CAFE GRAZINI - ESTABLISHMENTS CAFE GRAZINI " D+
133 WASHINGTON STREET
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�CONII(Tq City of Salem, Massachusetts
Board of Health 10
a 120 Washington Street, 4th Floor, Salem, MA 01970
P Tel. (978) 741-1800 Fax. (978) 745-0343 PabliCHealei
health@salem.com Prevent. Promote. Protect,
KimberleyDriscoll Lar Ramdin, MPH, REHS, CHO
Larry
Mayor Health Agent
FOOD ESTABLISHMENT PERMIT
(must be posted on the Premises of the Food Establishment)
2017
Permit Number: FM-16-627
Permit Type: Food Establishment 25-99 seats
Goods& Services: Food Service: 25-99 seats
Name of License Holder: CAFFEE GRAZIANI, Inc.
Name of Food Establishment Caffe Graziani
Address of Food Establishment 133 Washington Street Salem MA 01970
Restrictions:
This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on
12/31/2017 unless sooner suspended or revoked.
Permit Fee: $0.00 L
Effective: 12/21/2016
Larry Ramdin, MPH, REHS, CHO
Health Agent
CITY OF SALEM, IV
r *.. � MASSACHUSETTS P b>i
BOARD OF HEALTH - •• .••��� .� �
F nr116 120 WASHINGTON STREET,4T"FLOOR
KIDIBERLEY DRISCOLL OF(' ') v TFL.(978)741-1800 FAx(978)745-0343
� LARRY RAMIDIN,RS/REI-IS,C1-10,CP-FS
�.E hcalth&alcm.com
MAYOR °\SPj Ur N,.�ySN HEAuri-I AGENT
Food Establishment Permit Application
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name:
2) Establishment Address: 1 Yv Ll5 1 Y1 S�
3) Establishment Mailing Address(if different):
4) Establishment Telephone No: ( z-
5) Applicant Name&Title: �� J I (ie S t
6) Applicant Address: l / Bos -)V
7) Applicant Telephone No: �/? / J�24 Hour Emergency No 179qj 3 ""�
/
/1,l ` Email:/ ' L (�
8) Owner Name&Title(if different from applicant):
9) Owner Address(if different from applicant):
10) Establishment Owned byr -( 11) If a corporation or partnership,give name,title and home address of
CCL- -e, officers or partner.
An association Name Title Home Address
[Iporporation //-- �,./-
An individual oLCt Vx S,c t-lzlc ?
Apartnership �rGt�r I
Other legal entity I
s057-0�
12) Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor,Manager,etc.
Name&Title: l Y1 h G ra Z l to 1 !L tA lG�.
Address: ////
Telephone No: L: Email:
Emergency Telephone No: aS
13) District or Regional Supervisor(if applicable)
Name&Title:
Address:
Telephone No: Fax: Email:
Check#:�� /l Date:— Amount:_
Food Establishment Information
'14)) Water Source: 15) Sewage Disposal:
DEP Public Water Supply No: (if applicable) Sbw
TlAe3 a T-3 30 Z
16) Days and Hours of Operation: � t Sal' �7_k 50n Z � 17) No. of Food Employees:
18) Name of Person in Charge Certified In Food Protection Management: /
Required as of 1011/2001 in accordance with 105 CMR 590.003(A)
19) Person Trained in Anti-Choking Procedures(if 25 seats or more): 021' Yes No
20) Location: 22) Establishment Type(check all that apply)
/ (check one) 0 Retail ( Sq. Ft) 0 Caterer
i Permanent Structure GrPood Service-( 110 Seats) 0 Frozen Dessert Manufacturer
Mobile 0 Food Service-Takeout 0 Residential Kitchen for Retail Sale
0 Food Service-Institution 0 Residential Kitchen for Bed and
( Meals/Day) Breakfast Home
0 Food Delivery 0 Residential Kitchen for Bed and
21) Length Of Permit: Breakfast Establishments... . .........•-•----•--------
(check one) RETAIL STORE RESTAURANT
Annual 0 Less than 1000sq.ft. $70 0 Less than 25 seats $140
Seasonal/Dates: 01000-10,000sq.ft. $280 0 Residential Kitchens $140
0 More than 10,000sq.ft. $420 4-25-99 seats $280
0 More than 99 seats $420
Temporary/DatesMme: - -----•----------------- --------------------•-v*--------------- ------------ --------------------------------------------------------...
0 Bed 8 BreakfasUChildcare Services/Nursing Home $100
- ------------•------------------------------------------------------------------------------------------
ADDITIONAL PERMITS
0 MAKE ICE CREAM,YOGURTISOFT SERVE $25
0 PASTURIZATION $25
0 ALL NON-PROFIT" $25
*Including, church kitchens, state funded childcare&private club
23) Food Operations: Definitions: PHF-potentially hazardous food(time/temperature controls required)
Non-PHFs-non-potentially hazardous food(no time/temperature controls required)
(check all that apply): RTE-read -to-eat foods Ex.sandwiches,salads,muffins which need no further processing
Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held
Pre-packaged Non-PHFs 1/ for More Than a Single Meal Service
Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly
Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility
Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill
Prepared by Consumer
Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance
Processed Foods for andlor HACCP Plan(including bare hand
Service Within 4 hours contact alternative,time as public health
control.
Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of
Non-PHF and Non- Retail Sale Animal Origin
Perishable Foods Only
Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered
Retail Sale Events or Institutional Food Service
Offers RTE PHF in Bulk Quantities
To be completed by the Board of Health
Retail Sale of Salvage,Out of Date
or Reconditioned Food Total Permit Fee:
Payment is due with application
1,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will
comply with 105 CMR 590.000 and all other applicable law. a been instructed by the Board of Health on how to obtain copies of 105 CMR
590.000 and the Federal Food Code.
24) Signature of Applicant: i
Pursuant to MGL Ch.62C, sec.49A, I certify un the penalties of perjury that I,to my best knowledge and belief,
Have filed all state tax returns and paid state taxes required under law,.
25) Social Security Number or Federal ID: 0 x/131/fZ k(/9 G
f
26) Signature of Individual or Corporate Name: L.Ia1-64 62127-14,12; `
r
i
QUESTIONAAJIREr—GREASE TRAPS 2013
1. NAME OF ESTABLISHMENT:_
2. ADDRESS OF ESTABLISHMENT: I3 3
3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP?
4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT HAVE?
CAPACITY IN GALLONS 30
5. HOW IS THE GREASE TRAP MAINTAINED? ON A DAILY BASIS? BY AN N•HOUSE ERSON 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?
- ,- M an
8. WHAT IS THE DATE OF YOUR LAST INVOICE FROM THE REMOVAL FIRM?
e
* The Commonwealth of Massachusetts Print ;oitn
Department of Industrial Accidents
Office of Investigations
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information /► � Please Print Legibly
Business/Organizati(o(nI Name: Ca 1 � Goo-7 L�((\I vtC.
Address: `
"U ( 5
City/State/Zip: ���� Phone#:
Are you an employer?Check the appropriate box: Business Type(required):
1. 1Q I am a e oyer with employees(full and/ 5. ❑Retail
onrrt---- .* 6. ❑ Restaurant/Bar/Eating Establishment
2.❑ 1 am a sole proprietor or partnership and have no 7• ❑ Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers'comp.insurance required] 8• ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152, §1(4), and we have 10.❑Manufacturing
no employees. [No workers'comp.insurance required]*
4.❑ We are a non-profit organization,staffed by volunteers, 11.❑Health Care
with no employees. [No workers' comp.insurance req.] 12.0 Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
"lf the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy information.
Insurance Company
tt'Name:klKsl- 7V���nSUtYADc2 Cc1
T (�
Insurer's Address: u 0 Lin c c2 l in —5-r -PU r�� l"SO 6 �1L c,� �I t
1 City/State/Zip: (o
' L 'r 0 (
Policy#or Self-ins.Lic.#�N f1 eJ `i [� 4kA f- 0� Expiration Date: l 4 19 -2-0
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby c der the pa' s nd penalties ofperjury that the information provided above is true and correct
Si afar : Date: tl
Phone#: �� Z Z
Oficial use only. Do not write in this area,to be completed by city or town ofciaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply your insurance company's name,address and phone number along with a certificate of insurance.
Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members
or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy
is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers'compensation policy,please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number.In addition,an applicant that
must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this
affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. #617-727-4900 ext 406 or 1-877-NIASSAFE
Fax #617-727-7749
www.mass.gov/dia
Form Revised 7/2010
MCONntzgw�'e City of Salem, Massachusetts
f5 •3
r Board of Health
120 Washington Street, 4th Floor, Salem, MA 01970
Tel. (978) 741-1800 Fax. (978) 745-0343 PabhCHCalttl
Iramdin@salem.com Prevent. Promote. Protect.
Kimberley Driscoll Larry Ramdin, MPH, REHS, CHO
Mayor Health Agent
FOOD ESTABLISHMENT PERMIT
(must be posted on the Premises of the Food Establishment)
2016
Permit Number: FM-16-11
Permit Type: Food Establishment 25-99 seats
Goods& Services: Food Service: 25-99 seats
Name of License Holder: Caffe Graziani Inc.
Name of Food Establishment Caffe Graziani
Address of Food Establishment 133 Washington Street Salem MA 01970
Restrictions:
This License is granted in conformity Wth the statutes, Regulations and ordinances relating thereto,and expires on
12/31/2016 unless sooner suspended or revoked.
Permit Fee: $280.00
Issued: 1/1/2016
r' CITY OF SALEM,
MASSACHUSETTS
PubltcHealth
BOARD or HiIAL fI-c
120 WASHINCPON S1 REIM,,4n,Fi.00k
KIMBERLEY DRISCOLL Trl..(978)741-1800 FAX(978)745-0343 LARRY RAMDIN,RS/RGHS,CI 10,
MAYOR Iramdin(@salem.com salem.com HLALTt-I ACI.N1'
Food Establishment Permit Application
(Application must be submitted at least 30 days before the planned opening date)
I - ,
1) Establishment Name: ra Z/ r"
2) Establishment Address: /33 / Gl O/ 70
3) Establishment Mailing Address(if different): /
4) Establishment Telephone No: a All � Z
5) Applicant Name&Title:
6) Applicant Address: IZI5 f0 Sf �p dZ/
7) Applicant Telephone No: k1 L4/ " 2 24 Hour Emergency No:(r 9 7.320 Email" 41g�� Ga✓/1CA'
S) Owner Name&Title(if different from applicant):
9) Owner Address(if different from applicant):
10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of
officers or partner.
association Name Title Home Address
corpora �p
inrvt wk lzSdoz� '
A partnership f % h
Other legal entity
12 Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor,Manager,etc.
Name&Tittle: .vvun„y �r4zjQ+� i S
Address: S-/L- C— ,k s S7 0
Telephone No: &117," 7j -7 Fax:—'— Email: G 6,&,/1C
Emergency Telephone No: JQ 0
13) District or Regional Supervisor(if applicable)
Name&Title:
Address:
Telephone No: Fax: Email:
Check#: /3,�� Date:d�6��/ Amount:
1' Food Establishment Information
'i ra
14) Water Source: C7 ( / u{ SA[ evn 15) Sewage Disposal: C- I y v�' S"L(Q"k,
DEP Public Water Supply No: (if applicable)
16) Days and Hours of Operation: f rk S -'P S IAO"' 17) No. of Food Employees: r
18) Name of Person in Charge Certified In Food Protection Management: n p I
Required as of 101112001 in accordance with 105 CMR 590.003(A) POW 1 6T esl—
19) Person Trained in Anti-Choking Procedures( if 25 seats or more): Yes No Pa.klo- P Gr(gvGJ(e se
20) Location: 22) Establishment Type(check all that apply)
eck one) O Retail( Sq. Ft) ❑Caterer
e manent Structure Gr Food Service-( !�- o Seats) ❑ Frozen Dessert Manufacturer
obile ❑ Food Service-Takeout 13 Residential Kitchen for Retail Sale
❑ Food Service-Institution 13 Residential Kitchen for Bed and
( Meals/Day) Breakfast Home
❑ Food Delivery ❑ Residential Kitchen for Bed and
21) Length Of Permit: Breakfast Establishments----------------------
(check one) RETAIL STORE RESTAURANT
n ess than 1000sq.ft. $70 ❑ Less than 25 seats $140
Seasonal/Dates: El 1000-10,OOOsq.ft. $280 ❑ Residential Kitchens $140
❑More than 10,OOOsq.ft. $420 ❑25-99 seats $280
❑More than 99 seats $420
Temporary/DatesMme: - -------- --- ---- ---- '"'"'' ... '_ "c"'"'`'_'_- - - -- ------_ --m,---------------------------------------- ------_ '".......
❑ Bed&Breakfast/Childcare Servies/Nursing Hoe $100
----------------------------------------------------------------- ..............--------------------- ....... ..........-..------------
ADDITIONAL PERMITS
❑MAKE ICE CREAM,YOGURT/SOFT SERVE $25
❑ PASTURIZATION $25
❑ALL NON-PROFIT' $25
*Including, church kitchens, state funded childcare&private club
23) Food Operations: Definitions: PHF-potentially hazardous food(timeltemperature controls required)
Non-PHFs-non-potentially hazardous food(no timeJtemperature controls required)
(check all that apply): RTE-ready-to-eat foods Ex.sandwiches,salads, muffins which need no further processing
Sale of CommerciallyPHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held
Pre-packaged Non-PHFs ✓ for More Than a Single Meal Service
Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly
Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility
Delivery of Packaged PHFs Sate of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill
Prepared by Consumer
Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance
Processed Foods for and/or HACCP Plan(including bare hand
Service Within 4 hours contact alternative,time as public health
control.
Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of
Non-PHF and Non- Retail Sale Animal Origin
Perishable Foods Only
Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered
Retail Sale Events or Institutional Food Service
Offers RTE PHF in Bulk Quantities
To be completed by the Board of Health
Retail Sale of Salvage,Out of Date
or Reconditioned Food Total Permit Fee:
Payment is due with application
I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will
comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR
590.000 and the Federal Food Code.
24) Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A, I certify u der the penalties of perjury that I,to my best knowledge and belief,
Have filed all state tax returns and paid state taxes required under law.
25) Social Security Number or Federal ID: 3( 2-9(
! /
26) Signature of Individual or Corporate Name: i /f deo% /'eGl
ooNDlTgw�! City of Salem, Massachusetts
RLT3; It
10
t Board of Health
�a 120 Washington Street, 4th Floor, Salem, MA 01970
D Tel. (978) 741-1800 Fax. (978) 745-0343 PublicHealth
Prevent. Promote. Protect.
Iramdin@salem.com
Kimberley Driscoll Larry Ramdin RS/RENS, CHO, CP-FS
Mayor Health Agent
FOOD ESTABLISHMENT PERMIT
(must be posted on the Premises of the Food Establishment)
2015
Permit Number: FM-15-12
Permit Type: Food Establishment 25-99 seats
Goods &Services: Food Service: 25-99 seats
Name of License Holder: Cafe Graziani Inc.
Name of Food Establishment Caffe Graziani
Address of Food Establishment 133 Washington Street Salem MA 01970
Restrictions:
This License is granted in conformity Wth the statutes, Regulations and ordinances relating thereto,and expires on
12/31/2015 unless sooner suspended or revoked.
Permit Fee: $280.00
Issued: 1/1/2015
'R
ft
CITY OF SALEM,
MASSACHUSETTS F Ith
BOARD of HIAIA-H •.... "..
120 WASIIING TONS 111FE T,4T"Fj,00a
KIMBERLEY DRISCOLS. TET..(978)741-1800 FAX(978)745-0343 LARRY RiMDIN,RS/RHIIS,CIIO,CP-FS
MAYOR Iramdin@salem.com HI;;\L;I'H ACiI'.N'I'
Food Establishment Permit Application
(Application must be submitted at least 30 days before the planned opening date)
1 Establishment Es ab Ishment Name:
2) Establishment Address: 3 3 W a sh h
3) Establishment Mailing Address(if different):
4) Establishment Telephone No:
5) Applicant Name&Title: 414 r&V Ct ( eS e OlWner
6) Applicant Address: ) "r� y T(In 5 f S �O5 O/tRoc 0 Z lZd"
7) Applicant Telephone No: (//j y7 24 Hour Emergency No: S044.tEmail: p 01
e¢�
8) Owner Name&Title(if different from applicant):
9) Owner Address(if different from applicant):
10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of
officers or partner.
An association Name Title Home Address
.(3)corporation
An individual ly4fav _ 7 ii,-e S 6-en t
A partnership
Other legal entity O ti Zt.ce nctGrk-
9;�Wa5f Z-*1
CyZI
12 Person Directly Res onsible For Daily Operations Owner, Person in Charge,Supervisor,Manager,etc.
Name&Title: /J 2 u (e S
Address: ct'-( � U57�(ri-` f!'lCt �Z/ Z l`
Telephone No / Fax: Emaih (UrKC , f
Emergency Telephone No:
13) District or Regional Supervisor(if applicable)
Name&Title:
Address:
Telephone No: Fax: Email:
Check#: _ Date: �a` ( Amount: �'
•" i Food Establishment Information
1r) Water Source: 15) Sewage Disposal:
DEP Public Water Supply No: (if applicable) G S,7 6e—�
'fes, ItiY �r'3
16) Days and Hours of Operation: A4 f 3o� 17) No. of Food Employees:
18) Name of Person in Charge Certified in Food Protection Management:
Required as of 101112001 in accordance with 105 CMR 590.003(A) &04 (�i ((Q
19) Person Trained in Anti-Choking Procedures(if 25 seats or more): Yes No I pS�
20) Location: 22) Establishment Type(check all that apply)
(check-one 0 Retail( Sq. Ft) 0 Caterer
Permanent Structure 0 Food Service-( Seats) O Frozen Dessert Manufacturer
Mobile 0 Food Service-Takeout 0 Residential Kitchen for Retail Sale
0 Food Service-Institution 0 Residential Kitchen for Bed and
( Meals/Day) Breakfast Home
0 Food Delivery 0 Residential Kitchen for Bed and
21) Length Of Permit: Breakfast Establishments
------------------------•- ----...............................
--(s<heck one) RETAIL STORE RESTAURANT
Annual 0 Less than 1000sq.ft. $70 0 Less than 25 seats $140
Seasonal/Dates: 0 1000-10,000sq.ft. $280 0 Rjasidential Kitchens $140
0 More than 10,000sq.ft. $420 25-99 seats $280
0 More than 99 seats $420
Temporay/Dates/Time: ------------------ --------- -- ----------------- - ---------------------------------------------------------------- -------
0 Bed&BreakfastlChildcare Services(Nursing Home $100
...................I.............. ----------- -------- - - ---------- ......................................................
ADDITIONAL PERMITS
0 MAKE ICE CREAM,YOGURTISOFT SERVE $25
0 PASTURIZATION $25
0 ALL NON-PROFIT"' $25
*Including, church kitchens, state funded childcare&private club
23) Food Operations: Definitions: PHF-potentially hazardous food(timdtempersture controls required)
Non-PHFs-non-potentially hazardous food(no time/temperature controls required)
(check all that apply): RTE-ready-to-eat foods Ex.sandwiches,salads,muffins which need no further processin
Sale of Commercially HF Cooked to Order HoyPHF Cooked and Cooled or Hot Held
Pre-packaged Non-PHFs ✓ for More Than a Single Meal Service
Sale of Commercially P paration of PHFs For Hot And PHF and RTE Foods Prepared For Highly
Pre-packaged PHFs old Holding for Single Meal Service Susceptible Population Facility
Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill
Prepared by Consumer
Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance
Processed Foods for and/or HACCP Plan an(including bare hand
Service Within 4 hours contact alternative,time as public health
control.
Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of
Non-PHF and Non- Retail Sale Animal Origin
Perishable Foods Only
Preparation of Non-PHFs Juice Manufactured and Packaged for repares Food/Single Meals for Catered
Retail Sale 11 Events or Institutional Food Service
Offers RTE PHF in Bulk Quantities
To be completed by the Board of Health
Retail Sale of Salvage,Out of Date
or Reconditioned Food Total Permit Fee:
Payment is due with application
I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will
comply with 105 CMR 590.000 and all other applicable la I have been instructed by the Board of Health on how to obtain copies of 105 CMR
590.000 and the Federal FoodCod
24) Signature of Applican /sG
Pursuant to MGL Ch.62C, sec.49A I certl under the penalties of perjury that 1,to my best knowledge and belief,
Have filed all state tax returns and paid state taxes required under law.
25) Social Security Number or Federal ID: 0 Ld� ` /1
26) Signature of Individual or Corporate Na
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u
Mayor
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--, , ,,CITY OF SALEM 1P
MASSACHUSETTS P Ith
NOV Zq Z013 BOARD m HEAI:rrl
120 WAS]11NGTON Snwi,r,4:-FLOOR
CITY OF SALE�µit,. 97g 741-1800 FAx 978 745-0343 LARRY'IU\MDIN,ILS/RL3FiS,CI 10,(:P-FS
KIMBE MAY DRISCOI.L ( ) ( )
BOARD OF HEALTH Iramdin@salem.com
MAYOR - HEALTH AG1',N•1' -
Food Establishment Permit Application
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name: CCA LCL✓I l
2) Establishment Address: 13 0 S
3) Establishment Mailing Address(if different):
4) Establishment Telephone No: q 7,f -7 41 7-e2—
5) Applicant Name&Title: P , G r aUQ e 5 e
8) Applicant Address: 71it r 5" can
jp
7) Applicant Telephone No: . / as 24 Hour Emergency NO: /7 Email:/tau l Q 9 1 a CO&I
8) Owner Name&Title(if different from applicant):
9) Owner Address(if different from applicant):
10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of
officers or partner.
An association Name Title Home Address
®orporation
An individual r^ VAI(e
A partnership
Other legal entity
12) Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor,Manager,etc.
Name&Title: L2
Address:
Telephone No: Fax: Email:
Emergency Telephone No:
13) District or Regional Supervisor(if applicable)
Name&Title:
Address:
Telephone No: Fax: Email:
Check#: // Date: Al � Amount:��V
Food Establishment Information
r 14) Water Source: G1 + f _SLICiV✓) 15) Sewage Disposal: 6,4-t O� i�✓Y�
DtP Public Water Supply No: (if applicable)
-i-&JLe- -11,we fl-j
16) Days and Hours of Operation: G-, so ' 8S-f 5M ( 17) No. of Food Employees:
18) Name of Person in Charge Certified in Food Protection Management: n I
Required as of 101112001 In accordance with 105 CMR 590.003(A) TA V
19) Person Trained in Anti-Choking Procedures(if 25 seats or more): "as No
20) Location: 22) Establishment Type(check all that apply)
check one) ❑ Retail( Sq. Ft) ❑Caterer
Ifto
Maasur 9JFood Service-( 5p Seats) ❑ Frozen Dessert Manufacturer
Mobile ❑ Food Service-Takeout ❑Residential Kitchen for Retail Sale
❑ Food Service-Institution ❑ Residential Kitchen for Bed and
( Meals/Day) Breakfast Home
❑ Food Delivery ❑ Residential Kitchen for Bed and
21) Length Of Permit: Breakfast Establishments,,,,,,,,,,,,,,,,,,,,,
—(Check one) RETAIL STORE RESTAURANT
`yt�-nual7 ❑Less than 1000sq.ft. $70 13 Less than 25 seats $140
e nal/Dates: ❑1000-10,000sq.ft. $280 ❑Residential Kitchens $140
❑More than 10,000sq.ft. $420 25-99 seats $280
❑More than 99 seats $420
Temporary/Dates/Time: .. ...... .. ......... . ...... ............. ....... .
❑ Bed&Breakfast/Childcare Seryices/Nursing Home $100
------------------_--..................................................................................................... ..............
ADDITIONAL PERMITS
❑MAKE ICE CREAM,YOGURTISOFT SERVE $25
❑ PASTURIZATION $25
❑ALL NON-PROFIT* $25
*Includ/n , church kitchens, state funded childcare 8 private club
23) Food Operations: Definitions: PHF-potentially hazardous food(timeNemparature controls required)
Non-PHFs-non-potentially hazardous food(no timeRemperature controls required)
(check all that apply): RTE-rea -to-eat foods Ex.sandwiches,salads,muffins which need no further processing
Sale of Commercially ?
HF Cooked to Order Hot PHF Cooked and Cooled or Hot Held
Pre-packaged Non-PHFs )/ V for More Than a Single Meal Service
Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly
Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility
Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill
Prepared by Consumer
Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance
Processed Foods for and/or HACCP Plan(including bare hand
Service Within 4 hours contact alternative,time as public health
control.
Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of
Non-PHF and Non- Retail Sale Animal Origin
Perishable Foods Only
Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered
Retail Sale Events or Institutional Food Service
Offers RTE PHF in Bulk Quantities
To be completed by the Board of Health
Retail Sale of Salvage,Out of Date
or Reconditioned Food Total Permit Fee:
Payment is due with application
I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will
comply with 105 CMR 590.000 and all other applicable law. 1 have eon instructed by the Board of Health on how to obtain copies of 105 CMR
590.000 and the Federal Food Code.
24) Signature of Applicant:
Pursuant to MGL Ch.62C,sec.49A,I certify under penalties of perjury that 1,to my best knowledge and belief,
Have filed all state tax returns and paid state taxes'required under law.
25) Social Security Number or Federal ID: `/��
26) Signature of Individual or Corporate Name: r t a "I �� V(fit-a t an t =,r c
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,0 Floor
Division of Food and Drugs Salem, MA 01970-3523
Tel. (978) 741-1800 Fax(978) 745-0343
City/Town of Address:
FOOD ESTAELLISHMENYINSPECTiON REPORT Tel.
Name D t Typ Operation(s) Type.0inspection
LY'Food Service LLHTbutine
AddressRis ❑ Retail F] Re-inspection
Telephone n Level ElResidential Kitchen Previous Inspection
J4 TF/
❑ Mobile Date:
Owner a HACCP YIN
[I Temporary El Pre-operation
❑ Caterer ❑Suspect Illness
Person-i Tim Li Bed&Br ass( ❑ General Complaint
HACCP
Inspector ou: / Permit No. '/ ❑Other
Each violation cked re fires an explanation on the narrative a s)and a citation of specific provision(s)violated.
Noe-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors_(Red
Items) Anti-Choking 590.009(E) ❑
Violations marked may Tobacco 590.009(F) ❑
y pose an imminent health hazard and require immediate Allergen Awareness 590.009(G) ❑
corrective action as determined by the Board of Health.
IFOORPROTECTION MANAGEMENT _ �_� _ ~�t� ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
❑ 13. Handwash Facilities
EMPLOYEEHEALTH .. .- - -
- . - _ _ _ .. _ _ _ _. J I PROTECTION FROWCHEMICALS
❑ 2. Reporting of Diseases by Food Employee and PIC
EI3. Personnel with Infections Restricted/Excluded El 14.Approved Food or Color Additives
_ _.
El 15.Toxic Chemicals
,..FOOD FROMAPPROVED SOURCE,_-_-
I TIMFITEMPERATURE:CONTROL'S....e7 ' .aiii _ _ 1
❑ 4. Food and Water from Approved Source _ ._ (P.otentlallyHaxardous Foods)"
❑ 5. Receiving/Condition [116. Cooking Temperatures
❑ 6. Tags/Records/Accuracy.of Ingredient Statements ❑ 17.Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling
PROT_ECnON FROM CONTAMINATION '�'+ _ - ' 19. Hot and Cold Holding
❑ Separation/Segregation/Protection ❑20. Time as a Public Health Control
Food Contact Surfaces Cleaning and Sanitizing tREGUiREMENTS FOR,HIGHLYSU$CEP718CEPOPULATION3;(H$P).
El 10. Proper Adequate Handwashing
C121. Food and Food Preparation for HSP
_ _
El 11. Good Hygienic Practices gCONSUMERADVISORY
❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices_(Blue .- Number of Violated Provisions Related
Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22):
of Health. Noncritical(N)violations must be corrected Official Order for Correction:Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code.This report,when signed below
C N by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2X order of the Board of Health. Failure to correct violations
4. Food and Food Protection (FC-3X590.004)
a)4) cited in this report may result in suspension or revocation of
25. Equipment and Utensils (FC-4X590.005) the food establishment permit and cessation of food
X. Water, Plumbing and Waste (Fc-5X590.006) establishment operations. If aggrieved by this order,you
27. Physical Facility (FC-6X590.007) have a right to a hearing. Your request must be in writing
28.EPoisonous or T x'c Materials (FC-7X590.008) and submitted to the Board of Health at the bove address
29. Special t� (590.009) within 10 days of receipt of this order.
30. O DATE OF RE-INSPECTIO
7
Inspector's Signature: / Print:
PICS Signa re: Print: I Page ofPages
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT 8 Cross-contaminatron
1 590.003(A) Assignment of Res onsibilit * 3-302.11(A)(1) I Raw Animal Foods Separated from
_ Cooked and RTE Foods*
590.003(B) Demonstration of Knowledge u Contamination from Raw Ingredients
2-103.1.1. Person in charge-duties 3-302.1.1(.4)(2) Raw Animal Foals Separated from Each
Other*
EMPLOYEE HEALTH Contamination from the Environment
2 590.003(C) Responsibility of the person in charge to 3-302.11(A) Food Protection*
require.reporting by food employees and 3-10115 Washing Fruits and Vegetables
applicants* - 3-:3(A.11. Food Contact with Equipment and
590.003(F) Responsibility Of A Food Employee Or An Utensils*
Applicant To Report To ThePersonIn -
Charge* Contamination from the Consumer
590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food*
3 590.003(D) Exclusions and Restrictions*
Food
Disposition of Adulterated or Contaminated
590.003(E) Removal of Exclusions and Restrictions 3-70L11 Discarding or Reconditioning Unsafe
_FOOD FROM APPROVED SOURCE Food*
4 Food and Water From Regulated Sources FT Food Contact Surfaces
590.004(A-B) Compliance with.Food Law* 4-501..i 1 I. Manual Warewashing-Hot Water
3-201.12 Food in a Hermetically Seated Container* Sanitization Temperatures*
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water
3-202.13 Shell Eggs* - Sanitization Temperatures*
3-202.14 Eggs and Milk Products.Pasteurized* 4-501.114 Chemical:Sanitization-temp.,pH,
3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. *
5-101.11 Drinking W'atec from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and
590.006(A) Bottled Drinking Water'+ Utensils Clean*
4-602.11 Cleaning Frequency of Equipment Food
590.006(B) Water Meets Standards in 110 Civ7R 22.0*
Contact Surfaces and Utensils*
Shellfish and Fish From an Approved Soutoe
4-702.11 Frequency of Sanitization of Utensils and -
3-201.14 Fish and Recreationally Caught Molluscan -
Food Contact Surfaces of ui merit*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and
3-201.15 Molluscan Shellfish from NSSF listed Chemical*
Sources* 10 Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Ae MatoAuL'rorit 2.301.11 Clean Condition-Hands and Arms*
,
3-202.18 Sheilstock Identification Present* 2.301.12 Cleaning Procedure*
590.004(0 Wild Mushrooms* 2-301.14 When to Wash*
3-201.17 Game Animals* -. 11 Good Hygienic Practices
3 Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco*
3-202.11 PHFs Received at Proper Temperatures* 2401.12 Discharges From the Eyes,Nose and
3-202.15 Package Irate rit'* Mouth*
3-101.1 i Foal Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting*
b TagsiRecords:Shelistock12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from
3-203.1.2 Shellstock Identification Maintained* Employees*
Tags/Records:Fish Products 13 Handwash Facilities
3-402.11 Parasite Detitrucnon'
Conveniently Located and Accessible
- -
3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities*
590.004(J1 Labeling o1 ingredients' 5-204.11 Location and Placement*
g Conformance with Approved Procedures
5-205.11 Accessibility,Operation and Maintenance
/HACCP Plans Supplied with Soap and Hand Drying
3-502.17. 3 cialized Processing Methals* Devices
4-301.11 Handwashin Cleanser,�Avaitabiht
3-502a2 Reduced oxygen packaging,criteria* - b-301.1.2 HandDr :Provision
8-103.12 Conformance with AppELyLd Procedures*
Denotes,critical item in the Weral 1999 Foal Code or 105 CMR 590.001).
•
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L1 �J411G�/�(Sil► �. .�iT.�J�lfl i�� Ra MO
MOA Wfill OTM AMA 9%
mill
.: r . .
3-501.14(C) PHR Received at Temperatures
FactorsViolatioRelated) Foodborne illness.interventions and Risk According to Law Coaled to
Fectors(Idams t-22) (Cont.) 41'F/45°F Within Hours,
PROTECTION FROM CHEMICALS 3-501.15 CuK)UE Methods for PHFs
14 Food or Color Additives 19 PHF Hot and Cold Holding
3-202.12 Additives* 3-501.16(8) Cold PHFs Maintained at or below
' _
3-302.14 Protection from Una rm590.004(F) 410/450 F*
Poisonous or Toxic Substances ed Additives* 3-501.16(A) -Hot PHFs Maintained atorabove
15 -
140T.
Containers*7-10L11 Identifying Information
Information-Original 3-501,16(A) Roasts;Held at or above 130°F. IFF
Co
7-102.11. Common Nam*-Workin Containers* 20 Time as a Public Health Carmol
7.201.I i Separation-Storage' 3-501.14 Time as a Public Health Cannot*
7-202.11 Restriction-Presence and Use* 590.004(H) Vananee Requirement
7-202,12 Conditions of Use*
7-203.1I Toxic Containers-Prohibitions* REOUIREMENM FOR HIGHLY SUSCEPTIBLE
7-204.11 Sanitizers.Criteria-Chemicals° POPULATIONS(HSP)' _
7-204.12 Chemicals for.fashing Produce,Criteria* 21 3-801.11(A) UnpaswwizBd Pre-Packaged Juices and
7-204,}4 Drying Agents.Criteria* [Beverages with Wanting labels*
3-801.11(B) Use of Pasteurized E R
7-205.11 Incidental UseFooPestiContacides;
;Criteria* 3-801.11(D) Raw or PartiallyCoated Animal Food and .
7-206.11 Restricted Use Pesticides;Criteria* Raw Seed S tits Not Served IF
7-206.13
Rodent Bait Stations* 3-801.11(C} Unopened Food PackageNot lto=served.
7-206.13 Tracking Powders,Pest Control and
Monitodn
CONSUMER ADVISORY
TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted Por Consumption a-
1Proper 6 Foods That are Raw.Undercooked or
16 PHFs Coatdng Temperatures for Not Otherwise Processed to Eliminate
exro*rnrwr
3-401.I lA(t)(2) Eggs- I55°F 15 Sec. Paiho *
-
E '-s-lmttoediste Service 145*F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
3.401.11(A){2) Comminuted Fish.Meats&Caw
Eggs*
Animals-155°F 15 see. *
3-401.11(5)(1)(2) Park and Beef Roast- 130OF 121 min* - SPECIAL REQUIREMENTS
3-401.11(A)(2) Ratites,Injected Meats- 155-F 15 540-009(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 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
3-301.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
145°F* 590.009 violations relating to good retail
3-401.12 Raw Animal Foods Corked in a practices should be debited under#29-
Microwave 16ST* Special Requirements.
3-401)I(A)(1)(b) All Other PHFs-,145°F 15 sec.
17 Reheating for Not Holding WOLA7TONS RELATED TO GOOD RETAIL PRAC77CES
3403.11(A)&(D) PHFs 165OF 15 sec.* (Itettvs 23-30)
303.1.1(5) Microwave-165°F 2 Minute Standing Critical,and non-crilicaI violations,which do not relate to the.
Time* foodborrne illness interventions and risk factors listed above;can be
3-103A I(C) Commercially Processed RTE Food- found in rhe following sections of the Food Code mrd 105 CMR
140°F" 590.000.
3403.11(E) Remaining Unsl'tced Portions of Beef Item I Good Retail Practices FC----r 690,�000
Roasts* 23. i t and Personnel`_ FC-2 ( 003
18 Proffer Cooling of PHFs 24. Food and Fuad Protaciion_, � FC-3004
3-501.74(A} Cooling Cooked PHFs front 140°F to 25. Equipment ane Uteraft FC-4 1 oW5
26. Water,Plumbs and Waste -i.FC-5 .008 i
70°F Within 2 Hours and Front 70°F 27. I Physical Facility FC-6 007
to 41°F/45'F Within 4 Hours. * 28. 1 Poisonous or Toxic Materials FC 7 .008
3-501.14(B) Cooling PHFs Made From Ambient 28. S R IreMeats .008 i
Temperature dngrcdients to 41°F/45°F 30• ( Other
IF
Within 4 Hours* s *xx as
*lh'acHcs critical rem in the tedeml 1 39 Fcmd Code m 105 ChtR 5935.000.
i
a 1
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,0 Floor
Division of Food and Drugs Salem, MA 01970-3523
Tel. (978) 741-1800 Fax(978) 745-0343
CltyffoWn of Address:
FOOD E$TAAWSHMENT SPECTION REPORT Tel.
Name O Da VTf Operation(s) Type of Inspection
l� d Service ❑ ne
Address Ris ail e-inspection
Telephone p Level ❑ Residential Kitchen Previous Inspection
L( ❑ Mobile Date:
OwnerI Y
HACCP a [I Temporary ❑Pre-operation
�/t ❑ Caterer ❑Suspect Illness
Person-i r e(P C) Ti ma 1 ❑ Bed&B akf t ❑General Complaint
Inspector In: I ❑ HACCP
P Out: ermtt No E] Other
Each violatio c ed requir s n planation on the narrative page(s)and a citation of specific provision(s)violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors_(Red
Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) [I
Allergen Awareness 590.009(G) ❑
corrective action as determined by the Board of Health.
FOODPROTEC71ON MANAGEMENT _ _ _ ❑12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties w
'EMPLOYEE HEALTH --- ---, ❑ 13. Handwash Facilities
__.._ 4_ _ ___,.,_s.._. ... _. (PROTECTION FROM`CHEMICALS.,�
❑ 2. Reporting of Diseases by Food Employee and PIC
E] 14.Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded
4FOOp'FROM SOU_RCE El 15. Toxic Chemicals
. _ved
'.TIMEREMPERATURE"CONTROLS_(PotentialtyHazardousfQods)
E] 4. Food and Water from ApproSource
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17.Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling
PROTECTION FROM CONTAMINATION _ l___ _-_- _ ❑ 19. Hot and Cold Holding
❑ 8.Separation/Segregation/Protection ❑20.Time as a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing -;REQUIREMENTS FOR HIGHLYSU$GEPTIaLE=POPULATIONS':(HSP),.]
El 10. Proper Adequate Handwashing El21.Food and Food Preparation for HSP
❑ 11. Good Hygienic Practices ,CONSUMERADVISORY_
❑22. Posting of Consumer Advisories a
Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related
Items) Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22):
of Health. Noncritical (N)violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590-000/federal Food Code.This report,when signed below
C N 23. Management and Personnel (FC-2x590.003) by a Board of Health member or its agent constitutes an
24. Food and Food Protection (Fc-3)[590.004) order of the Board of Health. Failure to correct violations
25. Equipment and Utensils (FC-4x590.005) cited in this report may result in suspension or revocation of
the food establishment permit and cessation of food
26. Water, Plumbing and Waste (FC-5x590.006) establishment operations. If aggrieved by this order,you
27. Physical Facility (FC-6x590.007) have a right to a hearing.Your request must be in writing
28. Poisonous or To ' Materials (Fc-7x590.006) and submitted to the Board of Health at the above address
29. Special Requir mens , (590.009) within 10 days of receipt of th1'�oiry�d8lYc�
30. Other � DATEOF) /Ili
Inspector's Signature: Print: J
PICS Signature: Priv 66 Page)o Pages
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION
$ Cross-contamination
FOOD PROTECTION MANAGEMENT 3-302.1.1(A)(1) Raw Animal Foods Separated frum
1 590.003(A) Assignment of Responsibilit * Cooked and RTE Foods*
590.003(B) Demonstration of Knowledge" - Contamination from Raw Ingredients
2-103.11. Person in charge-duties 3-302.1.I(A)(2) Raw Aninud Foods Separated from Each
Other*
EMPLOYEE HEALTH Contamination from the Environment
2 590.003(0) Responsibility of the person in charge to 3-302.11(A) Food Protection*
require reporting by food employees arid 3-302.15 Washing Fruits and Vegetables
applicants* 3-304.11. - Food Contact with Equipment and
590.003(F) Responsibility Of A Food Employee Or An *
Applicant To Report To The Person In Utensils
Contamination from the Consumer
Charge* 3-306.14(A)(B) Returned Food and Reservice of Food*
590.003(G) Reporting b Person in Charge"
3 590.003(D) Exclusions and Restrictions* Food
Disposition of Adulterated or Contaminated
590.003(E) Removal of Exclusions and:Restrictions 3-701..11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Food""
_
4 Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Compliance with Food Law* 4-501.11 I Manual Warewashing-Hot Water
Temperatures*
3-201.12 Food in a Hermetically Sealed Container* Sanitization TemPs*
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water
3-202.13 Shell Eggs*
Sanitization Temperatures*
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 - Chemical Sanitization-temp.,PH,
3-202.16 lee Made From Potable Drinking Water* concentration and hardness.*
5-101.11 Drinkin Water dirnn an A roved System* 4-60 IA I(A) Equipment Food Contact Surfaces and
590,006(A) Bottled Drinking Water^ Utensils Clean*
590.006(B) Water Meets Standards is 31.0 CMR 22
.0*
and Fish Froman Approved Sourcece 4-602.11 CleaningFrequency of Contact Surfaces and Utensils*uiment Food-
Shellfish Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught Mollusccit Food Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and
3-201.15 Molluscan Shellfish from s1SSF Listed Chemical*
Sources* 10 Proper;Adequate Handwashing
Game and Wird Mushrooms.Approved by
Re MatoAuthorit 2-301.11 - Clean Condition-Hands and Arms*
-
3-202.18 Shellstock identification FFresent* 2-301.12 Cleaning Procedure*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201.17 Game Animals* Il Good Hygienic Practices
g ReceivingfCondition 2-401.11 Eatin ,Drinking or Using Tobacco*
3-202.1.1 PHFs Received at Proper Tera ratures* 2401.12. Discharges From the Eyes,Nose and
3-202.1.5 Package Integrity* Mouth*
3,!'GL' Farad Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting*
6 TagstRecords:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from
3-20312 Shellstock Identification Maintained" Employees*
Tags/Records:'Fish Products 13 Handwash Facilities
3-402.11 Parasite Destruction* Conveniently Located and Accessible
11 Numbers and Capacities*
3-402.12 Records,Creation and Retention* 5-203. -
590.004(l) Labeling of Ingredients' 5-204.11 Location and Placement*
7 Conformance with Approved Procedures 5-205.11. -Accessibilit .Operation and Maintenance
7HACCP Plans Supplied with Soap and Hand Drying
3-502.17. Specialized Processing Methods* Devices
3-502.12 Reduced rax 4-301.11 Handwashin Cleanser,Availability
oxygen packaging,criteria* 6-301..12 Hand Drying Provision
8-103.12 Conformance with A oved Procedures"
Denotes,critical item in.the federal 1999 Pani Calc or 105 CMR 590.000.
3-501.14(C) PRFs Received at Temperatures
Violations Related to Foodborne ltiness.interventions and Risk According to law Cooled to
Factors(items 1-22) (Cant.) 41'F/45°F Within 4 Hours,
PROTECTION FROM CHEMICALS 3-501.15 Conlin Methods for PHFs
14 E....-__N 14 PHF Not and Cold Holding
Food or Caton Additives
-.- •- 3-501.16(B) Cold PHFs Maintained at or below
3-202.12 Additives* _ 590.004(n 4101450 F*
3-302.14 Protection from Unapproved Additives* 3-50i.16(A) Hot PRFs Maintained at or above
15 Poisonous or Toxic Substances 1400F. *
7-101.11 Identifying Information-Original 3-501.16(.4) Roasts Held at or above 130°F. "
Containers*
7-102.11. Common Name-Workin Containers* Timeas a Public Health Control
20
7-201.11 Separation-St3-501.t9 Time as a Public Health Control*
7-202.11 .Restriction-Presence and Use* 590.004(H) Variance Requirement
7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Containers-Prohibitions* POPULAi9DN3 HSP
7-204.11 Sanitizers.Criteria-Chemicals
7-204.12 Chemicals for Washin Produce,Criteria' 21 Bevem 3-SOL 11(A) Unpasteurized Pre-packaged Juices and
7-204.14 Drying Agents.Criteria* _ . es with Warning labels*
A�--•--• 3-501.11(B Use of Pasteurized Eggs
7-205.11 Incidental Food_Contactm Lubricants' 3-801.11(D) Raw or Partially Cooked Animal Food and .
7-206.11 Restricted Use Pesticides;Criteria* Raw Seed Sprouts Not Served*
7-206.12 Rodent Bait Stations* 3-501.11(C) Unopened Food Package Not ReAct-ved. "
7-206.13 Tracking Powders,Pest Control and -
Monitoring* CONSUMER ADVISORY
TiME/i EMPERATURE CONTROLS 22 3-603.11 1 Consumer Advisory Posted for Consumption of
16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked of
Not Otherwise Processed to Eliminate
PHFs 3-401.I1A(1)(2) Eggs- 155'F 15 Sec. Path ens"
EM,-Immediate Service 145°F15sec* 3-302!13 Pasteurized Eggs Substitute for Raw Shell
3-401.11(A)(2) Comminuted Fish.Meats&Game E -
Animals-155°F 15 sec.a
3.401.11(8)(1)(2) Pork and Beef Roast- 13(1°F 121 mm* SPECIAL REQUIREMENTS
3.401.11(A)(2) Ratites,Injected Mears-155°F 15 590.069(A)-(D) Violations of Section 590.009(A)-(D)in
sec.* catering,mobile food,temporary and
3-40LI I(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 sm. * 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 good retail
3401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165°F* Special Requirements.
3-40IJ I(A)(1)(b) All Other PRFs-145°F 15 sec.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3403AI(AWD) PHFs 165°F 15 sec.* (Items 23-30)
3403.11(8) Microwave- 165°F 2 Minute Standing Critical,mrd non-critical violations,which do not relate to the
Tithe* foodborne illness interventions and risk facrors listed above, can be
3-403.11(Q Commercially Processed RTE Food- found in the following sections of the Food Code mrd 105 CMR
140°F* 590.000.
3403.11(E) Remaining Unsliced Portions of Beef ( item i Good Retail Practices FC 580ow
Rcasts* 23.
, Mang ement and Personnel FC-23 .003
18 Proper Cooling of PHFs 24.. Food and Food Protection FC .004
25. i E4uloment and Utensils I FC-4 .005 i
3-501.14(A) Cooling Cooked PHFs from 140°F to 1-26-i Water,Plumbing and Waste i FC-5 .006 ;
70'F Within 2 Hours and From 70°F - 27. 1 Physical Facla FG-6 .007
to 41°F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008
3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements , .009
Temperature Ingredients to 41°F/45°F 30. i Oma --
Within 4 Hours* "�'""""°"`•zi"`
•Denouts criucal ilei in the federal 1999 Fred Code a 105 C1+4R;90.()00.
r
CITY OF SALEM
BOARD OF HEALTH
9
Establishment Name: Date: I Page: of Zf
Rem Code I C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
NO. Reference R-Red Rem Verified
PLFASE PRI T LE LV
1.
zjA UA,r
Discussion With Person in Charge: Corrective Action Required: o ❑ yes.
I have read this report, have had the opportunity to ask questions and agree to correct all oluntary Compliance ❑ Employee Restriction i
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 twent i-fi dollars or suspension/revocation of ❑ Embargo ca Emergency Closure
your food permit. \
❑ Voluntary Disposal ❑ Other.
A-1 Exterminators Service Slip / Invoice
P.O. Box 310 ..__._._..w_ .._ __ -11
Lynn, MA 01903-0310 INVOICE: 972275
781-592-2731 DATE: 3/27/2014
i ORDER: 972275
CAFE GRAZANI CAFE GRAZANI
Bill To: 133 WASHINGTON STREET Work 133 WASHINGTON ST
SALEM,MA 01970 Location: SALEM,MA 01970
OBEIM —10111011-
3/27/2014 7:12 AM (None) 008 Keith Michon
3272014
1.00 101 REGULAR PEST CONTROL SERVICE $45.00
SEATING AREA/KITCHEN/2RR/SMALL STORAGE AREA SUBTOTAL $45.00
(DOES NOT INCLUDE BSMT) TAX $0.00
Inspected all areas as needed,all areas inspected including all stations,monitors and snap
traps check ok at this time. TOTAL $45.00
AMT.PAID $0.00
BALANCE $45.00
Customer Signature Technician Signature
i
pp 1 1,11
` > CommonwealthofMassachusetts'
c City of Salem
m Board of Health , r Kimbedey Driscoll
t 120 W ashington Street;4th Floor r 'MByOf ,
> SALEM,MA,01970'
x,
` � �.= - Food/RetaiLEstablislment Permit
DATE PRINTED: " 3_ `12/11/2012
� > Y
W
ESTABLISHMENT NAME: n Caffe Graztanix
File]Number.BHF-2004-000270` k " 133 Washington Street fi £.
<. u
Salem t `rMA ,01970
k.
m LOCATEDrAT. 0133 WASHINGTON STREET*>
SALEM,"MA `0100 '
Permit Type Permit No. .$ ' Permit Issued`..Permit Expires 5 � `' .Fee Restrictions/Notes u "
FOOD SERVICE " BHP-2013-0122 Jan;1, 2013 -.:Dec 31, 2013 ,,$280.00 9a {
ESTABLISHMENT z a 4 -
' 3
4, s Total Fees $200.00
g 6 ` + 0- g 1
ry £ g r -4
Ke
a : PERMIT_EXPIRES , December 31, 2013
€ -
° _WBoard of Health t 4 t t
This Permit is not transferable and must be reissued upon change of ownership or location The permit must be posted z,
in a prominent location in the Establishment. k -0 k,
In aecordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,
all plans for such must be submitted to and approved by the Salem Board of Health page V"
� L a
5 F ».xaava
CITY OF SALEM,
MASSACHUSETTS b PubUcHealth
BOARD o}•HEAL rl-1 DEC 1 1 2012 P-111.
120 WASHING l oN srnc.,�[,4111 FI t
IQNIBERLEY DRISCOIJ Ti-,i,.(978)741-1800 FAX(978)'E�j ���ALEti
Iramdin(@salem.com H jF„j' RRY'RAMUIN,Iiti RLI-[S,CHI,CP-F$
MAYOR H I3A1:I'I-1 A6 ENT
Food Establishment Permit Application
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name: C a i e G ra z r a o i
2) Establishment Address: 133VAI a5 h ,i fio() f 56C I em
3) Establishment Mailing Address(if different):
4) Establishment Telephone No: q -7dntIql q 2
re + fi r ez t cLwt
-
5) Applicant Name&Title: L4l C'( P
6) Applicant Address: "OO5--b.rj 07 (2-e
7) Applicant Telephone No: I 5LZ 124 Hour Emergency No: Email: M 5& [dm(1 O Ade f'
8) Owner Name&Title(if different from applicant):
9) Owner Address(if different from applicant):
10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of
officers or partner.
An association Name Title Home Address
A�rporation
An individual
A partnership
Other legal entity C-
12 Person Directly Res onsible For Daily Operations Owner, Person in Char e, Supervisor, Manager,etc.
Name&Title:
Address:
Telephone No: Fax: Email:
Emergency Telephone No:
13) District or Regional Supervisor(if applicable)
Name&Title:
Address:
Telephone No: Fax: Email:
Check#: �. "I Date: 12- l Amount: 2 V
1
Food Establishment information
14) Water Source: C t G.F Sit/e m 15) Sewage Disposal: .�
DEP Public Water Supply No: (if applicable) / I
Sun 7 3 0 1 -r"e Wei -t-ii ur Fr-.3 r/ I
16) Days and Hours of Operation: { p g 17) No.of Food Employees: l
18) Name of Person in Charge Certified in Food Protection Managemen
Required as of 1011/2001 In accordance with 105 CMR 590.003(A) t ,(tom 1A &CC,Vc,.(le.
19) Person Trained in Anti-Choking Procedures(if 25 seats or more): ZYes No
20) Location: 22) Establishment Type(check all that apply) -
(check one) 0 Retail( Sq. Ft) 0 Caterer
Permanent Structure L Z D-Food Service-( e-O Seats) 0 Frozen Dessert Manufacturer
Mobile D Food Service-Takeout 0 Residential Kitchen for Retail Sale
0 Food Service-Institution D Residential Kitchen for Bed and
( Meals/Day) Breakfast Home
D Food Delivery 0 Residential Kitchen for Bed and
21) Length Of Permit: ...•••----•......---• ____ Breakfast Establishments,---------------- -- -
(cheek one) RETAIL STORE RESTAURANT
t(nnuak 0 Less than 1000sq.ft. $70 0 Less than 25 seats $140
Seasonal/Dates: 0 1000-10,000sq.B. $280 0 Residential Kitchens $140
0 More than 10,000sq.ft. $420 tfPA-99 seats $280
0 More than 99 seats $420
Temporary/Dates/Time: ------------ ------ - ---- --
- ------------------ ----- - --
- ------_ ------
0 Bed&Breakfast/Childcare Services(Nursing Home $100
- -
--------------------------- - ------------- -----------------
ADDITIONAL PERMITS
0 MAKE ICE CREAM,YOGURT/SOFT SERVE $25
0 PASTURIZATION $25
0 TOBACCO VENDOR $135
0 ALL NON-PROFIT $25
Including, church kitchens, state funded childcare 8 private clubs)
23) Food Operations: Defrnhicns: PNF-potentiaJty hazardous food(timetfemperature conhots raqutred)
Npn•PHFs-ncn-potentially hazardous food(no tima/temperature controls required)
check all that appl RTE-ready-to-�f foods(Ex.sandwiches,salads,muffins which need nor furfher processing
Sale of Commercially —_ PFJP Cooked to Order --F
o#PHF Cooked and Cooled or Hot Held
Pre-packaged Non-PHFs fMore Than a Stngie Meal Service
Sale of Commercially Preparation of PHFs Fpr Hot And PHF and RTE Fpods Prepared For Highly
Pre-packaged PHFs Gold Holding for Single Meal Service Susceptible Population Facility
Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill
Prepared by Consumer
Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance
Processed Foods for andlor HACCP Pian(including bare hand
Service Within 4 hours contact alternative,time as public health
control.
Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of
Non-PHF and Non- - Retail Sale --- Animal Origin
Perishable Foods Only
Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered
Retail Sale. Events or Institutional Food Service
Offers RTE PHF in Bulk Quantities
To he completed 6v the Board of Health
Retall Sale of Salvage,Out of Date
or Reconditioned Food Total Permit Fee:
Payment is due with application
1,the undersigned,attest to the accuracy of the information provided in this application and 1 affirm that the food establishment operation will
comply with 10$CMR 590,000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR
590.000 and the Federal Food Code.
24) Signature of Applicant: �+- ---
Pursuant to MGL Ch.62C,sec.49A,1 certify u er tha penalties of perjury that 1,to my best knowledge and belief,
Have filed all state tax returns and paid state taxes required under law.
25) Social Security Number or Federal ID: d U J 7
26) Signature of Individual or Corporate Name:
Massachusetts Department of .Public' Health Salem Board of Health
Department 120 Washington Street,0 Floor
Divisidn of Food and Drugs Salem, MA 01970.3523
Tel. (978)741-1500 Fax(978) 745-0343
City/Town of Address:
FOOD ESTABLISHMENT INSPECTION REPORT Tel.
Name / Da ` TTyjaOfOperation(s) Type of Inspection
( 0 r r LKi Food Service U Routine
Address Ri k ' (� Retail Re-inspection
Levet ❑ Residential Kitchen Previous Inspection
Telephone ❑ Mobile Date:
Owner HAGGP YIN ❑ Temporary ❑Pre-operation
❑ Caterer ❑Suspect Illness
Person-tn harge tG} ❑ Bed 8 Breakfast E]General Complaint
T)
T! ; ❑HACCP
In:Inspector Out Permit No. El.Other
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Anti-Choking 590.009(E) ❑
Items) Tobacco 590.009(F) ❑.
Violations marked may pose an imminent health hazard and require immediate Allergen Awareness 590.009(G) ❑
corrective action as determined by the Board of Health.
FOpO:PROTECTION MANAGEMENT.' ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
- y ❑13. Handwash Facilities
EMP40YEE HEALTH - . ..,
.. �PROTECTtONFROWCHEMICAtS
❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals
FOOOFROMAPPROVEDSOURCE .. . . .._.._ TIMFJtEMPERATURE.CONTROLS(PotentfaliyHazardous'Food'
❑ 4. Food and Water from Approved Source
❑ 5. Receiving/Condition
❑16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy.of Ingredient Statements ❑ 17..Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling
PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding
❑ 8. Separation/Segregation/Protection ❑20. Time as a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY-SU (HISP):
❑21. Food and Food Preparation for HSP
❑10.Proper Adequate Handwashing - . ._
❑ 11. Good Hygienic Practices CONSUMERADVISORY
❑22. Posting of Consumer Advisories
Violations Related to Good Retait Practices_(Blue Number of Violated Provisions Related
Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1.22):
of Health. Non-critical(N)violations must be corrected Official Order for Correction:Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code.This report,when signed below
C NJ by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2x590.003) order of the Board of Health. Failure to correct violations
24. Food and Food Protection (FC-3x590.004) cited in this report may result in suspension or revocation of
25. Equipment and Utensils (Fc-4x590.005) the food establishment permit and cessation of food
26.Water, Plumbing and Waste (Fa-5x590.006) establishment operations. if aggrieved by this order,you
27. Physical Facility (Fc-exs90.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7x590.008) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION:
5. &tadac
Impeetor's Signatw* Uk
PtCs Signature. f Print /t?ti ttAi f %
t
Violations Related to Foodborne Illness
Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION
g Cross-contamination
FOOD PROTECTION MANAGEMENT 3-302.11(A)(l) Raw Animal Foods Separated from
1 590,003(A) _Asia mint of Res onsibilit * Cooked and RTE Foods*
590.003(B) Demonstration of Knowledge' Contamination from Raw Ingredients
F2-1.03. Person in chazgz-duties 3-302.1.1(A)(2) Raw Animal Foods Separated from Each
Other*
EMPLOYEE HEALTH Contamination from the Environment
2 590.003(C) Responsibility of the person in charge to 3-302..11(A) Food Protection" -
require reporting by food employees and 3-302.15 Washing Fruits and Vegetables
applicants* 3-304.11 Food Contact with Equipment and
590,003(F) Responsibility Of A Food Employee Or An
Utensils*
Applicant To Report To The Person In Contamination from the Consumer
Charge* 3-306.14(AYB2 Returned Food and Reservice of Food*
590.003(G) Reporting by Person in Charge'"
3 590.003(D) Exclusions and Restrictions* Disposhion of Adulterated or Contaminated
Food
590,003(E) Removal of Exclusions andRestr'c ons 3-701.1'! Discarding or Reconditioning Unsafe
Fond*
FOOD FROM APPROVED SOURCE
4 Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water
3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures*
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical W'arewashing-Hot Water .
3-202.13 Shell Eggs* Sanitization Tem ratures*-
3-202.14 Eggs and Milk Products,Pasteurizzd* 4-501.114 Chemical Sanitization-temp.,pH,
3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. *
5-101..11 Drinking Water from an Approved System* 4-60Ll I(A) Equipment Food Contact Surfaces and
Utensils Clean*
590.006"A) Bonded Drinking Write *
590.006,(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Clean ng Frequency of Equipment Food
Shetlrrsh and Frsh From an Approved Source
Contact Surfaces and Utensils*
4-702.11 Frequency of Sanitization of Utensils and
3-201.13 Fish and Ree ea onally Coupltr Molluscan Food Contact Surfaces of E u nient"
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and
3-201.15 Molluscan Shellfish from NSSF I stat Chemical*
Sources* 10 Proper,Adequate Handwashing
Game and Wild Ailushnioms Approved by 2-301.11 Clean Condition-Hands and Arms*
Requilatory Authority
3-202.18 Sheilstock identification Present* 2-301..1.2 Cleaning Procedure*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-20.1.17 Game Animals* - ll Good Hygienic,Practices
3 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco*
3-202.11 PHFs Received at Proper Tem eratures* 2401.12 _ Discharges.From the Eyes,Nose and
3-202.15 Package 7nte tit y* Mouth*
3-101.11 _Food Safe and Unadulterated* 3-301.12 PreventingContanunation When Tasting*
E6 Tags/Recotds:Shelistock 12 Prevention of Contamination from Hands
3-202.18 Shefistock Identification* 590,004(E) Preventing Contamination from
3-203.12 She!lstock Identification Maintained" Employees*
TagstRecords:'Fish Products 13 Handwash Facilities
3-40211 Parasite Destruction* Conveniently Located and Accessible
3-402.12 Records.Creation and Reientiun"
5-203.11 Numbers and Capacities*
590.004(1) Labeling of Ingredients° 5-204.1.1 Location and Placement*
5-205.11 Accessibility,Operation and Maintenance
� Conformance vAth Approved Procedures _.
/HACCP Plans Supphed with Soap and Hand Drying
Devices
3-502.11 5ecalizedlruessin Methods* 6-301.11 Handwashin Cleanser,Availability
3-502.12 Reduced ox en acka"nom,criteria*
8-103.!2 Conformance with Approved Procedures* 6-301-12 1 Hand Drying Provision
Denotes,critical item in.the Hera]1999 Food Chic or 105 CMR 590,000.
,t CITY OF SALEM
� BOARD OF HEALTH
Establishment Name: re ( r � r Date: Page: of
Rem Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R-Red Item Verified
PLEASE PRINT CLEARLY
A A 4/) n I l . 1 i✓
1N
t Ili
.p
i
1
I
t _
1
i
Discussion With Person in Charge: Corrective Action Required: ❑ No es
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
v.t noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. / T'
'� ! �P�lic
El Voluntary Disposal ❑ Other:
rI �_�------ L
S'
3-501.141C) PHFs Received at Temperatures
Violations Related to Fnadhome illness Interventions and Risk According to Law Canted to
Factors(Items 1-22) {Cont.) 4-1OF145°F Within 4 Hours,
PROTECTION FROM CHEMICALS_ 3-501.15 Cooling Methods fix'PHFs
14 Food or Golar Additives 19 PHF Hot and Cold Holding
3-202.1? -!t-Additives . - 3-501.16(B) Cold PRFs Mabasimed at or below
3-342.14 Protection from Unapproved Additives* 590'OD4(F) 410145°F*
15 Poisonous of Toxic Substances
3-501.16(A) Hot PHFs Maintained at or above
7-101.11 Identifying Information-Original 140T' *
Containers* - tm
501.15(A) Roasts Field at or above OWE
7-142.11, Commou Name-Workin Containers* 20 Time as a Public Health Control
7-201.11 Separation-Storage* 50119 Tim as a Public Health Control*
7-202.11 .Restriction-Presence and Use* (1.(i44H} Variance._-cluirerneut --
7-202.12 Conditions of Use*
7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY-SUSCEPT[BLE
7-244.11 Sanidzers.Criteria-Chemicals* POPULATIONS(HSP)
7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and
7-2£4.14 Drying A encs.Criteria* I Besuaues with Warmag, Is*
7-205.11 incidental Fan l C x tett Lubricants* 3-84I.1I(B) Use of Pasteurized Ems*
7-206.11 Restricted Use Pesticides,Cnteria* 3-802.11(D) Raw or Partially Cooked Animal Food and
7-206.12 Rodent Bait Stations* Raw Seed Sprouts Not Served.
7-206.13 Tracking Powders,Pest Control and 34802.11 C Unripened Food Package Not Re-served,
T+2onitann *
CONSUMER ADVISORY
TIPMSTEEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Pasted for Consumption of
16 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or
PHFs Not Otherwise Processed to Eliminate
3-401,110(1)(2) Eggs- t55"F 25 Sec.
Rub o gens.""'"1
Eggs-Immediate Service 145°Fl5sec* 3-302.13, Pasteurized Eggs Substitute for Raw shell
3401,11(A)(2)01.i1(Af{2) Comminuted Fish.Meats 8:Game r,.
Animals-155'F 15 sec.*
3.441.21(B)(IX2) Potts and Beef Roast- 130°F 121 min* SPECIAL REQUIREMENTS
3-401.11(A)(2) Rabies,Injected Meats-155`17 15 590.009(A)-(D) Violations of Section 590.009(A)-(I3)in
sec.* catering,mobile food,temporary and
3-401.1.2(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 see. * above if related to foodborne illness
3-401.11(()(3) Whole-muscle,intact Beef Steaks interventions and risk factors. Other
145`F x 5W009 violations relating to good retail
3-401.12 Raw Animal Fords Corked in a practices should be debited under#29-
Microwave 165`F* - Special Requirements.
3-441:11(0)(10) All Other PHFs- 145'F 15 sec.
17 Reheating for Hot Harding i OILA77d)yR RELATED 7O GODD RETAIL PRA CTICE$
3-403.1 I(A)&(D) PJWs 165'T 15 sec. * (Items 23.30)
3-403A I(B) Microwave I65'F 2 Minute Standing Critical and non-critical violations, which do not relates to the
Tire* frodborne illness intervennons and risk farrows listed above, can be
3-303.t 1(Gj Commercially Processed RT6Fend- ,)need in zhe following,reeziansof the Food Cade acrd 105 CMR
1400F* 59tr 000.
3-403.11(E) Remaining Unsliced Parnous of Beef item Goad Retail practices i FC 590.000
Roasts* i 23. _ i mmgg mentandPatsonnel FC-2 .W3
1$ Proper Coaling of PHFs 1 24. _ 1 Food and Food Protection w. I FC-3 .004
1 25, t Equipment and Utensils FC-4 .W5
3-501.14(A) Cooling Cooked PHFs from 140`Fto Water. and Waste m 71 FC-5 006
70°F Within 2 Hours and From 7WF 27. Physical Facili FC-6 .007
to 41`F/45'F Within 4 Hours. * L288 Poisonous or Toxic Materials _FFC-7 Wal
3-501.14(B) Cooling PHFs Made From Ambient lir°_. Sp ial Fdequiremarus ctp9
Temperature Ingredients to 41 OF/45°F 30• i Other
Within 4 Hous"
'Deaotas aifieal iwni in the 0-3eza7 1999 Food Coda ar 105 C.N1R 590.000.
MassachusettsDepartment Det of Public 14ealth Salem Board of Health
M 120 Washington Street,4 Floor
Division Of Food and Drugs Salem,MA 01970-3523
Tel. (978) 741-1800 Fax(978) 745-0343
City/Town of Address:
FOOD ESTABLISHMENT INSPECTION REPORT Tai.
Dal Type Type of Operations) T e of Inspection
G ' U Z 7L /) r 11 �' �jj Food Service Routine
Addressi Ri (] Retail r El Re-inspection
Level ❑ Residential Kitchen Previous Inspection
Telephone 3,-41 . ❑ Mobile Date:
OwnerHACCP YIN ❑ Temporary ❑Pre-operation
JJ(91Y). GyV %Co AJ , ❑ Caterer ❑Suspect Illness
Person-in Charge(PIC) Time ❑ Bed&Breakfast ❑General Complaint
In �Z7 ❑HACCP
Inspector o Out: :11 Permit No. ❑Other
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provisions)violated.
Non-compliance with:
Violations Related to Foodbome illness interventions and Risk Factors_(Red Anti-Choking 590.009(E) ❑
Items) Tobacco 590.009(F) ❑.
Violations marked may pose an imminent health hazard and require immediate Allergen Awareness 590.009(G) ❑
corrective action as determined by the Board of Health.
FOOL}PROTECTION MANAGEMENT ❑12. Prevention of Contamination from Hands
❑ 1, PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities
EMPLOYEE HEALTH _ __ ,,. _. I _ - -,✓ - ..
pROTECTIONFROM'CHEMICALS',
❑ 2. Reporting of Diseases by Food Employee and PIC -❑ 14.Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded 015.Toxic Chemicals
FOOD FROM APPROVED SOURCE IMEREMPERATUR CONTROLS(Potentially Hazardous Foods)
❑ 4. Food and Water from Approved Source
. ❑ 5. Rece;vingtCondtion
❑ 16. Cooking Temperatures
- ❑ [] 17. Reheating 6. Tags/Records/Accu of Ingredient Statements �
❑ 7. Conformance with Approved ProcedureslHACCP Plans
❑18.Cooling `
PROTECTION FROM CONTAMINATION _ 19. of and onlding
❑ S.Separation/Segregation/Protection El 20,Time as a Public Health Control
F19. Food Contact Surfaces Cleaning and SnnittYing REQUIREMENTS FOR HIGHLY-$UsdEPTIBLE=POPULATIONS(N&P):e.,
❑21.Food and Food Preparation for HSP
❑ 10. Proper Adequate Handwashing
� CONSUMER ADVISORY
❑ 11. Good Hygienic Practices O ❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related
Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors(Red Items 1-22):
of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000tfederal Food Code.This report,when signed below
C N by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2X590.003) order of the Board of Health. Failure to correct violations
24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of
25, Equipment and Utensils (FC-4X590.005) the food establishment permit and cessation of food
26.Water,Plumbing and Waste (Fc-5X590.006) establishment operations. If aggrieved by this order,you
27. Physical Facility (FC-6X590.007) have a right to a hearing.Your request must be in writing
28. Poisonous or Toxic Materials (Fa7X590.006) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF REINSPECTION:kccLA
Inspector's Signature: r' Print:
PICS Signature�'� Page olj,tPages
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION
g Cross-contamination
FOOD PROTECTION MANAGEMENT 330211(A)(1) Raw Animal Foods Separated From
1 590.003(.0) Assignment of Responsibility*-� Cooked and RTE Foods*
590.003(B) Demonstration of Knowledge" Contamination from Raw ingredients
2-103.11. Person in charge-duties 3-302.11(A)(2) Raw Animal Foods Separated from Each
Other'
EMPLOYEE HEALTH Contamination from the Environment
2 590.003(C) Responsibility of the person in charge to 3-302.11(A) Food Protection*
require reporting by food employees and 3-302.15 Washing Fruits and Ve etables
applicants* 3-3{k;.l 1 Fund Contact with Equipment and
590.003(F) Responsibility Of A Food Employee Or An Utensils*
Applicant To Report To The Person In -
Charge* Contamination from the Consumer
8306.14(A)(B) Returned Food and Reserviee of Food*
590.003 G Reporting b Person in Charge* Disposition of Adulterated or Contaminated
3 590.003(D) Exclusions and Restrictions* Food
590.003(E) Removal of Exclusions and Restrictions 370711 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Food*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Compliance with Food Law* 4-501..1.11 Manual Warewashing-Hot Water
3-201.12 Food in it Hermetically Sealed Container* Sanitization Temperatures*
3=201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water
3-202.13 Shell bbC*Es Sanitization Tem eratures*
3-202.14 E=gs and Milk Prtxtucis. Pasteurized* 4-5(11.114 Chemical Sanitization-temp.,pH,
3-202.16 Ice Made From Potable Driakiag Water* concentration and hardness. *
5-101.11 DrinkingWater from an Ah roved System" 4-601_!'1(.0) Ecryipment Food Contact Surfaces and
590.006(A) Bottled Drinking Water* Utensils Clean*
590.006(B) Water Meets Standards in 310 CMR 220* 4 602.11 Cleaning Frequency of Equipment Food-
590,006(B)
Shellfish and Fish From an Approved Source Contact Surfaces and Utensils*
4-702.11 Frequency of Sanitization of Utensils and -
3-201.14 Fish and Recreationally Caupllt Molluscan 'Pool Contact Surfaces of Equipment*
Shellfish* _ 4-703.11 Methods of Sanitization-Hot Water and
3-201.15 Molluscan Shellfish from NSSP fasted Chemical*
Sources* 10 Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Re ulatoAuthodt 2.3111.11 Clean Condition-Hands and Arms*
3-202.18 SheilstockIdentification Presem^ 2-301.12 Cleaning Procedure*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
Gam
3-201.17 e Animals* Il Good Hygienic Practices
5 RecelvingiCondition 2-401.11 Eating,Drinking or Using Tobacco*
3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges.From the Eyes,Nose and
3-202.1.5 packagehite.rlt-* Mouth*
3-1 Gi.11 Food Safe and Unadulterated* 3-301.12 ..Preventing Contamination When Tasting*
6 Taa,3stRacords:Shelistock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from
3-20312 Sheilstock Identification Maintained* 1 - Employees*
Tags/Records;Fish Products 13 Handwash Facilities
3-40211 Parasite Destruction* Conveniently Located and Accessible
3-402.12 Records.CreaScn and Retention* 5-203.11 . Numbers and Capacities* -
590.004(1) Labeling of Ingredients' 5-204.11 Location and Placement*
T Conformance vrith Approved Procedures 5-205.11 . Accessibility,Operation and Maintenance
fHACCP Plans Supplied with Soap and Hand Drying
3-50211. Specialized Processing Methods* Devices
3-502.12 Reduced oxygen packafing,criteria* - 6-301.11 Handwashing Cleanser,Availability
8-10112 Conformance with Approved Procedures* 6-301.12 Hand Drying Provision
"Denotes critical item in the federal 1999 1`�)d Code or 105 CMR 590.000.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name:_ Sa T �YLz�n/. i Date:_"n. Page:D. of
ttem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date`
No. Reference R-Red ItemVerified
/ I 1 PLEASE PRINT CLEARLY tt
r-c17 7L-
n
1
I^r �;;Ui c r �W f c' J 7P✓ -i- r� Lk
-
f✓ r "lf it
rwCYAO
bi a4 A - -
Ur,/. On.
it , Z2! figj�'.
7) - A.Aba, I
Gn V
Discussion With Person in Charge: Corrective Action Required: ❑ No es
I
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ 'Voluntary Compliance ❑ Employee Rest 'Iction/
P PP Y q 9 Exclusion I
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 sus�peennssi6n/reevocation of ❑ Embargo ❑ Emergency Closure
your food permit. / / f / i�/ � G�--
C !� / t/// ❑ Voluntary Disposal ❑ Other:
U
3-501.14(C) PHFs Received at Temperatures -
Violations Related to Foodborne illness Interventions and Risk According to Law Cooled w
Factors(Nems 1-22) (Cont.) I 41'FI45°F Within 4 Hours.
PROTECTION FROM CHEMICALS -
1-401-15 Conlin Methods for PHFs
ng
14 Food or Color Additives _ 19 - Col Hot qM Cold fineHold at
3-501.16(8} Cold PHFs Maintained at or below
3-202.12 Additives* 590.004(F) 4107450 F*
3-302.14 Protection from Un ,roved Additives't 3-501.16(A) Hot PHFs Maintained at or above
15 Poisonous or Toxic Substances 140°F *
7-101.11 identifying Information-Original 3-SOI.16(A) Roasts Held at or above 130'F. "
Containers* 20 1 Time as a Public Health Cantroi
7-102.11. Common Name-Working Containers* 3-501.19 Time as a Public Health Control*
7-201.11 Separation-Stpa * - 590,004(H) Variance Requirement
7-202.11 .Restriction-Presence and Use*
7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPT118L.E
7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP
7-204.11 Sanitizers.Criteria-Chemicals* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and
7-204.12 Chemicals R)r Washin Produce,Criteria* - .Unpast ur with Warning Labels*
7-204.14 n encs.Criteria* Bev, 801.11(B) Use mgeof s with W Ea
7-205.11 incidenRestricts Food Pesticides;Contact.
;Criteria s 3-801..11(D) Raw or Partially Cooked Animal Food and
7-206.11 Restricted Use Pesticides;Criteria* Raw Seed Sprouts Not Served *
7-206.12 - Rodent Bait Stations* 3-801.11 C Unopened Food Package Not Re-served,
7-206.I3 Tracking Powders, Pest Control and
Moniegrzin * CONSUMER ADVISORY -
TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Pasted for Consumption of
Animal Foods Thai are Raw,Undercooked or
16 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate
PHFs - Pating*ens.*Erx�'A. '1
3.40LIIA(1)(2) Eggs- 1557 15 See.
_ - 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Eggs-Immediate Servide 145°Fl5sec*
3-401.11(A)(2) Comminuted Fish.Meats&Game
Animals-155'F 15 sec. * SPECIAL REQUIREMENTS
3401.11(8)(1)(2) Pork and Beef Roast- 130OF 121 min*
590.004(A)-(D) Violations of Section 590.009(A)-(D)in
3-40LI I(A)(2) Ratites,Injected Meats-155'F 15
see.* catering, mobile food,temporary and
3401.1I(A)(3) Poultry,Wild Game,Staffed PRFs, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-165'F 15 see. * 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
3401.12 Raw Animal Fools Cooked in a practices should be debited under#29-
Microwave 165°F* Special Requirements.
3-40lJ TA)(1)(b) All Other PHFs--145'F 15 sec.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-403AI(A}&{D) PHFs 165'F 15 sec. * (items 23-30)
3-403.11(B) Microwave 165`F 2 Minnie Standing Critical,and non-critical violations,which do not relate to the
Ti=* foodborne illness interventions and risk factors listed above, can be
3.403,11(C) Commercially Processed RTE Food- found in the failowing sections-of the Food Cnde and 105 CNiR
1400F* 590.000.
3-403.11(E) Remaining Unsliced Portions of Beef item Gaol Retail Practices i .FG 1 590.000
Roasts" j�3.___ i Management and Personnel FC-2 .003
Proper Coolie of PHFs i 24. Food and Food Protection FC-1 .004 _i
18 g 1 25. ! Equipment and Utensils 1 FC-4 .605 1
3-50L14(A) Cooling Cooked PHFs from 140'F to 2, 1 Water,Plumbingand Waste 1 FC-5 .W6
70`F Within 2 Hours and From 70'F 27. 1 Pn sical Facility FC-6 007
to 41°Fl45'F Within 4 Hours. * 128_ ' Pasonous or Toxic Materials FC-7 .008 i
3-501.14(8) Coaling PRFs Made From Ambient ~�2c. Special Requirements 009
Temperature Ingredients to 41°F/456F � � I other. -- �
Within 4 Hours* stgemmn..rze:
*D mtrs critical iwin in the federal 1999 Ford Cale or 105 CNiR 590.000,
CITY OF SALEM
( � BOARb OF HEALTH
Establishment Name: CG � � 7,E yr Date: 1, /3.2 4 z Pager_ of
Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Data
No. Reference R—Red Item Verified
PLEASE PRINT CLE RLV
T � �I
r c- .Gf4
SPS. �Li=
( ( Cpn S ( Ili QP
i _
A f 5, s 7t" " _ (
C U1 ' P nJ nJ [ ,G. v
I
7 -40 k2b
�• p r c7 _
J
G is lei /IN5, Il .s
legrn II J
J�
(^ ii
l
Discussion With Person in Charge: Corrective Action Required: ❑ No 8—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-i0IA,RC) PHFs Received at Temperatures -
Violations Related to Foodbarne Illness interventions and Risk According to Law Cooled to
Factors{items 1-22) (Cont.) 41'F/45°F Within Homs.*
PROTECTION FROM CHEMICALS 3-50!.15
Cooling Methods for PHFs
ing
14 Foal or Color Additives 19 ColPHINot and Maintained
ineHoldat
3-501.16{B) Cold PHFs hiain4�rined at or below
3-202.12 Additives* 590.004(F) 41'1#5'F*
3-302.14 Protection from Una roved Additives* 3-50 L I6(A) Hot PHFs Maintained at or shove
15 Poisonous or Toxic Substances 1300E *
7-101.11 Identifying Information-Original 3-501.16(A) Roasts Heid at or 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 Se azafioa-Stora e* - 590.004(H) Variance Requirement
7-202.11 .Restriction-Presence and Use* -
7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP
7-204.11 Sanitizers.Criteria-Chemicals*
7-204.12 Chemicals for Wash! Produce,Criteria+ 21 3-801.1.1(A) Ueverag s witzedh
Pre-packaged Juices and
:Beverases with Warning Labels*
7-204.14 Drying Agents.Criteria* 3-801.11(8) Use of Pasteurized Eggs*
7-205.11 R stricte Food Contact Lubr,Criteria* 3-801A I(D) Raw or Partially Cooked Animal Food and
7-206.11 Restricted Use Pesticides;Criteria' Raw Seed Sprouts Not Served.*
7-206.12 Rodent Bait Stations- 3-801-II(C) Unopened Food Package Not Re=served,
7-206.13 Tracking Powders,Pest Control and
Monitarme CONSUMER ADVISORY
TIMEti EIPERATURE CONTROLS 22 3-603.11 Consumer Advisory Pasted for Consumption of
Animal Foods That are Raw.Undercooked or
16 Proper Cooking Temperatures for Not OtherwiseProcessedto Eliminate
PHFs Pathogens.+`peC>.s fn,2a!r
3-401-11A(1)(2) Eggs- 155 F 15 Sec.
Eggs-immediate Sentice 145'FlSsec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
3-401.21(A)(2) - Comminuted Fish.Meats&frame
Animals-155'F 15 sec. * SPECIAL REQUIREMENTS
3.401.11(8)(1)(2,) Pork and Beef Roast- 130'F 121 min*
3-401.11(A)(2) Ratites,Injected Meats-155'F 15 590.009(A)-(D) Violations of Section 590.009{A}-(D)in
s,c�* catering,.mobile faod,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-265'F 15 sec. * above if related to foodborne illness
3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
1450F- 590,009 violations relating to good retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited trader#29-
Microwave 165'F* Special Requirements.
3.401:11{A}(1)(b) All Ortho PIFs- 145'F 15 sec.+
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRAC77CES
3-403.11(A)&(D) PHFs 165"F 15 sec.' (Items 23-30)
3-4403.11(B) Microwave- 165'F 2 Minute Standing Critical,and non-critical violations,which do not relate to the
Time* - foodbome illness interventions and risk factors listed above, can be
3-403,11(C) ConmtercWly Processed RTE Food- found in the foilowing secrians of the Food Code and 105 CMR
14000* 590.000.
3-403.1i(E) Remaining UnsticedPortions ofBeef Prem i Good Retail practices I FC 530.000
Roasts* ! 23. i Management and Personnel i FC-2 .003
1g Proper Cooling of PHFs 24. i Food and Food Protection -- I FC-3 .004
25. Equiprnem and Utensils i FC-4 .005
3-501.14(A) Cooling Cooked PHF%from 140'F to -n i Water.Plumbinq and Waste i FC-5 006 `.
70`F Within 2 Hours and From 70'F ( 27. 1 Physical FaciVity FC-6.007 '
to 41'F/45'F within 4 Hours. * i 28 Poisonous or Toxic Materials i FC-7 .008
3-501.14(6) Cooling PHFs Made From Ambient 29. Special R uirements _009 ; -
Temperature Ingredients to 4I'F/456F Other -- --
Within 4 Holes° s_svosmt2cc
Demvvt critical intim in the federal 1999 Food Cade or 105 04R 590.000.
p
4 Commonwealth of Massachusetts
City of Salem
Board of Ilealth Kimberley Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Food/Retail Establlishment Permit
DATE PRINTED: 12/15/2011
ESTABLISHMENT NAME: Caffe Graziani
File Number:BHF•2004-000270 133'Washington Street
Salem MA 01970
LOCATED AT: 0133 WASHINGTON STREET
SALEK MA 01470
Permit To Permit No. Permit issued Permit Expires Fee Restrictions t Notes
FOOD SERVICE BHP-2012-0047 Jan i,2012 Dec 3 i,2012 $280;00
ESTABLISHMENT
Total Fees: $280:00
PERMIT EXPIRES IDecember 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 revonaflans,improvements,or equipment changes are made,
all plans for such,must be submitted to and approved by the Salem Board of Health: Page l
4 • CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET,4...FLOM
TFL. (978) 741-1800
KINUIERI.EY DRISCOL L FAA (978) 745-0.343
[tiSAYOIZ IrMdint silcnicom
LARRY RAhtDIN,RS/RVI iS,(;I 10,CP-PS
Hv-yI:FII AGI;NT
201,2tAPPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT? �
NAME OF ESTABLISHMENT � t C�� ��t�G`Z lin t —I ✓�( TEL#� l �' 7 q j �Z-Q
ADDRESS OF ESTABLISHMENTI �J Y v_ 5 ��tst � FAX# 1 9"Q(o (S2-
MAILING ADDRESS(if different) }
EMAIL-Business': 1� 0 �� Cl//� Cal '( ( AZIGt�e6sita: _ 4'K .,(J( GI L(Ct l
OWNER'S NAME C--t t 04CAP 111 c v1 t tt LIGt C�faUpti�e..Se TEL#
ADDRESS_ � L4 7AW rSt (1 5� C CA�� 0-2 1 u t) Aff rJ 2 ( A
STREETII CITY STATE ZIIP
tR
CERTIFIED FOOD MANAGER'S NAME(S) kmA M G f'tnUGt( eSe CERTIFICATE#(S)W 0_7J`3'
(Required in an establishment where potentially hazardous food is prepared)
EMERGENCY RESPONSE PERSON Y a L ' '�G`V t jts e Grl NC404I lT`HOME TEL# iv 7 5Z,7-----------------
DAYS OF OPERATION Mond T PW ones Thu sda Friday Satu day - Sunday
HOURS OF OPERATION / �.
Please wrifa In fans day. `t CiC�✓`-"�" - Q� �V 3¢4VYt' �J '�d�u4Yt
(For example Ilam-11pm)
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 --------------------------- --------
'y less than 25 seats-
(Outdoor Stationary Food Cart$210) 25-99 seats =$280
more than 99 seats
-------------------- E§------d----------------------------------....---------...-----------...-----------------------
BED/BREAKFAST/ YES NO $100
CHILDCARE SERVICES/NURSING HOME--•-------- ------------------ -------••----------- ......• ------••• .------------ - -
ADDITIONAL PERMITS
MAKE(not just serve)ICE CREAM, YOGURTISOFT SERVE YES NO $25
TOBACCO VENDOR YES $135
ALL LYON-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 Ion 49A.I certify under the pains and penalties of perjury that[,to my best knowledge and belief,have filed all state tax
returns,95 paid alt state tax
ra uired under w. / �}
Si ature Dale Social Security or Federal Identification Number
Updated 523/11 FOODAP201 Ladm Checks{&Date Q
CITY or SALEM, MASSACHUSEITS
BOARD OF FIE.-1L:I'FI
120 WASHINGTON STREET,4". FLOOR
IML31'.RLk.Y DRISC:OLL TEL. (978) 741-1800
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F,\x {978) 745-0343
MAYOR Ieamft"s cm coin
LARRY IUMD1N, RS/Rfil i5, [lo,CP-I�S
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This Form will he collected during your next Board of Health inspection.
QUESTIONAIRE —GREASE TRAPS 2009
1. NAME OF ESTABLISHMENT: *0 GlZlChl
2. ADDRESS OF ESTABLISHMENT: ) V Q ► 1L
3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP?
4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT HAVE?
CAPACITY IN GALLONS rl 0
5. HOW IS THE GREASE TRAP MAINTAINED? ON A DAILY BASIS? BY AN IN-HOUSE PERSON OR
BY AN OUTSIDE CLEANING SERVICE?
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6. WHAT IS THE FREQUENCY THAT THE GREASE IS REMOVED FROM THE TRAP?
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7. WHAT IS THE NAME OF THE FIRM WHO REMOVES AND/OR PICKS UP THE GREASE FROM
YOUR ESTABLISHMENT? �C, 8 dy e 2—Z
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8. WHAT IS THE DATE OF YOUR LAST INVOICE FROM THE REMOVAL FIRM?