and equipment vented as required 45 Dressing, looker areas provided used, clean Other C46 Toxics properly stored, labelled, used 47 Premises litter -free, unnecessary articles, cleaning maintenance equipment properly stored. Authorized personnel 48 Living/sleeping quarters and laundry separate 49 Linen properly stored 50 No pets or other live animals except guide dogs 51 Bulk foods stored, labelled, dispensed 52 Salad 'oar operations prepared, refrigerated, displayed, protected THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM HEALTH DEPARTMENT - 9 NORTH STREET, SALEM, MASS. 01970 NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS 216-95 $25.00 City of Salem Board of Health of PERMIT TO OPERATE A FOOD ESTABLISHMENT Permit No. 216-95 Feb. 22 19 95 In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws a Permit is hereby granted to: Salem Ward Eight Cafe Whose place of business is 109 Lafayette Street Type of business and any restrictions Food Service To operate a food establishment in Salem (City or Town) Permit Expires Dec. 31 19 95 Copy W If Board This Copy To Be Retained By Local —� of _ Board of Health Health MPH,RS,CHO HEAL'Hli AGENT FORM 738 Rev 1986 .. V V �ta(y1M� MAs I CITY OF SALEM HEALT" DEPARTMENT BOARD OF HEALTH _..._ Salem, Massachusetts 01970 Application for Permit to Operate a Food: Establishment Name of Establisht Business Address Date / 7 -.is— Mailing Address (if dil Name dr Title of Appli Address of Applicant Name of Owner (if different from applicant) If corporation or partnership, give name, title tit home address of offrars.or partners. Name Title Home Address a -IV State of. Name & Address Incorporation of Local Agent _ Emergency Response Person: Name Type of Establishment Fee Retail Food ❑ — Food Service ❑ — Caterer ❑ — Mobile Food* ❑ — Residential ❑ 7 12 Home Phone L492� Duration of Permit Annual ❑ Temporary ❑ Seasonal ❑ AmountTo Be Paid TOTAL: Dates of Operation if not Annual: PAYMENT IS DUE WITH APPLICATION • Applications for mobile food units or pushcarts must include a list of the handwash and toilet facilities available on each route. Attach separate sheet. Additional Information Water Source Days & Hours of Operation Sewage Disposal If Restaurant: Vii: Number of Seats Number of Non -Smoking S its Person Trained in Anti -Choking Procedures (if 25 scats oEinore).' Yes No Signature of Applicant - !+; Pursuant to M.G.L. 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 Ind paid all statc;taxes required under law. r Social Security Number or Federal Identification Number Signature of Individual or Corporate Name;: . by Corporate Officer (if applicable) FOR BOARD OF HEALTH USE ONLY Date:Reccived 1 Date Iss Approved By. . This permi.t.is.not transferable and must be reissued upon change of ownership from the ..Health Department. ._Ali improvements and equipment replacement in Food Establishment must be approved by_the Health Department prior'to installation, in accordance with the Hass.- Dept:'of- Public Health Sanitary Code, Chapter X. ... Applic4nt,s.for. Mobile Food Unit or Pushcart permits shall list the handwash and toilet"facilities available -on' each route on the back of this form. thepermit'fee -is $25.00 which may be paid by check made payable' to the City of Salem or paid in cash at the Board of Health Office. Food Establishment permits expire. on the 31st of December or one year from the date issued. Applicant Signature NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS 205-95 $2.00 .................._.utY-------..of.-------------SaLem Board of Health STORE LICENSE—MILK AND ,CREAM This is to Certify that -------- Salem--Ward--Eight--Cafe............................... NAME residing at .................................. ................ .......... ....__... ...._...._......... _................................ and having a place of business at----------- 09Lafayette. .Street in the .... C3tY... ...... of ------ Salem --------------------------------------- .......... ...........................................has been granted A LICENSE TO SELL MILK AND CREAM and is subject to the Provisions of the Laws of The Commonwealth of Massachusetts, relating thereto, and upon such terms and conditions, and to the rules and regulations established by the Board of Health, of the ......Q.ity......... of .............. .......Salem ISec . 31 19LJ5....... .... govern ing the sale of Milk and Cream and shall remain in force until xkiKAwVxdtIycx1*tmxx1Wxx,., unless previous to that time is suspended or revoke License Issued ---- _..--------- Feb .-- 22 19 9._-ObtMPH tRS o CHO HEi A Air INSPECTOR OF MILK POST THIS LICENSE IN A CONSPICUOUS PLACE /THIS LICENSE SHALL NOT BE SOLD. ASSIGNED OR TRANSFERRED. FORM 444 (j, HOB.Id WARREN'M (OVER) ROBERT E. BLENKHORN HEALTH AGENT_ (617) 741-1800 ` E h +(a1MMa CITY OF SALEM HEALTH DEPARTMENT BOARD OF HEALTH Salem, Massachusetts 01970 9 NORTH STREET Date: I -q_5,-' APPLICATION FOR LICENSE TO SELL MILK/CREAM Name of Establishment: Address/Phone Number: �U l N ��✓1LJ J� �� This license is not transferable and must be renewed annually from the :Salem Health Department, in accordance with provisions of / Chapter 94, Section 40 of the General Laws. / ✓ �� FEE: $2'00 0 per annum PLEASE PRINT WfE OF APPLICANT 10A11V T-/ 6A O06`44) NOME ADDRESSr#V(' 19OLAI R-9 Z PHONE / ! y b s� S NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS 161-94 $25.00 City of Salem Board of Health of PERMIT TO OPERATE A FOOD ESTABLISHMENT Permit No. I6i-94 March 1119 94 In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws a Permit is hereby granted to: Salem WardRight Cafe — Lonnie Thibodeau Whose place of business is 3 Ward Street (F�ood Service Type of business and any restrictions To operate a food establishment in Salem (City or Town) Permit Expires December 31 19 94 C.A.O. Copy Board This Copy To Be Retained By Local of Board of Health Health FORM 738 Rev. 1986 HEALTH AGENT OW4 V ii ... •. IIIIVV....IalaVNVNrr�� WWWWYYYY CITY OF SALEM HEALT" DEPARTMENT MAR 1 0 1994 BOARD OF +IEALTH j Salem, Massachusetts 01970 Z ' 'CITY 8F SALEM Application for Permit to Operate a. FoodF�.ctamisfiment ate IZ3 5y Name of Establishment: ""_Ko, -4-n o-�� s Business Address a)- aa f�-y Mailing Address (if different) Name a Title er Applicant_1 6 V 0 � Lr Th,U � b D g-{ Uy� '�hA2� Address of Applicant Name of Owner (d dilfuent from applicant) If eo:potaGon or partnership, give name, title g home address of offiars.or partners. Name Title Home Address i'QDiikw-cl- luta State of , . Namck Address Incorporation " of Local Agent( Emergency -Response Person: Name P^- U °' J, 136,0L""1-` ' Home Phone Type of Establishment Fee Duration of Permit AmountTo Be Paid RetarT Food um ❑ Food Service ❑ Catcrcr ❑ Temporary ❑ Mobile Food• ❑ Residential ❑ Seasonal ❑ TOTAL: Dates of Operation if not Annual: PAYMENT IS DUE WITH APPLICATION • Applications for mobile food units or pushcarts must include a list of the handwash and toilet facilities available on each route. Attach separate sheet. Additional Information Water Source Days & Hours of Operation Sewage Disposal + j If Restaurant: 11� Number of Seats Number of Non-Smoking � ats Person Trained in Anti -Choking` Procedures (if 25 uau o%'tnoc5)."'Yes No Signature of Applicant ;i;'^'rn Pursuant to MGG Ch.62C=sec.49A. I'certify underthe penrlucs of pedury that 1. to my bat knowledge and belief. have filed all state tail Ktarets'i6d paid a1[slate ltixcrrdjuii cd uadet;law. e f r Soaaf Security Number or Federal Identification Number Signature of Individual or Corporate Name— by . - Corporate Officer (if applicable) FOR BOARD OF HEALTH USE ONLY " v 1 D`ate,Reaived * D`f to potted 't '' + ' t' ie eA roved B Permit B Issued '..This.. -permit is>aot t=siisferahle�apd..,_must be reissued upon change of -ownership from the ..Health:' DeparEmeat..._.Al.l improvements and equipmentreplacemtaL in Food Establishment must.-be.-approved.by�the::Health. Department prior to installation, in`accordance with the Mass Dept -of Public Health Sanitary Code,.Chapter %. ]it s tr. Mobile. Food Unit,,or Pushcart permits shall list the handwash and toilet^ faci3ities available -on eac3t route -ors the back of this form. T6ieTjexmit'fee 'is $25.00 which may be'pa d by check made payable to the City of Salem .or :paid-ii2 cash at the Board of Health Office. Food Establishment permits expire. on the 31st of December or one year from the date issued. Applicant Signature NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS 161-94 $2.00 Cit- Salem Board of Health STORE LICENSE—MILK AND :CREAM This is to Certify that ... Salem_Ward_Eight Cafe -Lonnie T. i,bodeau. NAME residing au ....... .......................... ---- ....... .. . -.. end having a place of business at ..... 3 -_Ward -_Street in the ..... C.i.ty......... of ........SA1 em---------------------------- ------- ----------------------------------.has been granted A LICENSE TO SELL MILK AND CREAM and is subject to the provisions of the Laws of The Commonwealth of Massachusetts, relating thereto, and upon such terms and conditions, and to the rules and regulations established by the Board of Health, of the .... City .......... of .............. .------- Salem governing F December.31, 145b the sale of Milk and Cream and shall remain in force until xbw1YAxd45x75fkjtI1W4V? .... unless previous to that time is suspended or revoked -- License Issued ............ ._March 11 ...... 19_94_ -C.H.O. HE T EPELTOR OF MILK POST THIS LICENSE IN A CONSPICUOUS PLACE THIS LICENSE SHALL NOT BE SOLD, ASSIGNED OR TRANSFERRED. FORM 444H W Hosss s WM1M " (OVER) 6 ROBERT E BLEHKHORN HEALTH AGENT (617) 711-1800 ti 4iwa� CITY OF SALEM HEALTH DEPARTMENT BOARD OF HEALTH Salem, Massachusetts 01970 AY 1 0�� CITY OF SALEM REALTH DEPT. 9 NORTH STREET Date: APPLICATION FOR LICENSE TO SELL MILK/CREAM Name of Establishment: Address/Phone Number: This license is not transferable and must be renewed annually from the.'Salem Health Department, in accordance with provisions of Chapter 94, Section 40 of the General Laws. FEE: $2.00 per annum PLEASE PRINT NAME OF APPLICANT {\ I�II(� �`�` Q n J 1 HONE ADDRESS�� 0 0/jVIl; � }Sv PHONE s