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YOUNG WORLD ACADEMY - ESTABLISHMENTSy��'Iy� far i� u rd mm� 2l� UuIIeY jirti�t universal one,m www.myuniversalop.com phone: 1-800-756-4676 UNV16162 MADE IN USA --, Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street, 4th Floor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/24/2011 ESTABLISHMENT NAME: File Number: BHF -2005-000045 Kimberley Driscoll Mayor Young World Academy 24 Valley Street SALEM MA 01970 LOCATED AT: 0003 GREEN LEDGE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2011-0339 Jan 1, 2011 Dec 31, 2011 $100.00 ESTABLISHMENT Total Fees: $100.00 PERMIT EXPIRES December 31, 2011 Board of Health % � Qi vwflT This Permit isnot transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 1?)es+, A r� ICIN BERLEY DRISCOLL MAYOR DAVID GREENBAUm, RS ACTING HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 41" FLOOR TEL. (978) 741-1800 FAX (978) 745-0343 DGREENBAUMi[1�SALL'M. COM 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Young World Academy TEL# 3 Green -Ledge Street p ADDRESS OF ESTABl3SHMENT Salem,t4A 01970 F.AX# 6 79-7W--1Sc3D MAILING ADDRESS (if different) EMAIL - BuE CelrirlNO:76� ADDRESS CITY TEL# 571- ]/V "yin 7 CERTIFIED FOOD MANAGER'SNAME(S) rlri oVinwCERTIFICATE#(S)_AIV — (Required in an establishment where potentially hazardous ood is rep red) Z �S� EMERGENCY RESPONSE PERSON HOME TEL DAYS'OFOPERATION ,.'r, -Monday I?`j Tuesday_.A , .: Wednesday '�, ;.Thursday '..' x ,Fnday` Saturday,.-, HOURS OF OPERATION Please write in time of day. �j�O Pn} -1 / example 11 am-11pm) (For exa��Yy1-"I� �Am flm IOP(A / y R /11 �Oprr) ��p fm TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 ---------------------------------------------------------------------------_ ---------- RESTAURANT YES NO less than 25 seats $140 (Outdoor Stationary Food Cart $210) 25-99 seats =$280 more than 99 seats =$420 T/ YE NO ES/NURSIN-----OME------(�uL�K----- IMNALkERMITS $100 MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES NO 5 ALL NON-PROFIT (such as church kitchens) Y 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 u itted t nd approved by the Salem Board of Health. Pursuant MCS pter 62 ion 9A, I certIfy under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax velums a nai I ate�tax4 r ' er the law. 0/ —49J:3_19' otgnarur uare bocral becunty or reaeraucenttncanon N1 Revised IOnli l FOODAP2011.adm - CheckN & Date 1 1 $ �� 0&4 0003 GREEN LEDGE STREET Telephone: Owner: Arthur Theophilopoulos PIC: Kimberly Livingston Inspector: David Greenbaum Date Inspected: Correct By: 8/23/2010 Risk Level: Permit Number: BHP -2010-0132 Status: PARTIAL COMPLY # of Critical Violations: 1 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) HACCP: Young World Academy City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection 0 Item Status Violation Critical Urgency PROTECTION FROM CONTAMINATION Handwash Facilities FAIL Critical RED Comment: The hand wash sink in the pre-school kitchen has very low water pressure. Restore water pressure. The hand wash sink in the toddler kitchen is missing paper towels. Provide disposable paper towels at this hand wash sink at all times. The bathroom in the far corner of the pre-school is missing soap. Provide soap at all times. Violations Related to Good Retail Practices (Blue Items) Equipment and Utensils FAIL Non -Critical BLUE Comment: The Roper fridge/freezer needs a thorough cleaning and organizing. The oven in the pre-school needs a thorough cleaning. The Estate fridge/freezer in the toddler kitchen needs a thorough cleaning. Provide visible, accurate thermometers in both fridgelfreezer units. Properly complete the sanitizing log. City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2010 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 20,2010) Page I oj2 l RED: Violations Related to Foodborne Illness Interventions. and Risk Factors (Require immediate corrective action) Item Status Violation Critical Urgency �L-ff)LO(t) City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2010 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 20,2010 ) Page 2 oft 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: 01/05/2010 ESTABLISHMENT NAME: File Number: BHF -2005-000045 Young World Academy 24 Valley Street SALEM MA 01970 LOCATED AT: 0003 GREEN LEDGE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE 13HP-201070132 Jan 4, 2010 Dec 31, 2010 $100.00 ESTABLISHMENT Total Fees: $100.00 PERMIT EXPIRES December 31, 2010 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH -. 120 WASHINGTON STREET, 4 FLOR- TEL. (978) 741-1800 ICIMBERLEY DRISCOLL FAX (978) 745-0343 DEC -"7 2bb'9 MAYOR DGREENBAUM&ALEM. COM G r OF SALEM DAVID GREENBAUM, BOARD OF HEALTH ACTING HEALTH AGENT 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Young World Academy TEL # 2Zd -7 V 4/-S-/ Y 3 Green -Ledge street U`/ ADDRESS OF ESTABLISHMENT -, w.r ♦ t gree FAX # 97ff -7/ 7 OS3 D Salem, A 01 -nom MAILING ADDRESS (if different) t EMAIL - Business': a"hIWebsite: �/ OWNER'S NAME�t✓ 4XI ADDRESS a2 CTR TEL # 27L 7Y!Z-L �i V STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) , &MMiT CERTIFICATE#(S) 4&aU (Required in an establishment where potentially hazardous foo is prepared 2 d0 h� wePw�- 070 Cf7 u r1 ql_. EMERGENCY RESPONSE PERSON (lliZur� 05 -FOcd ) HOME TEL# X— ®AYS®F OPERp71QN s$IMondayj�Tuesd`ay$�, Wetlnestlay' ;,ThGrsday: ' ?�Fnday Sattlrday Sunda`* - Y HOURS OF OPERATION Please write in time of day. '//y / 7, G ! 7.4r0ml `% //� / h1 i � �(Q + 1 For example 11am-N //{/!j !� - t /; vi fn TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than I0,000sq.ft. =$420 ------------------------- --------- ---------------..-------------------------------------- -5---------------------------- -- RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart $210) 25-99 seats =$280 more than 99 seats =$420 -- - -- - -- ------------------------------�-. -----N ----------------------------------------------------------------------------------------- ------- BED/BREAKFAST/ < aYEV NO , - $100 AUUl I IUNAL PhKMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES $135 ALL NON-PROFIT (such as church kitchens) YES O $25 Y '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 G s(hap8te 2 --7 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 a iA / es.te4ui> under the I� . 0 /— DD -3 ! J Oi. 0 Revised 424/07 FOODAP2008.adm Check# & Date Social Security or Federal Identification Number id SENT 8V: 1 978 744 0530; JUN -10-09 6:53PM; PAGE 1/1 Pest Control Service Agreement B & B PEST CONTROL 271 Weallem Avenue, Suite 203 LYNN. MAS SAC14US " 01904 (781) 504217 GY:i1pEP . . /r t ufv. Bl�TE aa>a �. .'�.—�• _, Plx80x 10 BE fhNtPCI BhrP'iLE MH.M( i SA L -i AA OA A A -� �. rw OY PPWaryh MBE SEIrw:Y✓ / � fxPxMYkgl Aee PFMEWN ... BFw¢E re BF YEuawreti.._�.. tJ - 04 Zvo, --.C'y ,✓ _ O I I NtoNTNLY I, I GUilfwewY ❑ f)Tt1Et1 jZ.EMEr"TS _ Ftul n4lign:rPx.y .---- _.,_,.... .� � •.. �•.�— —_. �•c.•.... ._.._,_.. A_-_,�-___,.___ -. .►�..--CY-- /.fY vt 2..-O �.,.ar.�e eH' vMd•✓el� . .• • SERVICE GUARAN'T'EE: We agree to apply Chemicals to control at) nua.namad pests In accordance with terms and conditions of this Service Agreement All tabor and materials will be furnished to provide the mast efficient pest control and maximum safety required by federal• stale and City regulations. SERVICE RENEWAL: This agreement shall be for an initial period a one year, and will renew Itself annually union elther party cancels this agreement by giving thirty days written notice before any expiration date. ANNUAL AGREEMENT CHARGE Po INITIAL SERVICE CHARGE �5--- .-----�� NY W lilZEB r OATE MONTHLY/ClUARTERLY PAYMENTS $ _ 3� uExp FOR CUSTOMER OAYe_....... ___... --------- --- ______ a' —:�-..�_.-_:......�_ —._ .. 1„:--s ' .SA.. `�X'�.• --._. _..,.V.7.d1_..e_ __.-_ l D i/4 lE1•.Q. ;,� CJ IMPORTANT MESSAGE FOR j—Ll PLEASE CALL DATE ii ll M 11 !� TIME `P'�y pN,-fl 4cA � tiG1 PHONE - AREA CODE 0 FAX LI MOBILE NUMBER EXTENSION AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WANTS TO SEE YOU RETURNED YOUR CALL '. WILL CALL AGAIN RUSH WILL FAX X, T6 YOU - SIGNED IOC FORM 4008 �� ■■■YY��TT��7777 MARE IN U.S.A. 0003 GREEN LEDGE STREET Telephone: a Owner: Arthur Theophilopoulos PIC: .Kimberly Livingston Inspector: Elizabeth Salandrea V Date Inspected: Correct By: 5/13/2009 Risk Level:. Permit Number: BHP -2009-0013 Status: SIGNED OFF 1#of Critical Violations , 2 :i (a Time IN: Time�CUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Criticalr violations must be corrected Ilmmediately or within 10 hbdays)(Non-critical violations must be corrected immediately. or within 90 days) I----1--- HACCP: Young World Academy City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection ■❑ Item Status Violation Critical Urgency PROTECTION FROM CONTAMINATION Handwash Facilities FAIL Critical RED Comment: Handwash sink in baby room at 96.4°F, and kitchen sink in baby room was at 96.2°F at time of inspection. Turn hot water up immediately to minimum of 110°F. Violations Related to Good Retail Practices (Blue Items) Food and Food Protection FAIL Critical BLUE Comment: Employee items stored in fridges/freezers in both kitchens. Store employee items separately to prevent cross contamination. Equipment and Utensils FAIL Non -Critical BLUE Comment: Oven in preschool kitchen needs thorough cleaning. Fridge in preschool kitchen missing thermometer. Provide visible, accurate internal thermometer for the fridge. Physical Facility FAIL Non -Critical Comment: Baby room has several stained ceiling tiles. Investigate for leaks and replace all stained tiles. Please forward last 3 months' extermination receipts to the Board of Health within one week. City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741.1800 BLUE GeOTMS® 2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 15,2009 ) Page I oft RED: t' ,Violations Related ,to,!-,' ,Foodborne Illness.Interventions and Risk Factors`(Repuire'" !immediate corrective action) r Item Status Violation Critical Urgency City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 15,2009 ) Page 2 oft Commonwealth of Massachusetts V10 City of Salem Board of Health Kimberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/18/2008 ESTABLISHMENT NAME: File Number: BHF -2005-000045 LOCATED AT: Young World Academy 24 Valley Street SALEM MA 01970 0003 GREEN LEDGE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2009-0013 Dec 18, 2008 Dec 31, 2009 $100.00 ESTABLISHMENT PERMIT EXPIRES Total Fees: $100.00 This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 K OERLEY DRISCOLL MAYOR JANET DIONNE, ACTING HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4"' FLOOR TEL. (978) 741-1800 -._.I� x—�"'° r qn, ED FAx (978) 745-0343 a `'l it li✓ 3 ti9 IDIONNE SALEM. COM DEC - 8 2008 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME F ESTABLISHENT ADDREOSS OF ESTABLISHMENT—� 5 w0(9"1pPfi/t'd �� 5�lPE FAX It 9%, �7 y- oss�,' MAILING ADDRESS (if different) Ja EMAIL - Business': OWNER'S NAME rfhi/r �2f)Dhl ADDRESS STREET Website: CITY TEL # CERTIFIED FOOD MANAGER'S NAME(S) -,�) Ia CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL DAYS OF OPERATION Monda .i:,,�Y.30esday,.Wednesda Thursday:.-, ? Fiida Saturda Sunda Y HOURS OF OPERATION/ Please write in time of day. . rlArll- G Dm %A�YJ-(��7»"I ! 70" 6po %(I1-�%)YI1 (For example I1am-11pm) i TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YESNO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 -- --- ------ - - - ----- le ss than 25 seats $140 (Outdoor Stationary Food Cart $210) 25-99 seats =$280 more than 99 seats =$420 BEDBREAA---------------- ------- ------------------------------------------------------------------------------------------ --$- 00 CHILDCARE SERVICES ADDITIONAL PERMITS - ---------- MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT (such as church kitchens) YES NO $25 Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid afl state taxes re pui;ed under the law. Signature j Date sJ�o Social Security or Federal Identification Number Revised 424/07 FOODAPjt108.adm 1wZJ&Datef!' /'7 /ira /J�/� $ D J .�-.•1 2 C�� '] j1 '^ n %_NT BY: 1 978 744 0530; JUN -13-08 8:30PM; PAGE 2/2 Pest Control Service Agreement B & B PEST CONTROL j; 271 Westiiim Amenue, Suits 203 LMN, MASSACHUSETTS 01W4 9158 (781) 599-4317 0 RISFET Young Wbrld 3 Green -Ledge Street Y. STITE . 71P OIrIE Fj VIIONE F PADPEMY nM WWCED 7 .. .............. //�_ -AONTHLY 0 QUARTERLY 0 GTJJEFI : evefr A.' .......... SEnVICF GUARANTEE: We agree to &PPIY cha"'i"Iti to control above-named pests in accordance with terms and conditions of this Service Agreement. All labor and materials will be furnished to provide the most efficient post control and mammurn safety required by federal, stala and city regulations. SEHVICE RENEWAL; This agreement shall be for an Initial period of one year, and will renew Itself annually unless either party cancels this agreement by giving thirty days written notice before any expiraffar! dale. ANNUAL AGREFMENT CHARGE By INITIAL SERVICE CHARGE $ Com Ia,�.ZD ATE MONTHLY/QUARTERLY PAYMENTS $ Fon I CUSIOMER—_, DAIJ. --------------- I ------------- $ 7 Young world Acae 3 Green -hedge Sr. 1 �; CLgin MA r01c'' a NTI ZA k a n a g a o -- B & B PEST CONTROL m 271 Western Avenue, Suite 203 o LYNN, MASSACHUSETTS 01904 co (791) 599.4317 i3 oo, ❑ MM ❑ IMM ❑ Ret ❑ =K ❑ aeaaa ❑ OMMR o co v em,ar o v �1CINCYI Com" 13 8 & B PEST CONTROL P.O. Sm 8077 j LYNN. MASSACHUSETTS 01904 (731) S99-4317 w our Tw ❑ REB. 1] cowl ❑ NMI o =caa t i i 2 raTA< 9gI4NflE SERVICE REPORT 09184 SERVICE REPORT 7145 YPW 0003 GREEN LEDGE STREET Young World Academy City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection Status: SIGNED OFF I# of Critical Violations: �1 Time IN: Time OUT: Urgency Description(s) BLUE: Owner to fax last 3 months' extermination receipts to Board of Health within one week. Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations :must be corrected immediately or within 90 days) i City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 22,2008 ) Page 1 oft HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION Handwash Facilities FAIL Critical ❑d RED Owner: Comment: Sink in kitchen in toddler room missing paper towels. Provide paper towels at all sinks at all times. Arthur Theophilopoulos' - Violations Related to Good Retail Practices (Blue Items) PIC: Equipment and Utensils FAIL Non -Critical BLUE Kimberly Livingston Comment: Toaster and microwave in preschool kitchen need general cleaning. Inspector: Freezer in preschool kitchen needs visible, accurate internal thermometer. Elizabeth Salandrea )ate Inspected: Correct By: Fridge in toddler kitchen needs visible, accurate internal thermometer. 5/21/2008 Physical Facility FAIL Non -Critical BLUE Risk Level: Comment: 1 ceiling the missing in toddler kitchen - replace tile. There are some water stained ceiling tiles in toddler room - replace stained tiles. Permit Number: Status: SIGNED OFF I# of Critical Violations: �1 Time IN: Time OUT: Urgency Description(s) BLUE: Owner to fax last 3 months' extermination receipts to Board of Health within one week. Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations :must be corrected immediately or within 90 days) i City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 22,2008 ) Page 1 oft lrr Item RED—:-- Violations ED:mViolations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) Status Violation Critical Urgency K 4 o Lw� � City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 22,2008) Page 2 oft 1 - t Commonwealth of Massachusetts City of Salem Board of Health lGmberiey Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2008 ESTABLISHMENT NAME: File Number: BHF -2005-000045 LOCATED AT: Young World Academy 24 Valley Street SALEM MA 01970 0003 GREEN LEDGE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2008-0168 Jan 3, 2008 Dec 31, 2008 $100.00 ESTABLISHMENT Total Fees: $100.00 PERMIT EXPIRES December 31, 2008 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 9 of 9 KIMBERLEY DRISOOLL MAYOR JOANNE SOOTT, HEALTH AGENT QTY OF SALEM, MASSACEiUSEM BOARD OF HEALTH 120 WASHINGTON STREET, 4- FLOOR TEL. (978) 741-1800 FAx (978) 745-0343 1sooma)SALEM.00M RE Pa{ � ?L DEC 3 - 2007 CfFi O� ti BOARD CA- n r 1 H 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT G i �///Il�GO TEL# ��-�y-�/s ADDRESS OF ESTABLISHMENT ZO SBM—L.eCLG� S- — FAX # MAILING ADDRESS (if different) EMAIL - Business': OWNER'S AD Website: CERTIFIED FOOD MANAGERS NAME(S) fjll�, gVlnr6 (Required in an establishment where potentially hazardous food is prep ed) CERTIFICATE#(S) ON A/o Ghare>,rn EMERGENCY RESPONSE PERSON HOME TEL # y Pl�asewOFOmeof RAdTION t0 (For example 11am-11 pm) /'� / ` Y /—'(' -7r %r(li TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES O less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than I0,000sq.ft. =$420 RCS l iil� CAIJT YES less than 25 seats =$140 (Outdoor Stationary Food Cart $210) - ,. 25-99 seats =$280 more than 99 seats =$420 . - - k --� --- ------------------ - -- ----- BEDIBREAKFAST/ YE - _ ----------------------------------------------------------------------- NO - - -- .100 CHILDCARE SERVICES.--_-_-------__._-. ---------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES$25 TOBACCO VENDOR YES O $135 ALL NON-PROFIT (such as church kitchens) YES $25 'Please pay total with one check payable to the City.of-Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. .. . In accordance with the State Sanitary Code, before-ariy renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. PursuanttditlGIL Chapter 2C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have fled all state tax returns nd f, 6I state xes required under the law. Date Revised 4/24/07 FOODA P2008.adm Check#& Security or Federal Identification Number 1—/0019d ry 0003 GREEN LEDGE STREET Young World Academy City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Permit Number: BHP -2007-0133 Status: SIGNED OFF # of Critical Violations: 2 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) Comment: There are water stained ceiling tiles in the infant side. Investigate the source of the leak and repair. Replace all stained tiles. City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 17,2007 ) Page I oft Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION Food Contact Surfaces Cleaning and Sanitizing FAIL Critical RED Owner: Comment: The dishwasher in the infant side not working. Repair dishwasher to good working order. Arthur Theophilopoulos Handwash Facilities FAIL Critical ❑d RED PIC: Arthur Theoiphilopoulos Comment: The left restroom in the pre-school side is missing soap. Provide soap in the restrrom at all times. �� Inspector: Violations Related to Good Retail Practices (Blue Items) David Greenbaum Equipment and Utensils FAIL Non -Critical BLUE Date Inspected: Correct By: Comment: The microwaves in both kitchens need a general cleaning. 4/17/2007 � The refrigerator in the infant side needs a general cleaning. Risk Level: Physical Facility FAIL Non -Critical BLUE Permit Number: BHP -2007-0133 Status: SIGNED OFF # of Critical Violations: 2 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) Comment: There are water stained ceiling tiles in the infant side. Investigate the source of the leak and repair. Replace all stained tiles. City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 17,2007 ) Page I oft NO Item RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) Status Violation Critical Urgency 414 �-d IL City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 17,2007) Page 2 oft PORTABLE SINK INFORMATION Please note : This information is from 2005 .... there may be other sites available on the Web. According to Standard #5.06 in Caring For Our Children, the National Health and Safety Performance Standards; "When plumbing is unavailable to provide a handwashing sink, the facility shall provide a handwashing sink using a portable water supply and a sanitary catch system approved by a local public health department. A mechanism shall be in place to prevent children from gaining access to soiled water or more than one child from washing in the same water. " No barrier (gloves) or chemical substitute (sanitizes solutions) is as effective as running water. The point of handwashing is defeated if children can gain access to the soiled water. Hand sanitizers do not substitute for handwashing. Some suppliers of portable toilets provide a variety of portable sinks. All require filling a container with a source of potable water that flows by gravity or by pumping action during use. All require emptying the catch container into a sanitary system. A large water container with a faucet can be combined with a catch container that is covered with a firmly attached grill to prevent children from getting into the contaminated water. Children must not wash in a communal basin because those who wash in the same water share contamination. A portable handwashing sink should only be considered when all other viable attempts foe installing a traditional sink have been exhausted. Two companies that make portable sinks are http://www.nuconcepts.corn/and http://www.portablesink.com/index.html Be sure to look for a model (teacher -sized vs. child -sized) that meets your program needs. As always, it is essential that child care providers check with OCCS licensers and local Board of Health and other inspectional services staff before making a financial commitment. FOR o=4 riiv L� I PLEASE CALL CAME TO SEE YOU WANTS TO SEE YOU A.M. DATE TIME —6t P.M. CYYlO WILL FAX TO YOU M O 1U OF Ce %� &513 PHONE AREA CODE NUMBER E%TENBION ❑ FAX ❑ MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED I PLEASE CALL CAME TO SEE YOU WANTS TO SEE YOU WILL CALL AGAIN RUSH: RETURNED YOUR CALL `. WILL FAX TO YOU ► • ="-�l 1 _ SIGNED W ®®". MAADE IN U�S..A. 8/2/06 In response to a complaint regarding odors and the service of expired milk an inspection was conducted at Young World Academy. At this time there are no odors and milk was found to have expiration dates of 8/5/06 and 8/13/06. No health code violations of this nature noted at this time. SENT BY: ; M Exterminators Corporate Offices 183 Shepard Street . Lynn, MA 01902 (781) 592-2731 (800) 525 -4625 - Fax (781) 592-7641 25-4625Fax(781)592-7641 1 978 744 0530; JUN -15.06 9:39PM; PAGE 1/1 Cape Cod 72 -Main S=t, Suite x7 W. Harwich, MA 02671 (508) 432-5866 (000) *99-5666- . Fax (508) 432-5299 New Hampshire 572 Scum Broadway Salem, NH 03D79 (603) 593-8099 1800)525-4825 Fax (6031890-3761 e -malt AthNoo Al Exle(minators.com Commercial, Industrial Pest Control Service Agreement � Date: :3 'Zi -06 casromer�G a (t)N 1 CagS p1J Tel. d 9V -tell - d�g 5 Address . r iF41CA Li 4( S}' . . Fax e -mar. city!jr.Irtn State 4,P% Zipcoda UI Sip Service- information and Location Customer Address Fax _....-..„..,,_ e -mall Gly State lip bode 1J Multiple Locetrclre nt) y4 WL-,. 0446S. Control. Th a Is for control d the following.. posts:_ •�" �2 / - . ( ) Roaches ( -Ants ( ) Rare ( ) Mice ( ) --Other 'Does not in, arpen ts. Pharoah Ants. " Does not include Termites, Wood Boring Insects or Flying "acts unless specifically mentioned... Special Insinuations: Service Schedule: A-1 Exlorminallote wlilpr Ide intensive service and will also provide Regular Pest control Services: ( rlI month- ( 2xmonth-( }wcoldy.- Exterior Rodent Control: ( ) lx month ( ) 2x month ( ) weekly. Exlerlor Matter Control: ( ) lx month (- ).2c month ( ). weakty- Bird Control: ( ) lx month ( ) 2x month ( ) weekly. payment: In consideration of me wires provided by A•1 -Exterminators, Shecustomeragrees-to pay A•1Exterminatorsits successors or 71wf •. j ti•S.: 4/1 c%rsriotl&s,. 6./1s�.ax.s� a upon receipt of invoice. r( oc AtAo rate fully with A-1 Exterminators- Whenever conditions Conduolvo to the this.COMICLare reported. in writing by A-1 Exterminalois to thecustomer,. me tined such conditions. slot& Is not respari&b e. Inn arty 04stness disruption or damage caused by- Insect& rises or its contents, and the customer specifically releases Ad Exterminators promptly provide, additional Service between regularly scheduled-viafis-es olicatlon of pesticldes.for the control of the above_ mentionedpests:- accordance with Federal and State requirements. and EPA and USDA standards. OM to Federal; State %no lot* laws and-reguletians. X I eOWMMatm railoves the . - nght to re-erdor the customs($ premises and remove any chemicals including rodent and insect baits upon termination of this agreement. Fifultil"M and Products: The customer agrees to pay_A-1 Exlermumlom far any equipment instated or placed on.lhe-customer s property necessary for the control of the above mentioned pests. Insurance: Upon Request A-1 Exterminators will furnish to the customer a certificate of insurance showing covmggo in affect. Terms of Contract: • This contract shall be effective for an original period of one year. Thereafter, this contract shall renew itself from month to month until mmvnatan-hY crown many upma lhirly tlays wrxten-notice'. Rate subject torperlodic review and increase by A•1'Exmminatorc aharinitief 12 month period. • The customer further agrees to additionally pay for any equipment or produces ordered or Installed on the customer's promisee as determined to be necessary by A-1 Exterminators far the control of Ne. abolie�mentbnedpests._ Such heme.mary-InrJude,.but not be Unsterile the foflowing:. Belt Stallions, Glue Traps, Multiple Ketch haps, fly spray. etc. A•1 Tire.... Accepted _ Date: '06 r 0003 GREEN LEDGE STREET Telephone:, _ Status Violation Critical Urgency FOOD PROTECTION MANAGEMENT Owner fq PASS ❑d RED Arthur Theophilopoulos RED PIC _" _ PASS PASS Kimberly LivingstonW RED Inspector:- L John Gehan Date = Correct By i 16$A ti% 5 PASS Risk Level: - RED Receiving/Condition PASS Permit Number RED 13HP-2006-0288° PASS Status _ m' RED ,Open n m PASS # of Critical Violations: .. � '1 t F Time IN: 4L% Time OUT Urgency Description(s) BLUE' a x Violations Related to Good '> Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non=critical violations s must be corrected immediately or within 90 days) ` = Young World Academy City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency FOOD PROTECTION MANAGEMENT PIC Assigned / Knowledgeable / Duties PASS ❑d RED Non-compliance with: RED Anti -Choking Tobacco PASS PASS EMPLOYEE HEALTH Reporting of Diseases by Food Employee and PIC PASS RED Personnel with Infections Restricted/Excluded PASS RED FOOD FROM APPROVED SOURCE Food and Water from Approved Source PASS RED Receiving/Condition PASS 0 RED Tags/Records/Accuracy of Ingredient Statements PASS ❑d RED Conformance with Approved Procedures/HACCP Plans PASS ❑J RED City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS& 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 14,2006 ) Page 1 of Item RED: PROTECTION FROM CONTAMINATION Violations Related to Separation/ Segregation/ Protection Foodborne Illness Interventions PASS and Risk Factors (Require Food Contact Surfaces Cleaning and Sanitizing immediate corrective action) PASS Proper Adequate Handwashing Good Hygienic Practices Prevention of Contamination from Hands Status Violation PASS PASS PASS PASS PASS Critical Urgency L RED V RED ❑J RED Q RED /❑ RED HandwashhFacilities FAIL Critical ❑ RED ✓Coomments: No paper towels or dispenser in preschool kitchen area. Provide dispenser and towels. WJall dispenser for soap off of wall in preschool kitchen. Replace or repair soap dispenser to working order. Preschool - childrens handwash sink missing paper towel dispenser and towels. Provide towels in dispenser. Childrens handwash sink had no hot water at time of inspection. Provide hot water at all times. Qildrens hand wash sink had no soap or soap dispenser. Provide dispenser with soap. LI-A—ursery bathrooms missing wall hung soap dispensers. Provide soap dispensers. per towel dispensers needed in both preschool bathrooms. Provide dispensers. PROTECTION FROM CHEMICALS Approved Food or Color Additives PASS�/❑ RED Toxic Chemicals PASS RED TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods) Cooking Temperatures PASS RED Reheating PASS RED Cooling PASS ❑o RED Hot and Cold Holding PASS ❑d RED Time As a Public Health Control PASS ❑Q RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) Food and Food Preparation for HSP PASS RED City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeOTMS® 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 14,2006 ) Page 2 of Item Status Violation Critical Urgency CONSUMER ADVISORY Posting of Consumer Advisories PASSd❑ RED Violations Related to Good Retail Practices (Blue Items) Food and Food Protection PASS BLUE Equipment and Utensils FAIL Non -Critical BLUE Comments: General cleaning of microwave on preschool side required. t,�neral cleaning of toaster oven required on preshool side. --�Saamtizer log on preschool side not up to date. Log should be maintained daily and accurately. V<visible thermometer in nursery refrigerator and freezer. Provide visible and accurate thermometer. "nursery microwave requires general cleaning. Water, Plumbing and Waste PASS BLUE Physical Facility PASS BLUE Management and Personnel PASS BLUE Poisonous or Toxic Materials PASS BLUE Special Requirements PASS BLUE Other- See Notes PASS BLUE GENERAL COMMENTS: 646:Owner must provide a monthly extermination crontract with a licensed pest control operator. Reinspection in one week, all violations to be corrected. �P(Y� �� City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 14,2006 ) Page 3 of 0003 GREEN LEDGE STREET Telephone: Owner: Arthur Theophilopoulos PIC: Inspector. T' David Greenbaum Date Inspected: Correct By: 4/6/2006 Risk Level: - a Permit Number BHP -2006-0288 Status: SIGNED OFF # of Critical Violations: 0 ,Time IN: Time OUT: Urgency Description(s): BLUE:' Violations Related to Good; Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) Young World Academy City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency FOOD PROTECTION MANAGEMENT PIC Assigned / Knowledgeable / Duties PASS RED Non-compliance with: Anti -Choking PASS Tobacco J_1*D EMPLOYEE HEALTH Reporting of Diseases by Food Employee and PIC PASS ❑d RED Personnel with Infections Restricted/Excluded PASS W RED FOOD FROM APPROVED SOURCE Food and Water from Approved Source _ PASS RED Receiving/Condition Tags/Records/Accuracy of Ingredient Statements Conformance with Approved Procedures/HACCP Plans PASS ❑�/ RED PASS ❑d RED PASS RED City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS@ 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 10,2006) Page 1 of Item Status Violation Critical Urgency RED: PROTECTION FROM CONTAMINATION 0 Violations Related to Separation/ Segregation/ Protection PASS ❑J RED Foodborne Illness Interventions RED Handwash Facilities and Risk Factors (Require Food Contact Surfaces Cleaning and Sanitizing PASS - RED immediate corrective action) Proper Adequate Handwashing PASS ❑J RED Good Hygienic Practices PASS 0 RED Prevention of Contamination from Hands PASS RED Handwash Facilities PASS 0 RED PROTECTION FROM CHEMICALS Approved Food or Color Additives PASS 0 RED Toxic Chemicals PASS RED TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods) Cooking Temperatures PASS 0 RED Reheating PASS 0 RED Cooling PASS 0 RED Hot and Cold Holding PASS RED Time As a Public Health Control PASS 0 RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) Food and Food Preparation for HSP PASS ❑d RED CONSUMER ADVISORY Posting of Consumer Advisories PASS RED City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeOTMS® 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 10,2006) Page 2 of ti Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and Food Protection PASS BLUE Equipment and Utensils PASS BLUE Water, Plumbing and Waste PASS BLUE Physical Facility PASS BLUE Management and Personnel PASS BLUE Poisonous or Toxic Materials PASS BLUE Special Requirements PASS BLUE Other- See Notes PASS BLUE GENERAL COMMENTS: 555:Provide visible accurate thermometers in the refrigerator/freezer unit. There is no hot water at the handwash sink in one class room. Restore hot water. Install wall hung soap and paper towel dispensers at all handwash sinks and restrooms. Please contact the Board of Health for final inspection. City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 10,2006 ) Page 3 of CITY OF SALEM BOARD OF HEALTH Name of Establishment: Young World Academy: Pre-school area Address: 3 Green Ledge Street Owner(s): Arthur Theophilopoulos Phone: 978-744-7965 Date: January 3, 2006 The owner of this establishment presented a Floor Plan and Menu for review in accordance with the State Food Code. This establishment is a childcare facility with a small food prep area to store prepackaged items such as crackers, cookies precut/prewashed vegetables, etc. All equipment and utensils are one use only. Any change in the menu or floor plan must be approved by the Board of Health. FOOD PREP A Hand Sink will be located in the prep area. Hand sinks must have wall hung soap and paper towel dispensers. These must be stocked at all times. Hand sinks must be used for hand washing only. Another sink for general purposes will be located in the food prep area. All floors, walls, and ceilings where food, utensils, paper products, etc, are stored, prepared or served must be intact, impervious, and easily cleanable. There may be no bare hand contact of ready -to -eat foods. Gloves, tongs, or tissues must be used when handling such food. CERTIFICATION Kimberly Livingston is the Certified Food Manager. FLOORS and WALLS Flpors and wa s in the food prep area must be smooth, impervious and easily cle nable. � TRASH A compacter is used for this and the other Young World facility. RESTROOMS Restrooms must have a sign stating that employees must wash their hands before returning to work. Restrooms must be clean and sanitary. The woman's room must have a covered receptacle. EXTERMINATION Monthly services of a Licensed Pest Control Operator are required. Please keep receipts for inspections. SANITIZING SOLUTION Sanitizing Solution must be accessible in the food prep area and for the childrens' tables. Test strips corresponding to the kind of sanitizer, must be on hand to check concentration of solution. Solution must be made daily, tested, and the results recorded on a log sheet for examination by Board of Health inspectors. Solution may be prepared in the sink and spray bottles may be filled there. Spray bottles with clean paper towels may be used, as well as wiping pails with wiping clothes always held in the solution in the pail. j2je, �e % YC — I— 3 -06 ooanne acou Health Agent Date IMPORTANT MESSAGE FOR ❑ FAX ❑ MOBILE AREA CODE l"UMBER TIME TO CALL TELEPHONED PLEASE GALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH - ---- RETURNED YOUR CALL WILL FAX TO YOU MESSAGE SIGNED FORM MADE IN p zo I m CD ' I p IMPORTANT MESSAGE DATE ��TIME M OF Qui DHON VU AREA CODE NUMBER EXTENSION ❑ FAX ❑ MOBILE AREA CODE NI,JMEER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL GALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU SIGNED rY` FORM 4009 1_. � MADE IN U.S.A. 0 M. ,i i cn FOR A.M. TIME P.M. PHONE RnEA CODE /� NUMBER EXTENSION ❑ FAX ❑MOBILE E 5-490L L � 7kow AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL F TO OU SIGNED FORM 4009 1�1 I• MADE IN U.S.A. z 0 m 117:141Dog RI m01171 Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street, 4th Floor SALEM, MA 01970 Food/Retail Establishment Permit UIILISWIIIb1 WHO'S PLACE OF BUSINESS IS File Number: BHF -2005-0045 Young World Academy 24 Valley Street SALEM MA 01970 LOCATED AT: 0003 GREEN LEDGE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2006-0288 Jan 4, 2006 Dec 31, 2006 $100.00 ESTABLISHMENT Total Fees: $100.00 PERMIT EXPIRES December 31, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 17 of 20 STANLEY J. USOVICZ, JR. MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAx 978-745-0343 W W W.SALEM.COM JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT o qEC 1 .2005, CITY OF SALEM BOARD OF HEALTH 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT YOUIV& (6bi? b AC4De�f2 V TEL # 978 7LIS"IOTJCI / ADDRESS OF ESTABLISHMENT c3 (9R&C-1( Lj�D9' 6 S1T- MIAILINGADDRESS(if different) %Ylii OWNER'S NAME AR-MUlZ "'r}r-4pPl4ii—OPOUL-DS TEL #,w-g�?7c/ ADDRESS o2 V Ct 1) e/4- <S CITY S Ito, 14 V STATE ZM ZIP CERTIFIED FOOD MANAGER'S NAME(S) Ktm LL%Siar1 CERTIFICAT #(s) 7yAAh 11qv (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME TEL # HOURS OF OPERATION: Mon. Tue. Wed. Thu. Fri. Sat. Sun. PEO STABLISHMENT 07 YES NO ..... ..... ............................ ..... RESTAURANT YES NO FEE (check only) less than 1000sq.ft.. == 25$ 50 1000-10,000sq.ft. more than 10,000sq.ft. 0 ....................................................... .................... less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 .............16--------------...-----------...------.........------------------------------------ BED/BREAKFAST YES NO - -- -----------...-- $100 - -----------------------------------------------------------------------------....------...------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE TOBACCO VENDOR YES YES NO NO $5 50 LL NON -PROS( (suM C church kitchens=_ YES NO $25 *Please pay total with one check payable to the City of Salem . This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowleAe„gnd belief, tyave filed pll state tax returns and paid all state taxes required under the law. or Number ------------------------------------------------------------------------------------------------------------------------------------- Revised 11/03/05 FOODAP2.adm Check# & Date -qb96 /. ZOO,$r Sly STANLEY J. USOVICZ, JR. MAYOR December 21, 2005 Arthur Theophilopoulos Young World Academy 3 Green Ledge Street Salem, MA 01970 Dear Mr. Theophilopoulos, CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAx 978-745-0343 W W W.SALEM.COM JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT The City of Salem Water Department has notified us that your water service has been restored and payments have been received. Therefore, all food operations at Young World Academy, 3 Green Ledge Street, Salem, Massachusetts are approved to resume effective December 20, 2005. S' erely, �anne Scott Health Agent Rt C .Bt,'F t') / ' l l 'o iU 62 ?V2 C.c, 12:15 P.1P(— DECEMBER::21, 2005 �l STANLEY J. USOVICZ, JR. MAYOR December 19, 2005 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 W W W.SALEM.COM JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT Arthur Theophilopoulos Young World Academy 3 Green Ledge Street Salem, MA 01970 Dear Mr. Theophilopoulos: The City of Salem Water Department has notified us that your water service has been shut off. Lack of water service to your establishment creates an imminent health hazard requiring immediate suspension of the food establishment permit. Therefore, all food operations at Young World Academy, 3 Green Ledge Street, Salem, Massachusetts, shall immediately cease and desist. This emergency closure shall be in effect until the Salem Water Department notifies the Board of Health that water service has been restored. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health, 120 Washington Street, 4`h Floor, within ten days of receipt of this Order. At said hearing, you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports, orders, and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. Sincerely, //Joanne Scott Health Agent / r/l -1Z, .A,, 4 7L"Pj�/c/Dav/v� /-� n) A C o S(� yfd /_-io Z>, "A "ZIA. Wow ACAD6-t BerATI 04 h-, � � r z f PHONE: P.O. Boi 2280,4747 Crestwood Drive, Waterloo, Iowa 50704 (319) 296-2987 FAX: 1-319-296-2315 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 W; orr- i 0, 1 41;20+ 16 17 MIA WO a, d, J AIT U 3 a 0 Lo C t -xn Ll IMPORTANT MESSAGE ' cP FOR - DATE_/;4)2 TIME.L` M Aze4e� OF PHONE AREA CODE NUMBER EXTENSION ❑ FAX ❑ MOBILE AREA CODE NUMBER TIME TO CAUL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEEYOU RUSH R ETURNEO YOUR CALL WILL FAX TO YOU 4mops. FORM MADE IN 0 !,Illi) i 'Ilii I� gill l �� it I'� I u CITY OF SALEM9 MASSACHUSETTS DEPARTMENT OF PUBLIC SERVICES 4 120 WASHINGTON STREET, 4TH FLOOR O' SALEM, MASSACHUSETTS 01970 �pMM6 BRUCE D. THIBODEAU, P.E. DIRECTOR OF PUBLIC SERVICES/CITY ENGINEER STANLEY J. USOVICZ, JR. TEL: 978-745-9595 EXT. 321 MAYOR FAX: 978-745-0349 TO: Joanne Scott, �Dir. �Of Public Health FROM: Raeleen Parro%%t ub. Services Business Manager/Water Registrar ,�U DATE: December 19, 2005 RE: Water Shut off at Young World Nursery, 3 Green Ledge St. and Water Shut off at Derby Fish and Lobster, 215 Derby Street Please know that water services have been terminated today and approximated 10:30 am. at the two above listed locations for non payment of past due water and sewer charges. It is the department's intention to restore water services to these locations as soon as the charges are collected. I will keep you informed of the status of these businesses as soon as payment has been made. Thank you for your services and support. STANLEY J. USOVICZ, JR. MAYOR December 19, 2005 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAx 978-745-0343 W W W.SALEM.COM JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT Arthur Theophilopoulos Young World Academy 3 Green Ledge Street Salem, MA 01970 Dear Mr. Theophilopoulos: The City of Salem Water Department has notified us that your water service has been shut off. Lack of water service to your establishment creates an imminent health hazard requiring immediate suspension of the food establishment permit. Therefore, all food operations at Young World Academy, 3 Green Ledge Street, Salem, Massachusetts, shall immediately cease and desist. This emergency closure shall be in effect until the Salem Water Department notifies the Board of Health that water service has been restored. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health, 120 Washington Street, 4`h Floor, within ten days of receipt of this Order. At said hearing, you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports, orders, and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. Sincerely, _ Jo��/`�-� cott Health Agent X52 rr7cf /'7 A"j &,Lf AY ib ✓r 7�zIf'7 /L/POv/OS ) /-� /10 on /:7-/9.05. CITY OF SALEM BOARD OF HEALTH Name of Establishment: Young World Academy Address: 3 Green Ledge Street Owner(s): Arthur Theophilopoulos Phone: 978-744-7965 Date: October 6, 2005 The owner of this establishment presented a Floor Plan and Menu for review in accordance with the State Food Code. This establishment is a childcare facility with a small food prep area to store prepackaged items such as crackers, cookies precut/prewashed vegetables, etc. In addition, formula is added to bottled water. The bottles are returned to the parents for washing. All equipment and utensils are one use only, Any change in the menu or floor plan must be approved by the Board of Health. Another food prep area is planned in another building for older children. The floor plan and menu for this location must be separately reviewed and approved by the Board of Health. FOOD PREP A Hand Sink will be located in the prep area. Hand sinks must have wall hung soap and paper towel dispensers. These must be stocked at all times. Hand sinks must be used for hand washing only. All floors, walls, and ceilings where food, utensils, paper products, etc, are stored, prepared or served must be intact, impervious, and easily cleanable. There may be no bare hand contact of ready -to -eat foods. Gloves, tongs, or tissues must be used when handling such food. CERTIFICATION Kimberly Livingston is the Certified Food Manager. FLOORS and WALLS Floors and walls in the food prep area must be smooth, impervious and easily cleanable. TRASH a� uQj X-� /�� ,J e}pl��fi „ STANLEY J. USOVICZ, JR. MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741 -1800 FAx 978-745-0343 W W W.SALEM.COM JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: CHILD CARE Name of Establishment: Young World Academy Address of Establishment: 3 Green Ledge Street Owner's Name: Arthur Theophilopoulos Restrictions: Application Date: 10/13/05 Permit for Food Establishment 325-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT IMPORTANT MESSAGE FOvid DATE V) - I a 0 A TIME m O FAX ❑ MOE3ILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE lC�i )(1,L) o r i h.vm nA l i k him SIGNED WymFORM 4009 MANE IN U.S.A. Z O y CITY OF SALEM BOARD OF HEALTH Establishment Name: L%On n/q GUrw LrD %%� Q'�'a'�' r/ :/ Date: /!l - /3 — 05 Page: / of / Item No. Code Reference C - Critical Item R - Red ItemVerified DESC IPTION OF VIOLATION / PLAN OF CORRECTION .-_.. PLEASE PRINT. CLEARLY Date —00e—Y) /" /N 6'T /�i C rn - e d OF /S ar',r r / s .a ),/'y , ev h/ GO Y,ouGaS /111r26f -G // VIA10Span121 =r o c od r•Pab,1,6 �» 71e rzn 4: u/r ry 9, G/iiLL 6e QdclP r0. PUdi D P /u GG —t-4111/ Jder b 15�'&S Q111dWd 6' A/ r G eo Z&/n,) Jt, ,0 y a Le/e A /__5 ,IeW a ks t7Me- ,e MI e lin 7 105' Y /ZM/,/- AS5tiCod Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twe-fiv/e do�llar/s�or sus' Vision/revocation of your food permit. Corrective Action Required: '❑ No ❑ Yes LI Voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension Ll Embargo LI Emergency Closure ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1.22) (Cont.) PROTECTION FROM CHEMICALS 14 15 16 17 C Yih4lwotiyl» Tjtiil T3 v ; • Food or Color Additives 3-202.12 Additiscs'r 3-302.14 Protection ,t orn Unapproved Additives* 24. Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers* 7-102.11 Common Name -Working Containers* 7-201.11 Separation - Stora e* 7-20211 Restriction - Presence and User 7-202.12 Conditions of Use` 7-203.11 Toxic Containers -Prohibitions* 7-204.11. Sanitizers, Criteria - Chemicals* 7-204-12 Chemicals for Washing Produce, Criterial' 7-204-1.4 Drying Agents. Criteria* 7-205.11 Incidental Food Contact, Lubricants* 7-206.11 1 Restricted Use Pesticides. Criteria* 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring* Yih4lwotiyl» Tjtiil T3 v ; • 4 Denotes critical item in the tcderal 1999 Food Code or 105 CMR 590,000. F3 Proper Cooking Temperatures for 19 PHFs 3-401.11A(1)(2) Eggs- 155'F 1.5 Sec. 24. B+>s-LmnediateService 145°F15sec* 3-401.11(x1)(2) Comminuted Fish, Meats & Game 20 Animals - 155°F 15 sec. , 3-401.11(B)(1)(2) Pork and Beef Roast - .130°F 121 min* 3-401.11(A)(2) Ratites, Injected Meats - 155'F 1.5 _ _ Poisonous or Toxic Materials Sectal Re uirements sec. 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, _i......-.__-_- Stuffing Containing Fish, Meat, Poultry or Ratites -165°F 15 sec. 3-40 LlI(C)(3) Whole-muscle,huact Beef Steaks 145°F * 3-401.12 Raw Animal Foods Cooked in a Microwave 165`F * 3-401.11(A)(1)(b) All Other PHFs- 145'F 15 see. Reheating for Hot Holding 3-403A 1(A)&(D) PHFs 165'F 15 sec. 4 3-403.11(B) Microwave- 165° F 2 Minute Standing Time* 3-403.1 I (C) Commercially Processed RTE Food - 140°F* 3-403.11(E) Remaining Unsticed Portions of Beef Roasts' Proper Cooling -of PHFs 3-501.14(A) CoonliLl CookeiIPH' Fs from 140f1' to 70°F Within 2 Hours and From 70'F to 41°F/45'F Within 4 Horns. * 3-501.14(B) Cooting PHFs Made From Ambient Temperature Ingredients to 41"F/45`F Within 4 Hours* 4 Denotes critical item in the tcderal 1999 Food Code or 105 CMR 590,000. F3 3501.14(() PHFs Received at Temperatures According to Uiw Cooled to 4YT/45'F Within 4 Hours. -SM, 15 Cooling Methods for PIFs 19 PHF Hot and Cold Holding 3-801.11(B) 3-501.16 E) Cold PEIFS Maintained at or below 590.004(F) 41°!45`F* 24. 3-501.16(A) Hot PHFs Maintained at or above 140°F. Raw or Partially Cooked Animal Food and Raw Seed S routs Not Served. 3-501.16(A) Roasts Held at or above 130'F. 20 Time �as a Public Health Control 27. 3-501.19 Time as a Public Health Control* Pasteurized Eggs SUI)Stilnte for Raw Shell 590.004(H) Variance Requirement . K a 21 3-80].11(A) Unpasteurized Pre-packaged Juices and Beverages with W:uning l.,abeds* 23. 3-801.11(B) Use of Pasteurized Eggs* 24. 3-801.1.1(D) Raw or Partially Cooked Animal Food and Raw Seed S routs Not Served. 25 26. 3-901.11(C) Ung ened I`orxi Pucka =e Not Re -served. CONSUMER ADVISORY 22 3 603.1 I Consumer Advisory Posted for Consumption of 23. Manacternent and Personnel Animal Foods ,chat are Raw. Undercooked or 24. Food and Food Protection Not Otherwise Processed to Eliminate 25 26. _Equipment and Utensils Water. Plumbin and Waste Pathogens.* r;rmuros rn,'aoa� 27. 3-302.13 Pasteurized Eggs SUI)Stilnte for Raw Shell 28. 29. _ _ Poisonous or Toxic Materials Sectal Re uirements FC - 7 .008 .009 crcbtAu ric4lulr5CNi CIV 13 590 -009(A) -(D) Violations of Section 590.009(A)-(D)in catering, mobile food, temporary and residential kitchen operations should be debited under tire. appropriate sections above if related to foodborne illness interventions and tisk factors. Other 590.009 violations relating to good retail. practices should be debited under #29 - Special Requirements. t1F9�3�'I>llillsY�1.7� ��:Y�iiYs. (.Items 23-30) Critical and non-critical violalions, i0ach do not relate to the firodborne Illness interventions and risk factors listed obove, can be found in the follondng sections of the Food Code and 105 CMR 590-00(t Item Good Retail Practioes FC 590.000 23. Manacternent and Personnel FC - 2 .003 24. Food and Food Protection FC -- 3 .004 25 26. _Equipment and Utensils Water. Plumbin and Waste FC 4 .005 FC -5 .006 27. Physical FC -0 .007 28. 29. _ _ Poisonous or Toxic Materials Sectal Re uirements FC - 7 .008 .009 30 Other _i......-.__-_- .:111QF, ,i6,0 24,, RESTROOMS Restrooms must have a sign stating that employees must wash their hands before returning to work. Restrooms must be clean and sanitary. The woman's room must have a covered receptacle. EXTERMINATION Monthly services of a Licensed Pest Control Operator are required. Please keep receipts for inspections. SANITIZING SOLUTION Sanitizing Solution must be accessible in the food prep area and for the childrens' tables. Test strips corresponding to the kind of sanitizer, must be on hand to check concentration of solution. Solution must be made daily, tested, and the results recorded on a log sheet for examination by Board of Health inspectors. Solution may be prepared in the sink and spray bottles may be filled there. Spray bottles with clean paper towels may be used, as well as wiping pails with wiping clothes always held in the solution in the pail. An opening inspection is scheduled for I PM on Tuesday, October 11, 2005 nne Scott dth Agent 0,6-06 Date co MPANY' 61) Bench" 'kl!10,4747 PHONE: 2AF.-Sc -P.O. Boz Crestwood Drive, Waterloo, Iowa 50704 JOBSCAM : (319) 296-2987 FAX: 1-319-296-2315 25 0 IN 12 3 I : In -: 7 1 2 3 ou- i 4 5 6 7 1 8 9 10 11 12 13 14 I 'COMPANY." P.O. Box 2280,4747 Crestwood Davel. :AWONE. Waterloo, Iowa 5070 (319) 2%-2987 FAX: 1-319-296-2315 JOB: 13ua-vlw& It- Z /,scnt-r-. 0 IN 12 3 I : In -: 7 1 2 3 ou- i 4 5 6 7 1 8 9 10 11 12 13 14 I f 11 14 SNACK SCHEDULE FOR MONTH OF O n T 7- �-rdckv am / P pm , vin onsban C,,,-, d' i '• > h �: ; ; o MCk ..,Y, C trYl UCCA GroGer) V y,D lam+ 15 n rr� ��'� -c C rr • ¢ G CLQ Qm a Irl U��CSt— arYl \�� m iXaO� IP-) Y�c c` , Q C1L. ai > ;rr� (i l �� pQ �Cj•�j� (1`7 � � jJ I � n r-SVIN . �rm ^r'CCXecS rn j1C�L�(jC��1►� j�C'�r1C�ilrlC\UO CQvYI J - n �O - ,Orr) Gx0lit P Sew - Cl 7- baba 460d bQbu srctcQs C.h;1c�.crer�s Cue's bca��s Conr-cl \nro,,1 y Ovr(:k u�oc \d Flcc� demy cLeo no} S�\vearro�e bGey s�cc�5 CcXDk,�p CS'Cc G'Cers 1 C12c�� tunes 3 I�.� Free7Q,,- )0% cs ,�(oZQAA fcodo plas ✓-c; s, I ve(wua F1�Rin5 Ukns� Ls I 1 I