The URL can be used to link to this page

BEN & JERRYS - ESTABLISHMENTS BEN & JERRY'S 60 WASHINGTON STREET IP v u _ A f' S 11 I: IP I M1 Commonwealth of Massachusetts City of Salem Bu"i u of Heaitin Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 f Food/Retail Establishment Permit DATE PRINTED: 01/06/2011 ESTABLISHMENT NAME: CBen-&Jerry's-j File Number:BHF-2005-000032 60 Washington Street SALEM MA 01970 LOCATED AT: 0060 WASHINGTON STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2011-0174 Jan 1,2011 Dec 31,2011 $140.00 Salem Heritage Days Scooper Bowl ESTABLISHMENT Total Fees: $140.00 PERMIT EXPIRES IDecember 31, 2011 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 J BOARD OF HEALTH 120 WASHINGTON STREET,41°FLOOR TEL. (978) 741-1800 KIN BERLEY DRISCOLL FAX(978) 745-0343 MAYOR DGREENBAUM&ALEM.CONI DAVID GRE NBAUM,RS ACTING HEALTH AGENT 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT i NAME OF ESTABLISHMENT e JikA C( fG J TEL it 'T f Y �� ADDRESS OF ESTABLISHMENT &0 J6 FAX# MAILING ADDRESS(if different) 01 cI ?0 EMAIL- Business: lvGSLDUf4SC y�Gr�o. C.om Website: GJw(n/• ✓1/1�Cj Gorn � r��eyi OWNER'S NAME ,6reff € L(hda 2)a'nW talc —TEL# I ' O- 0 ADDRESS lP / rad 6,,-d 94-e f- c l G'sv1 M 74- D/�( STREET CITY STATE C��-Q rZIP /� CERTIFIED FOOD MANAGER'S NAME(S) ` re� ��^ yI �u �— CERTIFICATE#(S) �l 1 I D J (Required in an establishment where potentially hazardous food is prepared) / EMERGENCY RESPONSE PERSON 6re7t-ba /�n UI tu./�- HOME TEL# vl 3i� WO `DAYSOF,OPERATION ^-Monday. .,fi'K; Tuestla : ! Wednesday,,. �4r litirsday., >' l Fnday I ,,,Batu day Sunday.; { HOURS OF OPERATION 1 q q Please write in time of day. 1 N0011 - ' N60, 1-q Y"�✓I" 1 1 A)OGYI '9 N -- / N�Dh / A=k-7-� For example Ilam-11 i ! TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 1 0,000sq.ft. =$420 ------------------------------------------------ - - ------------------------------------------------------------------------------------------' ------- RESTAURANT YES NO less than 25 seats �1 (Outdoor Stationary Food Cart$21 25-99 seats =8280 more than 99 seats =$420 ----------- ----- -------------------------------------------i -----.._--------------------------------------------------------------------------------------- BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES/NURSING HOME ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursupnt 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 r um nd paid all state taxes required under the law. la�aG.,li0 )057�( 7-sy- - S1`gnkW Date Social Security or Federal Identification Number Revised lonli 1 FOODAP201 Ladm Check#&Date—'7- - $ CITY OF SALEM _ BOARD OF HEALTH Establishment Name: Date: `) -3 12 Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Deft- 140. Reference R—Red Item Verified PLEASE PRINT CLEARLY Discussion With Person in Charge: Corrective Action Required: ❑ .No ❑: Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and toExclusion comply with all mandates of the Mass/Federal Food Code. I understand that ❑ Re-inspection Scheduled L) Emergency Suspension noncompliance may result in daily fines of my-five dollarsuspe cation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: 3401.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness interventions and Risk - According to Law Cooled to Factors(items I-=) (Cont.) - 41°F/45*F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cor lin Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding. 3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below 590.004(F) 410/450 F* 3-302.14 Protection from Unapproved Additives* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 140°F. 7-101,11 identifying Information-Original 3-501.16(A) Roasts Held at or above 130°F. Containers* 7-102.1 I. Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Contrul* 7-202.11 ,Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS HSP 7-204.11 SanChemicalserq.Criteria i Chemicals* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* .Bevera s with Wanting Labels* 7-204.14 d encs.Criteria* 3-801.I1(B Use of Pasteurized Eggs* 7-205.11 incidental Food ContaPesticides, Lubricants* 3-801.11(D) Raw or Partially Cooked Anintal Food and 7-206.11 Restricted Use Pesticides,Criteria Raw Seed Sprouts Not Served.* 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders,Pest Control and 3-801..11 Unopened Food PackageNot Re-served. Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooldng Temperatures for Animal Foods That are Raw.Undercooked or PHFsNot Otherwise Processed to Eliminate 3-401.11A(1)(2) Eggs- 155°F 15 See. Patho ens.*e've 11" E immediate Service 145*Fl5sec* 3-302.13PasteuErized Eggs Substitute for Raw Shell 3-401.11(A)(2) Conuninuted Fish.Meats&Game . Animals-155°F 15 sec. 3-401.11(B)(1)(2) Pork and Beef Roast- 130°F121 min* SPECIAL REQUIREMENTS _ 3401.11(A)(2) Ratites,Injected Meats-155cF 15 590.009(4(1)) Violations of Section 590.009(A)-(D)in sec.* catering, mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec.* above if related to foodborne illness 3401.11(C)(3) Whole-muscle,intact Beef Steaks interventions and risk factors. Other 145T* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3.401.11(A)(1)(b) All Other PHFs-145*F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 31403.11(A)&(D) PHFs 165-F 15 sec. * (Items 23-30) 3.403.11(B) Microwave-165`F 2 Minute Standing Critical and non-critical violations,which do not relate to the Time* - foodborne illness interventions and risk factors listed above, can be 3403.11(C) Commercially Processed RTE Food- found in the following sectionsof the Food Cade and 105 CMR 140°F* 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef Hem I Good Retail Practices 1 ,FC 590.000 Roasts* 23. Manattement and Personnel FC-2 .003 18 Proper Cooling of PtIFa 24. Food and Food Protect on FC-3 .004 25. Equipment and Utensils FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140*F to 27. Physical Fac@t .006 70°F Within 2 Hours and From 70°F 26. Warse Plumbingand 1 FC-6 .007 to 41°F/45°F Within 4 Hours. * 28. Poisonous or Toxic Materials I FC-7 .008 3-501.148) Cooling PHFs Made From Ambient 29. Special Requirements 009 Temperature Ingredients to 41°F/456F 30. Other Within 4 Hours* - *Denotes critical item in the federal 1999 Fwd Code or 105 CMR 590.000. k CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4'FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAx(978) 745-0343 MAYOR LRAMDINQSALEM.COM LARRY RAMDIN,RS/RE;FIS,CHO,CP-FS HEALTH AGENT PLAN REVIEW APPROVAL DATE: March 29,2012 To: Guenevere Blanchard ESTABLISHMENT: Ben and Jerry's, 60 Washington Street, Salem MA 01970 DATE RECEIVED: March 26,2012 The Salem Board of Health has reviewed your submitted plans as and has approved them as follows: [ X] AS SUBMITTED [ ] Rejected [ ] Conditionally as follows: Reviewed By: Date: March 29, 2012 Larry A. Rat din Health Agent You are required to contact the Salem Board of Health to schedule an inspection prior to opening the establishment or utilizing the renovated/newly constructed space,at least five(5)business days prior to desired occupancy/opening. This approval is issued by the Salem Board of Health,the applicant is required to secure all other permits,and approvals that are required by other Municipal,State and Federal agencies. 1 CITY OF SALEM, MASSACHUSE'I'1'S IV BOARD OF HEALTH 120 WASHINGTON STREET 4`FLOOR Public Health STREET, Prevent.Promote.Protect. TEI,. (978) 741-1800 Fr\x(978) 745-0343 KIMBERLEY DRISCOLL IramdinQasalemxom I,r\RRX RAMI>IN,R5/RLFI S,Cl-f0,CP-l;S MAYOR HIi:AL:rf-I AC;I7.N'I' REMODELING PLAN REVIEW APPLICATION FOR CURRENTLY LICENSED flMlPIMENTS p1'l REMODEL _CONVERSION 09 SF H 2`3 101 Application fee :$90.00 CIV O Category: Restaurant-X , Institution , Daycare Retail Market , Other Name of Establishment: Ber\ -A- Address:— Address: CooCv�cS1� c5'fi Ao- Phone, email if available: C[ } - �-1 9 - 3-szo Name of Owner: Mailing Address: (eco ( lceSl2�l,�\�zmf Telephone: L( ��do Applicant's Name: C�U1 (t2e RLIA,.ticl l A Q Title (owner, manager, architect, etc.): C Mailing Address: 5p,?s CPI :t \f'iyx m 6 Ct�:)-y Telephone/email: ��$ '3 i� d SU r I have submitted plans/applications to the following authorities on the following dates: Plumbing Building 31 -z311 Fire Planning Electrical Conservation Engineering Licensing 3/-Z-3b7- Historical Commission City Clerk Public Services Water Assessors Hours of Operation: Sunk Mon Tues (- 4- Wed 1' Thurs FRI Sate el Number of Seats: oNumber of Staff: (Maximum per shift) Maximum Meals to be served: (approximate number): Breakfast Lunch '10 Dinner 370 r Type of Service: (check all that apply): Sit Down Meals Other Take Out X Caterer Mobile Vendor Project Start date: Completion date: Please enclose the following documents: Application Fee $90.00 (Check or Money Order matle out to "City of Salem" ) Proposed Menu (including seasonal, off-site and banquet menus) Manufacturer Specification sheets for each piece of!equipment shown on the plan Site plan showing location of business in building; location of building on site including alleys, streets; and location of any outside equipment(dumpsters, well, septic system - if applicable) C Plan drawn to scale of food establishment showing location of equipment, plumbing, electrical services and mechanical ventilation (color coded) j Equipment schedule FOR OFFICIAL,USE ONLY DATE RECEIVED I\y FEE AMOUNT O RECEIVED BY DATE APPROVED: APPROVED BY: Ben& Jerry's 60 Washington St Salem, MA 01970 March 28,2012 Dear Health Dept, *Potato: New product, organic. Shipped frozen in a 51b bag (see photo). Potatoes are cooked to order; any potato cooked will be served within an hour or disposed of. Cooked at 410 degrees. Stored frozen in a walk-in freezer, separate from any other frozen product. Partially cooked before frozen and shipped. *Greaseless Convection Oven: Cooks a maximum of 5lbs of potatoes at 410 degrees. Average amount cooked per serving 1-1 1/21bs (see photo, cut sheet&health dept letter from manufacturer). Average cook time 3-6 minutes. * Refrigerator: Manufactured by True (see cut sheet), model TWT-48. Stores soda, water, and ketchup sauce. Adjustable temp, planning on 34 degrees. *Server Window: 36"wide x 72" long. Sliding window compartment 24"tall, to be kept closed except when in use. Interior Menu will be posted in the upper 20% space of window(see photo) *Paper Cone: Potatoes are served in a biodegradable paper cone (see photo). Size small/6oz, medium/8oz, large/I Ooz. Cones are dispensed be Dispense-Rite metal container, model #ADJ-2 (stainless steel, length 22", diameter 6 7/8", cup capacity 6-15oz, spatial orientation drop-in). *Sink: One piece Deep Drawn, 9"x9"x5" (see cut sheet) 1 %"stainless steel drain w/strainer plate. Splash mounted gooseneck faucet w/paddle lever, aerotor. Thank you, A �A -� � Guenevere Blanchard Our organic potatoes are shipped frozen, in a 5 lb bag. 41 �o. t°. Then we cook them in this convection oven .10 s }� 'i v > a h A A676 0 - Coote I i After cooking, we serve them in these biodegradable paper cones. The cones are stored in this box, under the cabinet .:; .. This is the fridge where we store water& soda... W — - ---�� x �tv 1 I VIII I � ,t Here are pictures of the potato station �w t_ r GREASELESS FRYER QXC,Inc.• 12021 Phmo Rd.,Jule 160,Dallas,7%7524:3•(972)6U)-8993,(886)668-3667•Far(972)W)-bMo E-mail:sales@(I-n-c.com•Weh.,kr wmr.y-n-e.cum October 26, 2011 To:Various Health, Building,Water, &Fire Departments Subject:Quik n'Crispy Greaseless Fryer Enclosed is a complete set of literature on the Quik n' Crispy® Greaseless Fryer, including letters from various health departments who have authorized the installation of the Quik n'Crispy®without a vented hood system The Quik n' Crispy is a hot-air oven, not a deep-fat or grease fryer, and does not use any grease or oil in the reconstitution process. The two primary reasons that we have been granted the variances from these various municipalities are because of the types of food that are prepared in the Quik n'Crispy®,and the unique patented design of the unit itself. All of the food and meat products recommended for use in our unit are pre-cooked items that are being reconstituted with hot air and radiant heat in our unit, not cooked from a raw state. These are the same types of foods that many operators currently prepare in a microwave. We are re-warming previously cooked items such as pre-cooked grilled chicken breasts, pocket sandwiches, and egg rolls. As such, these departments typically view and treat the Quik n'Crispy the same as they would a microwave oven. In addition,the combination of the patented cooking basket/drip tray,the convection blower in the rear of the unit,and the resistance heater in the top of the unit,crisp the exterior of the product,sealing in the moisture and oils,thereby retaining a moist interior. The air circulated in the Quik n'Crispy® is heated and recirculated. Additional outside air is not needed and essentially no heated air is exhausted. Another key reason why we have been granted variances from these municipalities is due to how well the Quik n'Crispy is insulated, resulting in very low external operating temperatures. Our equipment is very well insulated and does not generate excessive heat. I have attached a copy of the temperature testing report from Underwriters Laboratories(UL File 118651 Test 11)that was conducted on our Model GF II,the model. Please note that this test involved removing the four 1"adjustable legs from the bottom of the unit; placing it on a softwood surface covered with 2 layers of tissue paper and then enclosed in a two-sided black painted enclosure. This enclosure projected a minimum of two feet beyond the front of the unit. In addition the unit was run at a higher temperature(450 degrees)than would be typically used in operation 370 to 420 degrees. The unit was run continuously for several hours under these conditions until the temperatures at the thermocouples became constant. Please review the temperature results on page 4. Under these very adverse conditions,the maximum temperature of any of the 3 sides was 91 degrees and the rear temperature was 86 degrees. The bottom of the unit that was resting on the tissue covered plywood without the adjustable feet was 113 degrees. Hopefully, you will concur that the Quik n'Crispy will not be the cause of excessive heat. Grease Traps have not been required because little or no oil is discharged from the food during the rewarming process,and any that is, is caught in the drip tray in the bottom of the Quik n'Crispy®. This oil,and any crumbs present,are removed with a scraper and paper towel,and then placed into a waste receptacle. Typically, disposable plates or paper lined plastic baskets are used to serve the menu items that are prepared in the Quik n'Crispy. The plates or paper is then placed into a waste receptacle after the customer has consumed their order. Since May, 1990,over 9,000 units have been placed in operation throughout the United States and,when used properly in conjunction with the recommended types of food,have proven to be reliable, safe units that are easy to maintain and clean. During the 18 years that we have marketed the Quik n'Crispy we are not aware of a Quik n'Crispy user who has been required to install a vented hood system or a grease trap. If you require any additional information please contact us at your earliest convenience at 1-888-668-3687, by email or sales@q-n- c.com,or visit our web page at www.q-n-c..com. Sincerely yours, Paul R.Artt President SII 15405 QNC GFII GP5 4C 3/15/06 12:56 Pn Page 2 .a Electrical Specifications Model GF II Electronic(Six Menu Operation) or Mechanical Controls Voltages US/Grnada:Single Phase•GO Hz. g' 120 volt(1740 watts• 14.5 amps) 120 volt(2200 watts• 18.3 amps) 208/240 VAC at 208 VAC(4326watts•21 amps) THE QUIK N' CRISPY Above Voltages VAC(and°watt,• amps) Voltages UL and GUL listed. GREASELESS FRYER Voltages In 0VA anal Single Phase•50 Hz. 230/240 VAC at 230 VAC(2460 watts• 10.7 amps) Introducing the new Quilt n'Crispy Model GFS, at 240 VAC(2670 watts• 11.1 amps) with twice the capacity of the Model GF II,it cooks quicker Above Voltage has CE Mark with Electronic Controls only. and crispier than before.It has been redesigned and resized Not UL or GUL listed to meet the needs of a variery of operators including Catering, GF II Receptacles(USA/Canada) Lodging,Contract Foodservice,Sports,Amusement,Military, Receptaue: aeceptecle: RmPtace: NEMA#14-30R NEMA#5-20R NEMA 95-15R and a host of others!In addition to preparing up to 5 lb.of L ho[-air fried appetizers per batch,it can also grill up to 55 hot dogs or 25 precooked hamburgers or chicken breast filers in �-- + under 5 minutes.As an added benefit,it also includes a 30A 125/25DV 20A 125V 15A 125V built-in grease and carbon filtration system. Model GF5 Electronic Controls(Fifteen Menu Operation) The versatility of the Quik n'Crispy contributes US/Canada/International•Single Phase•50/60 Hz. immensely to it's popularity.Besides hot-air fried foods,it 208/230/240 VAC grills precooked meats hot and sizzling on the outside,while at 208 VAC(4326 watts•21 amps) keeping the meat tender and moist inside. It bakes pizzas and at 230 VAC(5290 watts•23 amps) ho[sandwiches,melting the cheese,warming the meats,and at 240 VAC(5760 watts•24 amps) leaving the bread warm and flaky,as if it were freshly baked.It GF5 Receptacle(USA/Canada) is also an excellent choice for toasting bagels,muffins or garliReceptacle: c NEMA#6-30R toast,and can be used to bake potatoes or frozen casseroles. O The Quik n Crispy helps food service operators expand �o their menu at a fraction of what a fryer,grill,oven,and vent system costs.And since grease is not needed,the savings 30A 125/250V continue to grow!Save thousands of dollars per year in fire Other Specifications insurance premiums[hat are incurred with the use of a deep External Dimensions(H x W x D) fat fryer or a self-contained fryer. GF II: 13.5"x 21"x 20" Reduce your staffing and labor costs by using the GF5:25"x 29"x 21" Quik n'Crispy in place of a full kitchen,or to supplement a (plus 4.25"overhang for air filtration cone) full kitchen—such as late at night when the kitchen is closed Cooking Basket(H x W x D) and there are still hungry customers to serve. GF II:2"x 12' z 12" GF5:3"x 16.5"x 16.5" Your QUlk n'Crispy dealer Is: Shipping Carton(H z W x D) GF II:23.5"x 23.5"x 18" G175:29"x 37"x 30" Shipping Weight GF II:70 Ib. GF5: 175 lb Patents GF II:US Patent Number 5,066,851 CC GREASELESS FRYER GF5:Patent Pending 888-688-3687 (972)669-8993•FAX(972)669-8990 Listings Web site www.q-n-c.com•Email sales®q.n-c.com COUS � C C' 12021 Plano Re.•Ste.160•Dallas,TX 75243 Fred photos courtesy of Brakebudt Brothers,Inc.,ConAgra Foods4amb Westin,Rngar Faro Products,McCain Snack Foods,Sara Lee Foods U.S.,and Sctrwant Food Service. 4— Y TRUE FOOD SERVICE Project Name: AIA# ® EQUIPMENT, INC. Location: 2001 East Terra Lane•O'Fallon,Missouri 63366 515# (636)240-2400•Fax(636)272.2408•(800)325-6152•Intl Fax#(001)636-272-7546 Item #: Qty: Parts Dept.(800)424-TRUE•Parts Dept.Fax#(636)272-9471 •www.truemfg.com Model#: Model: Worktop: TUVT 48Solid boor •- " I • • 1 True's worktop units are designed with enduring quality that protects your long term investment. Designed using the highest -' quality materials and components = - - to provide the user with colder F. product temperatures,lower �1+A utility costs,exceptional food safety and the best value et today's food service marketplace. 1 Oversized,environmentally r7 friendly(134A)forced-air refrigeration system holds 33°F to 38°F(.5°C to 3.3°Q. 1 All stainless steel front,top and ends. Matching aluminum finished back.Top and backsplash are one piece formed construction. Bacteria and food particles cannot be trapped underneath as with other two- 1 piece worktop units. 1 Front breathing. / Heavy duty PVC coated wire shelves. 1 Foamed-in-place using Ecomate. A high density,polyurethane insulation that has zero ozone depletion potential(ODP)and zero global warming potential (GWP). ROUGH-IN DATA specifications subject to change without notice. Chart dimensions rounded up to the nearest W(millimeters rounded up to next whole number). Cabinet Dimensions Cord Crated (inches) Length Weight (mm) NEMA (total ft.) (lbs.) Model Doors Shelves L Dt H* HP Voltage Amps Config. (total m) (kg) TWT-48 2 4 483/s 30'/e 333/e A 115/60/1 5.0 5-15P 7 280 1229 766 848 yt 230-240/50/1 4.2 ♦ 2.13 127 t Depth does not Include 1'(26 mm)for rear bumpers and%:(7 mm)for front bumper. ♦Plug type varies by country. Height does not include 6%"(159 mm)for castors or 6"(153 mm)for optional legs s w" APPROVALS: AVA/LABLEAT.• �0r®•r�� E CE 8/11 Printed in U.S.A. I' 1 Model: • • TWT-48 • �•• 'STANDARD FEATURES - DESIGN Insulation-entire cabinet structure and solid ELECTRICAL • True's commitment to using the highest doors are foamed-in-place using Ecomate.A Unit completely pre-wiredatfactory and ready quality materials and oversized refrigeration high density,polyurethane insulation that has for final connection to a 115/60/1 phase,15 amp systems provides the user with colder product zero ozone depletion potential(ODP)and zero dedicated outlet. Cord and plug set included. temperatures,lower utilitycosts,exceptional global warming potential(GWP). food safety and the best value in today's food 5"1127 mm)diameter stem castors-locks 115/60/1 service marketplace. provided on front set. 36"(915 mm)work ' NEMA-5-15R REFRIGERATION SYSTEM surface height. • Factory engineered,self-contained,capillary DOORS OPTIONAL FEATURES/ACCESSORIES tube system using environmentally friendly • Stainless steel exterior with white aluminum Upcharge and lead times may apply. (CFC free)134A refrigerant. liner to match cabinet interior. U230.240V/50Hz. • Oversized,factory balanced refrigeration system • Each door fitted with 12"(305 mm)long U 6"(153 mm)standard legs. with guided airflow to provide uniform product recessed handle that is foamed-in-place with U 6"(153 mm)seismic/flanged legs. temperatures. a sheet metal interlock to ensure permanent U 2'h"(64 mm)diameter castors. • Extra large evaporator coil balanced with higher attachment. U Barrel locks(factory installed). Requires one per horsepower compressor and large condenser; • Positive seal self-closing door(s)with 90°stay door. maintains cabinet temperatures of 33°F to 38°F open feature. Door(s)swing within cabinet U Single overshelf. (.5°C of 3.31C)for the best in food preservation. dimensions. U Double overshelf. • Sealed,cast iron,self-lubricating evaporator • Magnetic door gasket(s)of one piece U 281/4"(718 mm)deep,1/2"(13 mm)thick,white fan motor(s)and larger fan blades give True construction,removable without tools for ease polyethylene cutting board. Requires"L" worktop units a more efficient,low velocity, of cleaning. brackets. high volume airflow design.This unique design SHELVING LI28'/4"(718mm)deep,%"(13mm)thick, ensures faster temperature recovery and • Four(4)adjustable,heavy duty PVC coated wire composite cutting board. Requires"L"brackets. shorter run times in the busiest of foodservice shelves 21 M61x 16"D(548 mm x 407 mm). U Heavy duty,16 gauge tops. environments. Four(4)chrome plated shelf dips included per U Exterior rectangular digital thermometer • Condensing unit access in back of cabinet,slides shelf. (factory installed). out for easy maintenance. . Shelf support pilasters made of same material as UADA compliant models with 34"(864mm)work CABINET CONSTRUCTION cabinet interior;shelves are adjustable on'1h"03 surface height. • Exterior-stainless steel front,top and ends. mm)increments. U Remote cabinets(condensing unit supplied Matching aluminum finished back.Top and MODEL FEATURES by others;system comes standard with404A backsplash are one piece formed construction. . Evaporator is epoxy coated to eliminate the expansion valve and requires ice de refrigerant). Bacteria and food particles cannot be trapped P rr si BTUConinformation. factory .All remote service department for potential of corrosion. BTU information.All remote units mus[be hard underneath as with other two-piece worktop . NSF-7 compliant for open food product. wired Burin Installation. units. 9 • Interior-attractive,NSF approved,white aluminum liner.Stainless steel floor with coved corners. PLAN VIEW _ 62'2/:z• n38s mmt 301 46slt6• i 391W 21 (26i mml 1sh2•_ 263!32W _► 1,1P118). � (646 mm) (714 mml I IW mm) n n ..,. !>6 mm) 293/a• 33`+116• ('66 mm) (842 mm) 391h• I6* (913 mm) L 2616• t % - —(3218- 51 021.1 . 19Na' "'+++III 63A6' (121 mm1 (a99 mmi IRB.) F(EUARON RIGHT VIEW WARRANTY METRIC DIMEN51ONS ROUNDED UP TO THE One year warranty on all parts NEAREST WHOLE MILLIMETER IModel Elevation Right Plan 3D Back and laborand an additional 4 year warranty on compressor. SPECIFICATIONS SUBJECT TO CHANGE -48 TFPV02E TFPVWS TFPv02P TFPYo23 (U.S.A.only) WITHOUT N011- -TRUE FOOD SERVICE EQUIPMENT 2001 East Terra Lane•O'Fallon,Missouri 63366•(636)240.2400•Fax(636)272.2408•(800)325.6152•Ind.Fax#(001)636.272.7546•www.tmemfg.com Www.truuem cola;;, ELECTRIC INSTALLATION 8c: SAFETY INFORMATION EMU": Mlarlylyff;" - a I - � r • - NOTE:Due to potential safety and operational reasons TRUE will not warranty any equipment that is conneded to an extension cord or adapter plug. , A N��plug in inore than one unit p--.-eiectricai circuit. fi / Do not, under any circumstances, cut or remove the ground prong from the power cord For personal safety, this appliance must be property grounded. ELECTRICAL-INSTRUCTIONS WIRE GAUGE FOR 2.0 VOLTAGE DROP IN SUPPLY CIRCUITS A. Before your new unit is connected to a power supply,check the incoming voltage with a voltmeter, If an}thing less,than 100%of the rated voltage for operation is noted correct:' 1 tmmediateh For proper voltage use wue size chaiYs " g below. 115 Volts Distance In Feet To Center of Load 1230 Volts Distance In Feet To Center o Load', Amps 20 30 40 50 60 70 80 90 100120140160 - Ams 2 AMPS 0 30 40 50 60 70 '80 90 10(1120110160 2 14 14 14 14 14 14 14 14 14 14 14 14 5 14 14 14 14 14 14 - 14 14 141--I—A ,-I"- x.14 3 14 14 14 14 14 14 14 14 14 14 14 � 12 i.6 14 14 14 14 14 14 14 14 '14 l3 14 ':12 4 14 14 14 14 14 14 14 14 14 12 12 • 127 14 14 14 14 14 14 14I4 } it 1? '}2 5 14 14 14 14 14 14 14 12 12 12 10 ' 10 "'8 14 14 14 14 14 14 14 14 _.14: 12 1_'.. i12 6 14 14 14 14 14 l4 12 12 12 10 10 10 1 9 14 14 14 14 14 14 14 14 12" ;L" E2 10 7 14 14 14 14 14 12 12 12 10 10 10 8 "'10 14 14 14 14 14 14 14 12 12p 12 30,,_atr> 8 14 14 14 14 12 12 12 10 10 10 8 .8 '} 12 14 14 14 14 14 14 12 12 12,- 10 10' -to 9 14 14 14 12 12 12 10 IO 10 B 8 8 14 14 14 14 14 14 12 12 l2 10 10 10 ' 8 10 14 14 14 12 12 10 to 10 l0 10 8 8 8 16 14 14 14 14 12 12 12 10 10 10 ;8 '-C 12 14 14 12 l2 10 10 10 8 8 8 8 6 18 14 14 14 12 12 12 IO 10 10, 8 8`, 811 14 14 14 12 10 10 10 8 8 8 6 r, 6 6: '20 l4 14 14 12 10 10 10 10 10r 8 S 8 16 14 12 12 10 10 8 8 8 8 6 6 6 25 14 14 12 12 10 10 10 10 8 8 6 6 18 14 12 10 10 8 8 8 8 8 8 8 5, 30 14 12 12 10 10 10 8 8 8-; 6 6 6 20 14 12 10 10 8 8 8 6 6 6 5_5', '-3514 12 10 10 10 8 8 8 8 6 6 ='S 25 12 10 10 8 8 6 6 6 6 5 4 4- 40 14 12 10 10 8 8 8 6 6 6 51 1 .5 30 12 10 8 8 6 6 6 6 5 4 4�'. 3: {3 -.50 12 10 10 8 6 6 6 6 6 5 4 4 35 10 10 8 6 6 6 5 5 4 4 3` 2 .}. -60 12 10 8 6 6 6 6 6 5 4 4.. 3 40 10 8 8 6 6 5 5 4 4 3 2 2 ' 70 10 10 8 6 6 6 5 5 4 4 2 2 45 10 8 6 6 6 5 4 4 3 3 .2 1 80 IO 8 8 6 6 5 5 4 4 3 2 2 50 IO 8 6 6 5 4 4 3 3 2 1 11 -90 10 8 6 6 5 5 4 4 3 3 1 -9 -100 10 8 6 6 5 4 4 3 3 2 1 1 WARNING: Compressor warrantles are void if compressor bums out due to low voltage B. All units are equipped with a 7 ft. (2.1m)service cord,and most be powered at proper operating voltage at all times. Refer to cabinet data plate for this voltage. C. TRUE requires that a sole use circuit be dedicated for the unit Failure to do so voids warranty. NOTE: To reference wiring diagram,-Remove front louvered grill, wiring diagram is positioned ort the inside cabinet wall. PREVENTATIVE MMMTEM"CE ;. Condensers accumulate dirt and wire cleaning every30 days. Dirty condensers result in compressor failure, product loss, and%st sales which are not covered by warranty. FOR INSTRUCTIONS ON CLEA7VING CONDENSER COIL SEE ON-LINE INSTRUCTIONS ON MA/NTTENANCE CAREAND CLEANING. 3 THE CLEANING OF THE CONDENSER IS NOT;COVERED BY THE WARRANTY! 3 1' a STAINLESS STEEL HAND SINKS ADVANCE TABCO. SPACE SAVER UNITS sM,w.F..�A�e„o�- Keyhole Bracket easier installation Item #: and greater stability. Qty Model #: r� Project #: FEATURES: One piece Deep Dram sink bowl design. Sink bowl is 9"x 9"x 5". All sink bowls have a large liberal radii with a minimum dimension of 1"and are square in design. Keyhole wall mount bracket. 1 1/2"stainless steel drain with strainer plate. Specific Features: -- 7-PS-22 and 7-PS-83 4°O.C.centerset faucet furnished with aerator. 7-PS-23 and 7-PS-84 4"O.C.splash mounted gooseneck faucet furnished with aerator. x-� �'- - 7-PS-83 and 7-PS-84 liquid soap&towel dispenser with hinged 7-PS-227-PS-83 box.Unit uses standard C-told towels. CONSTRUCTION: All TIG welded. 7-PS-23 Welded areas blended tomatchadjacent surfaces and to a satin finish. Die formed Countertop Edge with a No-Drip offset. WITH SOAP& TOWEL DISPENSERS One sheet of stainless steel-No Seams. MATERIAL- Heavy gauge type 304 series stainless steel. Wall mounting bracket is stainless steel and of offset design. _ All fittings are brass/chrome plated unless otherwise indicated. MECHANICAL: Faucet suppt/is 1/2"IPS male thread hot and cold. 7-PS-84 7-PS-83 StandardFaucet conforms to NSF 61 Standard An optional faucet upgrade is required for compliance.to A8 1953 Standards. For Replacement Faucets&Upgrades,Drains&Accessories visit our website at www.advancetabco.com ® Customer Service Available To Assist You 1-$00-645-31 66 8:30 am-8:00 pm E.S.T. Email Orders To:customer@admcetabco.com.For Smart Fabrication"Quotes Email To smarVab@aovancetabco.com or Fax To 631-586-2933 ADVANCE TAS NEW YORK GEORGIA TEXAS NEVADA x advancelabco.rnm Fax:(631)242-6900 Fax: (770)775-5625 Fax:(972)932-4795 Fax:(775)972-1578 B-8 DIMENSIONS and SPECIFICATIONS TOL Overall:±.500"Interior:±2W FITTINGS SUPPLIED AS SHOWN ALL DIMENSIONS ARE TYPICAL ' TOP VIEW FOR 7-PS-83 TOP VIEW FOR 7-PS-84 TOP VIEW FOR 7-PS-22 TOP VIEW FOR 7-PB-23 ;f n - 57-41 t6° 0. r 9° If - 9' 12'— 7-PS-63 — 1r n 7-PS-23 -D"Spout Faucet `s Towel Dispenser L- n � j Peck 261/2' Mounted Faucet Soap 8" Dispenser r< s t � 12 tbs. 20 Its. c j 1 I 7-PS-22 7-PS-8a Towel .,-�_ Dispenser 5 f Faacet� F 1 °D"Spout ta• L # � Fauces --�-� 2- 261/2' s Soap Dtspenneer e' 12 lbs. T r j 201biL l I i y� 1 03 IM6, ADVANCE TABCO is constan7 engaged in a program of change spec ficour ations wit oul prior or notiwe e�e.erve the right to B-$a 200 Heartland Boulevard,Edgewood,NY 11717-8380 0 ADVANCE TABCO,JULY 2009 0l/7- 5 eV//ffV `J / .0 BV f -�erPraq 7 WORT( S7-4TION X60 W,4SPIIv67off $r. 77,40 O&T WIA40041 5ALFM MA 0/970 .._.._..__ -._ CouwrER �STe�G GooL�13 Ex 1 5T/P16, G nO l E tC CpvN' IJ 9 BI o i T T s�a1h pooh counotEi� ►� 120S ice 36 36 TAKAV. ovr YN�nr, n . w�N L Y 1V Q E ST_ Larry Ramdin From: Tom Daniel Sent: Thursday, March 29, 2012 8:35 AM To: Larry Ramdin Subject: RE: 60 Washington Street Q Potato 4 Thanks again, Larry. The Board recommended approval last night. The sink issue didn't come up. From: Larry Ramdin Sent: Wednesday, March 28, 2012 12:13 PM To: Tom Daniel Cc: Thomas St. Pierre Subject: 60 Washington Street(3 Potato 4 Hello Tom, In reference to design Review Board Agenda meeting scheduled for 3/28/2012 Agenda item : 60 Washington Street(3 Potato 4): Discussion of proposed signage and carry out window I have spoken to the owner of this Food Establishment and she has provided the Board of Health with all the required information on the window change and use protocols to ensure that there are no adverse Public Health consequences to the change in the window and the operation of the new window. Please be advised that the Board of Health has no objections to the change in the window to allow for take-out. Sincerely &"V e � Larry Ramdin Health Agent Salem Board of Health 120 Washington Street , 4th floor Salem MA 01970 978-741-1800 (phone) 978-745-0343(fax) t Sale Redevelopment Authority Design Review Board Proposal March 28, 2012 60 Washington Street (3 Potato 4): Discussion of proposed signage and carry out window Proposal for March 28 DRB Meeting The submission, dated March 15, 2012, includes the window plan, photos and signage drawings. The proposal is for two signs: 2' x 2' blade sign fabricated on PVC and a 1' x 2' window sign. The blade sign will hang from a new sign bracket and will not be lighted. The window sign will obscure less than 20 percent of the window. Both signs are vinyl. A sliding glass carryout window will be added. Staff Comment for March 28 DRB Meeting The signage complies with City and SRA guidelines. Please note the photoshop images are not to scale. Or sN��tN o of 6Q�'P 4 } �F `R 4r j ck. Your gaze V 9 T 14 Rdd Space Sauce Rdd 1 CHUB' -- -- CURRY KETCHUP imnlyo PESTO MAYO CHIPOLIE MAYO RC PEPPER THAI CHIU SAUCE BBQ fl, PEH UT 513TRY MUSTARD HCC ° UfRdd Chink. a5 3 a � Cr r 7 r� 1l [` ^".. � �L y ..1. a - +„d me•WP. 113. F J{J. SS Y S. � h, .. F fA r q x' wlrv„^!�+.y�.��J� •� a5� "9W e .Y... .'_Y'�' 4'M i �i a� b. j l SF Iahb �y "7 Lip 4 1 b A TRe• •}, 1 LI1 ✓' j r 4 Y r .. `F i t 3� n� X W07% 10�60 WrJSfv1wroov Sr; 1Ta4 00— WhVk0W 5114rkf Mss 0/970 ,r our Wt1VD 0 w r LY/VV 4;7. I# r - 4- , i " CITY OF SALEM, MASSACHUSETTS BOARD OIz H[,_,uA I 120 WASHINGTON 5'I'REfiT,4".14,008 K.1vBL.RL1?Y I�RIS(:OLL F\xTEL. (978)741-1800 NIA1 OR Imin(978) 745-0343 �7mdiQsnlem.com r LARRY IZANIDIN,RS/RH IS,CI10,CR-I'S HV?A7 a'ITAGItN'1' This Form will be collected during your next Board of Health inspection. QUESTIONAIRE — GREASE TRAPS 2W e�`Ojj 1. NAME OF ESTABLISHMENT: 2. ADDRESS OF ESTABLISHMENT: 0 0 Ia;, Vt4 NG7t1✓ i ( d 3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP? f 4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT HAVE? CAPACITY IN GALLONS 100"9 ` (i"c- 4,(" , L 5. HOW IS THE GREASE TRAP MAINTAINED? ON A DAILY BASIS? BY AN IN-HOUSE PERSON OR BY AN OUTSIDE CLEANING SERVICE? 6. WHAT IS THE FREQUENCY THAT THE GREASE IS REMOVED FROM THE TRAP? 7. WHAT IS THE NAME OF THE FIRM WHO REMOVES AND/OR PICKS UP THE GREASE FROM YOUR ESTABLISHMENT? vw- 8. WHAT IS THE DATE OF YOUR LAST INVOICE FROM THE REMOVAL FIRM? 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: 12/14/2011 ESTABLISHMENT NAME: Ben & Jerry's File Number:BHF-2005-000032 60 Washington Street SALEM MA 01970 LOCATED AT: 0060 WASHINGTON STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2012-0015 Jan 1,2012 Dec 31,2012 $70.00 ESTABLISHMENT Total Fees: $70.00 PERMIT EXPIRES Oecember 31, 2012 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a.prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 0eco, ;t1 CITY OF SALEM, MASSACHUSETTS t ! BOARD OF HFkLTH J 120 WAsH1tiGTON STPiLrT,4"'FLOOR TGL. (978) 741-1800 KI NIBE1tL3 Y DRISCOLI, F_\x (978) 745-0343 MAYOR Ira1ndit1&S11Cm.001M l,ARRY RA�tDIN,RS/RF[IS,CI ID,CP-I-S HIS.\ixiI A(;ISN'1' ' 201_ APPLICATION FOR PERMIT T/O� OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT_ $CSN jr{/ S _- TEL#-2q,-77? -74M ADDRESS OF ESTABLISHMENT_ &0 'OT— FAX# MAILING ADDRESS(if different) Z&-roo j GUp EMAIL- Business': Shp�A"" Website: _ OWNER'S NAMEmill� (�(� TEL#_ ADDRESS ' ��, lY� 01 ?T— STREET �,,n CITY ' STATE �p ✓�� ZIP /JUf CERTIFIED FOOD MANAGER'S NAME(S) ,CyW l;l-� (�(� CERTIFICATE#(S) L"�/ (Required in an establishment where potentially hazardous food is prepared) G EMERGENCY RESPONSE PERSON Jam.-'""' HOME TEL# q Z DAYS OF OPERATION Monda — i 'Tuesday i Wednesday 1 _:Thursday-: ' IEddat-�' Saturdlay I Sunk HOURS OF OPERATION �f�J�, V1-6111--1 (2-f/ — (LM+ 2 6 Please write in time of day. I �� (For example Ilam-11pm llt(^' () /Y-P-4/11 (d� " d �� (J �/� { d �/'1'1 ✓J —�"/`r TYPE OF ESTABLISHMENT FEE check only) RETAIL STORE ES NOess an 1000sq. . 1 0 - . . =$280 C lG6- "( t^✓^ more than 10,000sq.ft. =$420 ---------------- ES-- le n 40 --------------------------------------- RESTAURANT YES N less than 25 seats =$140 (Outdoor Stationary Food Cart 0-210) 9 seas. =$2 more than 99 seats =$420 BED/BREAKFAST/ ES ----------------Y--ES-----NO--- $100 CHILDCARE SERVICES/NURSING HOME ----------------------------------- -------------------------------------------------------------------------------------------------------------- - ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES $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 any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns and paid all state taxes required under the law. v ?� - .3I - Si atur late Social Security or Federal Identification Number -- --------------------------- ---------------------------------------- U [ed 23/11 FOODAP201 Ladm Check#&Da ---------- $7 uv 1 o' CITY OF SALEM _ BOARD OF HEALTH �t'l� ' qfaa 61 Page: of 1 Establishment Name: .1/1 `� iQ r c,�� Date: Item Code C-Critical Rem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date- No. Reference R-Red Item Varifed PLEASE PRINT CLEARLY L 1 C�ISJt lSL t "lctl t�tl^G (f1 P C� `I t 1 « 4� 4o t -I .0oS -t r Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. �/�� — -"' ! ❑ Voluntary Disposal ❑ Other: r 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne ltlness Interventions and Risk According to Law Cooled to Factors(Hems 1-22) (Cont.) 4tF/45°F Within 4 Hours. FROM CHEMICALS 3-SO1..I5 Coolie Methods for PHFs PflOTECTiON .._..._......_ FR 19 PHF Hot and Cold Hotdfng 14 Food or Calor Additives__ 3-501.16(B) Cold PITFs Maintained at or below 3-202.12Additives*' 590.004{F} 41°145°F* 3-302:14 Protection from Un raved.4dditives'r 3-501.16(A) Hot PRFs Maintained at or above 15 Poisonous or Toxic Substances 1400F. * 7-101.11 Identifying Information-Original 3-501,16(A) Roasts Held at or above 130'F. Containers* 7-102.11. Common Name-Working20 Containers* Time as a Public Health Control ntr( 7-201,11 Separation-Storage* 3-501: Time as a Public Health Ceontral" 7-202.11 ,Restriction-Presenceand Use* 590.0044((H) VarianceR uiremem 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPiIgLE 7-204.11 Sanitizers.Criteria-Chemicals* - POPULATIONS HSP - 21 3-80111(A) Un smrized Pre-packaged Juices and 7-204.12 Chemicals far WashingProduce,Criteria" � re �� 7-204.14 Drying Agents.Criteria* Beverages with Wanting Labels" 7-205.11 Incidental Food Contact,Lubricants* 3 801.11CB) Use of Pasteurized EW * 7-206.11 Restricted Use Pesticides,Criteria* 3-801.1 I(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. 7-206.12 Rodent Bait Powders, 3-801.11(C) Unopened Food Packs Not Re-served. 7-2(16.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEFI EMPERATURE CONTROLS 22 3-603.11 Coniumer Advisory Pasted for Consumption of 36 Proper Cooking OTR Temperatures far Animal Foods That are Raw.Undercooked or PHFs Not OtherwiseProcessedto Eliminate Pathogens.' 3-401.11Att)(2) Eggs- 155F 15 Sec. eft ti I" r Eggs-Immediate Service 145°Fl5sec* 3-30113 1 Pasteurized Eggs Substitute for Raw Shell 3.401.11(A)(2) Comminuted Fish.Meats&Game Eggs' Animals-155'F 15 see.° 3401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* SPECIAL REQUIREMENTS 3-40I.11(A)(2) Ratites,Injected Meats-155°F 15 590.004(A)-(D) Viaiatians of Section 590.009(A)-(D)in sec.* catering,mobile ford,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Staffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sec. * above if related to foodborne illness 3-401.11(C)(1) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to goal retail 3-401.12 Raw Animal Fords Cooked in a practices should be debited under#29- Microwave 165F* Special Requirements. 3, 401:11(A)(1)(b) All Otber PHFs-445'F 15 sec.* 17 Reheating for Not Holding VIOLATIONS RELATED TO GOOD RETA&PRAC77CES 3-403.11(A)&(D) PHFs 165"F 15 sec. * (Items 23-30) 3-40111(B) Microwave 165"F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Time* foodborne illness intervendans and risk factors listed abase, can be 3-403,11(C) Commercially Processed RTE Food- found in the following sections.of the Food Code and 105 CMR 140°F 590.000. 3-40111(E) Remaining Unsiiced Portions of Beef 1 Item 1G--mood Retail Practices FC 590.000 Roasts* �3__ j 1Aar ent and Personrrel -FC-2 .003 ' 1g Proper Cooling of PHFs 24,Food and Food Protection FC-3 .004 25. Equipment and Utensils ( FC-4 .005 1 3-501.14(A) Cooling Cooked PHFs from 140°F to 2g;1-Water.Plumbinq and Waste l FC-5 .006 70°F Within 2 Hours and From 70'F 27. ( Physical FacilityFC-6 007 � to 4I`F/45'F Within 4 Hours. * 126 Poisonous or Toric Materials FC 7 .008 3-501.W.B) Cooling PHFs Made From Ambient 29. Special Requirements .009 Temperature Ingredients to 410171450F 30 Other Within 4 Hours* ssvoe�mm::axc: 3 Denotes anical harp in the federal 1499 FoW Code a 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: ;� f'{1 * � Sys Date: '"f L h S/(I Page: of a Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date- No. Reference R—Red Item Verified —r PLEASE PRINT CLEARLY r .J t hI -In' --- Z.o f v, oe j c, c-\ej Q, ( ( Q .d t � M 1cr.C.�iwo- St -bP CZ or O ;)Z:(77 ��ZCrKO c7 C ✓ 1i4t2e 1 t ;pI-)trl, Cl 11 i9 1 U - i v i Cz t 1 rSY;S fi I �� ✓ �� fti.uz,r ctS cin F ,K � tlna�ll�h 7Yt�Q'� 'fb S.r T)tiTcer-f Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction r + inspection, to observe all conditions as described, and to Exclusion violations before the next ins p El Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal El Other: A 3.501,14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(8ems 1-22) (Cont.) 41'Ff45°F Within 4 Ileum PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Not and Cold Holding 3-50IA6(B) Cold PflFs Maintained at or below 3-202.12 Additives* 590.004(F) 41°145°F* 3-302.14 Protection from Unapproved AdditivesiQ 3-50IA6(A) Hot PRFs Maintained at or above 15 Poisonous or Toxic Substances l40°F. * 7-101,11 identifying Information-Original 3.501.16(A) Roasts Held at of above 130°F. Containers* 20 Time as a Public Health Control 7-102.11. Common Name-Working Containers* * 3-501;19 Time as a Public Health Control* 7-201.11 Separation-Stora 7-202.11 Restriction-Presence and Use* 90.004(H) Variance R m cement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 'Toxic Containers-Prohibitions* POPULATIONS MSP 7-204.11 Sanitizers,Criteria-Chemicals" 7-204.12 Chemicals fru Washing Produce,Criteria*' 21. 3-801.11(%) LJnpastettri,'red Pre-packaged Iuices and Bevem es with Warning Labels* 7-204.14 ants,Criteria' 3-80IAI(B) Use of Pasteurized Em* - 7-245.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Auimaal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Ss Not Served. 7-306.12 Rodent Bait Stat ons° 3-801.11 C Unopened Food Packa Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY _ CONTROLS 22 3-603.11 Comstmter:Advisory Posted for Consumption of TIME/TEMPERATURE Cooking Temperatures for Animal Foods That are Raw.Undercooked or 16 TURE Proper Not Otherwise Processed to Eliminate P Pathogens.,� '°° 3.401AIA(1)(2) Eggs- 155 F 15 See Egos-immediate.Service 145°Fl5sec* 3-302.13. Pasteurized Eggs Substitute for Raw Shell EggO 3401.11(A)(2) Comminuted Fish,Meats&Game Animals-155°F 15 sec. 3401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 590.004(%)-(D) Violations of Section .540.004(%)-(D)in sec.* catering,,mobile food,temporary and 3401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited udder the appropriate sections PoultrY or Ratites-165'F 15 sec * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Ottaer 145OF* 540.009 violations relating to good retail 3401.12 Raw Animal Fords Cooked in a practices should be debited under#29- Microwave 165T* Special Requirements. 3401,11(A)(I)(b) All Other PHFs-145°F 15 sec. 17 Reheating for Hot Holding VIOLA77ONS RELATED TO GOOD RETAIL PRACTICES 3403:11(%)&(D) PRFs 16S F 15 sec. * (Items 23-30) 3-403.11(B) Microwave- 165`F 2 Minute Standing Critical and non-critical violations,which do not relate to the Time* foodborne illness intervennow and risk factors listed above, can be 3403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140°F" 590,000. 3403.11(E) Remaining Unsticed Portions of Beef item Good Retail Practices FC 59At1 Roasts* 'L-2.3_vIM Management and Personnel !-FC-2 .003 fig Proper Cooling of PHFs 1 24, i Food and Food Protection I FC-3 .004 1 25. i Equipment and Utensils 3-501.14(A) Cooling Cranked PHFs from 140`F to f2g, Water.Plumbing and blasts FC-5 .006 70°F Within 2 Hours and From 70°F 27. Phvsical FAcifi FC-6 .007 to 41`F(45°F Within 4 Hours. * 128. Poisonous or Toxic Materials l FG-7 008 i 3-501.14(B) Cooling PRFs Made From Ambient 1 20ecial Requirements .009 Temperature Ingredients to 41017/456F 30 1 Other Within 4 He=* *Dmotea mificai iWm in the federal 1999 Feed Cale or IV QdR 390.000. I CITY OF SALEM � - BOARD OF HEALTH Establishment Name: 0 * ` )' x , S Date: LfI�S�/1 Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item PLEASE PRINT CLEARLY Verified � P rI e O c a ' f v y �t� u ,I! 1 LP 0 , av � ; T fi h Ito C G t't lY -fCF (Ln- ctkp t ';Z-S C'xni c� 'ten �o CM r a le I Fnoncompliance ssion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes ge read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restrictionions before the next ins ection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension ly with all mandates of the Mass/Federal Food Code. I understand that may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure ood permit. /— / ❑ voluntary Disposal ❑ Other: � 3-501.140 PHFs Received at Temperatures Violations Related to Foodborne filrress interventions and Risk According to law Cooled to Factors fftems 1-22) (Cont.) 41'F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501..15 Coolie Methods for PHFs 14 Food or Calor Additives 19 PHF Hot and Cold Holding 3-50IA6(13) Cold PRFs Maintained at or below 3-202.12 Additives* 590.004(F) 4i°145'F* 3-302.14 Protection from llna roved.0.dditives' 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 146°F. *6°F. 7-10131 identifying Information-Original 3-501.£6(A) Roasts Held at or above 130'R * Containers* Time as a Public Health Central Common 7-102.11. CommName-Working Containers* 20 3-501.14 Time ase PublicHealthControl* 7-101.11 Separation-Stow e* 590.064(H) Variance Requirement 7-202.11 .Restriction-PresenceandUse* 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 'Toxic Containers-Prohibitions* POPULATIONS HSP 7-204.11 Sanitizets.Criteria-Chemicals* 2] 3-801.11(,A) Unpas#eurixed Pre-packaged iuices and 7-204.12 Chemicals for Washing Produce,Criteria* .Beverages with Warning labels* 7-204.14 Drying Agents,Criteria* 3-801.12(B) Use of Pasteurized Eggs* 7-205.11 incidental Food Contact,Lubricants* 3-801.1 t(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides;Criteria* Raw Seed S ms Not Served- 7-206-12 erved7-206.I2 Radent Bait Stations* 3-801AI(C) Unopened Food Package No Re-served. 7-206.13 Tracking Powders, Pest Castrol and Monitoring* -CONSUMER ADVISORY _ T1MEfiEMPERATURE CONTROLS 22 3-603,11 Consumer Advisory Posted for Coonsumption of 1� Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked o No Otherwise Processed to Eliminate PHFs - Patbo•ens.*`0"`'/` 3-401.11A(i)(2) Eggs- 155°F 15 Sec. Eggs-Immediate Service 145°Fl5sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell E * 3401.11(A)(2) Comminuted Fish.Meats&Game .Animals-155°F 15 sec. * SPECIAL REQUIREMENTS 3401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 min* 590.009(A)-(D) Violations of Section .594.009(A)-(D)in 3-401.11(A)(2) Ratites, Injected Meats-155°F 15 sec.* catering, mobile laud,temporary'and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat. debited under the appropriate sections Poultry or Ratites-165°F 15 sec * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and rU-factors. Other 145°F* 590.049 violations relating to good retail 3401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Micmwave 165F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165'F 15 sec.* (Items 23-30) 3-403.11(B) Microwave-'165°F 2 Minute Standing Critical,mid non-critical violations,which do not relate to the Time* - foodborne illness interventions and risk factors listed above, carrhe 3-403,11(C) Commercially Processed RTE Food- }bund in the following sections of the Food Crude and 105 CMR 140°F* 590.000. 3-403.11(E) Remaining Uosiieetl Portions of Beef % item ! Good Retail Practices -FC 59A.000 R��„ 2-3._ i Management and Personnel FC-2 .00.3 i 1g Proper Cooling of PHFs t Food and F Protection F FC-3 004_� 1 25. 1 Equipment and Utensils FG-4 DOS I 3501.14(A) Coaling Cmked PHFs from 140°F to 1 26. ~Water.Plumbi and Waste � FC-5 .006 70`F Within 2 Hours and From 70°F 27. Physiced Facility FC-6 .007 to 41°F/45'F Within 4 Hours. * 28-- Poisonous or Toxic Materials E FC-7 .008 3-501.14(B) Coating PHFs Made From Ambient 29. S ecial Reouirments .009 Temperature Ingredients to 4171450F ;_30. 1 Other Within 4 Hours* *Dmo u%critical i�,m in the f&ral 1999 Food Code a'105 CvIR 390.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Rem Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION [we No. Reference R-Red item Verified ' PLEASE PRINT CLEARLY Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 0 Voluntary Disposal 0 Other: 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(items 1-22) (Cont.) 41'F/45'F Within 4 Hours. PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PRFs 14 - Food or Color Additives 19 PHF Not and Cord Holding 3-501.16(6) Cold PHFs Maintained at or below 3202.12 -TAdditives* 590.004(Fl 41°145°F* 3-302.14 Protection from Un roved Addiuves't 3-501.16(A) Hoc PHFs Maintained at or above 15 Poisonous or Toxic Substances 140`F. * 7-101,11 Identifying Information-Original 3-501.16(A)A) Roasts Held atorabove 130°F. Containers* * 7-102.11. Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Stora * - 3-501:19 - Time as a Public Health Control* 7-202.I1 .Restriction-Presenceand Use* �90.604(H) VarianceR Requirement 7-202.12 Conditions of Use* 7-203.11 roxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS HSP 7-204.1.2 Chemicals far WashingProduce,Criteria* 21 3-861.1.1{A) Bev rages wit Pre-packaged els* and 7-204.14 in Agents.Criteria* .Beverages with Waxers Labels* 3-801.11(6) Use of Pasteurized B * 7-205.11 Incidental Food Contact,Lubricants* - 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served.* 7-206.12 Rodent Bait Stations' 3-801.11 C Unopened Foal Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* .CONSUMER ADVISORY TIMEtrEMPERATURE CONTROLS Animal 3.603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or PHFs - Not Othermse Processed to Eliminate Pathogens.* 3-401.I lA(I)(2) Eggs- 155'17 15 See. x ovr, r Eggs-Immediate Service 14501715sec* 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game E r ,Animals-155°F 15 sec. * SPECIAL REQUIREMENTS 3401.11(13)(1)(2) Pork and Beef Roast- 130°F 121 min* 590.009(A)-(D) Violations of Section.590.009(A)-(D)in 3-401.11(A)(2) Ratites,Injected Meats-155'F 15 sec.* catering,,mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Staffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-I65°F 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to gold retail 3401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165F* Special Requirements, 3-401.11(A)(1)(b) All Other PHFs- 145°F 15 sec. 17 Reheating for Not Holding VIOLA77ONS RELATED TO GOOD RETAIL PRACTICES 3-403.41(A)&(D) PHFs 1657 15 sea* (Items 23-30) 3-403.11(B) Microwave--165`F 2 Minute Standing Critical.and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in the folloning sections of the Food Code and 105 CMR 140°F* 590.000. 3403.11(E) Remaining Unsliced Portions of Beef item Gond Retail Practices j .FC 590.1190 Roasts* ;_23. 1 Management and Personnel -1 FC-2 .003 1g Proper Cooling of PHFs j 24. i Food and Food Protection i FC-3 .004 125. I Equipment and Utensils I FC-4 005 I 3-507.14(0) Cooling Cooked PHFs from 140'F to 26, Water.Plumbingand Waste FC-5 .006 70`F Within 2 Hours and From 70°F 27. Physical Facility 1 FC-6AD7 . to 41'F/45'F Within 4 Hours.* L28. Poisonous or Toxic Materials + FC 7 .008 3-501.14(8) Cooling PHFs Made From Ambient 29. S ecia ft uireme us 009 r Temperature Ingredients to 41°F/45°F 130. Other i Within 4 Hours" Nnous criticat d4m in the Lederal 1999 Foal Cale a'105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Item Code C—Cdticat Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item -Verified PLEASE PRINT CLEARLY T a r: Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance El Employee Restriction Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: 3-i01.14(C) PHFs Received at Temperatures Vioiadons Related to Foodborne illness interventions and Risk According to Law Cooled to Factors(Nems 1-22) (Cont.) 41'F/45`F Within 4 Hours. ROTECTION FROM CHEMICALS 3-501.15 Coohn^Methods for PHFs P P Food or ICALColor Additives - 19 PHF Hot and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Additives* 590.004(b) 410145'F* 3-302.14 Protection from Una roved Adduivesi4 15 Poisonous or Toxic Substances 3-501.16(A} Hot PHFs Maintained at or above 7-1011 Identifying Information-Original 2d1400F..) 3-501.16(A) Roasts Held at or above 130'F. Containers* _ 7-102.11. Common Name-Working Containers* 20 Time as a Public Hearth C * 7-201.11 Separation-Stora e* 3-501:19 Time as a Public Health Control- 7-201. ontnt of ral 7-202.11 .Restriction-Presence and Use* 590.0040 Variance] uiremeffi 7-202.32 Conditions of Use* 7-203.11 Toxic Commiter;-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPi1®LE 7-204.11 Sanitize".Criteria-Chemicals* POPULATIONSS(HSP) Unpasteurized Chemicals for Washin Produce,Criteria' 21 3-801.11(A) Unpas#suced Pre-packaged Juices and :Beverages with Warning Labels* 7-204.14 ants.Criteria* 3-801.11(6) Use of Pasteurized E.-as* 7-205.11 Incidental FoodContact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides; s;Criteria* Raw Seed Sprouts Not Served.* 7-206.12 - Rodent Bait Stations* 3-801.11(C) Unopened Food package Not Rc-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEMEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures far Animal Foods That are Raw.Undercooked or Not Otherwise Processed to Eliminate PHFs 3 40LIlA(i)(2) Eggs- 155'F 15 Sec. Patho i' E Eggs-immediate Service 145'F15sec'r 3 302.13. Pasieuriasd Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game Animals-155'F 15 sec. SPECIAL REQUIREMENTS 340L11(B)(1)(2) Pork and Beef Roast- 130'F 121 min* 3-401A I(A)(2) Ratites,Injected Meats-155`F 15 590.009(A)-(D) Violations of Section 590.009(A)-(I))in sec. * catering,mobile ford,temporary and 3401.1 I(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited udder the appropriate sections Poultry or Ratites-165'F 15 sec. * above if related to foodborne illness 3401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145OF* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165'F* Special Requirements. 3-401;1l(A)(1)(b) All Other PHFs-145'F 15 sec. 17 Reheating for Hot Holding VIOLA77ONS RELATED TO GOOD RETAIL PRACTICES 3-403AI(A)&(D) PHFs 165°F 15 sec.* (Items 23-30) 3403.11(B) Microwave- 1650 F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 1400F* 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef Item Good Refait Practices J .FC 6911.000 i Roasts* �' 223. 1 Management and Personnel , FC-2 .003 - i lg Proper Cooling of PHF9 L4 i Food and Food Protection FC-3 .004 25. Equinment and Utensils1 FC-4 005 3-501.14(A) Cooling Cooked PfWs from 140`F to ;2- Water.Plumbing and Waste __v ^I FC---ss 006 700F Within 2 Hours and From 70'F 27. Physical Facility Fr,-6 .0=07:= to 41`F/45'F Within 4 Hours. * 128. TPoisonous or Tewc Materials ' FC-7 .008 I 3-501.14(6) Cooling'PHFs Made From Ambient 129. S eciai ReqUirernentS .009 Temperature ingredi.ents to 41'F/45°F 30- i Other Within 4 Hours* "*`' 3 Denotes critnat mra in the federal 1999 Focd Cate m'105 CMk 590.000. Page 1 of 1 Elizabeth Salandrea From: sjh [sjgoog@gmail.com] Sent: Thursday, April 21, 2011 11:27 AM To: Elizabeth Salandrea Subject: Fwd: Sery Safe Certification ---------- Forwarded message ---------- From: Sarasin,Michael <MSarasinggltech.org> Date: Thu, Apr 21, 2011 at 11:09 AM Subject: Sery Safe Certification To: sj ooQna,email.com Susan Hull is scheduled for a class with me on Tuesday May 3, 2011. Thank you, Michael Sarasin 4/22/2011 r i Commonwealth of Massachusetts r F i City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Temporary Food Permit DATE PRINTED: 03/23/2012 ESTABLISHMENT NAME: Ben & Jerry's Fite Nwnber:BHF-2005-000032 60 Washington Street SALEM MA 01970 LOCATED AT: 0060 WASHINGTON STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions!Notes TEMPORARY FOOD BHP-2012-0399 Mar 24, 2012 Mar 25,2012 Permit for Salem's Spring Fling- Food to be served: Ice Cream Total Fees: PERMIT EXPHiES March 25, 2012 Board of Health Page 1 2� CITY OF SALEM, MASSACHUSETTS v~ � BO.ARD of HEALTH 120 WASHINGTON STREET,4" FLooR TEL. (978) 741-1800 1iIR4BERLFY DRISC4LL FA.1(978)745-0343 MAYOR `D�I?r•NBnual(�snl Fat.CUM DAVID GREENBAUM,RS Ac TING HEALTH AGENT APPLICATION FOR A TEMPORARY FOOD SERVICE PERMIT �G FEE: 1-3 DAYS= NO ---w9- NON-PROFIT=-$2&- 4-7 DAYS= $f 89 OVER 7 DAYS= >7 DIVIDED BK.Z x flo =THE AMOUNT DUI (EXAMPLE:14 DAYS DIVIDED BY 7=2 x600=$1201 CHECK PAYABLE TO THE CITY OF SALEM NO CASH ) NAME OF EVENT ((^�. LOCATION ��aaV( DATE(S)OF EVENT c"`�(t k f Y , cX) NAME OF APPLICANT_ �P ��/<!'i,� ,��.�J",�I�++ Ce(' CP)M�{ ('J!' 4'IZJy1 7" NAME OF BUSINESS 6C�V, -�:JLJYJ TELEPHONE# -C'`I c1 `�Lt I-so ADDRESS C�JC �.�C� ✓� t CERTIFIED FOOD MANAGER'S NAME ,UZc A, CERTIFICATION# A PLAN OF THE ESTABLISHMENT IS: ENCLOSED DRAWN ON THE BACK TYPE OF REFRIGERATION: —GAS FCE DRY ICE OTHER METHOD FOR COOKINGIHOT HOLDING: GAS _OTHER METHOD FOR SANITIZING: __CHEMICAL OTHER SOURCE OF FOOD: NAME: 'rc& C..r-yza t., ADDRESS O FOODS TO BE SERVED INCLUDING INGREDIENTS AND METHOD OF PREPARATION: I HAVE READ THE BOARD OF HEALTH,"REQUIREMENTS FOR TEMPORARY FOOD ESTABUSHMENTS."I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS REGARDING THOSE REQUIREMENTS. I UNDERSTAND THEM,AGREE TO ABIDE BY THEM AND UNDERSTAND THAT FAILURE TO DO SO WILL RESULT IN REVOCATIC OF MY TEMPORARY FOOD ESTABLISHMENT PERMIT, PURSUANT TO MGL C62c,S49A,I CERTIFY UNDER THE PENALTIES OF PERJURY THAT I,TO MY BEST KNOWLEDGE AND BELIEF,HAVE FILED ALL STATE TAX RETURNS AND PAID AL TATE TAXES REQUIRED. 1 UNDER LAW. Ay`_ SIGNATURE DATE f SOCIAL SECURITY OR FE 7-0I TEMPAPPL10-11.0 REVISED 10/6110 PERMIT# CHECKNB DATE CITY OF SALEM BOARD OF HEALTH Name of Establishment: Ben & Jerry's Ice Cream Address: 60 Washington Street Owner(s): Susan Hull Phone: 978-744-7500 The Owner of this establishment came before the Board of Health because she has been operating this establishment since April 1, 2011 without a valid food permit. FLOOR PLAN The floor plan for the previous owner will not be changed. Hand sinks must have wall hung soap and paper towel dispensers. These must be stocked at all times. If the hand sink is located close to a food prep area, a splashguard may be necessary to prevent cross contamination. All floors, walls, and ceilings where food, utensils, paper products, etc, are stored, prepared or served must be intact, impervious, and easily cleanable. EQUIPMENT All food service equipment must be NSF (National Sanitation Foundation) approved. MENU/FOOD PREP The menu will remain the same as under the last owner. There may be no bare hand contact of ready-to-eat foods. Gloves, tongs, or tissues must be used when handling such food. CERTIFICATION There must be a Certified Food Manager working at this establishment full time. When a CFM is not onsite there must be a Person-in-Charge (PIC) who is fully trained in sanitation techniques and has a thorough understanding of the operation. Please provide copies of Serve Safe certificates to the Board of Health. ALLERGEN AWARENESS The allergen warning must be posted on all menus and menu boards. Information was given to the owner. EXTERMINATION Monthly services of a Licensed Pest Control Operator are required. Please keep receipts for inspections. SANITIZING SOLUTION Sanitizing Solution must be accessible at each prep station and for the patrons' 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 3rd bay of the 3-bay 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. Outside area of premises, including the dumpster area, must be kept clean and sanitary. CHOKE SAVING There must be a person trained in choke saving techniques at all times the establishment is open. /A Iva David Greenbaum Date Acting Health Agent &usnull Date Iii �Wv3��. Wit, cpi ,�{• (tsv- rn dG��413- ,�I ,cjC2t�'4�'cS1h^1 5(h i I Commonwealth of Massachusetts City of Salem Board of Health Kirnberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 04/15/2011 ESTABLISHMENT NAME: Ben & Jerry's File Number:BHF-2005-000032 60 Washington Street SALEM MA 01970 LOCATED AT: 0060 WASHINGTON STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2011-0430 Apr 15, 2011 Dec 31,2011 $140.00 ESTABLISHMENT Total Fees: $140.00 PERMIT EXPIRES IDecember 31, 2011 Board of Health ` R 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 y d BOARD OF HEALTH 120 WASHINGTON STREET,4"'FLOOR TEL. (978) 741-1800 KINIBERLEY DRISCOLL FAx(978) 745-0343 MAYOR DGRFENIIAUM@SALEM.COM DAVID GREENB AUM,RS ACTING HEALTH AGENT 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT � 4Sf� TEL# /BL -7L �,( IO0 ADDRESS OF ESTABLISHMENT FAX# MAILING ADDRESS(if different) D EMAIL- Business': 2:e, UG 11 G� ,6CU8 ��1Qebsite: OWNER'S NAME �� TEL# D2 �(—os F z7 ADDRESS 06 ewt5r ;Z 6AIl "" n if D STREET ' L CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) l�5 6ut't-u CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared)�,e,rR.N q/-7 � — �7 EMERGENCY RESPONSE PERSON (/ , Ly HOME TEL# ( � 1-7 ��S �� / DAYS:OFOPERATION dMonday (',"`Juesday °.Wednesdays ''Thursday>` F-ridgy• `Saturday" Sunday HOURS OF OPERATION Please write in time of day. c(,V / �✓� (�' ( '� (Z I �Z— (Forexamplellam-llpm) ! ! TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES ® 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 ----------- --- ----- .... BED/BREAKFAST/ YES -- $100 CHILDCARE SERVICESINURSING HOME----------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES $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 any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns and paid all state taxes required under the law. 3703 -3 711 Signat a Date Social Security or Federal Identification Number Revised 10/7/11 FOODAP201 Ladm Check#&Date 1 I CITY OF SALEM BOARD OF HEALTH Name of Establishment: Ben & Jerry's Ice Cream Address: 60 Washington Street Owner(s): Brett & Linda Danyluk Phone: 978-744-7500 The Owner of this establishment came before the Board of Health because he had been operating this establishment since September without a valid food permit. FLOOR PLAN The floor plan for the previous owner will not be changed. Hand sinks must have wall hung soap and paper towel dispensers. These must be stocked at all times. If the hand sink is located close to a food prep area, a splashguard may be necessary to prevent cross contamination. All floors, walls, and ceilings where food, utensils, paper products, etc, are stored, prepared or served must be intact, impervious, and easily cleanable. EQUIPMENT All food service equipment must be NSF (National Sanitation Foundation) approved. MENU/FOOD PREP The menu will remain the same as under the last owner. There may be no bare hand contact of ready-to-eat foods. Gloves, tongs, or tissues must be used when handling such food. CERTIFICATION There must be a Certified Food Manager working at this establishment full time. When a CFM is not onsite there must be a Person-in-Charge (PIC) who is fully trained in sanitation techniques and has a thorough understanding of the operation. EXTERMINATION Monthly services of a Licensed Pest Control Operator are required. Please keep receipts for inspections. SANITIZING SOLUTION Sanitizing Solution must be accessible at each prep station and for the patrons' 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 3`d bay of the 3-bay 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. Outside area of premises, including the dumpster area, must be kept clean and sanitary. CHOKE SAVING There must be a person trained in choke saving techniques at all times the establishment is open. anne Scott Date Health Agent Brett Danyluk Date - �IsAFE ® �L_ �°r J I� R7:0�1 I 5WM 9/4' ° KIADA TOIL. (i ],E 1 1 , 26E aE 20E PAtB — / I 14 ,,% •• BEN & JERRY'S REV. PRELIMINARY PLAN or IM I' °° sre — scale:3/16'=1'-0" 1i�11'I, °° 4e 5'M we SALEM, MA ICS ME -- 795± GSF ME PUBLIC AREA =214± NSF 4M 9E � .4°E ��, I @ 50 SF PER =5 PEOPLE - f� I SERVING AREA = 188± NSF I -- 4 E KITCHEN /A.D.A. TOIL. = 288± NSF ° .0 00 o @ 200 SF PER = 3 PEOPLE _ •In v+ o 4294 NAPE d 6 TOTAL OCCUPANTS 4"W"" s a"" e&LI� ( F O Ben&Jerry's Ice Cream Shop r«me 8 Decembw 2M4(mv.15 DecembarM) Downtown Salem, Salem,MA WAwS EQUIPMENT SCHEDULE- BEN & JERRY'S ITEM On MANUFAMRR MODEL NO. POW RMIJIREM PWWING NOIES M6c.N= VOL15 H[ P ARP Watt HP Donrecf Wtg.Hl. 0 wnwL lW.Lt 2 GOMTCO !OW 12D w 11- ke L� {1' f F'LLLSt 2E DIP CASE O MA51FR ULP I` Ll.-opt 110 60 1 1 11 11 15CORP S",R YL1JEMh 5..15P me LXPlA 1 NNIS tKLT L066L 12D 60 1 OJ - IB 0110W a! OIPF611d. I W 101W.W. w"Y-10011 _ _ _ ur I If MM l�Y 16fN1ATOM of ee WII R[OOlOt I Pram 0r6T04 ea.eee - - - - 3110 LP 4RISATm IWaDYNf! W 11 PIWLAYFl+f>®R I MA51043T IB 60 1 m - 421 E OOTR!YM10t OMAI.AT I MOII NR OBaOD - - _ DRNN TO RO6mGT 1tA91E 4 3 v DRAM 5E HOT 1 EP 0 - 4E NOT U:rtD i� - I0E ICE GAPO/ O GPMEKO R k.!lW.et WODI 1 IVNTQtlY OIOA FB 601 52 - W G� yr VT GI PWtOGT MtT! IWD!!K I2',EG'C I TRJ'PNCEr 5!K 1'Olt IL!faSM1 19E MIXER O NE M PP` f 120 L'P 1 - 16Y.1 . Al OORP 4.^" PL IR KsO 2 VRA•KX 01001 120 60 1 0 _ "W40 CGI6) 6TI0W eR RrvidwATW F KW=eLLT WT-40 10 W I 40 - 0 IN awl 2Y WOAOrm 14E Npf U5ED O - r R now KA 6 I PNOn.G10 PSLtl2D m 11- - SOMCl GOr✓D a2' ft WIIIWIAIP C4 I � 0.�-QODO 12D 60 1 - M OIMTAL6 I T00 64a0D MO 60 I _ _ _ 61lNY20011D �. 201 MCFl6HT 1MRGNN+VISE O FIAST[R-INL? i16.'LIIID 115/.g� 1 yT/ 15A CORP 90" ]! OQ4+lGT Hi I 0001X W2E0 � 60 1 O If40 BA a2' 22I TR"55.TA€l9 0 IPRI611r Ia MGWATOR I MA9104pLT CCR.2'!,R to 60 1 55 - 10 M GLI✓D 90' 6T".W Sim I _ _ _ _ _ 1 FOR 4 BFRY WORM Y1TMKlf T16QMYWr60N 1 AP/.TAO T-8.5446RL.x _ KK SWMY _ _ - FFF2,WAW CA I 261 MRM! N0 2 MER WAL 1140110t V,IVL JIT]lE n 5MRAIEMOA DS.ItiP 1[W T gAFY D1K4p. O Jrw,1 z9b 9 1 z3 24^ "W5fE HIRE EMIi.V1n4 4aIITS <G F/AR TISK 0 40"/.TRB(A – 2.qf OFFICE FUPIIINRE 01. EOI 6PFE O - 51E 4.OGKEPS p - � 1 WbT MT 200 I - y - OD' wNMIGA1l WAN 5Jf NPFFLE GONE 5NELF G UY7011 - 54E 5TERW 5YETEM 0 Rip TEv _ E£RYIGE CORP 3O.]O VSTALL POvkR I'V ,115TF11 SF�'AKFRS 4:01!O0X I COM" 5EF UNDEFLpJNTER PEFRI6ERATOR SE O MASTFP.NLT IK�2 115 EO I 4.0 1/Ti I'4E-PP 24- YV(,!STEPS WPOOP. 6 OISP� Od6LT4 3tlE FREEZERFEP{.N-IN p MR5TERAiLT TPFNB D♦= U55./ N', I WMEPa•D4-ICP IIo- 39E VR.IS R A�-In O MA5'IEK£ILT GGP-2PWMEM�A.9-I'P IP :O ITZ I!E PROP-IN 5TAIIILLh 5T 1- ADJAIIGEP MTM Y4lY.ET AJTi VAS NH1 VNF.FOP AGE CRfmi NPSN efW 12-mwxl0^ O T15F&XET VI 1/Y4.A W 11.1`.W 11TF 40 S FTSERVE O TAttOR 95a 5E YCCWRO 65. 42E DROP-III IGE P1114 O [WTOM STMKE'h 5iE(y. Ben&Jerry's Ice Cream Shop for the 6 December 2004(mv.15 De mblXM) Downtown Salem, Salem,MA WALLIS 1 7 EQUIPMENT SCHEDULE- GREEN MOUNTAIN COFFEE ROASTERS M REM MANUFACNRFR MODS NO. POWER REGUIRFiADA$ PLUMBING NOM M6G NOM Mn Nz I M Amp WR XP Comxl Mnip.M. CLR[!wlNOt9 3 WWMP 41E AT U EJ 4`:f EN'FTY.,K'1'JKAp£ 0 5n CRW AMI:ICNIL -{ ..JGY,15n 15 rPGWPS ]OB 601 PDp ,fjyA LE.ry, 5'rt5M' WfILTRATIVI{5't51EN 53E v.C,pLFHKfR[.iLR G 11AhTE.WEI4T W.RB.R 115 JO I 90 Iry p� S S5' ,x nor VEa CGI�S wmea I RR4 sow ]ta eD I eb - IGMIIFsoR V1'tKPgbW eaoLm.PeIIP! A9E !>P/JF'N1�Ak'R25.41K'L p b'yVfltC.tG I>I-I-It' YY I'1W 1 bY:Y•yl Wti}H'JINh'I•GH Cipl'Iy:F. lYXle'YIp' T16FMKET 'i'1YI MVI,I I,-114117 4: FCE 4FY4fk O l vi 621 lyp I`v ISn LL'FP 94' W pEInA BIV 52E 0.0.PFFRIG$Vi4yt O P.SMP-61L'I fPl•FlD Ilj 5p 9p - I@ 15h pGVp _ _ W NFI,A 5-F•P %N S[ ILE PM O w i pIE-IIID 1112 ilyplFELi YWSIE 39E GA&1PKI5TER 0 fi*P05YS1CM ELLIF2E STUGN40 WG}L,In4lxtyN,PKAw,QH • � � � " < RxI ATEfi NAPE WARF IVAYr'{3.4f+"4/ICt 1GY I�h IgYU � G'fAVY/.,.KE C vLIG R6i90P.0 ITO Wi I Ila PV Iff'(A 5-r.P £1tCiP 96 (.LP GtW,;RN P 0 DISa@IW.PITE AF'J•P 5RFL/•".'6P N,.t,OCi+ 4Y� .P5l30 - 51� 6NpLpt/Tt1l.FY thY p ;.ONCL'Fi5FT5 120 ti1r,4r Rb509C9BI.R B IW Hek.5n1 F GtiSflkY G',. U 1 0 fi FN.IYI 5'pkyLINVLL I:q 6(X7 CA51l.hT6N£ 0 /AdIC@i� RpyAD98W 120 DO I I.IJ WM4FlA5-IA *`-p1�•C'V 816YLt1RR 1 wsm 1CD60 1 RB YM - IOMl1FsoR tl` yr otronnw GfIwO.Mm Il91�'1115 Ben&Jerry's Ice Cream Shop r«me BDecember 7DOdIrev.lS DetembersKpol Downtown Salem, Salem,MA WALUS S� ERgYstl II&VT11�L-4- BEARER OF THIS PASS MAY MOVE DIRECTLY TO THE FRONT OF THE LINEI Ground Control, Can You Hear Mez � ...Gluten Free... ❑rganic..Vegan... No ❑holesterol...No Preservatives... No Artificial Flavors or Colors... � 0 Grams Saturated Fat... 0 Grams Trans Fat... E WL- Only Use Sea Salt... pr iL SoumedMO% �. x � r C .- . Pbfafoes 100%bamboo papa, plafety _ 3 Potato LlI Salem,So Washngton St Yd hh �J* OPick Your Size SM MED LG $3 S4 $5 Add Space Sauce © Add $1 BIG BANG SRUIE THAI 0-01-1 SAUCE WARY KETEHUP BBO MAYO PEANUT SWAY PE510 MAYO MUSTARD HONEY O-UPOITE MAYO CURRY SAUCE GRRLIC PEPPER SAUCE VEGRN GRAVY © Add an Extra! .50 Vegan Bacon Bits Vinegar Malt Siracha Hot Sauce Krypto Ketchup a.. THE BEARER OF THIs pAss MAy MOVE DIRECTLY TO THE FRONT 0F THE LINE, � � t s ;r 4 4 4 t t w; • i TaE BEARER OF TgIs ppss m MOVE DIRECTLY TO TaE FR - NT 6iF TaE LINE! �� ' YY %�� .k, t / 1 t�... . �' r �LL , i ` t c �� +ti °1 ��(�i �� v�, i RSR o� ,�ais E e�� vE Q�`ss �Py to tai �� os&�c-cr.©� �ta� �sN FRONS y F • ' i i WER v TAE BEARER OF TA1S ppss MAy M�YE DIRECTL}' Tri TAE FRONT OF TAE LINE! t mow, f ul! Ufa r THE BEARER OF THIS ppss MAy MOPE DIRECTLY TO THE FR0NT OF THE LINE! • � � . • . �� o° '' . �� o z ' �, � � � i i �� • �� ✓�"" --- i 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: 01/04/2010 ESTABLISHMENT NAME: Ben & Jerry's Fite Number:BHF-2005-000092 60 Washington Street SALEM MA 01970 LOCATED AT: 0060 WASHINGTON STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2010-0004 Jan 4,2010 Dec 31,2010 $140.00 ESTABLISHMENT Total Fees: $140.00 PERMIT EXPIRES D ecember 31, 2010 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 r CITY OF SALEM, MASSACHUSETTS * + BOARD OF HEALTH 120 WASHINGTON STREET,4"'FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAx(978)745-0343 MAYOR DGREENBAUM&ALEM.COM DAVID GREENBAum, ACTING HEALTH AGENT 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABrLIS�7HM,E/NT��,l NAME OF ESTABLISHMENT �r�/� TEL# ADDRESS OF ESTABLISHMENT © W C(SYII r) S�3'to ems- FAX# f1 z`- MAILINGADDRESS(ifdifferent) y�� EMAIL- Business': wCSC00 UL2hOd.C�IJYH Website: WwW. bej; /-Coryi /-C,?le-yj / OWNER'S NAME IBJ///2 rl U LGCu/ __�GLYtu)/t—at, TEL# '7 �n �d- 6 7S `� ADDRESS t0 '?V-A /S-d -t TEL MTr olq?O STREET p-f�- CITY STATE -7 C rZIP CERTIFIED FOOD MANAGER'S NAMEIS) �l"' ' Nl ulL' CERTIFICATE#(S) (Required in an establishment where potentially hazardous flood is prepared) EMERGENCY RESPONSE PERSON'?Ke-� Or-1-1 hd� �GLtl /u HOME TEL# DAYS OFOPERA IONW Mond0M " TM@sd`a"; �Wetlnesday, W Tfiursday i ,F,t tla'" " Saturda , S,unday HOURS OF OPERATION Please write in time of day. NO I 40 yV� dbiY3'1 For example Ilam-11 m N 't� - ! Y TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 1 0,000sq.ft. =$420 --•------ -------------- •---_ ---- -----------------------•-------- ------ ------------------------------------------_ -- RESTAURANT YE NO less than 25 seats $140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 ---------•-•-•-------------------------- - --------- --------- ------------------ ----------- --...........................---- --------- BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES/NURSING HOME ----------------------------------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,before any renovations, improvements, or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Saction 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax r rid paid all state taxes required under the law. /0/14/0 2© sLH QST-7 Date Social Security or Federal Identification Number. -- -------------------------- •— -- �'7T7—=------- --------------- Revised 424/07 FOODAP2008.adm Check#&Date Commonwealth of Massachusetts 3 City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 One Day Catering Permit DATE PRINTED: 05/28/2009 ESTABLISHMENT NAME: Ben &Jerry's File Number:BHF-2005-000032 60 Washington Street SALEM MA 01970 LOCATED AT: 0060 WASHINGTON STREET SALEM, MA 01970 Permit Type Permit No: Permit Issued Permit Expires Fee Restrictions/Notes CATERING BHP-2009-0469 Jun 3,2009 Jun 5,2009 Food to be served: Ice Cream Sundaes Total Fees: PERMIT EXPIRES IJune 5,2009 Board of Health Page 1 i CITY OF SALEM, MASSACHUSETTS r BOARD OF HEALTH 120 WASHINGTON STREET,4"FLOOR TEL. (978) 741-1800 K MBERLEY DRISCOLL FAX(978)745-0343 MAYOR NIONNEnG SALEM.COM JANET DIONNE, ACTING HEALTH AGENT CATERING NOTIFICATION FORM 2008 FEE: $25/Event $200/Year Date of Application: SIU109 Date of Event: (if 41 CQ Check#: Check Date: Name of Catering Business: WI C4M O(Ma Ol��`ti. Address of Catering Business: YJ� washcr5fr Sf• Ealam a brn tq Owner of Catering Business: f�� Ignd cC lajun Address.ofOwner: �P Bw -4 St- �,m MA 0lq9D Name of Customer: MIc tt OW A RXU,L— Address of Event: &�IVA&Wes &&mM-�6 ki Menu: ICE c(hm Q* ( A n e f CITY OF SALEM, MASSACHUSETTS + • BOARD OF HEALTH 120 WASHINGTON STREET,4"FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 MAYOR 1D10NNE SALEM.COM JANET DIONNE, ACTING HEALTH AGENT MEMORANDUM Date: 9/3/08 To: CATERERS SERVING FOOD IN SALEM From: Janet Dionne,Acting Health Agent RE: Board of Health REQUIREMENTS A reminder that the Salem Board of Health requires: All food establishments(this includes catering)preparing food for service in Salem employ at lease one Certified Food Manager. Such establishments which employ 10 or more full time employees directly involved in food preparation shall employ at least two Certified Food Managers. The Board of Health office maintains listing of classes of which we are notified. The Massachusetts Department of Public Health "Minimum Sanitation Standards for Food Establishments, State Sanitary Code Chapter X, " 105 CMR 590.000, regulates all food establishments in the State including catering operations. Section 590.033 requires that • Each caterer have as its base of operation a food establishment that complies with the regulations and is permitted by the local Board of Health, and • Each caterer notify the Board of Health of the city in which it plans to serve food, prior to serving it elsewhere than its own establishment,and • The caterer give notice to the board,on a form provided by the Board, prior to or within 72 hours of serving food elsewhere than its own establishment The Salem Board of Health has determined that the fee for this notification procedure shall be$25 per event up to a maximum fee of$200 per calendar year. A caterer may pay$200 at one time if he or she expects to cater more than eight events before December 31st. To summarize: Caterers must notify the Salem Board of Health, on the enclosed form, of any events being catered in Salem, and each catering business must have at least one Certified Food Manager in order to serve food in Salem. Enclosed are the notification fortes as described. You may make copies of this form or call the Board of Health for additional forms. Please call me if you have any questions regarding these requirements. Sincerely yours, Janet Dionne, Senior Sanitarian (caterers memo) Commonwealth of Massachusetts . City of Salem Board of Health IGmberiey Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/29/2008 ESTABLISHMENT NAME: Ben &Jerry's File Number:BHF-200"00032 60 Washington Street SALEM MA 01970 LOCATED AT: 0060 WASHINGTON STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2009-0239 Dec 29,2008 Dec 31,2009 $140.00 ESTABLISHMENT Total Fees: $140.00 PERMIT EXPIRES December 31,2009 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"'FLOOR TEL. (978) 741-1800 KINIBERLEY DRISCOLL FAx(978)745-0343 NIAYOR IDIONNE&ALEM.COM JANET DIONNE, ACTING HEALTH AGENT 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT � p 'ac.ry 4 NAME OF ESTABLISHMENT w rt*G. C. SUd S Aa � ti STEL# `0 S -7` 9 -7SCId ADDRESS OF ESTABLISHMENT � 0 W 0._9 Liy a c n , S fi FAX# MAILING ADDRESS(ifdifferent) r EMAIL-Business': WC SCOOOSC°� Yq,hmc) .God m Website: q OWNER'S NAMEA.£ T- 4 r • TEL# ADDRESS 8AocPFowvn, Sr Srn[CtM )MC, STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) BafZ \Q ba,,4 L k IC CERTIFICATE#(S) Sl`t 7 S 5-0 (Required in an establishment where potentially hazardous foo/dd is prepared) G K EMERGENCY RESPONSE PERSON NR J IZ r- HOME TEL# l7 S 'Z SFO7,7 DAYS OF OPERATION Monday ",Juiasday Wednesda 17hursda ?:' '4>Fdda Saturda ,Sunda. HOURS OF OPERATION Please write in time of day. (For example 11 am-11 pm TYPE OF ESTABLISHMENTFEE (check only) RETAIL STORE YES NO less than 1000sq.ft. 1000-10,000sq.ft. 80 more than 10,000sq.ft. =$420 - -------------------------- --- ------------------------------- ----------------------- RESTP.URANT YES NO less than 25 seats =$14 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 ----------------------------------------------------------- ---- ------------------------------------------------------------------------------------------------ BED/BREAKFAST/ YES N $100 CHILDCARESERVICES------------------------------------------ --------- ----- --------------------------------------------------------------- --- ADDITIONAL PERMITS MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE YES O $25 TOBACCO VENDOR YES $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 any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns and paid all state taxes required under the law. Signaf Date Social Security or Federal Identification Number Revised 424/07 FOODAP2008.adm Check#&Date �h(j )?.,� -%0 $Aso 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: 01/07/2008 ESTABLISHMENT NAME: Ben & Jerry's File Number:BHF-2005-000032 60 Washington Street SALEM MA 01970 LOCATED AT: 0060 WASHINGTON STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2008-0265 Jan 7,2008 Dec 31,2008 $140.00 ESTABLISHMENT Total Fees: $140.00 PERMIT EXPIRES IDecember3l, 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 1 of 1 -a • �, CITY OF SALEM, MASSACHUSETTS lI r c BOARD OF HEALTH tr 120 WASHINGTON STREET,4'm FLOOR TEL.(978)741-1800 KIMBERLEY DRISOOLL FAX(978) 745-0343 MAYOR ISOOTTOSALEM.COM JOANNE SCOTT, HEALTH AGENT 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT 13tk) aw a s T rc CKc4Lw, TEL# T7 8 -7 4 4 - 7S U o ADDRESS OF ESTABLISHMENT (0 W r S I n a s f FAX# MAILING ADDRESS (if different) EMAIL-Business': 6 tA) ,Q an x f Ali, P Bio Iwo ,Cow% Website: r OWNER'S NAME_{I&,l f�a 11 tc t TEL# ADDRESS 31'La CP t, CIN Vvl o O 19 -7 0 STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) RA u( t)r+ n4 W t CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON S a c• HOME TEL# DAYS OF OPERATION I Monday Tuesday Wednesday Thursday Friday Saturday Sunda HOURS OF OPERATION I q Please write in time of day. )Z� CI j Z- ( Z - °I 1 L 1 )2- �1 1 -2- 9 1 For example 11am-11 part 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 $14 (Outdoor Stationary Food Cart$210) 25-99 seats = 280 more than 99 seats =$420 -'-'----------'-'--------------'-`-'------------------------------------'........ ................. BED/BREAKFAST/ YES NO $100 CHILDCARESERVICES----------------------- ...-----------------------------------------...---------------------------- ADDITIONAL PERMITS MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES $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 any renovations, improvements, or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns and paid all state taxes required under the law. o 0— IZ(-w/off Sigrifituye Date I Social Security or Federal Identification Number Revised 4/24/07 FOODAP2008.adm Check#&Date :KN fOg �a/J-0�07 $ 1 CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: - 2- -<jP Page: of Item Code C-Critical Item r DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date { No. Reference i R-Red Item -F r r-.- <• Verified r tw vsi ' r - wa^� PLEASE PRINT CLEARLY I Y?r 1- jJ 11T- hl k7r1 r } j ) N �GLS+`\-�N Vic. W\ � � T—?✓- \- �- '7i'.2C.� �pfi _ CNS as cs� S--Gil'^. Glw-�` —rc - e.�"�e ��, �Lr-li;v� �--•car�c'��1 C'C C2 OQ��.`ii- l�(av� t � t s (i f Y i 3 4 Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes ! ❑ Voluntary Compliance ❑ Employee Restriction/ I have read this report, have had the opportunity to ask questions and agree to correct all Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. �n t (� \�. ❑ Voluntary Disposal ❑ Other: i r I. 4(C) _PHFs Received faTemperatures Violations Related to Foodilsorne Illness Interventions and Risk According to Lax Cooled to Factors(items 1-22) (Cont.) 41'FiaS'F Within 4 Hours, PROTECTION FROM CHEMICALS 13-50IJ5 _LIK1111of Wthe&for Pfff's L14 Food or Color Additives 19 PHF Hot and Cold Holding 3 '56I.j6(B) Cold PH17s , aintained at of below 3-202,12 A(utive 590,0441") 4i V45`F* 3-302,14 proleclion don ed Addilives" 1-50 1,16(A) Flat PHFs Maintained at or above I-S Poisonous or Toxic Substances klentifying Intbi mation-- Ori�,onal i-501.16(A) ( PcKods field at or above 130'F. as a Public Health Control 7 102A t 1 continnin Name - "Vorkin"Count.tie rs's 3-501,191 Tinicasal'utdielleaRliControl, 7-20 1.11 sepalanion-stoli C, (11) Variance R 7202 11 Reetriction-Prestnce and U,e* 7-202 12 Condition,of Live ISO a* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-20111 Toxia Comenneiz,-ITobilinionii :'6 lnic�N* -7 204. Sanin ims,'Cntei is ie POPULATIONS HSP) 21 3-801 A I(A) Uniftimeurized Prc.�paciaged Joim and 7-204.12 Chonicitis for Nk"a'h��xlitcej.:i.itctW 7 204.14 Drvrnn Aeenie,Criteria, 3-81)1.11(B} Us--of Pasteurized Egp* 7-205�J I licadstaid F�N)d cienaci,I Wit icants, ?-861.11(D) Raw or Parimlle Cooked Animal rood and E7:2:0:6 I �_lZeoik-led Ulsii Pii'ticides CriternORaw sc.ed 7-2€76.12 Rodent Foil svtoons" ,a *e i'tior Rem-served.� r7_ 7=M61 3 Toicking ROw&. ,Pmt Control and -K lu�ul nu(=Tr Imoridoein., CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS _22 37>0�-, IF or Animsi F,_,ods That arc Raw.UndeuxxAcd i); 16 Proper Cooking Temperatures Not Odwrwise Processed to Elonniate PHFs i.-111 '1 i 3-401 JJA(Ii(_-') Fgtp�- 15i'F 15 Sec. diaec Service 145'Fi5sw :1.g0°A3 Riqteuoyed Eglf�;Subsniwle lot Raw She', 3 J I�(A)(2 Conninnintil Fish,Meats&Ginuc Anneals- 15*i'T ieec. SPECIAL REQUIREMENTS -71-401_F I(1b)(1)(2) Pork and Beef Roast -_1:W-F'121 nun* Violafion�s oi-Section I l antes, 11jec!In Meats I-15,F 15 1 1)(21 R 1 _'�90�0090V)-71))j in catering. mobile "al,temporal v and PlIF's, T_Fount�� Wi d ianie, Stolle reside kitc 3-401-J1(AP�; hell operations Should he Suififing,Containing Fish, Meat, debited Under the appropriate sec-tnuls "uttr ,or Ratnts-1 )5"Tf5 sec above if rel iled to foodlion 1-401�Jjf(') 3) whde'-Inusete. Intact Bai� stcat's inlet ventions, and risk hictom Other 590.009 violation relatiti.o. to 1-okid fetid; 3-401.12 Rim Animal Ivikk Ccxyked in a prat aces should be debited under 1129 - — Mtoowave 165'F* Special Requirements. _TZIA I(An(l)(Iro All Othei KfF,- 1452 15 sec. ' I 7_ Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.1 i(A)&,(6) 11f It-, 14551T. 15 sec. (items 23.30) „v4iciowave-165° riiiai find nim-(riucal viotationj, which do nen elao,to the. T�03.11(B) ici7owave- 165"F 2 a!hi standing, C Tore" ftiodhorne Wricss tenet ventioto and risk factors toted above, "in be 3-"t03.I 1(C) Com merciany Processed RTF FevXl found in thee,fielknt ing sectiorei of the Food Cade and 105 CMH 140 F -7-40-3 Tl Cl 7) Remajrunp CrczlneTPor�wnsof Bect mTnqqcEmem and FC 2 1 .003 item �N'z z- 18 Proper Cooling of PHFs Food land Pood Protection 3 004 7- -----------Equipment and Ut"mis FC-4 008 3 501 146k) _rn ___I---.----- ---I FC-_5 006 k28 �W 700F Within 2 Hours and Fomn 79"T' cal Facility.. c ------ to 41'F14.51,Within 4 Hines. Po'"'it;; A Materials FC -7 008 �3-301 148) Cooldia PHFs Made FionlArnbieot Sp ed Psqoirernenn; 0069 Tempera;tire Ingredients no 41l F/45'FOther_ Within 4 HixiW Denotes attest Item m the Eark^xal 1904 Feist G�ie"r 165 Cvlk 590 000, CITY OF SALEM BOARD OF HEALTH s Establishment Name: Date: Page: of Item f, Code C-Critical Item• ,, ,, DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item - " Wiz' f`� - verified .� PLEASE PRINT CLEARLY I a j 71i ,�_ L 'J c4"L 1 ,1 k--VT av V N V C o-Z 1 oWi'\ l jp 9"Lav l j- N�i1V1M NttiaT lNVoi \n' S ro 'L ('.zo (-Vi, ,3 l�1A : r�oc-), t� i r } Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twerity-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. J �` — /� U Voluntary Disposal ❑ Other: v Q PI-IN Received atTemperawrris Violations Related to Foodbarne,Illness Interventions and Risk According to LaNk Cooled to Factors(items 1-22) (Core) 'WF/45"F Within 4 Houis. PROTECTION FROM CHEMICALS — T50i 1-5 Co 11n«tilethods for PlifFs 19 PHF Hot and Gain Holding L14 Food or Color Additives 3.501.16(B) Cold PHN,Maintained at or boloo, 5-2o 2.f2—-Arj I I i vc 590(y)4(F) 41`145°F, 3-30114 prote'.non —V) lf`a,%Iainrauietlat or above LL5— Poisonous or Toxic Substances 14WF� W", Originalleld at or above. I Containers' F Time as a Public Health Control 7 102111 1 Common Name 3-501 lo Trmc a Public health Control* 7-2()t.jj Set) —------ Variance R�� L:� 590.004(1-1) nc 7-202.11, ri" Restriction -prerchc�and 7-202.12 C.....;,ZZTa Tjse" 7-263.12 Toxic Cradampte, - REQUIREMENTS FOR HIGHLY SUSCEPTIBLE -- 7-204.11 SaZ� POPULATIONS(HSP jjiji7CjS, rn'r,"—6aIIucIJ,;* 21 3-801 11(A) Unpaucurize'd Pre.-faa:1,1ged Afic s and 7-204.12 Chcnnicais 3-801.11(B) Use ol'Pateinl7e 'I-2 05,1 i Incidental Foi,)d Cornact�Lturrjcanis' - 206.1 i Kerr rcicd ise Pcars oder-Criteria, kaw Set 7-206.12 Roilera Bait Studonsl ��Vrorrc;Not Sin,ycd� 3 Ni 1,Ll f�lLn(Retied I Net Ra served. cac Ing )%'our" " _0 Morik�� InL CONSUMER ADVISORY 7-106 13 T k 11 1, , Pest Control and TIMErrEMPERATURE CONTROL S Cousumer 22 Posted!(it Ciat In of _1 Alfliptai -Uhat arc Raw, Underci"-rd ra 16 Proper Cooking Temperatures for Aninwl Rod, PHFS flet OflieTcisc Procc�qsed ot 1,11ilnuoli-I 3 401A I A(lr(2) Eggs- 155F 15 3ir Fels Solastitive for Raw ShclI 11 Pzt;ieurizj�d Eg — jj� ,�d Comininuied FiAh, lvfew & Gainu Annuals- 1 5"F I twc. 1 01.1 and li,�ci Roost J30'FI21 nun- -1-4 1(B)(I)(2) Pic k SPECIAL REQUIREMENTS vi(Aatirtn�of Section In 3-d01.11(A)Q) ltinin�e, injectd Mcati� � 155 F 15 Sec. cateringmobile f(Wtemporal v and I�11(A)-TT -PoultrTV,1—dclarac Stutfed Yf tla, r"idential kitchen operations Miould he Sluffing Containing Fish, War, debited under the appropriate sections Pouftry or kiauoti,165"T' 15 sec. above if related to fixAlrorne illness 3-401.IjiQ(3) 'Nhole-tritic,1c. Intact Beef Steaks inteiveiitioti.sand risk factors, Other 1451,41 — 590.009 violations relating to coax]retail3-401.12---F,�Iouo I ( ,,rkd I� be debited under#29 - 105,F* Special Requirements. 3-401,IUAr(I)(1r) All Othcr PHF-s-- 145�47 15 S". E17 Reheating for Hot Holding —VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(.4)&(D} pflj,s 16511- 15 se, ;1 {items 23-30) — 7�i�T(,�-- Critical acd non-cruical viotaliorij, which do narrelare I the 3-403.1 T03) P�munne, Standing Time' __ foodhorne Wrest interventions card risk factors Kited above, (an be 403 11(C.) comcommerciallyPtuc - ,f-b X found in oheft),loiwng.verrions of the Food Code and 105(AIR c=�Ieli 140'F 2i3s J__M�unqqoTiant no Rnntj 590 000 I(E) Remaining Unsticed Portionsoce7 J1 Roastsr 00-, 24, FIxA and Fund Protection 28 Proper C;-01,119—01 PHFs-- ,004 5 E tensils FC-4 005 3-501,14(A) coitling cook+�([PHFs f"oln W)T IT, --- -gi�l ---5- 70,1;Widan 2 lfour�and From 701= Water,Pluab)aq arLd FC-— caj Fabliv FC-6 007 T _±_hye to 41 7145'F Within 4 I'll In 8� Poisonous or Toxic Materials FC-7 008 H F—1m a( Fir (566 I T"i Front Ambient 7 Temperature higredients to 41"FAS'J 0. Other rT,-0—I I)enoes critical kian ia I h,,fexlrml 1999 Food 105 MR 590 000. CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAx 978-745-0343 Kimberley Driscoll WWW.SALEM.COM Mayor JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT T3 Z ,J 4 ,j_6 Tc WLIA y s ADDRESS OF ESTABLISHMENT 6n (y a r, t,n� nL + FAX# i MAILING ADDRESS(if different) _5'o,oh r- EMAIL--Business': -W--t S o o JA s 7 CL �o o . C_v KI Owner's: to W ch, CG nl OWNER'S NAME `, n,f-'LF atin 1, iNbG.. be, , 1tk)c TEL# cf � 8 - 7 ` Q -.(- 7SU _ , ADDRESS (5 R R A b 1=o o-VJ , S i Sc,, r cvn M " 6 19 7 ( STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON �0.by t K., HOME TEL# Cl "? OAYSOFOPERATION_ _ Monday Tuesday Wednesday finrsday Ftiday Satnrday Sunday HOURS OF OPERATION ^i Please write in time ofaay. 1-;L-9 IZ- 9 IZ-c( 2-- 9 { 2- 9 tZ- � Ifor example itam-11am1 TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES V� less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 - - ------------- ------ - ................... ... .... RESTAURANT YE NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 - - - ------ --- - --- - ------ ----- -....-$. ..... ...... _----------- ------------ -------- _- BED/BREAKFAST YES ido00 ..... .. . ........ -.----- -- ....-.-._.... ...... ...... .- -------- - .-..-.......----- ------ ............. ADDITIONAL PERMITS MAKE (notjust serve) ICE CREAM, YOGURT, SOFT SERVE YES C $5 TOBACCO VENDOR YES $50 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 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 fall state tax returns and paid all state taxes required under the law. s6 -gy-4 & 3 Signature - Date Social Security or Federal Identification Number ----..------------------ ------ -------------------------- ----- -------------- ---------- .---------- - ---------------- - ------------ ----- -------- P,evised 11/13/06 FOODAP2007.acre Check#&Date ? $ �_ CITY OF SALEM BOARD OF HEALTH Establishment Name: e s Jevr 5 60 /r;,+ '5� Date: Page: / of / Item Code c-critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item - Verified PLEASE PRINT CLEARLY. oAn er Ow a vo 70.5'e d es�d 6/i has lest-a /rd PUrGw Cr f_. �o� awn /cr r fa � r � 7✓v lrc% 1/ 4CI. "-:) / ee/ ti l�e_ 500/-24- 2)e Oa 4-60 u r Li OU/1 /1t �✓P s/�u QS /y 4- he- -P&" rd 4yll / is �rvrrhu f/ — /LI l sei QZ 10-7 f2a vZzj 14&--, ode-, ✓�Sv I�s • su kat_.' / C�e ..14f. e wd drso->ar Discussion With Person in Charge: -;Ij^j,/ iN (�- Corrective ction Required: ❑ No ❑ Yes /✓' �A ew `y ❑ V,diuntary Compliance ❑ Employee Restriction/ I have read this report, have had the opportunity to ask questions and agree to correct al4 Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five tars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal 0 Other: 3-501,14(C) 'PHFs Received atrenaier"Itures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(items 1-22) fCont.) 41'F/45'F Within 4 Hours. PROTECTION FROM CHEMICALS _TiOl.15 Coolinv Methods for PHFs s 19 PHF Hot and Cold Holding 5_4 Food or Color Additives 3-501,16(B) Cold PHFs Maintained at or below 1- w 3- 02.12 Addifi ' '0 590.004(F) 41°/45°Fr 3-302.14 p'ut'ree;afrom(Loa a roved A(lail"es, F 3-501,16(A) Ilot PHFs Maintained at or above 15 Poisonous or Toxic Substances 140'F. 7-101.I I Identifying Information-Original 3-50116(A) Roasts Held at or above 1301F. Containers* F20 Time as a Public Health Control 7-10211 Common Name-Workini,Containers' 7-201.11 SeparaCion--Stora e"` 3 501,19 Time as a Public Health Contra!* 7-202.'11 Restriction Presence and Use* E590004(H) Variance Leguirenteat 7-202.12 Conditions of I!so, REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203 11 Toxic Containers-Prohibitions POPULATIONS(HSP) 7-204.11 Sanitizers,Criteria-Chemicals- 21 3-801.J I(A) Unpasteurized Pre-packaged Juices and 7-204.1 'henfic2lsiifor Washing � Beverages with Warnim?labels* 7-204.14 Dr irigAgents,Criteria- 7-205.11 ]anet dental Food Contact. Lubricants* bricts* 3-901,11(B) Use of Pasteurized Eggn� 3-801A 1(D} Raw or Partially Cooked Animal Foal and 7-206.11 Restricted Use Pesticides.Criteria* Raw Seed Spro routs Not Served.'r 7-206.12 Rodent Bart Stations' 8( 1.14C) Unopened Fund Package Not Re-served. 7-206.13 'Pro king Powders,Pest Control and CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603,11 Consumer Advisory Posted for Consumption of lfi �Proper Cooking Temperatures for Animal Foocls'lliat are Raw. Undercooked or PHFs Not Otherwise Processed to Elirrunate 3-40 1-11 A(l)(2) Eggs- 155'F IS Sec. Pathogens.* ""I"" taLjmraechau,Service 145°P75sec* 3-302.13 Pasteurimd Eggs Substitute for Raw Sheli _ T401 I I—(A)(2) Comminuted Fish, Meats&GameE>_Rs* Apirnab;- 155'F 15 qcv. r 3-401.11(B)(1)(2) Porkand Beef Roaqt- 130'F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites, Injected Meats- 155°F 15 590.009(A)-(D) Violations of'Section 590.009(A)-(D) in see. - catering. mobile food,temporary and 3-401-11(A)(3) Poultry, Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections _L'()ultr% of sec.15 see I above if related to foodborne illness 3-401.1 1(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 1450F It 590.009 violations relatin,,,to.-()oil retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 1651'* Special Requirements. 3-401A I(A)(1)(b) All Other PHFs 145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165'F 15 sec. "` (Items 23-30) 3-40111(B) Microwave-165'F2 Minnie Standing, Critical and non-critical violations, which do not relate to the Time* foodborne dhiess interventions and rick factors listed above, can be 3-403A 1.(C) Commercially Processed RTE Food- found in tine following sections of the Food Code and 105 CMR 140'F* 590.000, 3-403.11(Ii) Remaining Unsliced Portions of Beef Item Good Retail Practices FC 590700-d Roasts* 23. Manatterrient and Personnel ____ FC-2 .003 F- _FC_-3 —.00418 - Proper Cooling of PHFs 24, Food and Food Protection — — 25_____Equipment and Utensils FC-4 *005 _7�01 14(A) Cooling Cooked PHFs from 140'F to 2& tslafta�,,Plumb! _FG-5+066 70'F Within 2 flours and From 70'F 2T - �n and�Waste . 007 to 41 1F/45'17 Within 4 Hours. 28— Poisonousor ToxicMaterialsFC -7 .008 3-501.14(13) Cooling PHFs Made From A29—mbient _30—. Other aa� _009 Temperature Ingredients lo,l 1'F145'F Within4 Denotes critical item in the federal ]()9c)Food Cade<)rlO5CMR 590000,. CITY OF SALEM / BOARD OF HEALTH Establishment Name: ReLn i ' LAI vKeac' /& Date: /��7 Page: / of t Item code c-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified ' PLEASE PRINT CLEARLY - 1611 a �� ,/�� n� Flo air(Y IW171 / ..r of l lr�� llncv� vt • vne <crs s/� uteP have 11") eve VVI A V-1 c leq �w / 1I/) (ai( . S/ h 112A as (1 frC.Z-(X D - e r y� a. u,[tw.r (1! G (a P... .✓ (d (!.f I F /'/ I In � ( .A . �. S(eg 114 DaNk In o BS n1 r r a ist 1 > 1 I Yr l bV� 1Lktf �3 (0 %00 k-m � a Q -r sgLa F Discussion With Person in Charge: Corrective Action Required:' ❑ No El Yes have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. A ( � �� 1� ❑ Voluntary Disposal ❑ Other: 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(Items 1-22) (Cont.) _41'F/45'F Within 4 Hours. x PROTECTION FROM CHEMICALS 3-501.15 Cooling Metlxds for PRFs 14 i Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Add thee„ 3-501.16(8) Cold PFIFs Maintained at or below 590D04(F) 41'/45°F* 3-302.14 Protection from Una r roved Additives" 't_501.16(A) Hot PHFs Maintained at or above Poisonous or'Toxic Substances - 140'F. * 7-101.11 Identifying Information-Original 3-501,t6(A) Roasts Held at or above 130'F. Containers' 20 Time as a Public Health Control 7-102.11 Common Name--WarkinR Containers* I 7-201.11 Se.aration-Stontnc* 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and L?se* 590.004(R) Variance Re uirentent 7-202.12 1 Conditions of Use, 7-20311 '1 oxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS(HSP) 7-204.12 Chemicals Eric Washine Produce,Criteria"` 21 3-90'1_11(A) Unpastew'izec{Pre-packaged Juices and 7-204.14 D", Agents,Criteria- Beveta¢es with Warning nine Iabels* 7-205.11 Incidental Food Contact,Lubricants* 3-801.1 l(H) Use of Pasteurized Eggs* 7-206.'11 Restricted Use Pesticides.Criteria' 3-801.110) Raw or Partially Cooked Animal Food and Raw Sccd S trouts Not Served. .x rl-06 206.12 Rodent$crit'Statuitrs* 3-SOL17(C) Uno cued Foal Package Not Re-served. " .13 ']'rac.kmg Powders,Pest Control and Monitarinn* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw. Undercooked or 16 Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate 3-40(.13A(1)(2) Figs- 155'F 75 Sec. Pathogens." 'T cIvs rrozom H es-hmmeditu Service 145°F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(1A)(2) Comminuted Fish,Meats&Came E es* Animals-155°F 15 sec. '" ' 3-401.11(,8)(1)(2) Pork and Beef Roast - 130` F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites, Injected Meats-155°F 1.5 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. * catering, mobile food, temporary and 3-401..11(A)(3) Poultry,Wild Game,Stuffed Pl*s, residential kitchen operations should be Stuffing Containing Fish,Meat, debited wider the appropriate sections Posits ,or Ratites-165°F 15 sec. * above if related to foodborne illness 3-401.1 1(C)(3) Whole-mosele Intact Beef Steaks interventions and tisk.factors. Other 145°F* 590.009 violations relating to good retail. 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29 - Micmwave 165'F* Special Requirements, 3 401.11(A)(1)(b) All Other PHFs--I45'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)c&(D) PHFs 165-F 15 sec. (Itetms 23-30) 3-403.11(B) Microwave-165'F 2 Minute Standing Ctutcal and non-critical violations, which do not relate to the Time* foodborne illness intervenrions and i W factors listed above can be 3-403,11(C) Commercialty Processed RTE Food- found in the following sertions of the Food Code caul 105 CUR 140'Fa' 590.000. 3-403.11(8) Retraining Un_sheed Portions of Beef item Good Retail Practices FC 590.000 -- Roasts:: 23. Manaciernent and PersonnelFC-2 .003 -- 18 Proper Cooling of PHFs 24. Food and Food Protection FC-3 .004 Equipment and Utensils 0 3-507.1.4(:1) Cowling Cooked PF(F25 FC 4 05 s from 140°F to 26 W ater,Plumbin and Waste FC-5 006 70'F Within 2 Hours and From 70'F ZTPhysical Facility FC-6- .007 _ to 4 PI7145rF Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 7 008 3-501.14(13) Cooling PF°IFs Made From Ambient 29. Special Requirements Temperature Ingredients to 41`F/45'F 30._ Other ______ Within I llours:a s oe nxea.x.a« `Denotes critical item in the Enteral 1999 Food Code or 105 CMR 590 000. Ben & Jerry's Franchise Operations & Systems Manual 2001 rage i of s Last Updated 12/01/2004 Last Updated 12/01/2004 Chapter 3 Inpex - Product Line - Super Premium Ice Cream - 23,ulk Tins Pre-.packed Pints - Be, &_J.erry'-, Bars Product Summary Ben & Jerry's Product`Line The packaged ice cream industry includes economy, premium, premium plus, and super premium market segments. Ben &Jerry's ice cream is part of the super premium category, the highest quality market segment. This category Is characterized by a greater richness and density than other kinds of ice cream. (As Ben & Jerry would say, "Less bunk, more chunk!") Ben & Jerry's ice cream is richer and creamier than other ice creams. We use lots of fresh Vermont cream, milk and pasteurized egg yolks. Our ice cream has an average butterfat content of 15.5%, which compares to 10% for most economy brands. Because we're using egg yolks, technically, we make what's known as a "French" ice cream. Eggs act as an emulsifying agent, and also help to make the ice cream creamier. Pure cane sugar is the only sweetener used in our original ice cream line, Creating a Super Premium Ice Cream +,.. Our ice cream is heavier than most because our production freezers have been modified to create a product with less air whipped into it. The amount of air whipped into ice cream is called its "overrun." The flavorings used by Ben & Jerry's include: premium quality extracts and fruits, nutmeats, chocolates, liqueurs, cookies and candies. Our ice cream is all-natural. We use no preservatives, chemical stabilizers or artificial ingredients with the exception of some candies (for example, Heath Bars'") which themselves contain some artificial ingredients. Three all-natural stabilizers (Guar Gum, Xanthan Gum and Carrageenan) are used to help protect the ice cream from texture defects that can occur when the ice cream is subjected to heat shocks or variations in temperature. Guar Gum is made from the Guar bean. Carrageenan is a gum extracted from seaweed. Xanthan Gum is derived from fermented sugars. All of the stabilizers increase viscosity and prevent ice crystallization. The combination of the above three factors (high butterfat content, low overrun and all natural ingredients) places Ben & Jerry's ice cream in the super premium market segment of the ice cream Industry. Ben & Jerry's is distinguished from other super premium ice creams such as Haagen Dazs'" by our marketing philosophy, which emphasizes a down home funkiness, the image of cows and Vermont, the two real and accessible founders of our company and our growing reputation as a socially responsible business. We further distinguish ourselves from other super premiums by our unique flavors. Ben & Jerry's Frozen Yogurt: Our frozen yogurt has between 2.0% - 6.0% of fat per 4 ounce serving. The fat content varies from flavor to flavor. http://www.benjerry.com/extranet/ops_manual/chapter3 sectionl.htmi 12/1/2004 ,. Ben & Jerry's Low Fat Frozen Yogurt: Ben &!Jerry's produces a low fat frozen yogurt. Our flavors with 3% or less are labeled "Low Fat" according to FDA guidelines. Ben & Jerry's Sorbet: Our fruit ice is a water-based frozen dessert that has no cholesterol, no lactose, and no fat. How We Package Our Ice Cream: The 2 1/2 Gallon Bulk Tubs 1. All scooping is done from these rectangular containers, which measure 10 1/4" high by 9 5/8" wide by 6 1/2" deep. 2. Bulk tubs weigh an average of 15.9 pounds excluding the weight of the box (8 oz.). The weight will vary from tub to tub based on a number of factors, including the types of ingredients used and the specific characteristics of that flavor. Some flavors always run light, while others tend to be heavy. The minimum weight per tub that you should receive is 15 pounds (without the container). 3. Each bulk is labeled on the top and side with an abbreviation of the name of the flavor and the production code date. The code date is one year from the date the ice cream was produced and it is the expiration date for the product. We use this date to ensure product rotation in our freezer and as a reference should there be something wrong with a batch. If you have quality problems with a tub of ice cream, it's crucial that you retrieve this information so that we can track it back via production run reports. 4. It will be stressed over and over again that if something is wrong with a product it should not be served! If you have received it in such a condition, you'll be given credit for any product that does not meet our quality standards. It's your responsibility to contact Ben & Jerry's and inform us of the flavor, code date and description of the nature of the problem. A detailed procedure for this appears in the section on Product Quality. Prepackaged Pints Prepackaged pints are packed eight per "sleeve." A "sleeve" is the term for the plastic over-wrap, which Is used to hold the eight pints together during storage and shipping. All eight pints in a sleeve are the same flavor. On the bottom of each pint container is a production code date. It indicates the date, time of day, and which factory and production line the pint was manufactured. As with the bulk, if there are any problems with a pint of Ice cream, do not serve it and notify Ben & Jerry's of the condition, the flavor and the production code. A guarantee on the side of each pint container states, "Your satisfaction guaranteed or your money back." Most people who seek refunds do so by mail, and our consumer relations department responds to every letter we receive. It's also possible that at some time, a consumer will come into your store seeking a refund for a pint of ice cream that didn't meet their expectations. As a representative of Ben & Jerry's, it's your responsibility to honor that guarantee and cheerfully refund the total amount paid for the pint, regardless of whether or not it was purchased at your store. Ben & Jerry's will reimburse you for any product refunds that you make to customers on our behalf. Ben & JerryTM Bars Ben & )erryTM Bars are individually wrapped and packaged 24 pops per case. Now available in these http:%/www.benjerry.com/extranet/ops_manual/chapter3/sectioni.html 12/1/2004 c..Iicious flavors; Vanilla, Cherry Garcia'"' Yogurt, Cookie Dough, and Vanilla with Heath'"" Bar y Crunch. NOW http://www.benjerry.com/extranet/ops_manual/chapter3/sectionl.html 12/1/2004 To:Joanne Scott Salem Health Agent December 27,2004 Joanne My name is John Serino.We met about two months ago in your office. I stopped in to understand how to proceed with health requirements regarding the opening of a Ben and Jerry's Ice Cream shop at 60 Washington Street in Salem,MA. As you requested,I'm delivering a floor plan and menu for the proposed store.Please review and advise next steps. We're hoping to open in late Spring of 2005.As soon as I have construction documents,I'll deliver and meet with Mr. St.Pierre. Thank you, John 207-641-7097 jserino@coastaltreats.com Ben & Jerry's Franchise Operations & Systems Manual auu l r Last Updated 12/01/2004 Last Updated 12/01/2004 +rr Chapter 3 Index. - lce.Cream, Yogurt, & Sorbet - Wet Toppings - Dry Toppings - Cones &Dips Beverage Ingredients - Baked Goods - Ice Cream Cake Ingredients - Paper PrOdUCtS Gifts Curr.of $pecified_1 quipment Approved Product List for Franchise Shops This is the list of products and ingredients approved for use in all Ben &Jerry's full scale scoop shops. Some items on this list may not be approved for use in more limited entities. The terms of your franchise agreement with Ben & Jerry's will specify which items your Ben & Jerry's may use and/or sell. The correct use of each of the approved items is explained In detail. Adhering to this list is a very important component of franchising. Our customers need to be assured that when visiting any Ben & Jerry's in the country they will be able to enjoy the same delicious menu item prepared the same way with the same high quality ingredients Ice Cream, Frozen Yogurt, Sorbet and Bars Only Ben & Jerry's frozen dessert products are approved. Wet Toppings Fresh Fruit Any seasonal fresh fruit can be used to make great sundaes (e.g. berries). Fresh fruit can be used as a fruit topping or as a layer in ice cream or yogurt cakes. Fresh bananas must always be in stock. Individually Quick Frozen (IQF) Fruit Any brand without chemicals, unnatural ingredients and preservatives. IQF fruit can be used on sundaes when fresh fruit is not available. (Let the fruit defrost fully, mix in 3 TBSP of powdered sugar to sweeten and gently mash the fruit to create a ladle-able consistency.) IQF fruit may also be used as decorations on cakes and pies. (Lightly coat the IQF fruit with sugar water to prevent frost from forming when they are In the cake display case. Add 3 T of sugar to 1 cup of IQF fruit.) Ben & Jerry's Hot Fudge Made by Masterson. Used as a topping, for cake decorating and to flavor hot chocolate and mocha beverages. http;//www.benjerry.com/extranet/ops_manual/chapter3/section2.html 12/1/2004 Lien &, Jerry's Nranchise operations & Systems Manual LUV! rage L OT > Ben & Jerry's Caramel Made by Masterson. Ben & Jerry's Chocolate Syrup Made by Masterson. Wet Walnuts Any high-quality brand Is acceptable. Fresh Whipped Cream FRESH. rBGH-free cream if available in your area. A little simple syrup and/ or vanilla syrup can be added. Make it with a mixer (18 years or older) or use the ISI dispensers. See section 4.3 Toppings for more information regarding how to make fresh whipped cream. Dry Toppings Chocolate Sprinkles Sliced Almonds SnickersT" Rainbow Sprinkles Walnut Pieces M&MsT" Confetti Sprinkles Pecan Pieces Reeses PiecesTM Gummi Bears &Gummi Worms Granulated Peanuts Reeses CupsT" Semi-sweet Chocolate Chips Trail Mix Heath Bars T"' Butterscotch Chips Honey Granola WhopperSTM Carob Bits Shredded Coconut HydroxT"' Cookies Peanut Butter Chips Toasted Coconut SnocapSTM Dark Chocolate Chunks Yogurt Raisins Butterfingers" White Chocolate Chunks Peppermint Patties NestlesT"' Crunch Cones and Dips • Ben & Jerry IST' Logo-wrapped Sugar Cones • Unwrapped Sugar Cones (for dipping ONLY) • Wafer Cones (with pointed bottoms) • Freshly-baked Waffle Cones (using CoBatCoT'" batter) • Ben & Jerry's"" Chocolate Waffle Dip Coating (made by Masterson) http://www.benjerry,com/extranet/ops_manual/chapterNsection2.htmi 12/1/2004 Ben &Jerry's Franchise Operations & bysieuis iv,auua, tVU L Beverage Ingredients • Toranni7m or MoninTm syrups - these flavors are used for flavoring coffee, mochas, ice cream sodas and egg creams; vanilla, strawberry, coffee or other popular flavors. . Fresh oranges, limes and lemons for fresh squeezed orange juice, lemon & limeade • Freshly-brewed tea for hot tea and iced tea . Herbal teas . Apple cider (natural, the real thing only) . High-quality Apple, Cranberry and Orange juices for use in smoothies (purchased locally or available through Bunzl) rBGH-free milk (whole, 2%, 1% and/or skim) • Coke or Pepsi, post or pre-mix • Bottled natural sodas (such as Orangina T`"), Nantucket NectarsT° juices and teas, Snapple TM lemonades & teas, Ocean Spray7m juice and teas, MinutemaidT° juice and teas - no promotional materials from these companies may be used • Bottled water and seltzer water; spring water, Perrier, Evian - no promo materials may be used • Locally purchased coffee & espresso, 100% Arabica (no promotional material may be used) • Locally purchased flavored coffee; hazelnut and others, 100% Arabica • Malt powder • CappachilloT"^ Concentrate (made for Ben & Jerry's by Coffee Enterprises) Baked Goods Our cookies and brownies are made fresh from Rhino Food's frozen fudge brownie and chocolate chip cookie dough batters. See section 5.1 Baked Goods for more information on storage, handling, and preparation of Rhino Foods batters. Ice Cream Cake Ingredients Fresh pp g whipped cream for frosting and borders • Wilton TM food coloring pastes and liquids • Buttercream, Decocream, Brill and colored jells - for small detailing only, not as a frosting http:,'/www.benjerry.com/extranet/ops_manual/chapter3/section2.html 12/1/2004 Ben & Jerry's Franchise Operations & Systems Manual 2001 rage ' of ' • InterbakeTMBurry Crunch - chocolate crunchies for cakes . Sara Lee TM Pound Cake • Wilton TM Meringue Powder (purchased through Wilton or locally) • Royal Icing or Gum Paste - to make flowers for cakes Paper Products All branded/logo paper products and lids are required when available: • 303, 305, 306 cow cups and clear dome lids • Generic 12-ounce sundae bowl and clear dome lid • 12-ounce Core Concoction Sundae container and lid • B&J logo 16 & 22 oz. cold cups and lids • B&J logo 21 oz. clear cold cup and lid (flat or dome) • For 2004 - B&J logo 16 oz. clear cold cup and lid (flat or dome) • B&J napkins • B&J 5# & 12# bags • B&J pint containers and lids • Generic 12 ounce clear banana boats • B&J logo cake boxes • B&J logo hot cups wraps • B&J logo Waffle Wraps • ChemcoT" cleaning system products - Dirt Buster, Purple Tiger T" Glass Cleaner and ChemocideTM Sanitizer. Gift Items Gifts and T-shirts approved by Ben & Jerry's. Please refer to the current listing in the Gift Catalog online at www.benjerry..com. Current Specified Equipment littp://www.benjerTy.com/extranet/ops manual/chapter3/section2.html 12/1/2004 .Ben & Jerry's Franchise Operations& Systems Manual Lvvi U Please contact your RFM for the most current equipment specifications available. t http://www.benjerry.com/extranet/ops_manual/Chapter3/section2.htrnl 12/1/2004 Today's Flavors Flavor choices may vary. Please check menu board for today's euphoric selections. Brownie Batter Ice Cream—K—Brownie batter ice cream with a rich batter swirl. Butter Pecan—'K -Rich buttery ice cream with roasted pecans. Cherry Garciag - K-Cherry ice cream with cherries and fudge flakes. ChocolatcK -Chocolate ice cream. Chocolate Chip Cookie Dough— K-Vanilla ice cream with gobs of chocolate chip cookie dough. Chocolate Fudge BrownieTM—K - Chocolate ice cream with fudge brownies. Chunky Monkey9- K- Banana ice cream with fudge chunks and walnuts. Coconut Almond Fudge Chip—K -Coconut ice cream with fudge chips and roasted almonds. Coffee-K-Coffee ice cream made with coffee extract from beans grown& harvested by small-scale farmers in Mexico. They are members of cooperatively run local farmer associations that practice sustainable agriculture. Coffee Coffee Buzz Buzz Buzz®- K- Coffee ice cream with espresso bean fudge chunks. Dublin Mudslide—K- Irish cream liqueur ice cream with chocolate, chocolate cookies and a coffee fudge swirl. Fossil FueiTK—K- Sweet cream ice cream with chocolate cookie pieces,chocolate dinosaurs and a truffle fudge swirl. Giant Chocolate ChunkrM-K—Vanilla ice cream with fudge chunks. Mint Chocolate ChunkTm—K -Mint ice cream made with all natural peppermint extract and fudge chunks. New York Super Fudge Chunkfl-K-Chocolate ice cream with white&dark fudge chunks, pecans, walnuts&fudge- covered almonds. Oatmeal Cookie Chunk— K-Sweet cream cinnamon ice cream with chunks of oatmeal cookies and fudge. Peanut Butter Cupxm—K - Peanut butter ice cream with real peanut butter cups. Phish Food*- K -Chocolate ice cream with gooey marshmallow, caramel swirl & fudge fish. Primary Berry Graham—K- Strawberry cheesecake ice cream with strawberries and a thick graham cracker swirl. Strawberry—K-Strawberry ice cream with frozen strawberries. Sweet Cream & Cookies'—K -Sweet cream ice cream with whole and broken chocolate sandwich cookies. ,.'riple Caramel Chunk—K- Caramel ice cream with a swirl of caramel and fudge covered caramel chunks. Vanilla - K- Vanilla ice cream made from vanilla beans grown and harvested by small-scale farmers in Indonesia. They're 12/20/04 rQotnbers of local farmer associations that support sustainable fanning practices. Vanilla Heath®Bar Crunch—K—Vanilla ice cream with Heath®Bars. LOW FAT FROZEN YOGURT Cherry Garcia®—K-Cherry low fat frozen yogurt with cherries and fudge flakes. Chocolate Fudge Brownie m—K- Chocolate low fat frozen yogurt with fudgy brownies. Black Raspberry—K-Black raspberry low fat yogurt with thick black raspberry swirls. Vanilla—K-Creamy low fat vanilla yogurt. CARB KARMA Chocolate Carb Karma—K -Chocolate ice cream. Half Baked Carb Karma—K-Chocolate&Vanilla Ice Creams with Fudgy Brownies&Chocolate Chip Cookie Dough SORBET Berry Berry Extraordinary—K/DE Swirls of blueberry fruit sorbet and raspberry fruit sorbet. Mango dime—K/DE—Mango sorbet with a hint of lime. `.,strawberry Kiwi—K/DE- Strawberry&kiwi fruit sorbet. Lemony LimenyTM—K/DE-Lemon and lime-flavored sorbets swirled together. NO SUGAR ADDED Blueberry No Sugar Added-K-Blueberry ice cream with frozen blueberries, sweetened with Splenda. Cherry Vanilla No Sugar Added—K-Cherry vanilla ice cream with pieces of Bordeaux cherries, sweetened with Splenda. ....................................................................................................................................... FOOD ALLERGY CONCERNS? We care. Let your scooper know so that we can assist you in your selection and take additional steps that may be necessary. ........I....................................................................................................................................................... K=Manufactured Kosher K/D.E.=Manufactured Kosher on dairy equipment Cherry Garcia&is a registered trademark of the Estate of Jerry Garcia and is used under license. HEATH is a registered trademark of Hershey Foods Corporation and is used under license. Phish Fwdg is a trademark of Phish Inc. 0 Ben&Jerry's Homemade Holding,Inc. 2004 I � 12/20/04 a+;yam+ry^.e �h':, W,� =�• ¢ »'+°"moi b "+,'vv, Commonwealth of Massachusetts City of Salem • " Board of Health 120 Washington Street,4th Floor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/05/2006 WHO'S PLACE OF BUSINESS IS: Ben & Jerry's File Number:BHF-2005-0032 60 Washington Street SALEM MA 01970 LOCATED AT: 0060 WASHINGTON STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2006-0011 Jan 1,2006 Dec 31,2006 $100.00 ESTABLISHMENT Total Fees: $100.00 PERMIT EXPIRES December 31, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 8 of 18 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH s 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 STANLEY J. USOVICZ, JR. FAx 978-745-0343 MAYOR www.SALEM.COM JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 06 ESTABLISHMENT NAME O FES ABP SIHME T 7R PER �OPERATE A FOODTE{L#�/7; ADDRESS OF ESTABLISHMENT` MAILING ADDRESS (if differe t) \1 `� M ' I q OWNER'S NAME E21 �+1 � TEL# 17 ADDRESSld CERTIF EI FOOD MANAGER'S NAME(S) C. /l{ 9� CERTIFICATE#(s) amiIt �7 IZIp Ja -2 (required in an establishment where potentially hazardous food is prepared.) / p EMERGENCY RESPONSE PERSON ' " �"�/'6 HOME TEL�D 7 �Y � 2�y ) HOURS OF OPERATION: Mon. L. Tue. Wed. ✓Thu. Fri. A Sat. 'Sun. TYPE OF ESTABLISHMENT // ! �ry FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. "=$250,. .......... -- -- - --------------------------------------------...--- ------------- - ----------'�--------- RESTAURANT YES NO y less than 25 seats g-�� more seats =$150 more than 99 seats =$200 --------------------------------------------------------------------------------.. ...--------------........----------......------------...-------- BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS -------------------------------------------------------- - ----------------------------------- ----- MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 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 t Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowled belief, have filed all state t x r urns an aid all state taxes required under the law. Signature Dae Social Security or Federal Identification Number ------------------------------------------------------------- ---------------- ---------------------------- Revised11/03/05 FOOD AIadm Check#&Date - --------- �a.-dam 4) 0-0 +p, CITY OF SALEM-MASSACHUSETTS �! BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR 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: FOOD SERVICE Name of Establishment: Ben & Jerry's Address of Establishment: 60 Washington Street Owner's Name: John Serino Restrictions: Application Date: 5/26/05 Permit for Food Establishment 302-05 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 V +pp CITY OF SALEM9 MASSACHUSETTS .aL BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2005 APPLICATION FOR PEq.,MIT TO OPERATE A FOOD ESTAABUSHMENT NAME OF ESTABLISHMENT // r1, IIS TEL# � ' V ADDRESS OF ESTABLISHMENT 6 6 "� 1 #A /l MAILING ADDRESS (if different) �' d OWNER'S NAfyTL� ✓l �l c/ II AC>> J j� TEL# L yl 166 ADDRESS�3�^ "`�"t" CITY6/ ST E t K_ ZIP 0 CERTIFIED FOOD MANAGER'S NAME(S) u�� Y CERTIFICATE#(s) D cf3"aZ- pd'L s� (required in an establishment where potenti IIy haza dous food is prepared.) 0 EMERGENCY RESPONSE PERSO 1 n ISR/A6 HOME TEL# all 96 f 7 HOURS OF OPERATION: Monlb')b TueWlOWed.w�l6 Thulti"6 Fri.10'1 Sat.1#-j6 Sun.l6'1a TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than I000sq.ft. =$ 50 1000-10,000sq.ft. =$100 /J �� more than I0,000sq.ft. =$250 RESTAURANT � NO V less than 25 seats =$100 ✓ 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES el $5 TOBACCO VENDOR YES $50 ALL NON-PROFIT(such as church kitchens) YES N $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 an el , have filed all state tax returns and paid all state taxes required under the law. Signa'ft Date Social Security or Federal Identification Number _______________ __ __ _ __ -----------------------------------T _ _r_____-________________ Revised 11/03/03 FOODAP2.adm Check#& Date oltl Vi � �� 0� � ( 60 ( • Hotly D.Zhang American Account Manager Red Cross 285 Columbus Avenue of Massachusetts Bay Boston,Massachusetts 02116 (617)375-0700 phone x 374 (617)375-0727 fax ZhangH@usa.redcross.org October 17, 2002 Ms. Joanne Scott Town of Salem Board of Health Re: Restaurant/Food Service Training and Certification M.G.L. ChapOr 94: Section 305D Dear Joanne: It was a pleasure to speak with you today about the Chokesaver with Restaurant Emergencies course. The following is a brief summary of the skills that Restaurant and Food Establishment employees will learn in just two hours: 1. Recognizing an Emergency 2. Emergency Action Steps; Check, Call, Care. 3. Protecting Yourself • Good Samaritan Laws • Obtaining consent • Preventing disease transmission • Demonstrate Glove Removal 4. Before Providing Care 5. Prioritizing Care • Demonstrate conscious choking skills (Adult, Child & Infant) • Have students practice abdominal thrusts. • Demonstrate unconscious choking skills (Adult, Child & Infant) 6. Wounds • Controlling severe bleeding • Care for Burns Course Materials: 2 Adult Choking Posters(One side English,the other in Spanish). Each participant receives a `Til Help Arrives Booklet and a wallet card" Emergency action steps to save a life". Course Cost: $240.00 flat fee fora maximum of 20 employees.It is$7.00 per person aver the maximum. Certificate:A "Chokesaver"certificate(wallet Size)will be sent approximately 10 days of ler course completion and it does not have an expiration date. For the M.G.I..Chapter 94: Suction 3051) go lul�ltpJhvww.stale_nulus/leaislla�+5/nu�Ilindes.hUn then click on "Link to a specific Chapter or Section" then fill in the Chapter and or section number. Please call me with any questions you may have or to schedule a class for a"best time" in .Ianuary or Feb ualy. Thank you for your interest, Best regards, Ufllted '? Way Voir ua at n•wnt Goslornedcrttcs.or�; 'Tn'Z+a 1W Ai h aw`[r ath'LIK. `�3a+.� .S 7� Y 4r Yj,i{ �j r� r .y.a lei s a� ..s, •... �Z^, y� j-r ar h i/a �`. i• i hq�ily..i lTT k { ia' C.w4'P S, �4Yj„ > G j��'�J�e r'.< K' a .r7 �' �X�a 7%b OSx ♦ + Tt ., e ` t < •' y a r v. ! 0 , , t �en �ecOnc fount'; ,_.r9'llJ.r !'0.� Y`L a ♦ a.�♦ ..+ t .',,' i i �.:a 'T k ti'41ar y+.j: w -. 1 Training . TM, P.O.Bos 3002 _ ' - Salem;MA.01970 975-744-4799 www.whensecondscount.net ATTENTION TO Did you know that the State of Massachusetts Code for Food Establishments, Chapter X, 105 CMR 590.009(E) states.:."each food establishment having a seating capacity of 25 persons or more shall: . (1) Have on its premises,while food is being served, an employee trained in manual procedures approved by the Department of Public Health to remove food"lodged in a person's throat-,and (2) Make adequate provision for insurance to cover employees trained in rendering such assistance. Are you. prepared to comply with the code? When Seconds Count, a CPR& First Aid Training Company is working with the City of Salem Board of Health to provide you and your employees with the training necessary to fulfill the requirements of the state code.We have developed a course specifically for restaurant employees that will train them to effectively be able to perform the Heimlich Maneuver and other necessary procedures to remove food lodged in a person's throat. We are offering this class on Monday, December 2,2002 from 6:00 p.m.until 7:30 p.m., Wednesday, December 4, 2002 from 9:00 a.m. until 10:30 a.m., Monday, December 9, 2002 from 6:00 p.m. until 7:30 p.m. and Wednesday,December 11,2002 from 2:00 p:m. until 3:30 p.m. All classes will be held at the Enterprise Center at Salem State College, 121 Loring Avenue, Salem. Pre-registration is required as space is limited. If you are unable to attend one of these course offerings, please contact When Seconds Count to schedule a course at your location or ours. We also carry a wide variety of First Aid supplies and barrier devices to aid in the successful, sanitary and safe food removal. For more information, please call 978-7444799 and ask how you can receive a free Face Shield Key Chain. Sincerely, When Seconds Count Commonwealth of Massachusetts sl City of Salem Kimberley Driscoll Board of Health Mayor 120 Washington Street,4th Floor SALEM,MA 01970 Temporary Food Permit DATE PRINTED: 08/08/2006 WHO'S PLACE OF BUSINESS IS: Ben & Jerry's File Number: BHF-2005-0032 60 Washington Street SALEM MA 01970 LOCATED AT: 0060 WASHINGTON STREET SALEM, MA 01970 Permit Type Permit Issued Permit Expires Fee Restrictions/Notes TEMPORARY FOOD Aug 8,2006 Aug 9,2006 Ice Cream to be served at the Salem Common Total Fees: PERMIT EXPIRES August 9, 2006 Board of Health ;i o CITY OF SALEM, MASSACHUSETTS 4y� BOARD OF HEALTH 3 + 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 p JOANNE SCOTT, MPH, RS, CHO �r Kimberley Driscoll HEALTH AGENT Mayor APPLICATION FOR A TEMPORARY FOOD SERVICE PERMIT I) FEE: 1-3 DAYS= $200 4-7 DAYS= $300 MORE THAN 7 DAYS= $400 CCHECK PAYABLE TO THE CITY OF SALEM,NO CASH NAME OF EVENTT 'SC 0166C I LOCATION S'D /,O� C'6MeWL641 DATE(S)OF EVENTy NAME OF APPLICANT ,d/ ^ ('C'eCw fa4 TELEPHONE# ADDRESS IC6 / Uf < 7� r 7 p < NAME OFBUSINESS ^e�V d e ` TELEPHONE# / qAlral ADDRESS V GC/ 0/ 7e) r CERTIFIED FOOD MANAGERS NAMEei*U370/'ffe/L , f-"1,1 fO CERTIFICATION# "ggq1S x A PLAN OF THE ESTABLISHMENT IS: ENCLOSED DRAWN ON THE BACK (,I av-eS TYPE OF REFRIGERATION: _GAS ICE DRY ICE _OTHER METHOD FOR COOKING/HOT HOLDING: GAS _OTHER I V METHOD FOR SANITIZING: CHEMICAL OTHER SOURCE OF FOOD: NAME: ADDRESS FOODS TO BE SERVED INCLUDING INGREDIENTS AND METHOD OF PREPARATION: I HAVE READ THE BOARD OF HEALTH, "REQUIREMENTS FOR TEMPORARY FOOD ESTABLISHMENTS." I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS REGARDING THOSE REQUIREMENTS. I UNDERSTAND THEM, AGREE TO ABIDE BY THEM AND UNDERSTAND THAT FAILURE TO DO SO WILL RESULT IN REVOCATION OF MY TEMPORARY FOOD ESTABLISHMENT PERMIT. PERSUANT TO MGL C6 , S49A, I CERTIFY UNDER THE PENALTIES OF PERJURY THAT 1, TO MY BEST KNOWLEDGE AND BELIEF, HAVE FILED ALL STATE TURNS AND P ID ALL STATE TAXES REQUIRED UNDER LAW. 0y1 e� -vr SIGNATURE DATE SOCIAL SECURITY OR FEDERAL ID# ----------- ---------------------------------------------------------------------------------------------------------------------------- TEMPAPPL REVISED 1102$/02 PERMIT p CHECK#&DATE 0060 WASHINGTON STREET Ben & Jerry's City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Telephone: Item Status Violation Critical Urgency Nature of problem or correction (978)744-7500 Non-compliance with: Not Done Owner: Anti-Choking PASS ❑ John Serino E a 0 Tobacco PASS ❑ PIC: John Serino _ FOOD PROTECTION MANAGEMENT Not Done Inspector:x' PIC Assigned/Knowledgeable/Duties PASS ❑d RED : � = David Greenbaum EMPLOYEE HEALTH Not Done Date Inspected: COrfeCt By . Reporting of Diseases by Food Employee and PIC PASS RED 5/26/2005 a Personnel with Infections Restricted/Excluded PASS RED Risk Level: - FOOD FROM APPROVED SOURCE Not Done 'Permit Number: n Food and Water from Approved Source PASS ❑J RED BHP-2005-0455 4, ;n. -: Receiving/Condition PASS ❑,/ RED Status: Tags/Records/Accuracy of Ingredient Statements PASS RED SIGNED OFF Conformance with Approved Procedures/HACCP PASS ❑,/ RED #of Critical Violations Plans PROTECTION FROM CONTAMINATION Not Done Time IN - Time OUT Separation/Segregation/Protection PASS RED ri 1 : .Notes: Food Contact Surfaces Cleaning and Sanitizing PASSd❑ RED 184 Proper Adequate Handwashing PASS RED Urgency Description(s): Good Hygienic Practices PASS RED BLUE: Violations Related to Good - Prevention of Contamination from Hands PASS ,/❑ RED Retail Practices (Critical Handwash Facilities PASSd❑ RED violations must be corrected immediately or within 10; days)(Non-critical violations GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. May 26,2005 ) Page 1 of 3 0060 WASHINGTON STREET Ben & Jerry's must be corrected Immediately PROTECTION FROM CHEMICALS Not Done or within 90 days) Approved Food or Color Additives PASS ❑d RED RED: - ' " - ' Toxic Chemicals PASS ❑� RED Violations Related to Foodborne Illness Interventions TIMEITEMPERATURE CONTROLS(Potentially Haz Not Done and Risk Factors (Require Cooking Temperatures PASS RED immediate corrective action) Reheating PASS ❑J RED Cooling PASS ❑J RED Hot and Cold Holding _ PASS 0 RED Time As a Public Health Control PASS 0 RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP PASS 0 RED CONSUMER ADVISORY Not Done Posting of Consumer Advisories PASS Q RED Violations Related to Good Retail Practices (Blue Not Done Management and Personnel PASS ❑ BLUE Food and Food Protection PASS ❑ BLUE Equipment and Utensils PASS ❑ BLUE Water, Plumbing and Waste PASS ❑ BLUE Physical Facility PASS ❑ BLUE Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other-See Notes PASS ❑ BLUE Emplolyees must wear disposable gloves while handling ready to eat foods. Certified Food Manager must be working in the food service area at all times until counter handwash sink is installed. Counter handwash sink must be installed an fully stocked with soap, paper towels and hot water within one week. Owner will call the Board of Health to confirm installation. Establishment is granted permission to open effective 5/29/05. GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. May 26,2005 ) Page 2 of 0060 WASHINGTON STREET Ben & Jerry's GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. May 26,2005 ) Page 3 of 3 e�tificate of chelevement 41pon recognition of meeting the profet onarrequirements for cert fication, EperiorAssessments', :GLC has conferred upon MICHAEL J. LATTA the designation of 3 , CERTIFIED PROFESSIONAL FOOD MANAGER Exam 1701 Recognized By Conference For Food Protection with affits rights, honors andprivari a Dou as F. Campbell, CFSP TCesetrt date Issued:8/26/02 AssessmentsTm, LLC Congratulations! You have passed the National Ex p erior Score Report Certified Professional Food Manager P examination. Your name has been added to the National Registry of Food Managers. Congratulations! You passed the Certified Professional Food Manager examination. Your Score is as follows: Se'ore Status Exam Date 75 PASS 8/26/02 This is to certify that _ 3 MI;CI 411 J ihA#A has met the necessary requirements for Food Man%r Certi Teatiom Exam 1701 Recognized By nference or Food Protection i MICHAEL J.LATTA I MILL POND #' i 393-02-2565 Exam Date: 8/26/6: F.rnnrinr AccaccmentxTM.T,I,C 800.624.2736 ertificate of chievement 4Jpon recognition of meeting the professionafrequirements for certification, EperiorAssessmentim, LLC has conferred upon DAVID J. LATTA t the designation of CERTIFIED PROFESSIONAL FOOD MANAGER Exam 1702 Recognized By Conferenga For Food Protection with adits rights, honors and privileges. Dougias F. Campbell, CFSP Certificate etifiaoeIssued:8/26/02 Congratulations! You have passed the National EXperior ASSeSS111entSTM, LLC Certified Professional Food Manager Score Report examination. Your name has been added to the National Registry of Food Managers. Congratulations! You passed the Certified Professional Food Manager examination. Your Score is as follows: Scores Status Exam Date 92 PASS 8/26/02 s This is to certify that > YI19)J LA''t'T has met the necessary requirements for Food Manager Certification. Exam 1702 Recognized By Conference For Food Protection DAVID J.LATTA 1 Mrr i.UnNT #: ___ _.. _ ._ Exam Date: COURT DOCKET NO. CITATION NO. CITY OF SALEM A 189 r= VIOLATION NOTICE NAME(LAST,FIRST,INITIAL) Jai , 5?17170 STREETADDRESS CITY/LOWN STATE ZIPyO1/Oet� LIC NSE O. / , �' LIC.EXP DAT DATE OF BIRTH OWNER'S NAME //(LAST,FIRST,INITIAL) V G�I17 Pr:i/1 U STREETADDRESS CITY/TOWN STATE ZIP i a 9 e 17F K) /S c2gO6 REGIS ATION NO. STATE EXP.DATE M�KE/TV YEAR COLOR DATE OF VIOLAT)OTI T E-- ITATION WRITT sy I/ NJURY PM ❑YEOS LOCATIONGA-5-0 00.`VIOLA'TI �)'� S ENFORCING D PT 1"o IV �i E ' OFFENS / HAP. SECT. FINES A 2 Od eYfl 8 eye. r_ SG, �Y y a c. D /o,5 � N� OFFI�yER / LD.NO. TOTAL ,�7 1i,.37/✓�,,, J FINE V LAT/// ` DUE G OFFICER CERTIFIES COPY,611,1 ,EN TO VIOLATOR /T, //�j'` 7 L L] IN HAND x �/ �-' �J'� ❑ BY MAIL DO NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY ORDER OR BY CHECK MADEPAYABLETO: 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 ON REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE PAYMENT IN THE AMOUNT OF $ CASE# SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL COURT DOCKET NO. Q CITATION NO. �✓ CITY OF SALEM A1Ciital{�9 z1!. „V VIOLATION NOTICE NAME,(- ST,FIRST,INITIAL) -{" r/ / .. STREETADDRESS CITY/TOWN STATE ZIP 4w4ajr t ; f _ r" . rr Gc 4 LICENSE NO. • IIC.EXP.DATE DATE OF BIRTH OWNER'S NAME(LAST,FIRST,INITIAL) STREETTJADDRESS fJ _'CCII'TY/TOWN j ST{A�TE ZIP ci REGISTRATION NO. STATE 'EXP.DATE NfAKE/T YEAR COLOR DATE OFES V OLAT N E ATE CITATION W ITT ERsQNAL �,_,,/�` INJURY / �M' INO LOCATION OF VIOLAT`q . , f - �4. ENFO CIN bEPT OFFENSE / CHAP SECT. FINES ?©e a16jlo A"7 e 105— OFFICER J/ " I.D.NO. TOTAL FINE $ DUE OFFICER CERTIFIES COPY,GIVEN TO VIOLATOR '1)' (/—/'y' 2/ El IN HAND X C.> �1 1 1fY (. /'• ❑ BY MAIL �,/ ti� DO NOT MAIL CASH-`FAY OIJLY BY POSTAL NOTE,MONEY ORDER 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 ON REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE PAYMENT IN THE AMOUNT OF 4 i ' $ CASE# SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL • aa • a •a• ai� a • a • • a 77 IL w mac-n--s b A/9 f * • aesw �� '� 3 r\ IMPORTAMT MESSAGE FOR s '�, C-(2t0 V DATE �-1 TIMEL,L(p.M� M i�G �J PHONE citio ( /n—g IW AREA CODE NUMBER EXTENSION O FAX ❑ MOBILE 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 K20IGL5 tO (l jWQL oy9 66 �em L Lai-os � we SIGNED 10 b FORM 9 MADE IN .S.A.