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CAFE JEFFERSON - ESTABLISHMENTS CAFE JEFFERSON 293 JEFFERSON AVENUE J V u u , d o IMPORTANT MESSAGE \' FOR v I DATE ( � Z. —TIME P.M. M 1 f lea OF PHONE AREA CODE NUMBER EXTENSION ❑ FAX Cl MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE �~ o t SIGNED SIw t�nIVERSAL. 48005"-' s.a. 0 Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 03/01/2011 ESTABLISHMENT NAME: Cafe Jefferson File Number:BHF-2005-000043 293 Jefferson Avenue SALEM MA 01970 LOCATED AT: 0293 JEFFERSON AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2011-0365 Mar 1,2011 Dec 31,2011 $140.00 ESTABLISHMENT Total Fees: $140.00 PERMIT EXPIRES December 31, 2011 Board of Health i This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 z CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4...FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 MAYOR DCRELNBAUM((7�sALEN COM DA\TID GREENBAum,RS ACTING HEALTH AGENT 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT �'4re-t TEL# q-?O- 7 L/5' - Z X88 ADDRESS OF ESTABLISHMENT Z93 See'f; eSold A ✓,�:- FAX# /' 715 &07 OOSq �C,E�u yul p/4�C� MAILING ADDRESS(if different) �--> TA d-(�— EMAIL- Business': Website: OWNER'S NAME 1RrC.�1%/ TEL#M G --?-7 `FoT ADDRESS Z ( YOA&kL Dpa- Wol3uJ2N STREET CIT'Y/ STATE ZIP CERTIFIED FOOD MANAGER'SNAME(S) fU/1��,�L .Gl///1�/� CERTIFICATE#(S) Xgzo'/--2�e-7- (Required in an establishment where potentially hazardous food is prepared)/�. / EMERGENCY RESPONSE PERSON /Ltae ,EL .��/�/�/�/ HOME TEL#.7S/ G `/O - ?2_L2_ DAYS OF OPERATION._ Mond Tuesday-, ": Wednesd Thursday:: 'l, Fdda Saturda `i', ; ;Sunda HOURS OF OPERATION Please write in time of day. ! (p – (p – 7 y — y Forexam ettam-11 I 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 NO less than 25 seats =$140 ✓ (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 B---E--D--/-B---R--E--A---K--F--A-S---T--/---------------------YES------146----------------------------------------------------------------------------------$-1-00-- ------ CHILDCARE SERVICES/NURSING HOME - ADDITIONAL PERMITS MAKE(not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,before any renovations,improvements,or equipment changes are made,all plans for suc must b bmitte had approved by the Salem Board of Health. Pur#uaot t9 M I-C a r 62C,S tion 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax retu d ai list a taxes re fired under the law. z Si tur ate Social Security or Federal Identification Number ------------ ------j 7��-,�Y—,'---}--�; --- Revised ionli 1017/11 FOODAP201 Ladm Check#&Date i. Commonwealth of Massachusetts ` e City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/06/2011 ESTABLISHMENT NAME: Cafe Jefferson File Number:BHF-2005-000043 293 Jefferson Avenue SALEM MA 01970 LOCATED AT: 0293 JEFFERSON AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2011-0176 Jan 1, 2011 Dec 31,2011 $140.00 ESTABLISHMENT Total Fees: $140.00 PERMIT EXPIRES December 31, 2011 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in'a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 i 7 . • d CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4`FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 KwOR - I)CRF.ENBAUNI SALEM.CONI DAVID GREENBAUM,RS ACTING HEALTH AGENT ! ^ v v � 2011 APPLICATION FOR PER IT OPERATE A FOOD ESTABLISHMENT � NAME OF ESTABLISHMENT ^ TPEELL1# / -C� / /'7 C� ZE ADDRESS OFESTABLISHMENT.. _5�:.. Iw 1 Ifs-X; -/(Q. � r MAILING ADDRESS(if different) EMAIL-Business': Website: C r It' )G' ✓say- ca1 OWNER'S NAME h1a"I Cipohon i TEL# ADDRESS Kill, STREET CITY STATE / ZIP / CERTIFIED FOOD MANAGER'S NAME(S) ,ACERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON l{l' -� C l�4hOYCJHOMETEL#��d 'D,AYS;QF OPERATION. Monday.?' ' 'Tuesday`: Wednesday;, ;r;Thursday ;.;i' k2 ^Friday, . I. =Saturday ;' Sundayt , HOURS OF OPERATION Please write in time of day. For example I lam-1I Pr TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 1 0,000sq.ft. =$420 RESTAURANT E NO less than 25 seats -$140 (Outdoor Stationary Food Cart$210 25-99 seats =$7.80 more than 99 seats =$420 ----------------------------------------------------------- --- BED/BREAKFAST/ YES N $100 CHILDCARE SERVICES/NURSING HOM --------------------------------------- ------------------------------------------------------------------------ ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES O $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES N $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,before any renovations,improvements, or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to V191-C er 6 C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax return nd a t s required under[he law. Si ature` / ---—Date— _— -- --— Social Security or Federal Identification Number Revised 10/7/11 FOODAP201 Ladm Check#&Date o2. S 0 d 1 n'h d A i�'1.s ' o ""H 7 �+r,.. .}'�'AM1 .;,,. ,";� •,, Massachusetts Department of Public Health Salem Board of Health Floor Division of Food and Drugs 120 Washington Street,4f" 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741.1800 Fax (978) 745-0343 r\ NameDate Type of Operation(s) Type of Inspection Cc�c -'f h(0//fa El-Food Service L],Routine Address1J9 �� Risk LJ Retail El-Re-inspection'.El-Re-inspection'.(793 Level ❑ Residential Kitchen Previous Inspection- Telephone 9 7 ^T a� ❑ Mobile Date: l 7 T cJ Owner � HACCP YM El ❑ Pre- perati n Cay I(�I/J ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) , Tim? ❑ Bed&Breakfast El General Complaint In:o(� ❑ HACCP Inspector Ek Out: Permit No. ❑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 Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. `FOOD PROTECTION MANAGEMENT,_.-®,m ";,°°� ,,,M„,,,, ; ,'� ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties � - - ❑ 13 Handwash Facilities EMPLOYEE HEALTHY �u �PROTEMON�F CMEMIGA sa,�ro ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15 Toxic Chemicals nr i FOLD FROM and Water from RCEApp �Source ?JIMEITEMPERATURE CONTROLS(PotenrilliAazardous Foods) � ❑ 4. Food and Water from Approved Source ,as ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 1 B.Cooling ;PROTECTION FROM CONTAMINATION � P =` cw "' 1 ❑ 19. Hot and Cold Holding L 3- vw, 4 El 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑-9. Food Contact Surfaces Cleaning and SanitizingdiEQUIREMENTS FORHlGH.L,Y SUSOEP,TI6LE Pf3PULATipNS{fl$P) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing El11. Good Hygienic Practices .CONSUMERADVISORY,y ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(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 by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (Fc-3)(sso.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food ' 26. Water, Plumbing and Waste (Fc-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (Fc-7)(59o.00a) 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: / /T1 I S,58011ISp6EfFOT 14,d. N )J'`1( Inspector's Signature: Print: PIc's Signature: og it Igg'-, Print: 1177C4 4,071, C Page of _Pa es i ,�t Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT g Cross-contamination 1 590.003(A) Assignment of Responsibility* 3-302.11(A)(]) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Coked and RTE Foods* 2-103.11. Person in charge-duties Contamination from Raw Ingredients 3-302.11(A)(2) Raw Anfrnal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(,C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* a licants* 3-302.15 Washing Fruits and Ve etables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contac'with Equipment and Applicant To Report To The Person In Utensils* Char * - - Contamination from the Consumer 590.003(6) Reporting by Person in Char>e* 3-30fi.14{A)(B Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 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 taw* 4-501.1.11 Manual Warewastung-Hot Water 3-201.12 Food in it Hermetically Scaled Container* Sanitization Tem eratures* - 3-201.13 Fluid Milk and Milk Products* 4-501.11.2 Mechanical Warewashina Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.14 Eggs and Milk Products.Pasteurized* 4-501.114 Chemical SaniGzaticnt-temp.,pH, 3-202.16 Ice Made From Potable Drinking Wafer* concentration and hardness.'k 5-101.11 Drinking Water from an Approved System* 4-601..11(A) Eduipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* ui 590.0(16(B) Water Meets Standards in 3 10 CMR 22.0* 4-602.11 Cleaning Frequency Contact'Surfaces and Utensils*q y of pent Food- Shellfish She)liish and Fish From an Approved Source 4-70211 Frequency of Sanitization of Utensils and . 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-HotWaterand 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* - 111 fle Mto Authority Proper,Adequate Handwashing Game and uthor'Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms* L 3-202.18 Shellstoek Identification Present'* 2-301.12 Cleanima Procedure* 590.004(0) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 1.1 Good Hygienic Practices 5 Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes, Nose and 3-202.15 Package tette it * Mouth* 3-101.11, Food Safe and Unadulterated* 3-301.12 Preventin&Contamination When Tasting* 6 Tags/Records:Shellstoek LL2 Prevention of Contamination from Hands 3-202.18 Shellstoek Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstoek Identification Maintained* Em to ees* Tags/Records:Fish Products 13 Handwash Facilities 3-40111 Parasite Destruction* Conveniently Located and Accessible . 3-402.12 Records.Creation and Retention* 5-203.11. Numbers and Capacities* 590.0040) Labeling of Ingredients' - 5-204.11 location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Metbods* Devices 3-502.1.2 Reduced oxygen packaging.criteria* 6-301.11 Hindwashing Cleanser,Availability 8-103.12Conformance with Approved Procedures* 6301.12 Hand Drying Provision *Denotes critical}tem in the federal 1999 Foal Cade or 105 CMR 590.000. YM. < .',y:'etA�. r','r'MdL, I{... /. r •� M@ssachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4'" Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name Dat Type of Operations) Type of Inspection S © Food Service ©'Routine Address R sk ❑ Retail ❑ Re-inspection A Level ❑ Residential Kitchen Previous Inspection Telephone -f t l ❑ Mobile Date: Owner 7�KY� HACCP YIN ❑ Temporary ❑ Pre-operation ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In:, 7 El HACCP Inspector I pu l I Permit No. ❑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 Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action.as determined by the Board of Health. FOOD PROTECTION MANACaEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties a ❑ 13. Handwash Facilities ' EMPLOYEE HEALTH '�-`�" _. _ �. v .,�. ..• ...,e .�a.,u-v�.�„®,maL" :;:PROTECTION FROM CHEMICALS p� ❑ 2.„Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals r FOOD FROM APPROVED from Approved pp ...,ed So„ „.„,�,„ �,,,.r_x.,� " -TIMEREMPERATURE CONTROLS(Pot tlslly 70iartlous Ft3tids)e" ` ❑ 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 e PROTECTION FROM CONTAMINATION 11° 0 krl 9. Hot anCol )Holding ❑ 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control i ❑ 9. Food Contact Surfaces Cleaning and Sanitizing '.RE(1UIREf1tENT3 FOR HIOHLY SU;TCEPTtBLEPQP44ATlON,S(HSP) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (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 P 9 3. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection order of the Board of Health. Failure to correct violations (FC-3)((590. 04) 25. Equipment and Utensils (FC-3)(590.005) cited in this report may result in suspension or revocation of 25. Water, Plumbing and Waste (Fc-5)(590.005) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-8)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) 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: Inspector's Signature• Print:,' , PIC'sSignature: Print: atJ C. 1GNofPage of- Violations Related to Foodborne Illness " Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 I 590.003(A) Assignment of Responsibility* 3-302.I 11(A)(1,) Raw Animal Foals Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* 2-103.11 Person in charge--duties Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foals Separated from Each EMPLOYEE HEALTH Other* 2 590,003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by foal employees and 3-302.11(A) Food Protection* applicants* 3-30215 NV'ashin Fruits and Ve*etables 590.003(F) Responsibility Of A Foal Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003((1) Reporting by Person in Char e* 3-306.14(A)(B) Returned Food and Resemce of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(F) Removal of Exclusions and Re-strictions Food 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 Foo_d_Law_* 4-501.t 1. Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* - 3-20113 Fluid Milk and Milk Products* 4-501.112 .Mechanical Warewashing-Hot Water 3-202.13 Shell ER s* Sanitization Tem erahires* 3-20214 Eggs and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinkin-Water' concentration and hardness. * 5-'101.11 DrinkingWater from an Approved S stent" 4-60 L.11(A) Equipment Food Contact faces and 590.006(0) Bottled Drinking Water* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0"` 4-602.11 Cleaning Frequency of Equipment Food- 5helitlslt 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 Caught Molluscan Food Contact Surfaces of E ui ment* Shellfish* 4-703A I Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Witt Mushrooms Approved by Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 1.1 Good Hygienic Practices 5 Receiving/Condition 2401..11. Eating,Donkin or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* - 2-401.12 Discharges From the Eyes, Nose and 3-202.15 Packae Irate it * Mouth* 3-101.11. Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 TagsfRecords:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(F) Preventing Contamination from 3-203.1.2 Shellstock Identification Maintained* Em ih ees* Tags/Records: Fish Products 13 Handwash Facilities 3402.11 Parasite Destruction* Conveniently Located and Accessibte 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* acities* 590.004(7) I Labeling of Ingredients` 5-20411 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging,criteria* 6-301.11 HandwashiEE Cleanser,Availability 8-103.12 Conformance with App,-.-...--edures* 6-301.12 Hand-Drying Provision 'Denotes criucai arm in the federal 1999 Food Code or 105 CMR 590.000. i CITY OF SALEM V r (� BOARD OF HEALTH ' Establishment Name: Date: ct 1� �, Page: 11-3? of Item, Code C.—critical Item DESCRIPTION OF VIOLATION/ PLAN dF CORRECTION , - .Dater No. Relerence R-Red Item f a verified j PLEASE PRINT CLEARLY C l n- s G2, 77 V0• /1`F3 s� C'I,vS71n J l)u ill �, �� r1 tSLGU Y l�Cti�. b' c��/P✓f. G/1 C /m r�2� Cts �-a"';.� [' r\ �' . f/ �l-fr-. GYI��,r • ,nn i5 � � .n Ca�rsr; "u�.�,' r- s .Q, i G 4*-5-01, Il ^ P( ccF'Ci c/,t rr �_� - )l�li// re yu " N S O-V=. A. I s tW-) ¢fU Q . 1C �' i= `cam 1 )lJ S� tf� /Ci !! Lei �E'12.0 iF z 4° nn Vcc,/7"A 4/D1` /U 070-,71- in 7J.J71- v, r - _ N cNC C.lrl"NP e,,-s / Ij a ..i. r`z •1 /' '� Wim: 7'tca Gb ,JA4eL lotfJ IYL r v%4-eAJ 03WO, Discussion With Person in Charge: ( ' Corrective Action Required: ❑ No SM z yes-, rhave read this report, have had the opportunity'to ask questions-and agree to correct all E] Voluntary Compliance • ❑ Employee Restriction/ 3 Exclusion violations before the next inspection, to observe all conditions as described, and t0 I Re=inspection Scheduled ❑ Emergency Suspension ±, c;mply with all mandates of the Mass/Federal Food Code. I,understand that -� ' noncompliance may result in dailyyfines of we ty five�doll�rs o+suspension/revocation of: ❑ Embargo_ ❑ Emergency Ciasure— .. . Your food':permit.[ �/✓/�- - ,J - f ❑ Voluntary Disposal ❑ Other: d y —Pti Fe Reserved a!Temperatures Violations Related to Foodborm Illness Interventions and Plsk A,c,)rdiug it)U" Cooled to Factors(11olims 1-22) (Cont) 41-F/45'F Witbin,1 How, 11 Coolint-, Methods for PHFI� PROTECTION FROM CHEMICALS Food or r Additives �-1 9 PHF Hot and Cold Holding 1-202,12 QUINC0 'S 0 1,1 B) (SR,PHIIs mAmooned at 11 m"', 590 W-4 If -11"145"F' -X roirtcCon from lJnaL)2rk.'vc Add jillwS,� 214 P PHF�Whim ed at or abOve LLF-- Poisonous or Toxic Substances 7 101.11 rtmormymg LfAmnahm (MOM! Rom, N to IyAwye U04 ---------4 1 Tarm as a Public Health Contra[ ' onirri yNoar- , ?VU! jQ nrr-aI . 71, IfIal'b( onlrui A] jiL �6�' nIe Reotor Roatfocilop- 2-12 caldoro;),ofttic,iF 2C3 t ----------- REQUiRFMIENTS FOR HIGHLY SlJSCEPTiBLr,. last I I wlyw=cc", - C1rr1oil:ak` 2 �j�l 7-1 21 WIA QAI 1 0pomwed Anpackayed%kys W 7 W W %mm"(rt TW ------ J�I)IA4 4- laic i, 01 40 1 K", '11 OItfodl iIotnmt'! Rii'd ,od TOM!hmh �i TArm"!and .......... 1:01PAURAEFI ADVISCIFY ot CONTROLS s.tA& An at Rat, Cya,nd a '--Pro-p-er-Cooking Terilperatui os,for yrs to humou" 1-01YAW: 1 camom"A AQ mms'tt 4..Lu t , M m! Nof Rant - 13VT Q! IQ, r 714 Th AT A :!Iitnli' 1'o I' lt-ltj�oitkr 11ld %mmAommm"Vkh Now w0v All AN, V15 7- 7 410100007 pill a nb 1075000 1WT4& QW- i k W.", 1, 161 F (IiLrir�23 301 py ------------ - --- --- ------- 19.1 1 TV ("mmm"N lux"Ved RIF Imm Kona P l:t:I;" i LY5r L-Clvad --r 2:i T s ICA AN c7- S; I !-. "c� 'FFmits I 2�3 ✓i lliat�z I Fo-n 1 70 0 Wun 2 !loll' no From 701 rq s_ aw TW* -M,jt 4, fhmlt; =cu> ,. .;x c c 7 a)iV ;AW iCuAry PW W& how NAR q .tacTc fill![C k1wIlt 1 �I'j t5 _30 OuIcT ------- W j Hain' ot"I'l t !",)n CITY OF SALEM BOARD OF HEALTH Establishment Name: Q Date: 3 1 �a 01 Page: of _ ttem Code C-Crtticei ttem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Rem Verified PLEASE PRINT CLEARLY e c I �� fl . i P cxb t r i ` J i All - U v d qvd (S0 r I"Oe o ,wh 01 XWI, v U( --fin o rYCR �p (i 1 4 _ -� , Ll� �il P i i Discussion With Person in Charge: Corrective Action Required: ❑ No ❑: Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federalfoodi Vie. I un rstand that noncompliance may result in daily fines of t nty- ' e dol s or su pension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: dl r � 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness,Interventions and Risk According to law Cooled to Factors(Items 1-22) (Cont.) 41°Fl45`F Within 4 Hours. * PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs 14 .- Food or Color Additives - 19 PHF Not and Cold Holding 3-202.12 Additives* 3-50L16(B) Cold PHFs Maintained at or below 590.004(F) 41'/45°F* 3-302.14 Protection from Unapproved Additives* 15 - Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 140°F. 7-101.11 Identifying Information.-Original 3-501,16(A) Roasts Held at or above 130'F. Containers* 7-102.11, Common Name-WorkingContainers* 20 Time as a Public Health Control 3-501.19 Time as a Public Health Control* 7-2 7 201.1.02.71 1 Separation-Storage*Restriction-Presence and Use* 590.004(H) Variance Requirement . 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS HSP 7-204.11 Sanitizers.Criteria-Chemicals* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* - 7-204.14 Drying Agents.Criteria* Beverages with Warning labels* 7-205.11 1 Incidental Food Contact,Lubricants* 3-801.11(B) Use of Pasteurized Eggs* 7-206.11 Restricted Use Pesticides,Criteria* 3-301.1.1(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 3-801,11(C) Unopened Food Package Not Re-served. Momtorin * CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.i 1 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.11A(1)(2) Eggs- 155°F 15 Sec. Pio ens.* E -Immediate Service 145°F15sec* 3-30213 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game E Animals-155°F 15 sec. * 3401.11(B)(1)(2) Pork and Beef Roast-130°F 121 rein* SPECIAL REQUIREMENTS 3.401.11(A)(2) Ratites,Injected Meats-155`F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec.* catering, mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Sniffed 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 3-101.11(0)(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 Cooked in a practices should be debited under#29- Microwave 165'F* Special Requirements. 3-401s11(A)(1)(b) All Other PHFs-145°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3403.11(A)&(D) PHFs 165°F 15 sec. * (Items 23-30) 3403.11(B) Microwave- 165'F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Time* foodborne illness interventions and ris&factors listed above, can be 3403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 1400F* 590.000. 3-403.11(E) Remaining UnslicedPortions ofBeef ( Hem Good Retail Practices FC 1 590.000 1 Roasts* Management and Personnel _FC-2 1 .003 ' 18 Roper Cooling of PRFs 24. Food and Food Protection FC-3 _.004 j 25. Equipment and Utensils i FC-4 .005 1 3-50LIZI(A) Cooling Cooked PHFsfront 140°F to 26. Water.Plumbing and Waste j FC-5 .006 70°F Within 2 Hours and From 70°F 27. Physical Facility FC-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. 1 Other Within 4 Hours* s:rue+oirx am. *Wnows critical i�m in the federal 1999 Fund Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Date: February 28, 2011 Name of Establishment: Cafe Jefferson Address: 293 Jefferson Avenue Owner: Michael Walsh Phone: 978-744-2488 The proposed owner of this establishment Michael Walsh presented a Floor Plan and Menu for review in accordance with the State Food Code. The floor plan and menu are approved as presented. Any changes to the approved floor plan must be approved by the Board of Health prior to implementing them. CERTIFICATION There must be a Certified Food Manager working at this establishment full time. A "Person in Charge" or "PIC' must be available at this location when the CFM is not present. The PIC must have knowledge of sanitation techniques, holding temperatures, operations, etc. FLOOR PLAN A Hand Sink must be located in each food prep and service area. Hand wash sinks are centrally located in the prep areas. The hand sinks must have wall hung soap and paper towel dispenses. These must be stocked at all times. The hand sink must be used for hand washing only. All floors, walls, and ceilings where food, utensils, paper products, etc, are stored, prepared or served must be intact, impervious, and easily cleanable. A three bay sink for washing, rinsing and sanitizing all utensils equipment, dishes is available. If a dishwasher is going to be used it must have a final rinse temperature of 180 degrees in the final rinse OR an automatically fed chemical sanitizer in the final rinse with an audible alarm. MENU/FOO D PREP All food must be purchased from a wholesaler licensed by the State. Fruits and vegetables must be washed prior to preparation. All food must be held at 41°F or lower, or 140°F or higher, at all times. Food may not be added to containers in holding unit. Instead, a sanitized container with new product may replace the existing container and the old product may be placed on top of the new product. There may be no bare hand contact of ready-to-eat foods. Gloves, tongs, or tissues must be used when handling such food. UNDERCOOKED FOODS The advisory was given to the owner. An advisory must be added to the menu. FOOD ALLERGEN AWARENESS The food allergen awareness advisory must be added to all menus and menu boards. Information was given to the owner. CHOKE SAVING A person trained in choke saving techniques must be available whenever this establishment is open for business. EXTERMINATION Monthly services of a Licensed Pest Control Operator are required. Please keep receipts for inspections. SANITIZING SOLUTION Sanitizing Solution must be accessible at each prep station and for the patrons' tables. Test strips corresponding to the kind of sanitizer, must be on hand to check concentration of solution. Solution must be made daily, tested, and the results recorded on a log sheet for examination by Board of Health inspectors. Solution may be prepared in the 3rd bay of the 3-bay sink and spray bottles may be filled there. Spray bottles with clean paper towels may be used, as well as wiping pails with wiping clothes always held in the solution in the pail. These must be clearly marked "sanitizer". Outside area of premises, including the dumpster area, must be kept clean and sanitary. TRASH Trash must be kept in appropriate trash receptacles and a grease barrel must be used to hold discarded food grease. The trash area must be kept in a clean and sanitary manner. ODOR Exhaust air must be filtered in such a manner to prevent the release of food odors to the outside of the premises. An application and check was not received. An opening inspection will be conducted on Tuesday, March 1, 2011 @ 2:OOPM. / 4& Z-Z8-1 David Glte Date Act,n H I Mi h elate 05/21/2009 08:31 FAX 19001/001 ® o z•5^ � N V 3 0 O �IIA 3' I 155" N -,i EQUIPMENT LIST m z DESCRIPTION ELECTRICA PLUMBING REMARKS AMPdVOLTc BTUS IINLE 1 MOP SINK 2 3 BAY BINK W/DRAINBOARD 3 HOT PLATE 18,8 205 HARD WIRE 4 CCWVECTION OVER 40 305 39' HARDWIRE $B TABLE 8 7 ISALAD UNIT 7 116 B 1 WORK TOP FAWMR 6 115 NEMA 5-15P 9 2 PANMU GRILL 2115 115 NEMA 3.161 10 TOASTER 14 116 NEMA 6-IBP ' 11 1 13 COFFEE MACHINE za 705 14 WORK TOP REFRIG 12 116 NEMA 5-15P 15 REFRIG.DISPLAYCABE 12 115 HARD WIRE 16 DRY DISPLAY CASE 115 HARD WIRE 1 A RANO SINK 10 ISLICER 5 116 1 - 2 21 2 2 • 2 2 . DRAWN BY KARPOUZIS&SONS COMMERCIAL REFRIGERATION PROJECT BCALE 203 JEFERSON AVE. 114"=4' SA EM MA JDATF APPROVED BY Z0 3�Jtld ONI 21071 61TVZL880S 8Z:91 5002/ZT/T0 I THE NATIONAL REGISTRY OF o4400Ds� FOOD SAFETY PROFESSIONALSO 4 k.. CERTIFIES MICHAEL WALSH HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR GERTIFIED3 �� THE FOOD SAFETY MANAGER sQ CERTIFICATION EXAMINATION President: �� 5 resston2ts�is.a;r o�pgmr esud"g -LC- ISSUE DATE: SEPTEMBER 22, 2009 CERTIFICATE NO:XE20422877 - TEST FORM: XEK 80656 �9d`, This certificate isnot valid ror more than.five veere From date or issue. _ Corporate Offices Cape Cod New Hampshire 183 Shepard Street 72 Main Street,Suite q7 361 South Broadway e-mail Al Lynn,MA 01902 W.Harwich,MA 02671 Salem,NH 03079 Atlnfo@ (781)592-2731 (508)432.5866 (603)893-8099 Al Exterminators.com (800)525-4825 \ (800)499.5866 (800)525-4825 A•1 Exterminators CFax(781)592-7641 1 Fax(508)432-5299 Fax(603)890-3761 Commercial, Industrial Pest Control Service Agreement ,1� Date: Z-Z`d-' lI Customerrf/ic'A(,--G (,c '14,15f1 (elFE l� Tel.If 79/ te/oT7yq Address Z9.3 _..Tr�r G'iZ5o1c,K q 1,;6 Faxq?B bdr7 OO S 9 e-mail pWa&1-)CAkS6)ApC.eyx-f City SAeC.'t State / ZlpCode OIF70 Service Information and Location Customer I i f^t, T -y5.4 Tel.0 %7rZ/97' Address Z9') 51' Fax e-mail City State Zip Code 81970 Multiple Locations(see attachment) Contra: This agreement is for the control of the following pests: ( oaches ( 4-, r is (-'fiats ( ice ( )**Other 'Does not include Carpenter Ants, Pharoah Ants.••Does not include Termites,Wood Boring Insects or Flying Insects unless specifically mentioned. Special Instructions: Service Schedule:A-1 Exterminators willproviaIntensive service and will also provide Regular Pest Control Services: ( x month ( )2x month ( ) weekly. Exterior Rodent Control: ( ) Ix month ( )2x month ( ) weekly. Exterior Insect Control: ( ) Ix month ( )2x month ( ) weekly. Bird Control: ( ) lx month ( )2x month ( ) weekly. Payment: In consideration of the service provided by A-1 Exterminators, the customer agrees to pay A��-/1 Exterminators, its successors or assigns the following sums: /Z< K 7LNG y !'y'!Z asd�i �CS// $ for each intensive service. 5jy // Cflcwt yC 9�d JG3��+ x $:,W $ for each regular service. $A/k for each exterior rodent service. $ e�, for each exterior insect control service. $ IV A for each exterior bird control service. Payment Terms: (-Jt5D ( )Charge. Payment due upon receipt of invoice. - ( )Total Annual payment in Advance$ less %discount$ Customer Obligation: The customer agrees to cooperate fully with A-1 Exterminators. Whenever conditions conducive to the breeding and harborage of pests covered by this contract are reported in writing by A-1 Exterminators to the customer, the customer shall take the necessary steps to correct such conditions. Pest Damage: The customer agrees that A-1 Exterminators is not responsible for any business disruption or damage caused by insects and/or rodents, on, or to the customer's premises or its contents, and the customer specifically releases A-1 Exterminators from liability for any such claims. Additional No Cost Service: A-1 Exterminators shall promptly provide additional service between regularly scheduled visits as deemed necessary by A-1 Exterminators. Services: Service is the inspection and/or application of pesticides for the control of the above mentioned pests. All services shall be performed in accordance with Federal and State requirements,and EPA and USDA standards. Materials: All materials used to control pests shall conform to Federal,State and local laws and regulations. A-1 Exterminators reserves the right to re-enter the customers premises and remove any chemicals including rodent and insect baits upon termination of this agreement. Equipment and Products: The customer agrees to pay A-1 Exterminators for any equipment installed or placed on the customer's property necessary for the control of the above mentioned pests. Insurance: Upon Request,A-1 Exterminators will furnish to the customer a certificate of insurance showing coverage in effect. Terms of Contract: •This contract shall be effective for an original period of one year. Thereafter,this contract shall renew itself from month to month until terminated by either parry upon thirty days written notice. Rate subject to periodic review and increase by A-1 Exterminators after initial 12 month period. •The customer further agrees to additionally pay for any equipment or products ordered or installed on the customer's premises as determined to be necessary by A-1 Exterminators for the control of the above mentioned pests. Such items may include,but not be limited to the following: Bah Stations,Glue Traps,Multiple Ketch Traps,Fly Spray,etc. A-1 Externr�ators Accepted �/ Date: By A/ 1�1 y By evel L ,mr" iN m PnMTitle Title By— Copy % S gn Name yyaae-OHlca Copy Yellow-Customer BREAKFAST SANDWICHES SANDWICHES Always made to order so you know it's fresh, hot and tasty! Cold or Hot these will hit the spot! Egg and Cheese on: Cold Sandwiches: $4.95 English Muffin Tuna Salad, Chicken Salad, BLT, Turkey, Ham $1.50 Toast or Zeppy's Bagel Hot Sandwiches: $5.95 $2 Turkey Rueben, Grilled Turkey & Swiss, Tuna Melt, Fresh Baked Butter Croissant Ham & Cheese Melt, Grilled Cheese w/ bacon and tomato $2.75 Ham, Bacon or Sausage Add SALAD $.75 each A crisp mix of fresh veggies! BAKERY House Salad $3.95 Muffins and croissants right out of the oven! Add Tuna or Chicken Salad for $1.95 Bagel $1.25 with Cream Cheese add .50 English Muffin $1 Mouthwatering Muffins $1.75 Croissants and Assorted Pastries $1.75 HADDOCK CHOWDER Thick and creamy with chunks of Haddock Ask about our Muffin, Pastry and Coffee packages for !URIDAYS ONLY!!! you office, next meeting or sports team! $4.75/5.75 BREAKFAST DRINKS French Toast$5 Coffee, Tea, Hot Chocolate $1.50/1.75/2 Oatmeal $3 Milk, Chocolate Milk $1.50/1.75 Can of Soda, Bottle of Water $1.25 OJ, Sparkling Water $1.50 Nantucket Nectars and Snapple $1.75 Reminder:Consuming raw or undercooked poultry,meat,seafood,shellfish or eggs may increase your risk of foodborne illness. IMPORTANT MESSAsE FOR p2m d A.M. DATE ( Aa/ ' 1 _I-_TIME�r�P.M. N m - 1�e VV �dYd OF CkC PHONE_ ! I AREA CODE NUMBER EXTENSIONS ❑ FAX O MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED '. 'PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE SIGNED f19VER5AL. 48005 MADE IN U.S.A. i NOTES _._______ _ IMPORTANT MESSAGE FOR L9 DATE L - TIME M S (Aid OF -� CV4 2C PHONE �'� ' ��`JO - Q q AREA CODE NUMBER EXTENSION ❑FAX ❑MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN � WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE I SIGNED RMVERSAL. 46005 mADei U.S.A. i NOTES CITY OF SALEM BOARD OF HEALTH Establishment Name: Ca'�� Pi(� Date: alQ4111Page: / of / Rem Coda C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date N ' o. Reference R—Red Item Verified PLEASE PRINT CLEARLY ` Q 2,Jnz( S -, Cf < C,7 / P 5'S J cin E t t - ofCT J,o l ( � tax l i Cc /r war c� fi J A or I f 'C e c Y m h(SN C� P `Ti GI 9r _ ki V n h lv l � f y r x t' a Discussion With Person in Charge: Corrective Action Required: ❑ .No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food de. I understand that noncompliance may result in daily fines o Aw Y ' dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. !/ ❑ Voluntary Disposal ❑ Other: 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne 111ness interventions and Risk According to law Cooled to Factors Mams 1.22) (Cont.) 41'F/45F Within 4 Hours. PROTECTION FROM CHEMICALS Cold 3-501.15 Coolie Methods for PHFs 14 Food or Color Additives 19 CHot and Cold Holding 3-501.16(B} Cold PHFs Maintained at or below 3-202.12 Additives* 590.004(F) 41.'/45°F* 3-302_14_ Protection from Unapproved Additives* 15 Poisonous or Toxic Substimces 3-50116(A) Hot PHFs Maintained at or above 140°F. 7-101.11 Identifying Information-Original 3-501,16(A) Roasts Held at or above 1300F. Containers* 7-102-11. Common Name-WorkingContainers* Time as a Public Health Control "' 3-501.19 Time as a Public Health Contr ii'" 7-201.11 Separation-Storage 7-202.11 Restriction-Presence and Use* 590.004(H) Variance R nirentent 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toric Containers-Prohibitions* POPULATIONS HSP 7-204.11 Sanitizers.Criteria-Chemicals* 7-204.12 Chemicals for Washing Produce.Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged luices and - 7-204.14 Drying Agents.Criteria* Beverages with Warning Labels* 3-801.11(B) Use of Pasteurized Eggs* 7-205.t l ResInctricted Food PesticContaides, ,Criteria** 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 -Restricted Use Pesticides,Criteria* Raw Seed S ms Not Served,* 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food PackageNot Re-serval. 7-20-6.13 Tracking Powders,Pest Control and i Monitoring* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate ' 3-401.11A(1)(2) Eggs- 155`F 15 Sec Pathogens.'"'"'t Eggs-Immediate Service 145'Fl5sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) - Comn»muted Fish.Meats&Game Eggs* - Animals-155°F l5 sec. 1401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* SPECIAL REQUIREMENTS _ 3-401-11(A)(2) Ratites,Injected Meats-155°F 15 590.009(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 3-401.11('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 Cooked in a practices should be debited under#29- Microwave 165`F* Special Requirements. 3.40111(A)(1)(6) All Other PHFs- 145'F 15 sec.* 17 Reheating for Hot Holding VIOLA77ONS RELATED TO GOOD RETAIL PRACTICES 3-003,11(A)&(D) PHFs 165°F 15 sec.* (Items 23-30) 3-401.11(B) Microwave 165'F 2 Minute Standing Critical and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3.403.11(C) Commercially Processed RTE Food- found in rhe following sections of the Food Cade and 105 CMR 1400F* 590.000, 3403.11(E) Remaining Unsliced Portions of Beef item Good Retail Practices FC 590.000 �. Roasts* 23. 1 Management and Personnel if FC-2 _.003 .i 18 Proper Cooling of PHFs 24. Food and Food Protection I FC-3 .004 25. E 3-501.14(A) Cooling Cooked PHFs from 140'F to t nt and Utensils FC-4 .005 26. Water,Plumbing and Waste FC-5 .008 I 70'F Within 2 Hours and Front 707 Physical Facili I FC-6 .007 to 41°F/45'F Within 4 Hours.* 28. Poisonous or Toxic Materials ' FC 7 .008 3-501.14B) Cooling PHFs Made From Ambient 29. Special Requirements I .008 Temperature Ingredients to 41'F/45°F C 30, I Other Within 4 Hours* 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. IMPORTANT MESSAGE FOR "-',- DATE 11 W _TIME g 'I . M 1 e ai 7 OF Qaft��k LU PHONE AREA CODE NUMBER EXTENSION ❑ FAX O MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE � lY1G, IAF C �O�I, SIGNED � ps FORM 4009 CC��// MADE IN U.S.A. NOTES Commonwealth of Massachusetts i City of Salem Board of Health lGmberiey Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/14/2009 ESTABLISHMENT NAME: Cafe Jefferson File Number:BHF-2005-000043 293 Jefferson Avenue SALEM MA 01970 LOCATED AT: 0293 JEFFERSON AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2010-0001 Dec 14,2009 Dec 31,2010 $140.00 ESTABLISHMENT Total Fees: $140.00 PERMIT EXPIRES December 31, 2010 Board of Health Lo This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4"'FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 MAYOR 1)G1ZEENBAUa4 a Sll +M.COM DAVID GREENBAUM, ACTING HEALTH AGENT 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT (i NAME OF ESTABLISHMENT Cc{?i 7 0e KC oh TEL# ADDRESS OF ESTABLISHMENT �93 Te- fr�erfean A✓2 FAX# MAILING ADDRESS(if different) EMAIL-Business': Website: OWNER'S NAME / "rn,! e-Aae�l R. G0631/'6LOdle TEL# EI 3 7J/ ADDRESS 513 u'li" J 019 STREET � dF CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) /�/"1;eAe e_1 X Caal/IANyYO CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# Gt ' 1- DAYS OF OPERATION ;Monda --- Tuesda ednesda Thursday Friday Saturday Sunda HOURS OF OPERATION ! I Please wnte in time of day. _ t0/- O// 'r'�l� For exam le 11am-11 m "�/�P /ori TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 ------------------------ - --- -.........--.........---------------------- ------._ ....--- --- -------------- - ...... RESTAURANT YES NO leess than 25 seats =$140 (Outdoor Stationary Food Cart$21 25-99 seats =$280 more than 99 seats =$420 BEDIBREAKFASTI YES $100 CHILDCARE SERVICES/NU RSI NG HOME.....---- - ............. ......................... ............ .. ........................ .. ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES0 $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax retu an ai II te, Ze /9(ed under the law. loo 013 -6-d- - 3 cl3Lj- Si / 3 -6d- - 3cl3- Si nature Dat - Social Security or Federal Identification Number / b abq(/¢0 III 'N,Z�%Pll W%ll CERTIFICATE NO. 6753096 Rk' ,0F', 44 Se#vSafe@ Certification tip•.: s ?,. . •. Ra a. 3 a�/I]C1=�iE L `R COG LIi4N D R O for successfully completing the standards set forth for the ServSafe® Food Protection Manager Certification Examination, �1, which is accredited by the American National Standards Institute (ANSI)—Conference for Food Protection (CFP). 11/2/2009 DATE OF EXAMINATION 11/2/2014 DATE OF EXPIRATION Local laws apply.Check with your local regulatory agency for recertification requirements. �� NATIONAL l RESTAURANT ® DavidGilbert ASSOCIATION® Chief Operating Officer, National Restaurant Association #0655 Executive Director,National Restaurant Association Solutions ©M National Restaurant Association Educational Foundation.All rights reserved.ServSafe and the ServSafe logo are registered trademarls of the National Restaurant Association Educational Foundation, and used under license by National Restaurant Association Solutions,LLC,a wholly owned subsidiary of the National Restaurant Association. This document cannot be reproduced or shared. RRigngl v.0908 CITY OF SALEM ^�/� BOARD OF HEALTH Establishment Name: lc_'C w f 2 fS ))I Date: I I IL4 /ncy Page: of / Item Code C-Critical Item DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date;.. No. Reference R-Red Item - : .Verifled PLEASE PRINT CLEARLY •_"_* "•' '•`- � I� PSiU �1Chv�t�vri Ctyid -+01(1aA_jY)C yyteC� iioz1 Y) CI A i3Vc 4 ilV\0 V\n 1' �WJa C ''. 14 1G �t�P I t\ t w[ iC�CX SP.Wt AGL 1 A J 's r t l� o.r vi �I �a ^� � h7iec( of lVl �s tivl� N)P, )J 0 U3np-r 'rte c ci I/ I nrA, -,-9 flOry A t `Sr�t D d k (P c-1 " "r L/ 1, [ Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes 4 I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ 4 inspection, to observe all conditions as described, and to Exclusion violations before the next ins P ❑ Re-inspection Scheduled ❑ Emergency Suspension f comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily twenty=five a -fil o n/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 0 Voluntary Disposal ❑ Other: ?-501 W(C) PHFs Received at Teomperateres Violations Related to Foodborne illness interventions and Risk According to Lay.-Cooled to Factors(ttertris 1-22) (Cont.) _ 41°:F/45'F Wiffiin 4 How's > _ PROTECTION FROM CHEMICALS 3-501.15 -Cooling Methods for PHFs 14 Food or Color Additives 14 PHF Hot and Cold Holding :-202.12 Add tne,k 1-501.16(B) Cold PHFs Maintained at or below 540-(Nis{F) 41145°F - 3 3(12.14 Protection from tfuapprov t Additives" 15P! oisonous or Toxic Substances 1-501.16(A) lint PHF s Maintained at or above ',-101.11 erai—ryinrinfca"ination-oriniwd .{( -- 14017. '� ( Containers- 1 5{11-15;�)-- Rollos li Id at or above 130'F. x 1 Time as a Public Health Control t-10211 ' ComonVtme 4lnikia, ou tin's" I i- --C- --f- i r 'OLii 1Sq) laukin Suuag _ -�� , �.li J _-- I Tim" as a Public.Health Control* � 7-202A] R-no u.on- Pr acne.."wd 1 x ----- _ 7� 20'2.12 Condthon of Use . -�� '03.(J let feurmei Prohfli3OJ REOUIREMENTS FOR HIGHLY SUSCEPTIBLE I - — — -- 1 POPULATIONS{HSPS_ _ X04.11 Saint ;lerti Crnc i+ cbe tie In - x 2 - - i + R"11npn tctirir:d Prepic ihed 7uxcs and 12 04 1 Chwn ri, xn �\ e hu: t u�t C n t"t;a l;x tiers e. +ith 14 tt�to lat to 1 7-204,14 1 Diivir As ole Cot 'ia' -801 11tB) L it Pu-ttiin cd} ii Inc } xx (tnf e (.tihi rr 's -_ -c-:--- 206.Ji i'La iii xi l+r Pr nwde .Cater."t;- - it;v) iRa nPntaH Cebi d Animal E2xd-and t- ._ _ - - lR"n J�St u�dl 3F._1P_a.rN..`. x S ddYot i7 F s u a I - _ R,se.C_t_d._ __jL J(. 00.1i 1 ra. .xt. ,..,L ' - -CONSUMER ADVISORY _ TIME/TEMPERATURE CONTROLS 2' 3,:('-'' 1 torsi= ar °c san n rvi :l tL onsmnpaon of 16 Proper Cooking Temperatures+or ] inn. rcw }'rt tc v tv nauc, h +c, v x i 1 t PliFa x r n 1 E iFs._ 4 Aa o;i w._lR�tx Shell.` Intnr,a� t S t ua 1 'l 17 A< ..1 i C : tut H-1 S.c :.ut, ...-_-__.------_' ""-u11! 13} J (2j i Pod( J "�.1 nus U0 i i'i min SPECIAL REQUIREMENTS _ _ -- A. ._ _. _d 4a. u. i r1`_. --.� t 1 ti a i � 2,220 m File 1. t' ttiiikporai and C:-d IIIc .rprx-lrrlat, of S k 1 v t 11 Rclt a ng tar nt Iox+sr N _-_�._ VIT)LA l iONS RELATEDf? eS " TO GOOD ETAIL Pi4ACT7C 103.1) U i s 1111 'c r c Ilenia 23-Jilt 3.40111(131 mi v.fw' 11t5l]i M,ae.a star'din",* l Cmuto zfJ, t t_fV tt u! do lw; � _ �l t li Fx rnr rte:/t s r unit xa r �rr rix trlrxlc t .«nt Gr• 3-403.1'JfCi t tin nu-eia l% t§tn, 'eci"'IF bl,iki -" r t ...i.ill l>a r,,��er..or of lw Ioo d t elde x1 id z <:xi.4 _-. . � „ item Good Retail Practices __..._ SPO.f4u3 4G'3-Ji{1—) 2c tirind _ s, se cair s -- 1 24 Fl:-d and i' ?od P,c<r r I r C 3 C i ,_._.._-.-. P a ire r C , rmW E EFi i Pruper Cooling of PNFs t - - -- --� ----I- - -- " - ---t 12 Eriu pax of anC, � , , utensil-9 F__-. a rp° Ctxd PHJs from I giF3-�ti. 4(A) 1r i Wa,ei Phbin ur Nasic PC o 006._ . ! i T;F-Within 7 1 f(,ifrsand Flom 70"- --"- r � Or Fac latFC-6 � GC7 701.id{BI ft ,Iii}! 1HF.��L�d.�.'."nt.lirh�ent hr's ins ,xtr� ec�3, - _C r 06c" 1 raii , ( - Tnp ur�rel recient',it i rid5'1 '1}i ..'S TIIIC3i1 Ctt ::a i9D_ .,eB xrF IGC( C CITY OF SALEM i BOARD OF HEALTH Establishment Name: �_ t' ,{.S�YI Date: 1*211L_4 1nc>i Page: of f Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item 'i Verified f PLEASE PRINT CLEARLY -An oo. >XI(Vf✓tkn5*0CC VIrI u 1 �� 0'i^^, irtes_),,VY7, ( A e.(`e V)n+Nd ,' J w,-)(CV t ny) nrt 1111-1 lop ;�irn,e aP(' C Itn hk'u(10 c)cI "id rpxpc-e —� Irrc c . M C_l .'W ¢ k rrs M,-) Cw-r ,_H , ,lr-Y Finri inoI/�1fti 17-P,t1PrU o )c"AA v { X n-c * irx f"i'2P l ICO vl irxr` VNGLP . _PcjGe cttIca c lIt _ � 1^avvvti r �1 a� ( �(li1 Y v�fi In NOr , , �(AP (_CnV1C�v1(O t _ -T.1 c cl��l/�C"1 �-Y 1-IP(�f �L,`• i �-1 = ( A :±p be r Gln ( A r,:fP C1=� cL.r vaI t ?,f7/VI . rp Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins 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 t e ty- ive dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. / _ ❑ Voluntary Disposal ❑ Other: i ' -561,14((9 PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to L'avCooled to Factors(Merits 1-22) (Cont.) I I=Fl45'F Within 4 How's.c _ PROTECTION FROM CHEMICALS 3-501.15 Coohrf D4ethods for PHFs -- 19 PHF Hot and Cold Holding 14 Food or Color Additives 3-26212 Adcluives'x 9 01 4'(F) 41 t/ PHI's Maintained at or below 3-302.14 Protection from thta nru.ed Additives+' i90.004(F) -51)1,16( -I i°(45°t 1 i c-5?3 i I G(1) IJnt PHP ilaint<�ined at or above 1.5 Poisonous or Toxic Substances .. 1401'. 101.11 li em }ning Into:rnauon-Ori,>i nal 3-501 75;, 1I Roast,Hsid at or above 196'F.'s �. t 102.1 I -C`rmmon Name !� "rki,t-,Container,' � >?k2 _. � Time as a Public Health Control -f- - s- ---j 501 ! ) Fiaw as a Public,Health alth ConuroV t 7-201.11 �t S`i a Saun Stxna _ 40.0Nfli) I ti , 3nce gegnt_o cot 7-2011 1 Rent ut on Ir unu 1ttl t, o- ------- 7-202.iT, - .. of Ls - REOUIREMENTS FOR HIGHLY SUSCEPTIBLE 7 '0311 Toxic Com aaei Prohrbi.rxtw E - POPULATIONS{HSP) t J2,4.11 1 Ssnuveu C'titou+ Chu uc. iti _! 1t-7-204.1? ClanuahtoPa,hn ,l uisvCirtcr,i'. ��I� Siltiiit,, rel , reu+t�cdPt ( ie6acdJutccsanti -} - - --t - ---� ' 4e rte with `+atn n - fatal,+. 7 ?64.14�D�tA�euu,(rtt it t Fc iiPt tc i.lredt s 206.!' R �a x 5c 1'r. ri ulc. Citreu t , n1.lmil C l oki ,rl 3aimal Frxx)and Raw S r � -btii t (C ! t2; + cry xs, ytlx._ttx ;�<r Rr-:erve1' I . I r C w ' Hr and lJ) 1 r ri }4c m,tcm ' i CONSUMER Y,t'l`ISr2Ry 1 TIMEITEMPERATURE CONTROLS 22 1 3-60_ ' 1 t'muxnro r AJsoiti flt icd krrCow,umRtioncy of ]b v r.<i i ndc Ilial re R,x Lnderwlke. Pruper Coon Fem �ru ' 1 5�'r 1 I hdFcd 1[e Sci '- ! t - -o1tP�.-ax � x r i.?1(AV . Coin ult< a tr... 7 SPECIAL 'tli.i ,Rat rt and l e t,t Ra (£ �} )),c I food i rU rdi d.t.i Wild Gai .a.S:a, ,.,.a,_, .,6t,u(d l5c i1»ri>=,t;iatt e�bila pa-, { , 1',• +t 1,' t t '.('C;UI EEIAiliS ( i�xl icl.. I t_ - _x�x _.. 2- .£t`•� U _, 1 i h i a nq for trot Fl inS WOLA TIONS REL I-ED TO GOOD RETAil F:IAXTiC EF; (itetttfi 2.3-3ih .? 403,1"B` ; c§. as s ,r If-s" F2 M,riw St-.nude, '"s t a ael x a- < r xss hihmw ra .- I i 1 e � Fr Gr ntc ;jt c u-its � x�ri blarZc t 2:,< fct �c»t 0c ifif.) Codd rind 1,;i r,l.q i i Oft f +J 09 t h r,d ed K-iii-m+ .4 iicei _item Good Retail Practices FC 590,000 h ast I _ Uiar eg mo la.d Pei tr 60^C_ 2 1 �} - ?+ 1 f 18 Frailer Cooling of PHFs t _._.rxt and ax1 PrN0 b0� PC;_ r to --, l 25 gwprr en anG rite 9 4 ,0.: ,,t I ?-5U1.1d(A) j axr, f,C aR:.ti PHI-'s how 1 «tP' 2 dJater P moiT.ir,'e u i ,':>_ FC 5 i OGu 7P, 1 -wnhn 21 l.extr�"_u1 From 'r t_> 1 'l FPatFC--6 07 11 iki= i' -Nb aaHnu,:. e as 'G -7 008_ i0l,i4tBi Crliw,, PFIT' Mif d Nom Anilnt _ s- y rrx,arR ,rtmet OC`3 rclnl raanc ht redients is , t '15'F , 40 iltitF r rtr m Y Htwdc'._ 'i cn,wz it G=k r, i,it r, i j } CITY OF SALEM BOARD OF HEALTH t Establishment Name: (-n-Fp _ {�.C� SIS Oil Date: I L4 /t'_10i Page: of Item Code C—Critical Item s Date- No. Reference R—Redltem DESCRIPTION OF VIOLATION!PLAN OF CORRECTION Verified, t PLEASE PRINT CLEARLY UC CC4 O 5 1'1C_J+P 11 1 X _LY uS I Y v' ( ri CC;C I P c l-F cY . F i'WillfiOn (J_)US dn)(-k +-)(1cey DVId ('.c C00,) :}F 14r,r.t cz t - r ' Ne � � o�vis r I�a� «fiiiec( c( (I 4>uct � i�wkttf5 fo o�Ntu_tP 1 li '4 YCQv<'e Sevtd cr , r pmrj 3( HiqG fitly 't r G�_' S'e', Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and t0 ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that r noncompliance may result in daily fines of t ry y-fi iv- or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. / ❑ Voluntary Disposal ❑ Other: 4 � F ;-)0114((t) ' PHFs Received at'ievrperatures Violations Related to Foodborne//mess interventions and Risk Aax)Tdi ug to Law•Cooled to LL Factors(Reins 1-22) (Cont) 41'F/45"F Within 4 Hotu'e + PROTECTION FROM CHEMICALS 3-501-1 s Coadin.Methods for PFHK _ 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202-12 FooAdditive,"rC __— 3-501.16(B) Cold PHd s Maintained at or below 3-302.14 Protcetion front Unapproved additives' j0t,I (F) 41" PHF v Maintained at or above IS ! Poisonous or Toxic Substances t4p'P, " 7101.11 Identut}mg lnt2: illation- (Ili toall I- t � ; 6r Coastal en i t 1 1 K1 Ri. mt,Field at or above 13001;, �..r 1102.1 d Common ti ire Wlmry,,irir:t tfn n ra r+ — L20 � � ` Time as a Public Health Contioi i 7 2(71.1 I Sena — ---� 0 1 t tmr as a Public Ileal h Control= t auun Stasi r �- - -.._ - -_ , `9C?')C>`iibfi 1 inancc.K:, atanxnt 7-202.11 � fest iit.nn- Pr,a.nf c an! I 7-20112 C_i idnnn of Uhf REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7 °03.(1 Toxic,(o tnnei Prob'*n=fit, POPULATIONS(HSP�� _ 71 N9..11 sanilie>_h Criuri, ( hfnr_i( Is 7 20412 Chelialp for AnClii_e�u_ 2E . 4-}—I -� i(A) Unpl teurrze,d[hr altamo r:gagc9 Jud ii: as aidpae i 04.14 D insAi ntc Criteria af x(`5.11 tnuU nt v! t vd r s ir,( t uh < t t 80° pill, I (it Pa lemiv d Eve,' --� �'0(_;l 2• nU dl , Pc afde .Cite r t<-itc ,il'viall Cfvm (I Animal F(xsl and �- a_. . LRf `,c d Sprout of Set� .r 7 '06.1 IT Ro t n )5 5raoom �-- — - - —i hc,<xi P tc ,. Itklf R 5Cn2d. *�I { r"°Qtl 11 ( lit k rib i'imTlst }t hl r`oni I and i �� is nnuim ___ __.. _.�. CONSUMER ADVISORY _ TIMEITEMPERATURE CONTROLS 2< 3liU?' or hwuct �c r sora r'o t d i4ir(artu,r9 paon o{ Proper mq Tem es p Cookeraturfor i 1 h n .i,t I xv3 1'i. t c f, u. lnderwo}:c d u; � F i t`t e 157Fi S , R. 5 1- _ �_ __ ...._m ...._i��._ .. .___. + flt� innt dill tc tc iiSii l iv..i r °Stn ' t-` r ,r' : ctttid t .n r.,�� zL t,..ttr j .._ �.. ,iii { - rh j } _ f: . Ku ht 1 SPECIAL aEQUIREMENT5 '(;Ii Ni(I _ IFts f S Ind ,fit}27nS1t,l'.. t ;61a 1 co .._._� 1 ( ciitC" 'T ibdL tixlu. ieti p� at V a:ld j 3 4J1.11i`Ai:?i { 3' ui -�;. wile, ,u stunt l i � � { .{xi:i n ,aI k k_i,r , 0t,i ;ric>ft t:otilt! 5 t "r,e ts,T t .Je i'is! ;I'm"°t I j 1 a �. ._ [. 4,� .,,a r n ' . ,:c 17 s.ia.1 Ji" ci " :rt) ! 37 ! . .. Fiebeahrq tot hut nSllnq ._......_..__k ViOLAF/s7Tv6 ftcf 4TFL TO Cst3£a+.,.?R67k?L d>fgFC`OCa:$ �+ i13.l ii l It-) i P[ Ib 'i W';' .7 (lfea74223ii) # 103.1!(b; _...—.(miclot" wt lit F i rio iu. S -rldoig ( C;41"";7icrr rr ,nf>i c tit < u to 3f r rf(i 70: le _ _ fi rio 1 rr r e `h 1 ,t -crm to rt f i 7 c 1<<rr t c r . i,,e br i140'F' l 4f.3.i Irl) Rci taming leu ed Pa: tt h, ! 13cer Tram Good RetailPractises _ FC 5rJ0.[itXi _"'.. ?4 ,t�y mr , dP r or al F"' 2 cc; arid of _ Proper Cooling ^? �trecllenis ,- 1'01 ' 1 1 S( t.t ifA1 rCakPfii i 4 i n 5 Jaetin0 _ e f W iihin 2 Ifcwr.,:.iJ t nam Ls-'r 12r _hid,` 'Fa- 'a�`_.. FC ' W7_ ! i ;i'1'145F}t-thin 4 h xn ..--- 0 r3toi�er _• r irtvtk e i i's, rC 00e i �Oi.t473j Crou PHF M i1 e Fir1i boot 1 .rtl,�ruitrzC in r.r=,uts f +, iid5`F ( _ _. W-dfi n: HimW "a ay. ry (+tn hAti ( c,.:' it ii; 1t r Page 1 of 2 David Greenbaum From: Bonnie and Ernie Follansbee[ernbon2@yahoo.com] Sent: Tuesday, November 10, 2009 9:16 AM To: David Greenbaum Subject: RE: The restaurant is Cafe Jefferson on Jefferson Ave. in Salem. I have gone in there several times, and some of the workers do not wear gloves. There's one in particular, the older lady, the owner's mother, that makes sandwiches without gloves, grabs people's muffins, etc. right over the top like she doesn't even care. She'll put gloves on IF YOU ASK, but only for that customer. I will only get coffee in there if she's working, and a few times, the group I was with just walked out. It is so disgusting, and with the health concerns now with H1N1, and other things, I would hate to see people get sick because of someone acting foolishly and carelessly. --- On Tue, 11/10/09,David Greenbaum <DGreenbaum@Salem.com>wrote: From: David Greenbaum <DGreenbaum@Salem.com> Subject: RE: To: "Bonnie and Ernie Follansbee" <embon2@yahoo.com> Date: Tuesday,November 10, 2009, 8:48 AM Yes, you can forward your concerns regarding the restaurant in question to me and the Salem Board of Health will investigate them from there to David J. Greenbaum, Acting Health Agent City of Salem Board of Health 120 Washington Street, 4th Floor Salem, MA 01970 Phone 978-741-1800 Fax 978-745-0434 From: Bonnie and Ernie Follansbee [mailto:ernbon2@yahoo.com] Sent: Monday, November 09, 2009 11:17 PM To: David Greenbaum Subject: Is this where I would report a restaurant in Salem that is violating health codes? Please direct me to who I need to talk to if this is not the person I want for this. Thanks. 11/10/2009 ;n Corporate Offices Cape Cod New Hampshire 183 Shepard Street 72 Main Street,Suite#7 522 South Broadway e-mail Al Lynn, MA 01902 W. Harwich, MA 02671 Salem,NH 03079 (781) 592-2731 (508)432-5866 (603)893-8099 A (800) 525-4825 (800)499-5866 (800)525-4825 A7 Exterminateinators.com A•1 Exterminators Fax(781)592-7641 Fax(508)432-5299 Fax(603)890-3761 Commercial, Industrial Pest Control Service Agreement L/ FDate: 1 Z -)'[-6 Customer AC )�f�,�tt' ti Tel. C17$� � t Z S8 Address *1 Q3 7 R F i-f r S r `' T Fax e-mail city SAl-P^ State hHSS Zip Code 171VZD Service information and Location Customer Tel.# Address - Fax e-mail City State Zip Code Multiple Locations(see attachment) Co rel: This agreement ja-tor the control of the folio g pests: / ( Roaches ( ) Ants ( Rats ( ice ( '•J"Other 'Does not include Carpenter Ants, Pharoah Ants.•'Does not include Termites,Wood Boring Insects or Flying Insects unless specifically mentioned. Special Instructions: Service Schedule: A-1 Exterminators will lospfide Intensive service and will also provide Regular Pest Control Services: (0 1x month ( )2x month ( ) weekly. Exterior Rodent Control: ( ) 1x month ( )2x month ( ) weekly. Exterior Insect Control: ( ) 1x month ( )2x month ( ) weekly. Bird Control: ( ) 1x month ( )2x month ( ) weekly. Payment: In consideration of the service provided by A-1 Exterminators, the customer agrees to pay A-1 Exterminators, its successors or assigns the following sums: $ '— for each intensive service. $ SIC.L for each regular service. $ —+ for each exterior rodent service. $ — for each exterior insect control service. $ for eacha nor bird control service. Payment Terms: ( COD ( )Charge. Payment due upon receipt of invoice. ( )Total Annual payment in Advance$ less—%discount$ Customer Obligation: The customer agrees to cooperate fully with A-1 Exterminators. Whenever conditions conducive to the breeding and harborage of pests covered by this contract are reported in writing by A-1 Exterminators to the customer, the customer shall take the necessary steps to correct such conditions. Pest Damage: The customer agrees that A-1 Exterminators is not responsible for any business disruption or damage caused by insects and/or rodents, on, or to the customer's premises or its contents, and the customer specifically releases A-1 Exterminators from liability for any such claims. Additional No Cost Service: A-1 Exterminators shall promptly provide additional service between regularly scheduled visits as deemed necessary by A-1 Exterminators. Services: Service is the inspection and/or application of pesticides for the control of the above mentioned pests. All services shall be performed in accordance with Federal and State requirements,and EPA and USDA standards. Materials: All materials used to control pests shall conform to Federal, State and local laws and regulations. A-1 Exterminators reserves the right to re-enter the customers premises and remove any chemicals including rodent and insect baits upon termination of this agreement. Equipment and Products: The customer agrees to pay A-1 Exterminators for any equipment installed or placed on the customer's property necessary for the control of the above mentioned pests. Insurance: Upon Request, A-1 Exterminators will furnish to the customer a certificate of insurance showing coverage in effect. Terms of Contract: •This contract shall be effective for an original period of one year. Thereafter, this contract shall renew itself from month to month until terminated by either party upon thirty days written notice. Rate subject to periodic review and increase by A-1 Exterminators after initial 12 month period. •The customer further agrees to additionally pay for any equipment or products ordered or installed on the customer's premises as determined to be necessary by A-1 Exterminators for the control of the above mentioned pests. Such items may Include,but not be limited to the following: Bait Stations,Glue Traps,Multiple Ketch Traps, Fly Spray,etc. Byp Exterminators w Accepts Date (" n a Print Title Title I'n( p +5/ By Sign Name White-OHloe Copy Yellow-Cualomer Copy Cafe Jefferson Menu Bagel w/egg& Cheese 2.29 +meat .50 Bagel 1.10 +Cream Cheese .40 Muffin 1.50 Croissants 1.40 Scone 1.50 Danish 1.50 English Muffin 1.00 Loaf Cake Slice 1.50 Choc. Chunk Cookie 1.25 Desserts Cheese Cake Slice 2.00 Canoli 1.50 Fruit Cup 2.50 Yogurt .95 Pie 2.00 Soups (sm/lg) 3/4.00 Garden Salad 4.50 Ceasar 4.50 Greek 5.00 Chef 5.75 Side 2.50 + Chicken/Tuna 1.25 Sandwiches 5.50 Tuna Salad, Egg Salad, Seafood Salad, Chicken Salad, BLT, Italian, Roast Beef, Reuben, Pastrami, Oven Roasted Turkey, Steak and Cheese, Grilled Chicken Combo-Any sandwich w/small soup and chips 6.75 Potato, Macaroni, Greek Pasta Salads 2.00 Beverages lee Coffee(sm/lg) 1.70/2.10 Tea 1.45 Milk/Choc Milk 1.35 Soda/Water 1.00 S. Pellegrino 1.25 V8/Coke (Glass Bottle) 1.35 OJ (sm/lg) 1.10/1.35 Nantucket Nectar 1.50 Orangina 1.40 CITY OF SALEM BOARD OF HEALTH Date: November 3, 2009 Name of Establishment: Cafe Jefferson Address: 293 Jefferson Avenue Owner: Michael R. Cogliandro Phone: 617-791-4347 The proposed owner of this establishment Michael R. Cogliandro presented a Floor Plan and Menu for review in accordance with the State Food Code. The floor plan and menu are approved as presented. Any changes to the approved floor plan must be approved by the Board of Health prior to implementing them. CERTIFICATION There must be a Certified Food Manager working at this establishment full time. A "Person in Charge" or "PIC' must be available at this location when the CFM is not present. The PIC must have knowledge of sanitation techniques, holding temperatures, operations, etc. The proposed owner has taken a Serve Safe class and will provide a copy of the Certificate upon receipt. FLOOR PLAN A Hand Sink must be located in each food prep and service area. Hand wash sinks are centrally located in the prep areas. The hand sinks must have wall hung soap and paper towel dispenses. These must be stocked at all times. The hand sink must be used for hand washing only. All floors, walls, and ceilings where food, utensils, paper products, etc, are stored, prepared or served must be intact, impervious, and easily cleanable. A three bay sink for washing, rinsing and sanitizing all utensils equipment, dishes is available. If a dishwasher is going to be used it must have a final rinse temperature of 180 degrees in the final rinse OR an automatically fed chemical sanitizer in the final rinse with an audible alarm. MENU/FOOD PREP A revised menu must be presented to reflect items not currently listed, such as steak and cheese subs. All food must be purchased,from a wholesaler licensed by the State. Fruits and vegetables must be washed prior to preparation. All food must be held at 41°F or lower, or 140°F or higher, at all times. Food may not be added to containers in holding unit. Instead, a sanitized container with new product may replace the existing container and the old product may be placed on top of the new product. There may be no bare hand contact of ready-to-eat foods. Gloves, tongs, or tissues must be used when handling such food. UNDERCOOKED FOODS The advisory was given to the owner. An advisory must be added to the menu. CHOKE SAVING A person trained in choke saving techniques must be available whenever this establishment is open for business. EXTERMINATION Monthly services of a Licensed Pest Control Operator are required. Please keep receipts for inspections. SANITIZING SOLUTION Sanitizing Solution must be accessible at each prep station and for the patrons' tables. Test strips corresponding to the kind of sanitizer, must be on hand to check concentration of solution. Solution must be made daily, tested, and the results recorded on a log sheet for examination by Board of Health inspectors. Solution may be prepared in the 3`d bay of the 3-bay sink and spray bottles may be filled there. Spray bottles with clean paper towels may be used, as well as wiping pails with wiping clothes always held in the solution in the pail. These must be clearly marked "sanitizer". Outside area of premises, including the dumpster area, must be kept clean and sanitary. TRASH Trash must be kept in appropriate trash receptacles and a grease barrel must be used to hold discarded food grease. The trash area must be kept in a clean and sanitary manner. ODOR Exhaust air must be filtered in such a manner to prevent the release of food odors to the outside of the premises. An application and check was not received. A change of ownership inspection will be conducted this week. David Oreefibaum Date Acti Healt Age ZP icha Cogl ndro Date 05/21/2009 08:31 FAX f�001/041 i 271 ® Q i � y 2 R @) atSJ 13'r- LF B'r ° GQI cin i g EQUIPMENT LIST m 2 DESCRIPTION ELECTRICAL PLUMB NG REMARKS F.c AMP V LT BTUS L 1 MOP BINK 2 B SAY SM WAFWNBOARD 3 HOT PLATE 1B.B 208 HARD WIRE 4 CONVECTION OVEN 40 2SB 3t4° HARDWIRE SISTABLE 8 SAtAO UNIT 1115 Q WORK TOP FREEZER 8 115 NEW 5-15P 9 2 PANK GRUL 2115 115 NEMA 5.15E 10 TOASTER 14 115 NEW ly15P 11 1 L3 COFFEE MAOHINE 20 tae 14 WORK TOP REFRID 12 115 NEMA 5-15P 15 FtEFRIG.DISPLAY CASE 12 115 HARDWIRE ld DRYDISPLAYCASE 115 HARDWIRE HANDSINK 10 SLICER 5 115 1 - 2 21 2 2 2 25. DAAWN BY KARPOuzIwoNs COMMERCIAL REFRIGERATION PROJECT SCALE 1203 JEMRSON AVE:1 J4W' SA i DATE APPROVED BY Z0 35vd ONI, 8D>1 OTTOZ4880S SZ:41 S00Z/ZT/T0 Cafe Jefferson Menu Bagel w/egg & Cheese 2.29 + meat .50 Bagel 1.10 + Cream Cheese .40 Muffin 1.50 Croissants 1.40 Scone 1.50 Danish 1.50 English Muffin 1.00 Loaf Cake Slice 1.50 Choc. Chunk Cookie 1.25 Desserts - Cheese Cake Slice 2.00 Canoli - 1.50 Fruit Cup 2.50 Yogurt .95 Pie 2.00 Soups (sm/Ig) 3/4.00 Garden Salad 4.50 Ceasar 4.50 Greek 5.00 Chef 5.75 Side 2.50 + Chicken/Tuna 1.25 Sandwiches 5.50 Tuna Salad, Egg Salad, Seafood Salad, Chicken Salad, BLT, Italian, Roast Beef, Reuben, Pastrami, Buffalo Chicken Salad, Oven Roasted Turkey, Combo-Any sandwich w/ small soup and chips 6.75 Potato, Macaroni, Greek Pasta Salads 2.00 Beverages Ice Coffee(sm/Ig) 1.70/2.10 Tea 1.45 Milk/Choc Milk 1.35 Soda/Water 1.00 S. Pellegrino 1.25 V8/Coke (Glass Bottle) 1.35 OJ (sm/Ig) 1.10/1.35 Nantucket Nectar 1.50 Orangina 1.40 10/30/2009 10:11 7813563960 EASTERMAS PAGE 01 EASTE" Frow Cindy Rice MASS Re: Foodhandler Certification Class FO ) Date; SAMITTY This letter is to verif% that r / . is registered has taken ServSaf'e C�ettificasion cusses Kc-certifications `— « Consultations the l'oodhandler certification class and examination + Basic staff trainings on-site scheduled for Resuht of tate examination will be availz.hle in approximalcN 4 weeks front that date. 1f you have any questions. please feel feet to call me at any time. c� 1`r�/ itespectl id h. 70 C:'hristina Drive ;-< rC < , C C . < Al � Braintree. MA 02184 781-356.1467 C.'ind< <1, Ricc. RS, MSFFI Fax: 781-J56-3960 c i nderrt�e&stern m assfi,odsa fety_com www.casternmasst'(iodsal'ety.com 16C1,l.7.eY a�:=w,..wY•.'fyT,,.:*C^`cyl .._`:f§(.yam.-}u� K..°„,hy��'f'�, !f ;d'�td`-.3..e:P:af �4't .,,Lt. . iii . nX^..�'�r-...-7 tr Mab+ �.=r..r r.. Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4'"Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name (� Da T e of 0 eration s Type of Insoaction t C, R SJf� ood Service [�-RoOfine Address a� L Q Risk ❑ Retail EIRe-inspection Level ❑ Residential Kitchen Previous Inspection Telephone C�G _ ❑ Mobile Date: OwnerO HACCP YM El Temporary ElPre-operation �( 1 ElCaterer El Suspect Illness I Person in Charge(PIC Time ElBed&Breakfast El General Complaint T In: [.'3,) ❑ HACCP Inspector OutO. , 5--- Permit No. ❑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 Anti-Choking Tobacco ' Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. [FOOD PROTECTION MANAGEMENT= r" ' '� ' �3.�. y,� £.,,�,� �m„,,�» � El 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties $ tee ❑ 13. Handwash Facilities EMPLOYEE HEALTH ri,. u. w 5 dy �g.p �,^ �rr _PRO TECTION FROM Ct1EM16A4S t 66ii r7y�-'I �v a70 m �`"`"° ❑ 2. Reporting of Diseases by Food Employee and PIC I •��>4=� � I ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOUD FROM APPROVErJ SOURCE. --"- "F. 7tMETEMPERATURE CONTROLS(Potemlatly Haaardous F©ods)"° ❑ 4. Food and Water Approved Source a ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling 1�PROTECTION FROM CONTAMINATION °"�',Xm t°P -:. ❑ 19. Hot and Cold Holding EA,9a A,at ❑ 8. Separation/Segregation/Protection [120.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing �,REQUIREMENTS FOR HIGHLY$U$GEPTIBLE POPULATIONS(HSP)'„, ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices COIiSUMER ADVISORY . ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions ❑ . immediately or within 10 days as determined by the Board and Risk Factors(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' , ., by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) 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-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.006) 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 RE-INSPECTION: S591nspctFc -14.dm NQr} / Lf Inspector's Signature: Print: Page PIC'sSignature: Print: _�of7iPages / . Gtr/r>'/��i9�/ ._f r Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Cross-contamination 1 590.003(A) Assign mentofRes ponsibility* 3-302.11(A)0) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* - Cooked and RTE Foods* 2-103.11. Person in charge-duties Contamination from Raw Ingredients 3-302A I(A)(2) Raw,Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590k03(C) Responsibility of the person in charge to Contamination from the Environment require repotting by food employees and 3-30111(A) I Food Protection* applicants* 3302.15 'Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food rimployee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Resell Ice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* d Food and Water From Regulated Sources F 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 Warewashina Hot Water 3-202.13 Shell Eggs* Sanitization Tem eratures* 3-202.14 .Eggs and Milk Products,Pasteurized* 4501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. * 5-lfll.11 Drirtkin Water from an A roved System* 4-60L1'1(A) Equipment Food Contact Surfaces and 590.006(A) Bottled DrinkingWater* Utensils Chan* 4-602.11 Cleaning Frequency of Equipment Fnnd- 590.0(I6(B) Water Meets Standards in 310 CMR 22.0" Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-70211 Frequency of Sanitization of Utensils and . 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* - 10 Proper,Adequate Handwashing Game and Wil(Mushrooms Approved by Regulatoty Author 2-301.11 Clean Condition-Hands and Arms"` 3-20218 Shellstock Identification Present* 2-301-12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* F Il Good Hygienic Practices g Receiving/Condition 2-401.11 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 hue rit * Mouth'' 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Sheilstock 12 Prevention of Contamination from Hands 3-202.18 Shelistock Identification* 590kW(E) Preventing Contamination from 3-203.12 Shelistoek Identification Maintained* Em to ees* Tags/Records:Fish Products 1-3 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* .5-203.11 Numbers and Capacities* 590.004(7) Labeling o1 Ingredients' 5-204.11 Location and Placement* Conformance with Approved Procedures 5-20 .11 Accessibilit ,O teration and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Methods* Devices 3-502.1Redued oxygen packaging,criteria* 6-301.11Handwashing Cleanser,Availability8-103.12 Conformance with A. roved Procedures* 6"301.12 Hand Drying Provision -Denotes critical item in the federal 1999 Pool Cate or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Pager_ Of( Item Code C-Critical nem DESCRIPTIONOF VIOLATION/PLAN OF CORRECTION Date j No. Reference R—Red Item. Verified .. PLEASE PRINT CLEARLY-. `. r� �i- i 1/i., n c0 Ct , -��✓vr l�Y. �.�.,11. // )O J-� H o �...n .in L/- TGt Gr:n ✓!/ 1 -f /n ( .�{(2. I/1 I AJ r1fi c4 to Qll o v n.Q'74%',in j ti -r� C r e7 x C /�• r� � Nin v d�].l' bz . Discussion With Person in Charge: Corrective Action Required: ❑ No Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. x/(/, ❑ Voluntary Disposal 0 Other: 3-501.14(C) PRFs Received at Temperatures Violations Related to Foodborne illness Interventions and Risk According to Law Cooled to Factors(items 1-22) (Cont) 4I'F/45`F Within 4 Hours. PROTECTION FROM CHEMICALS3-501,15 Cooling Methods for PHF's IF 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives k---- 3-50116(B) Cold PHFs Maintained at or below 590.004(F) 41V45°F Poisonous or Toxic Substances 3-302..14 Protection IromiIIna roved Additives* 3-501.16(A) Hot PHFs Maintained at or above 15 4017. * 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130°F. Containers"` 7-102-11 Common Name-Working Containers* 20 Time as a Public Health Control 7-201.17 Se aration-Storage" 3-501.19 Time as a Public Health Contrah' 7-20211 Restriction-Presence and Use" 590.004(H) Variance Re uirement 7-202.12 Conditions of Use* 7-203.11 'toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers,Criteria-Chemicals* POPULATIONS(HSP) 7-204.1.2 Chemicals for Washing Produce,Criteria" 21 3-801,11(A) Unpasteurized Pro-packaged Juices and 7-204.14 Dain Aents.Criteria* Beverages with Warning f abols* :r801.11(B) 7-205.11 Incidental Food Contact Lubricants* Uge trt'Pasteurized E rs' 3-80111(D) Raw or Partial! Cooked Animal Food and 7-206.1 t Restricted Use Pesticides.Criteria* Y Raw Seed Sprouts Not Served. 7-266.12 Rodcat B tit Stations"` 3-801.11(C} Una ened Food Packave Not Re-served. 7-206.13 'tracking Powders,Pest Control and MonitarinR* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-60-311 Consumer Advisory Posted for Cgn"11100n of Animal Foods 95tat are Raw, Undercooked or 16 Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate Ekc.",Ye t!l/2G0 3-401.1IA(1)(2) Eggs- 155'F 15 Sec. Pathozcns h Yqs-hmnedtue Service 145°P15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish,Meats&Game E s* Animals- 155'F 15 sec.* 3-401.11(11)(1)(2) Pok,and Beef Roast- 130'F 121 min* SPECIAL REQUIREMENTS 3-401.1I(A)(2) Ratites,Injected Meats- 155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec.11 catering. mobile food,temporary and 3-401..1.1(A)(3) Poultry,Wild Game, Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited wider the appropriate sections Poultry or Ratites-165'F 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks Interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Anand Foods Cooked in a practices should be debited under 1129- Microwave 165`F* Special Requirements. 3-401_11(A)(I)(b) All Othea PRFs-- 145°FN 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165'F 15 sec. a' (Items 23-30) 3-403.11(B) Microwave-165°F 2 Minute Standins Critical and non-eridcal violations, which do not relate to the Time" foodborne illness interventions and risk factors lister!above, can be 3-403.11(C) Commercially Processed R'rE Food- found bt the follou4ng sections q/the Food Cade and 105 CNIR 14WF* 590.000. 3-403.LI(E) Remaining Unsliced Portions of Beef Item Good Retort Practices _ FC 590 000 1 Roasts': 23. Mann ement and Personnel FC-2 .003 1 ..-.-.-.- ---- 18 Proper Cooling of PHFs 24. Food and Food Protection ___ FC-_3 .004 25 E ui meat and Utensils FC 4 .005 1-501,14(A) Coaling Cooked PHFs front 140`F to - --- - F - 26 Water. Plumbin and Waste FC-5 006 70"F Within 2 Hours and From 7WF 27 Ph sical Facility FC 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 Froin Ambient 29. S ecisl R uiremettts _ .009 Temperature Ingredients to 41°F14i'F 30 -_Other t Within 4 hours" s.=wpmr�mct6-znio< °Denotes critical item at t6a Wead 1999 Food Code or 105 CM12 5901-000. ST1.R�TTF 5 Hallberg Park INVOICE SERVICE North Reading, MA 01864 Pumping & Drain TOLL FREE:800-794-9265 t DATE: S t CO.,INC. FAX: 978.276-0548 WEB:www.servicepumping.com ARRIVE j "Protecting Your Environment for Over 75 Years" t.'_ DEPART: HOME PH: I. PML. WORK/CELL PH: } NEW [REPEAT BILL TO: I"-,'- < --S, r r JOB NAME: v l -[' icy { -.,t - i 1 i PROBLEM: LOCATION: ❑LEFT SIDE JOB TYPE: ❑EMERGENCY ❑ INSIDE ❑OUTSIDE ❑FRONT ❑REAR ❑ RIGHT SIDE ❑IN/NEXTTO DRIVEWAY .MAINTENANCE - SUB CONTRACT QTK WORK REQUESTED PRICE AMOUNT ',qGREASETRAP <'1Q)UT gallons/Ibs. Cl SEPTIC TANK gallons i ❑CESSPOOL gallons j ❑PUMP CHAMBER IN/OUT - gallons - i ❑SEWER MANHOLE IN/OUT gallons i ❑HOLDING TANK IN/OUT gallons ❑SAND TRAP IN/OUT gallons STORM DRAIN IN 1 OUT gallons 3 (7 OTHER IN/OUT gallons i ❑DIGGING FT IN. # 3 ❑TREATMENT: ❑CCLS ❑BIO-REM-E-D ❑SEPTIC SCRUB I 1 I i j 1 { P.O.# ET1R111t.CK# TECHNICIAN NOURS RATE AMOUNT TOTAL MATERIALS TOTAL LABOR �t 1 TOTAL 1 Payment Method(circle one): CASH CHECK MC VISA AMEX BILL(TERMS'PLEASE PAY WITHIN 30 DAYS) i CREDIT CARD #: / , } .:iir_ :?'..r •-� '� 51GNA71177E:_.._ Thank You (I hereby acknowledge the satisfactory completion of the above described work) ,arae rur NB6S CUSL4M"prinVngsen ce _uca-'tsb b.: INEt6.1,:.4 1-111,u�_rvw a+. - 978-2 6-0217 � GREASE CONTROL LOG DATE AMOUNT GREASE TECH. SIGNATURE WATER/SEWER COMMISSION 5 HALLBERG PARK,NORTH READING, MA 01864 (800) 794-9265 Commonwealth of Massachusetts i City of Salem Board of Health IGmbedey Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/22/2009 ESTABLISHMENT NAME: Cafe Jefferson File Number:BHF-2005-000043 293 Jefferson Avenue SALEM MA 01970 LOCATED AT: 0293 JEFFERSON AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2009-0377 Jan 9,2009 , Dec 31,2009 $140.00 ESTABLISHMENT Total Fees: $140.00 PERMIT EXPIRES December 31, 2009 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In-accordance with-the State-Sanitary-C-ode;-beofre-any-revonations,improvements;or-equipment-changes are-made,all,--- plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS ! BOARD OF HEALTH 120 WASHINGTON STREET,4"'FLOOR TEL. (978) 741-1800 KIMBERL.EY DRISCOLL FAX(978)745-0343 MAYOR IMANCINI&ALEM.COM JANET MANCINI, ' ACTING HEALTH AGENT e 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Ca!P�e 7'e�V'SOr TEL# 9-78 7 N y L� Y(9 S ADDRESS OF ESTABLISHMENTA 13 T'FrP,r 0AJ Atte FAX# MAILING ADDRESS(if different) EMAIL-Business': (� <gI�yWebsite: / OWNER'S NAME f2Q�e ICt(xtvl ;S TEL# 61J -3LJ _� 3 ADDRESS I NDN C�U CDUJ--'- UJ✓ +9J *,koAJ ,(/V{ 0'VV I STREET (• CITY STATE /J (�q ZIP CERTIFIED FOOD MANAGER'S NAME(S) GC'OL�t h<-�1rX�9 ICbt�NI S CERTIFICATE#(S) % Z / / (Required in an establishment where potentially hazardous od is pre ared EMERGENCY RESPONSE PERSON HOME TEL# DAYS`OF?,QPERATION.. ',1. : Mori T; .Tuesda ,r,,_,. -' Weddesda ;Thursd ^" --Fdda `•4;S6turda ._+=i Sunda ';;: ': HOURS OF OPERATION I Please write in tune d day. 16AM 3 p-, GAS- 3PM CAxA 3ryl (,c - 3 P^ 6e ?� 7ah 3p 7a H / (For example 11 am-t t pm) i 3 TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than I0,000sq.ft. =$420 --------------------------------- -- ----------------- --------------- ---------------------------------- ----------------------------------------- RESTAURANT YES NO less than 25 seats $140 (Outdoor Stationary Food Cart$210) 25-99 seats =$ 0 more than 99 seats =$420 --------------------------------------------------Y-------ES------ [& $---10-------- BED/BREAKFAST/ NO 0 CHILDCARESERVICES/NURSING HOME ................................................... ......................................... ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,before any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returnsetums a_� t x required der t e law. i/// /07 3330 y3i 2/ 3 Signature Date Social Security or Federal Identification Number Revised 424/07 FOODAP2008.adm Check#&Date r. •drv'A: •:1. +.R:.+F. '.f,4,T[ F,., . •+e�Fyr1`•$�1>tl`.t.� .! � S•� 7"s. ': " ":�+:i'.R""^u':c. d'.. . .�:.✓��i w. . ,�' r+.�,d rc'�r'' •.+ i Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4'"Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name DatUP e of O eration s Type of Inspection f Food Service Routine Address C Risk t ❑ Retail He-inspection Level ❑ Residential Kitchen Previous II spactign Telephone El Mobile Date: I�r� 0 Owner HACCP YM ❑ Temporary ❑ Pre-operation pr AI r, 14^11, ❑ Caterer ❑Suspect Illness Person in Charge(PI ) �) e, El Bed&Breakfast El General Complaint r InTim: )'5v ❑ HACCP Inspector (�p Out:g� l Permit No. ❑ 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 Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. r FOOD PROTECTION MANAGEMENT .. „ , ,o-g,, '®`� ) ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH ,'�"',` • aysi'�`®"' r`a 'y `'' ' ' �'� '� t`PROTECTION FROM CHEMICALS ,U,j p ,e i'° 1 ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals ('FOOD FROM.APPROVED SOURCE TM �.m'MAM ".:, ;: -•' & „ ❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CDNTROLS(Bbtertiaity Hazardous Foods)r� e aHmn F L] 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 .4 i-� """�° =ei� El 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ",,REOt1IREMENTS FO. . . . . .4Y SUSO'€P'f1ELEP8P1iLAT1Qf (HSP} El21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(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 G by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.0044))) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (Fc-a)(sso.00s) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(51o.006) and submitted to the Board of Health at the above address 29. Special Requirements (990.009) within 10 days receipt of this or r. �1w� 30. Other DATE OF RE-INSPECTION: S 5901nspecfPormb14.tlm Inspector's Signature: Print: ' PIC's Signature: Print: . .e y Page,4_ofA Pages - r F Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT F8 Cross-contamination 1 590.003(A) Assignment of Responsibility' 3-302.11(A)(]) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* - Cooked and RTE Fcxtds* 2-103.11. Person in charge-duties - Contamination from Raw Ingredients 3-302.110)(2) Raw Annual Foods Separated from Each EMPLOYEE HEALTH Other* 2 590k03(,C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A Foal Protection* _ applicants* 3-302.15 Washin Fruits and Ve etables 590.003(F) Responsibility Of A Food Employee Or Al 3-304.11. Food Contact with Equipment and Applicant To Report To The Person In Utensils* Chase* Contamination from the Consumer 590.003(G) Reporting by Person in Char e* 3-306.14(A)(B) Returned Food and Reset-vice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(F.) Removal of Exclusions and Restdetions Food 3-701.7.1 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Ford* 4 1Food and Water From Regulated Sources F 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.11 1 Manual Warewashing-Hot Water 3-201.1.2 Food in a Hermetically Sealed Container* Sanitization Tempe totes- 3-20113 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eg s* Sanitization Temperatures* 3-202.14 E>>s and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. 5-]01.11 DrinkingWater from an Approved System* 4-60111(A) Equipment Food Contact Surfaces and 590.006(A) Bottled DrinkingWater* Utensils Clean' 4-602.11 Cleaning Frequency of Equipment Food 590.006(B) Water Meets Standards in 310 CMR 22.0* Shel/flsh 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 Caught MaOuscan Food Contact Surfaces of Equipment* Shellfish* 4-703.7.1 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Author" 2-301.11 Clean Condition-Hands and Aims* 3-20118 Shellstoek Identification Present* 2-301.12 Cleaning Procedure* -590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices g Receiving/Condition 2401.11 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 Package Integrity* Mouth* 3-101.11. Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstoek 12 Prevention of Contamination from Hands 3-202.18 Shellstoek Identification' 590.004(E) Preventing Contamination from 3-203.12 Shellstoek Identification Maintained* Em to°ees* Tags/Records:Fish Products 13 Handwash Facilities 3-40111 Parasite Destruction* Conveniently Located and Accesslbte 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(J) Labeling of Ingredients' 5-204.1.1 Location and Placement* g Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying Devices 3-502.11 S ecialized Proeessin Methods* 6-301.11 Handwashin Cleanser,Availability 3-502.1.2 Reduced oxygen packaging,criteria* 8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drying Provision "Denotes critical item in the federal 1999 Frxxl Code or 105 CR 590.000. i }� CITY OF SALEM BOARD OF HEALTH Establishment Name: r� _ j Q2itc Date: Page:Page:_ of a Rem , Codes C—CriticalIteme, DESCRIPTION OF,VIOLATION/PLAN OFORRECTION Date*; No Reference`$ R-Red Item a �" b = . sem. - .. y s, ;, Verified 0 � PLEASE PRINT CLEARLY Al� } x ' 'Y -!f'♦ 0, i f CV AkAzd Inc,rt - .�—• i i n s i S i i i Discussion With Person in Charge: Corrective Action Required: ❑ No Yes I have read this report, have had the opportunity to ask questions and agree to correct all lel �lt7ntary 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 suspepsion/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal 0 Other: Violations Rallafed to Foodborne lifitess Inteciientions and Risk According,to La'% Cooled to Factors(item 1-22) (Cont) .1 PF_i45`F Within Hours. 5G1 n t " PROTECTION FROM CHEMICALS —Cx)fin Food or Color Additives Lit- PHF Hot and Wit Holding L 1-4 3501.16(B) Cold PHI-il Mwntainildat or b-low 3-202,12Additives* )90,0(pffl 3-3{12,14 114 Prowdion 15 Poisonous or Toxic Substances , 3-501,16�A) I-lot PH F��,%fairlt a raed;it or lar-1ve 140'F Identifying btfianaition 0H.1fla. 3_„01 16 101.11 ��k�.sts Hod at or above 130'1 Time as a Public Health Control 7-10211 (omraon'Nam,- - Worlim,,Coatainer,�' Ti-OT,T)——— IF _T26 1-1 T— Em",as a Public Health("aal.0V Varian 1-2£)2.12Rc,�tlliction -Po"rence and i _1-_2()2-12 _Condition:of Lso' REOUIREMENTS FOR HIGHLY SUSCEPTIBLE 7--22_0041.1 0111l To7ii;Coplamta�-Prolid*ioni LI-1 POPULATIONS(HS sammers,Cri'laria -chemic;iK,* IS� . .... 1217 3-801.11(A) Ulripovteurizeall joices Wad 7 104.12 chvlwcldsfigw hi rodllce,Criteria" Jte�eowees with Warnin.T�aWl,* 7-204,14 Di vhol.Asealm Criteria�' _�-801ARB) f i,;c of Pal,teak oxd to Incidental Lexi Contact,lAdaicaraO 3-b0l,11(0) Raw orPartialiv Cooked Artitird Food and [f-200 I L�: Rcmriocd 11�e Pesticide:. critekle Not Stived. Toickmg Powderv. Pest Control and CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-003 11 ('0usumor W�isoiv NAted for Cotatimption of Animal FoodK lhat ire Raw, Undercooked N F-16 Proper Cooking Temperatures for Not Otherwise Fliminate PHFs ��illx(, 3-401 IIA(1)(2) FIggs- 13��'F 1.5 Padlo,ins 4ervtcc 145'Flfis ew 3-30" i l Pl',ctekntzl,d for Rale Shell 1 4)1.1 comnlinad;jr Ardwak- I_i5,T 1-1 see. SPECIAL REQUIREMENTS 401.1 I(B)(J)i21 Pia;),, apil b".c"Rilaia L`R)"F121 min .. ._._ 7 Viokifions of Secthio 590009(A)-(D) in 3-401.11(1s)(1) Rxites, lliJcctai brats - 1�5�F 15, Qatering. mobile.Rlixo-ternporary and 3-401.11(A)(3) Msldcntial kitc+ien opciafirtai shoald he Pooftry, Wild Gawe� Stuffed Plifis', Fish, Meal, f debated under the lbuve if relaled to locidborne illnxs� Pouhr or Ratiles 165�'F J5 sec, * i 3-40Ll!iQ3) vact Bef Stew interventions and risk factors. Other 1 590.1009 violations reladn,� tosrood retail 45"F I 1 3-401.12 Raw Animal F(loih Cooka]in a prat uccs Should be dcbitM under#29 - Tfi, 145"1"1� sec� it()the, PiT 1=7 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 71(511(A)&(D) Pt{Its 1657T (Items 23-30) 3-4()3 11(B) Microwave- In-5'F 2 Mint ie Glitiral and non-f iiiiiail vioartwill, Ivnich do no;rtiece to i/.ic Time, 'Iroodburtie, dieess hiferl,enlioav und risk jactors 111c10 i,idawcan be cominelcialIN Pavess��,d H_T�TI—XIT— fiiiaill ill se(fions ofthe Food Code nuui 1(,'5 CNIR 140 F, 5,00,(X& - -- - -- --- --- -- --- T-- Reillaillill"', of Beef ii, dowiiietail Practices FC 590,000 R last 3 _Managiarneit Personnel I FG 2 i �003 iil ai 24� Food and F;jxi cC 3 064 Proper Cooling of PHFs Equip I Ltaijd'UT1ejr)�qiia, 005 (7(x,hnl; -lits 14Y F to ---------- 3-501.14(A) Coohrxl PHF,� fi W2i2i.ftu �irl Tid',yaste _rly qa TOO!;Within 2 Hours From 71)�T P�y a�_ FC-6 ON to 4 J`F/45'P Within 4 flours FC-7 008 ,-501 iF4CBTT Coolin',PHFs Malde Nora Ambient r Temperawre ingredients Io 41 OB45'F 30, 1 Offir, Wrthin 4llours' re Iint lc li i t 1994 rosin(,C.,de or 763 CNIR 391)(y)"), i. . .� ri JFK �'¢�- .>. !�< �,lY�} t=moi^ s-_+.r-vm.�Y'�:n'34r2de�M7,di b+-..�ra.f^h'41,•it..r�'tS.d++Y„ '%6}i : Massachusetts Department of. Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4'"Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 NameDate Type of Operation(s) Type of Inspection (-c ( vK Food Service ® Routine Addressr - s c Risk Retail ElRe-inspection Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: Owner '1 HACCP YM El Temporary ElPre-operation r DJ Aj n I ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast El General Complaint In: It,-00 ❑ HACCP Inspector _ Out: -, O Permit No. El Other Cl r"49C.,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 Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOQi)PROTECTION MANAGEMENT„;, -112. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties ❑ 13 Handwash Facilities EMPLOYEE HEALTH PROTECTICN FROM CHEMICAI,8"a""" ❑ 2 Reporting of Diseases by Food Employee and PIC --�t� •� r �- � � - _� , I�A + �� a El 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded FOOi,TIMErrEMPERATURE CONTROLSD FROM APPROVED SOEIRCE M�"� '„„„p s"n ,�,� El 15.Toxic Chemicals ❑ (Poterttrally Hazardous Foods} ;^,'>r 4. Food and Water from Approved Source �- �YOe ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 16.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 a REQUIREMENTS FORHIGHLY$USCEPTIBLEPOPULATIONS(HSP}' ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices :cONSUMEk ADVISORY; .. ="',"rt,- El t`❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related ❑. Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(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'a IN ' by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590o03) order of the Board of Health. Failure to correct violations 4. Food and Food Protection (FC-3)(590.0044)) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (Fc-9)(990.009) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(59o.0os) 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: S. Inspector's Signature: ` Print: PIC's Signature: - Print: Cl C l PageLof Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 590.003(A) AssigtmentofResponsibility' 3-302.11(A)(]) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* 2-103.17. Person in charge-duties Contamination from Raw Ingredients 3-302.11(.4)(2) Raw Annual Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* applicants* 3-302.15 Washin Fruits and Veetables 590 003(F) Responsibility Of A Fo(Xl Employee Or An 3-304.1 t Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003 G Re orcin b-Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(F.) Removal of Exclusions and Restrictions Food - 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 J.i( Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Seated Cvn ainer* Sanitization Tem eratures* 3-201.13 Fluid Milk and Milk Products* 4-507.1 i2 Mechanical Warewashing-Hot Water 3-202.1.3 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..1.1 Drinking Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(11) Water Meets Standards in 310 CMR 22.0* 4-602.1 t Cleaning Frequency d Equipment Food- 590.006(11) Surfaces and Utensils* SheAtish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-20114 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-HotWaterand 3-201-15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Regulatory Authority Game and uMushrooms Approved by 2-301.11 Clean Condition-Hands and Aims* 3-20118 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.1.7 Game Animals* 1.1 I Good Hygienic Practices 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 I Package Integrity* Mouth* 3-101.11, Food Safe and Unadulterated* 3-30112 Preventing Contamination When TastiEaL 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202-18 Shellstock Identification* 590.004(F) 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 5-203.11 Numbers and Capacities* 3-402.1.2 Records,Creation and Retention* 5-204.11 Location and Placement* 590.004Q) Labeling of Ingredients 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Nand Drying 3-502.11 Specialized ProcessingMethods* Devices 3-502.12 Reduced oxygen packaging-criteria* 6-301.11 Handwashina Cleanser,Availability 8-103.12 Conformance with Approved Procedures" 6-301.12 Hand Drying Provision *Denotes critical IIem in the federal 1999 Fad Code or 105 CMR 590.000. i 4 CITY OF SALEM BOARD OF HEALTH i Establishment Name: aa cz, Date: /aQ Iv �jj Page: d of 7 Item mCode.m, "C-Cntical Item ,; < DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Na. x Reference R Red Item 4 ' ,. y,. '<�, ....., ° - '. v„,�=:. >Y,: &A e x 7;Q n fr <jr ..)s<” j.,,'t ~` �rr"`tc^� gta z';,�.,�., ��,f , 'Verified CLEARLY 291, Cetc, Vo i �AJ dO_)r N4DC14 j Gr!'L2 CIc n C'." � J ZZ e. 14,-,,,-_& ,_ � o ' n 4- :z 3�i- it Ln)s.cLo r P M202, , — ,/ � I J r ,� lL OkC c-r -!" 0+ I I C o -IL n , Q� st rt= n o } / _ L t/J S ( nl 90 c /I 1 S n n , n i 7l� --�J _ 1 �c,h0. LS'ILf SI /'. I A/ , V S— CJ. = r IL f—, Discussion With Person in Charge: t _ Corrective Action Required: ❑ No Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ voluntary Compliance ❑ Employee Restriction / inspection, to observe all conditions as described, and to Exclusion violations before the next ins P �Re-inspection Scheduled Li Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twentjfa, a dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. �i/ �� ❑ voluntary Disposal ❑ Other: 3-50 1.1 401"t PHFt Rce,eIved af Temperatures Violations Related to Foodborne Illness interventions and Risk Aceord4w to Lau CkxAM to Factors(items 1-22) (Cont) ---I I�,Fi,15'F Wifliin,l Hates. 561.1 for PHF,, PROTECTION FROM CHEMICALS 19 PKF Hot and Cold Holding [E4 d oi'&df�r Additives --7-9HFs Nlaint,towd at or 202 590 0041 J, 1 1`,145' 3-,'U)2,14 Protection (Tom Add I I t vf,-i 3 SI}'�16i,A) H(A ItHF, %fainnnned at orabove Poisonous or,roxie substimees 1401F it; 101 11 idmloin,inion-toon, Ot cojrtafirers* 20 Time as a Public Hoafth Conti at 7-162-t1 Common i�tmo--workit E sat tiny rs-� 3-io, It) T' 7-10 1.11 Senwatik,n- --L_�, litni.`tirl H) Variance R I r�i I� Inera 7.20111 lr-�t,ic;ion-ProsLace tied L se* 7 202.12 Coadinom of UREQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7 203, —Toxic Cutitainol.--Fr—ohi te�i w)I—'I 7-204.11 SirinnZerS,Criteria -ChCiair41SPOPULATIONS(HS PS* 1211F33-1,0iT�,V? pack aged Joicts and 7-204.12 Chelnicals for Cgnodal� I Reveratata 204 14 tet, Uie flll 1-80 1,11(B) L,2( i- , Incidental FtN,xl Cvntoc��Aifu7ic-,UiW� Fi� - l.aobe•niaslx 77 (,, I -06.11 Ro�qrnted Use Pe,ocides,Critei in, Rwwsteds 7 r36.?i RaSc.at BmtSluao�,n -scrve(L 7-206,1 Tiacking Pow&ri.Pt�i Control and C.n+ Nn!Packaji, Not Rc Monirorin", CONSUMER ADVISORY 22 3-o0 I! Cormonet Agiooi y PtAzed for coliounpiell T TIMEITEMPERATURE CONTROLS i Animal Bto& lli�ttire Raw. Undercooked c., 16 Proper Cooking Temperatures for PHFe Not Olutm ise Pr(xessed To Eliminate ptaho"=S flys 15"'F 15 sc 30 i Fl,- S4dwaul,�fel Raw Shed 1-40LIT(A)(2) C M 'onnocil!-ish� cvs Haute Amin tt� i i)T, 15 aec. H(B)(h(2) I Port andll�c! Roast - 130,1` 1�11 Hil!iL ,46 SPECIAL REQUIREMENTS �1-1—r-�.— 59,0.0013(A) til) 77 Vice uowrf SecVon 'i90.()(i9(A'I-(r)) In 1-401.11(A)Q? 1 Raines, Injected Mcats - 155 T 15 clitkrinn. rn,krk Ix, ternpurary and remdentitil kitchen operations should tv, 3-401.2 I(A)_3) Poitur),Wild Stuffed 11H s, Stuff mg('Ontaininj,,�FiIhMeal, deliated under In,-apprupriale set'lions Foultry or Rabies.1057 15 sec. akvc if telaltA to tuudlwvn Ihws�s linaci Ileof Steaks interventions and it faclors, Other 145" 590nm�009 violati6w;relatto,�ood retail Anima'Foi�d.Cottked in a praetice,%,hould N,,debited under h'29 - Microwave 101 5 11 R-1,ur eitionts- 3-401,11fAr(l)(b) I All Other PRF,.- 145'T 15 sec Reheating for Hot Holding VIOL i4TIONS RELATED TO GOOD RETAIL PRACTICES {[tents 23-30) 3-403.11(B) '"iclowwe- 10,F 2 Mint it standirn, Criiwai and nvn-(r41n:al whinh do inn i-eidre vt Me, Time, Fovdharne illnesr inrervonnmT and riskjot torr 1ad abole, an be COUITTIUVGWY PkMemeed RTEKxtd- loqnd in tiu,"ollownig sec rioi?s qf;he Food Code wid 105 CMR -16 F° 590.000, Reniaoun', Un,,,beed Portions of Beef. .....----------- 3-403,11(E') Good Retail Prartices PC 590(HIO 1 72,ask* Manoomeni and Perannet PC -2 .603 Proper Cooling of PHFS 24 �Pcradand Food Pji��ftiort 004 —1-1— - I- - —4--- --—.1 1=8 25 Eq FC-I i OrI5 -71,501.14(`A) Cooling cook,"d PHES front 1-1t}'F25to 2 -241ter,Ki Mbimi'vd Wnste 7011 within 11 Hours wid From 70,1, 27 F,,Lwalc,,Fa l_qg�ijej�or FC-6 FC-7 1 .008 5()1,1 4(B) Cooling PHFs Made honk Ambient r '46__ Tentforature It,41 1-/45:F withm-1 Huurs CITY OF SALEM BOARD OF HEALTH Establishment Name: rc,Fr e4rj,,-i Date: i;) Page: Ek Item C cal item DESCRIPTION OF VIOLATION PLAN OF CORRECTION ft Date Code it, �V rified No" 1Refe,.�'.'-.`-;[CR--CR1!d M4',' wj� �% �, - i`,* $11 _ a PLEASE PRINT CLEARLVr" &cbl Un J RJ 9r Q a 4-Pma,7,10' POA,nbZan /A 1-0 A, cjQ4 C"&� fx-1 . /7, /A 1.174 dariL - -cnpl a�gcz to) t/7 rr n Gee*l-f.Cr ( R0,-P,,,A A)-9 r Z- P,2r Y 5 V <4� ' - J a 1�4- r",^C , /JOOL4, 'C7 0 r C7� /AJI �Z j VI Discussion With Person in Charge: -Corrective Action Required: Ea No es I have read this report, have had the opportunity to ask questions and agree to correct all o Voluntary Compliance 0 Employee Restriction Exclusion violations before the next inspection, to observe all conditions as described, and to Re-nspection Scheduled Cl Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that Ll Emergency Closure noncompliance may result in daily fines twenl -1dollars, LI Embargo your food permit. U Voluntary Disposal U Other: 3—it,TJ I 74(E) flifFs Rerived all-mPeratures, Violations Related to Feadborne fitness Interventions and Risk Accoi di ail to Lau Cooled to Factors(item 1-22) (Cont) 4 1 F/4F Within 4 Hour�- for PROTECTION PROM CHEMICALS 19 PHF Hot and Cold Holding 14 Food or Color Additives I I 3-202,12 Additivos* 1501 16{H) )ld PHFs Maintained at or lielow 590 004(F) 4lV450 F, 3-102,14 Ptutection front lhiajoprovo.d tkddilve," 15 Poisonous or Toxic Substances 440€,1 6(A) I iol E>HF Maintained at or above tj,711d,ty'n hibl�litat"01, -caw"i, 5 1.16(A) Poasts Held at or above OWE I-—J t=oasts I-.�—�,e'P"l4h1l.1 1 20 Time as a Public Health Control 3�501 19 1-1,02,11 Common Nalue - Workiii,C onnaiaers 7-'x01.1€ �90 004H) —_-Llime as a Public Health Coultel' 7-20111 Req,iction- and U,c' 7-202.12 Condition",of Uso* - 'toxic Container - Poahibi:ion�* 1-203 REQUIREMENTS FOR HIGHLY SUSCEPTIBLE _ 1204.11 'an iirze7",Croeiin-Cheaniads* POPULA IONE�±SPJ 7-2k4.12—TFie clic cls forCiftetial 3-80 t I(A) Unpostcurizcd Pte-psol aged Juices,and 7-104,1 flt�,Criteria- — Bevcrazes with WarniLlg-L�4—),.Isl wL— 3-901 1103) Use of LaLl—lteume ' 7.205,111 incidental Food Contact,Imbitcants, -,3-SOFAI(D) thaw sir Pailmily Cuok,d Animal Food and 7-206 Raw, Seed Smo-tqNut Sca-ved. 7-206.12 Rodent lKnt stattorvO 110 1 I I(C�� 1�xxi Packtqtr Not Re served, 7 206.13 Tracking Powdffc.Pest Control and L --T------ monitoring' CONSUMER ADVISORY 1') 3-603-11 1 ('011surnor Ao�isory Posted for TIMEfTEMPERATURE CONTROLS r 011"ki;nPaton of 16 Proper Cooking Temperatures lot--- Animal Fxxls That art.Raw, Undervooked ca PHFsNot(he }the ise Prix e-qsed to Flillartate IIA(l)(2) Egg��- 155'F 15 S,�O� 14.i'Fi5sw 1-302.1 i PaAeunyzd Fggs Subgitw lot Raw Shell 3-40L11tr1}(2) Cominnutted t sh Meals Game -.Aaiund - l'55"F 15 secSPECIAL REQUIREMENTS 3 40 1 11(B)t 1)(2) lork and Beet Roam - 130F 121 min^ Violjtj,mi,�of Section �90.ii;t)�AI (D)jn� 3-401.11(A)(2) Ratitcr, Injected kl�at., 155 F 15 sec. caterine. inobilc food,temporary and d tu f� he 73�ZO TF(A)l 1;, tv, V�T Car,,, S f d plfrs; resident, kitchen opciations Sniffing Cont mins.Fish,Mont, I debt ed under the appropriate sections aW-ve ifcclaced to foodhorne i liness 401 1 J(C)i3l Whole muscle,ln,,qct Beef Steaks interventions and risk famr5 Other 145 F 4---- -- 590.009 violations relating to good retail K as Xlalrnal Food,Cool ill a pacticeN, should be debited under/t29 - __ M mowave 163'F liecittiremetilm 3-ZL I I 0�;�71 (bT Alt Oilker Pfff`s-- 1451: 15 sec. --LIP Reheating for Hot Holding VIOLATIONS RELATED TO 606D RETAIL PRACTICES 1i(A)&(1)—) Pff, 165-F 1,1 (Items 23-30) -3-463.11('B) Nficrowaw- 1654,r 2 Rllrlull Standing Cfi,tral anal rte m-c rab.cd vlVlalion.v, which do not relate an&r. Time" foodbome illness mwrvenlions aril r14 jw fors Imed erbovc� can be 3-403.11 tc) Commercially —low-1 found in o.1 the fauel Code anid 105 CAM 140'F J90060, 3-403,11(E) Remaining Unshced Portions of Beef Item Good Retail Practices Roast"* 23, 1 Management and Peisorincl ._I_PC003 Proper Cooling of PHFs FC - 3 W4 -7 �ohljgCook PHI, 117— 005 3-:501.141A) 26, PWav,Pimbinqand Waste Pyrcal F 7o'F Within 2 Jfour�and From / .-aosi!)L 1 007 to 4 I'T-'145'F Within 4 Hours. PC 1 Poisonous or Toxic Materials -7 008 00 9 4(B) Coaling PJ Made From Ambient—' Tmperature hrgrewt.nts to 41`F/45�1; A 0293 JEFFERSON AVENUE Cafe Jefferson City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency 3Telephone: - - TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) r (617) 347-2439 Hot and Cold Holding FAIL Critical ❑Q RED Owner: - a Comment:The back True freezer has a temperature of 32°F. Repair unit to maintain a temperature of 0°F. I George& Dino Papagiannis Violations Related to Good Retail Practices (Blue Items) ?PIC: - Equipment and Utensils FAIL Non-Critical BLUE George Papagiannia Comment:The Hobart oven needs a thorough cleaning. Inspector: The front refrigerated display case needs a thorough cleaning. David Greenbaum, Date Inspected:Correct By: . 15/21/20'08 IRisk Level 'Permit Number: BHP-2008-0197 rStatus: SIGNED OFF #of Critical Violations: 1 tTime IN: Time OUT: Urgency Description(s): i BLUE: Violations Related to Good Retail Practices (Critical I .violations must be corrected immediately or within 10 days)(Non-critical violations -must be corrected immediately or within 90 days) I City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 21,2008 ) Page I oft Item Status Violation Critical Urgency RED ,Violations Related to Foodborne Illness Interventions. and Risk Factors (Require immediate corrective action) I City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 21,2008 ) Page 2 of F s Commonwealth of Massachusetts _ City of Salem s Board of Health IGmbedey Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 FooNRetail Establishment Permit DATE PRINTED: 01/07/2008 ESTABLISHMENT NAME: Cafe Jefferson File Number:BHF-2005-000043 293 Jefferson Avenue SALEM MA 01970 LOCATED AT: 0293 JEFFERSON AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2008-0197 Jan 4,2008 Dec 31,2008 $140.00 ESTABLISHMENT Total Fees: $140.00 PERMIT EXPIRES (December 31, 2008 Board of Health P1 This Permit is not transferable and must be reissued upon change of ownership or location:The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 4 of 24 CITY OF SALEM, MASSAC HUSEM c BOARD OF HEALTH "s 120 WASHINGTON STREET,4"'FLOOR TEL. (978)741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 p� ®/�__ L MAYOR iSCOTTCrr7 SALEM.COM ,T'4,EC�;V D JOANNE SOOTT, 4 JAN 3 2008_ HEALTH AGENT Ui TY OF SALEM 3OARL) OF HEALTH 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT C a.f e_Se f f e R ral, Tom, C' , TEL# 9 QO'—9 V V--2—'Lt 8'� ADDRESS OF ESTABLISHMENT-:?- dI -3 T e ff etzJvn P}VPn 2 FAX# MAILING ADDRESS(if different) e- e, f A-1,,yA EMAIL-Business': Website: ` OWNER'S NAME 6-fo �--5Qn- 1" d,P j /rni S TEL# ADDRESS I NI An y 2+. ),ye, ee STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) �T p 5 R y-Q �/�L 3) c n i 1 CERTIFICATE#(S) s t e 'J� 7�rfreS *'RL' (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON 01�yo 6 kec 6 / d ^^/ S —HOME TEL#1-'181-"7`2l-Il DAYS OF OPERATION 1 Monday TuesdayWednesday Thursday Friday Saturday Sunda HOURS OF OPERATIONrt Please write in time of day. 3 6aoA PM , f!ant_'3 PM 6e'l,-3e/A7 PM r<u,.,-.3 PA, For example 11 am-11 pin) 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 � NO less than 25 seats = 140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 -------'----------'----'--'-- �p � _---------------------------- BED/BREAKFAST/ YES l/ $100 CHILDCARESERVICES-------- --./- ------------------------------------------...........----------------------------- ----- ADDITIONAL PERMITS / MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES q4 $25 TOBACCO VENDOR YES $135 ALL NON-PROFIT(such as church kitchens) YES O $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have fled all state tax returns and paid all state to re det,lhe.liw._. /// /z z4 2 Fzr/* 93o431913 Signature a Date Social Security or Federal Identification Number ----------'------------- ----'- -----"- t-' -----'- -- ----------------------"--'--' Revised 4/24/07 FOODAP2008.adm CheckH&Date Y $ -- X1'1 E�,jgrminators INVOICE PLEASE REMIT PAYMENT TO: Al 1 SHEP RD TREET,LYNN,MA 01902-4597 P.O.Box 310 Lynn,MA 01903-0310 ® 781-592-2731 1-800-525-4825 FAX 781-592-7641 271952 CURRENT 30 DAYS 60 DAYS 90 DAYS Pest and Termite Control Professionals RT DATE DAY TYPE DATE �-'�6i AGCT NO. c�"r mower ,A.r.n .v.•u•.v r 0725 T�je 101 07/25/06 CAFE JEFFERSON CONTROLFOR REGUL..AR NEST CONTROL./ � � 40. 00 29? JEFFERSON AVE sERVICEcrlaF Sf-3 M FF 01970 / NUMBER UNITPRICE AMOUNT 9'78-744--2488 0600AN MOUSE G/BD ' (y n �^ •a� MULTI-CT TRAR � �rf 1C�/ DATE r • (/� I p`�`/ PROTECTA CHECK NO 1. A )/ PROTECTA LP / �t -- t r RTU BAIT STAB ) COMMENTS ❑MC ❑VISA []DISCOVER RAT GLUE BDr /I �N `•� j 1'..ITC}'EN/PREP/DINING AREA/RR AS VA lEEPED ACCT If EXP DATE SALES TAX U � y`,, •' (•••�� C.O.D.❑ CHG❑ N/C❑ TOTAL DUE TOTAL AMOUNT PD y ADDITIONAL COMMENTS r I t I COMMERCIAL SANITATION REPORT i Floors—Clean ... .. . .. .. . .. ... .. ... .. . .. YES NO Fl Counter Surfaces—Clean . . .. .. . .. .. . .. .. . .. 0 F1 Drain Areas—Clean . .. ... .. . .. .. . .. ... .. . .. ❑ ❑ Rest Rooms—Clean . .. ... .. ... .. . .. ... .. ... ❑ ❑ Dining Areas—Clean .. ... .. . .. ... .. . .. .... ❑ ❑ Employee Areas—Clean . .. . .. ... ... .. .. . ... ❑ ❑ Locker Areas—Clean . . .. .. . .. . .. ... .. .. ... . ❑ ❑ RESIDENTIAL WARRANTY INFORMATION StorageAreas—Organized . . .. ... .. . .. . . . ... ❑ ❑ DWELLING TYPE WARRANTY YES❑ NO❑ Comments 1 Family ❑ 3 Family ❑ 30 Days ❑ 60 Days ❑ 2 Family ❑ 6 Family ❑ 90 Days ❑ 6 Mos. ❑ REASON FOR NO WARRANTY .Partial service requested...................'....................................................... ❑ POST APPLICATION REQUIREMENTS -Poor sanitation.............................................................................................❑ -Kitchen/bathroom cabinets not prepared...................................................❑ OCCUPIED AREAS MUST BE VACATED FOR HOURS. •Closets/furniture not prepared..........:.........................................................❑ THOROUGHLY VENTILATE TREATED AREAS BEFORE THEY ARE REOCCUPIED. DO NOT ALLOW ADULTS, CHILDREN,OR PETS ON -Rodent proofing needed..............................................................................❑ TREATED SURFACES UNTIL DRY. -Other CONTRACTING ENTITIES HAVE RECEIVED ALL MASSACHUSETTS DEPARTMENT OF FOOD&AGRICULTURE'S PESTICIDE TIME IN BUREAU CONSUMER SHEETS,WRITTEN STATEMENTS,POSTING NOTICES AND HAVE AGREED TO NOTIFY TENANTS 2-7 DAYS PRIOR TO APPLICATION TIME.THE ABOVE SERVICE HAS BEEN SATISFACTORILY COMPLETED. INS 5-1 n STONER SIGNP,TURE -; ^ LIC.# 4 V TEG. ,.H SIGNATURE TEC SEE REVERSE SIDE FOR PERTINENT INFORMATION l•WWWhite—Office Copy Canary--CustomerCopyPink.—Remittance Copy CHECK THE CONCENTRATION OF EPA REG NO. LIST CODE TOTAL AMOUNT OF MATERIALS C ] MATERIALS USED MATERIALS USED USED(oz.,gal.,Ibs.) ( ] Advance Dual Choice 0.5o0% 499-459 [ ] Avitrol Concentrate 25% 11649-10 [ ] Avitrol Whole Corn .51/11 11 E349-7 [ ] 8PtooSee Label 449-452 [ ] CB-60 Extra See Label 9444-175 [ ] Conquer 027V,or-05% 1021-1641-57076 [ ] Contras Flux .005% 12455-79 [ ] Drax Sugar 5% 9444-131 [ ] Drione Dust See Label 435=992 [ ] Gentrol IGR Concentrate 9% 2724-351 [ ] Intruder HPX - See Label 9444-183 [ ] Larva Lur 2% 655-802 [ ] Maxforce Ant Bait Gel .001% 432-1264 [ ] Maxforce FC Bait Station .05% 432-1256 [ ] Maxforce FC Gel A1% 432-1259 [ ] vlaxforce FC Select .01% 432-1259 ' [ ] Maxface Ge'. See Label 432-1254 [ ] Maxforce Tick Svstem .70% 432-1248 [ ] Nylar Carpet Spray See Label 4758-169-57076 [ ] Phantom .25%..5%,.125'% 241-392 [ ] Purge It See Label -9444-33 [ r ] Precor 1.20/6 2724-352 [ ] Pro Control Fogger See label 499-465 [ ] Recruit N AG .5% 62719-454 [ - ] Recruit IV .5% 62,119 453 [ ] Rozoi Tracking Powder .02% 7173-113 [ ] Suspend SC .01%or.03% 432-763 [ ] Temoo 1%Dust - 3125-569 [ ] Termidor SC .06°%,or.125% 7969-210 - [ ] Tim-bor 98% 64405-8 [ ] Wasli Freeze See Label 499-362 [ ] Weather Blok .005% 100-1055 [ ] Whitmire f See Label [ ] ZP Trackin. Powder 10511, 12455-16 [ ] Other [ ] [ ] [ ] [ ] TARGET PESTS METHOD APPLICATION BAIT STATION APPLICATION CODE PLACEMENT CODE [ J Ants [ j Millipedes ( j Squirrels Bait Station -BS Under Sink us [ ] Bees [ J Mites ( [ Termites Broadcast -BC Behind Stove BS [ Birds [ ] Powder Post Beeties ( ] Ticks Brush -BR Behind Refrigerator BR [ j Centipedes ( j Raccoon [ J Wasps Crack&Crevice -CC Closet C ( [ Crickets [ j Rats [ j Wood Boring Insp. Duster -D Floor F ( j Earwigs [ ] Roaches [ ] Other Foam -FM Sill S ( j Fleas - ( j Silverfish [ ] Inspection Only Fog -F Cabinet CB Micro Injector -MI [ J Flies ( J Skunk [ ] Other Slab Injector -SI [ ] Hornets ( ] Sowbugs [ ] Other Ultra Lovr Volume -ULV [ ] Mice [ J Spiders Rod -R A-1 EXTERMINATORS MISSION&GOOD PRACTICE STATEMENT A-1 Exterminators adheres to all Federal and State regulations pertaining to the use of pesticides.Our mission is to provide our clients with satisfaction through reliable pest control services.On occasions,we shalt instruct you to vacate the area of treatment or to remain off of treated surfaces until they have dried.Your family,clients,employees,and pets are always our first priority.Labels and MSDS sheets are available upon request.Commercial property and public buildings shall be posted to notify you of the pest control services being provided at your location.On file in the contracting entity's office is a list of"Materials In Common Use—General Pest Control."Please refer to this notice for information required should you have questions.Do not hesitate to contact our office for pest control questions or needs. A•1 Exterminators PLEASE REMIT PAYMENT TO: 183 SHEPARD STREET,LYNN,MA 01902-4597 INVOICE _ tP.O.Box 310 Lynn,MA 01903-0310 ® 781-592-2731 1-800-525-4825 FAX 781-592-7641 _ CURRENT `30 DAYS ` 60 DAYS 90 DAYS Pest and Termite Control Professionals "`'� 46 4 W' DATE DAY TYPE DATEL.LIU ACCT NO It ti('�t11 I'htr,Fla[wn/J Ln 327 rue 101. 03/27/07 CAFE JEFFERSON — " CONTROL FOR ' REOOL_AR PESTr OONTROL SERVICE CHARGE 40. 00 293 JEFFERSON AVE_ Y NUMBER UNIT PRICE AMOUNT SALEM 119 01970 + MOUSE GL BD ��••�--+��,, 97.8— 2488 11/22/06 0600AMr MULTI-CT TRAP 4 •��; �;+ — - - DATE 3' 36,� /� P 30TECTA ' I / f/ CHECK NO. 4n / / 1{+,/'PROTECTA LP A RTU BAIT STA COMMENTS ❑MC ❑VISA. E DISCOVER RnTGLUE BD .ice KITCHEN/PRF1 /E LN0 AREA/RR AS NEEDED > IACCT# EXP DATE - SALES TAX - ,(( C.O.D.❑ CHG❑ r NIC❑ TOTAL DUE e TOTAL AMOUNT PD O 6 - c ' ADDITIONAL'.COMMENTS y s ( b I J COMMERCIAL SANITATION REPORT YES NO Floors—Clean. . ... .. . .. . . .. . ... ... . El Counter Surfaces—Clean . .. .. . ... .... .. . .. . ❑ '" - DrainAreas—Clean ... ... .. . .. ..o-:.. ... .. . . ❑ ❑. Rest Rooms—Clean .. . .. ... .. .. ... ... ... . . ❑ ❑ Dining Areas—Clean . . .. ... .. . .. ... . .. ... .. ❑ ❑ Employee Areas—Clean . ..:. ... .. ... ... ... .. ❑ ❑ - LockerAreas—Clean . ... . . . ... .. .... ... ... .. ❑ ❑ RESIDENTIAL WARRANTY INFORMATION Storage Areas—Organized .. ..... ... ... ... .. ❑ ❑ DWELLING TYPE ". WARRANTY YES❑ NO❑ Comments 1 Family ❑ „� 3 Family ❑ 30 Days ❑ 60 Days ❑ - 2 Family LlJt6 Family ❑ 90 Days ❑ , 6 Mos. ❑ 4 i r - REASON FOR NO WARRANTY, .Partial service)requested:...............r:,..........................................................❑ ` POST APPLICATION REQUIREMENTS .^ .Poor sanitation.............................................................................................❑ ' +Kitchen/bathroom cabinets not.prepared...................................................L] OCCUPIED AREAS MUST BE VACATED FOR HOURS, -Closets/furniture not prepared...:.................... ❑ THOROUGHLY VENTILATE TREATED AREAS BEFORE THEY ARE """"""""""""""""""""""" REOCCUPIED. DO NOT ALLOW ADULTS, CHILDREN,OR PETS ON -Rodent proofing needed...":............. ..........................................................❑ TREATED SURFACES UNTIL DRY. •Other. 1` CONTRACTING ENTITIES HAVE RECEIVED ALL MASSACHUSETTS DEPARTMENT OF FOOD&AGRICULTURE'S PESTICIDE' TIME IN BUREAU CONSUMER SHEETS,WRITTEN STATEMENTS,POSTING NOTICES AND HAVE AGREED TO NOTIFY TENANTS 2-7 DAYS PRIOR TO APPLICATION TIME.THE ABOVE SERVICE HAS BEEN SATISFACTORILY COMPLETED., INS 5 J1 a1 'A�STOMER SIGNATURE "��' _ •�/LLIG�# (,( 1• fT.EG,H SIGNATURE TECH NO SEE REVERSE SIDE FOR PERTINENT INFORMATION White—Office Copy Canary—Customer Copy Pink—Remittance Copy CHECK THE CONCENTRATION OF EPA REG NO. LIST CODE TOTAL AMOUNT OF MATERIALS [ ] MATERIALS USED MATERIALS USED USED(oz.,gal.,lbs.) ( ) Advance Dual Choice 0,500% 499-459 ( ] Avitrol Concentrate 25% 11649-10 ( ) Avitrol Whole Coin ,545 116497 ( 1 BptooSee Label 449-452 [ ] CB-80 Extra See Label 9444-175 [ ] Conquer .027%or AS% 1021-1641-57076 [ ) (',entree Blox "005% 12455-79 [ ) Drax Sugar 5% 9444-131 [ ] Dricne Dust See Label 435-992 ( ) Control OR Concentrate 9% 2724-351 [ ) Intruder HPX See Label 9444-183 - - - [ 7 Larva Lur 2%. 655-802. ` ( ) Maxforce Ant Bait Gel .001% 432-1264 [ ] Maxforce FC Bait Station .05% 432-1256 [ ] Maxforce FC Gel .01% 432-1259 [ ) Maxforce FC Select .01% 432-1259 [ ] Maxforce Gel See Label 432-1254 [ ) Maxforce Tick System .70% 432-1248 [ ) Nyll Carpet Spray See Label 4758-169-57076 ( ] Phantom .25%_5%_125% 241-392 [ ] Purge III See Label 9444-33 [ ) Precor 1.2% 2724-352 [ ] Pro Control Fogger See Label 499-466 [ ) Recruit IV AG .5% 62719-454 [ ] Recruit IV .5% 02719-453 [ ) Rozol Tracking Powder ,02°% 7173-113 [ ] Suspend SC .O1°<5 or.03% 432-763 [ ) }em o I%Dust 3125-569 [ ) Termidor SC .06%.or.125% 969-210 [ ] Tim-bor 98% 64405-8 ( ) Wasp Freeze See Label 499-362 [ ] Weather Blok .00596 100-1055 [ ) Whitmire I I See Label, ( ) ZP Trackinq Powder 10°% 12455-16 [ ] Other [ ] ( ) [ ] TARGET PESTS METHOD APPLICATION BAIT STATION APPLICATION CODE PLACEMENT CODE [ j Ants [ j Millipedes [ j Squirrels Balt Station -BS Under Sink US ( ] Bass [ j Mites ( j Termites Broadcast -BC Behind Stove BS ( j Birds [ 1 Powder Post Beetles - [ ] Ticks Brush -BR Behind Refrigerator BR [ ] Centipedes [ ] -Raccoon - [ j Wasps Crack 8 Crevice -CC Closet C [ I Crickets [- ] Rats ( j Wood Boring lnsp. Duster -D Floor F [ ] Earwigs [ I Roaches ( ] Other Foam -FM SdI S Fleas Fog -F Cabinet CB [ j [ j Silverfish - [ J Inspection Only Micro Injector -MI ( ] Flies [ j Skunk [ ) Other Slab trajector -SI [ ] Hornets [ ] Sowbugs ( ) Other Ultra Low Volume -ULV [ J Mice ( j Spiders -Rod -R A-1 EXTERMINATORS MISSION&GOOD PRACTICE STATEMENT A-1 Exterminators adheres to all Federal and State regulations pertaining to the use of pesticides.Our mission is to provide our clients with satisfaction through reliable pest control services.On occasions,we shall instruct you to vacate the area of treatment or to remain off of treated surfaces until they have dried.Your family,clients,employees,and pets are always our first priority.Labels and MSDS sheets are available upon request.Commercial property and public buildings shall be posted to notify you of the pest control services being provided at your location.On file in the contracting entity's office is a list of"Materials In Common Use--General Pest Control."Please refer to this notice for information required should you have questions.Do not hesitate to contact our office for pest control questions or needs. AA-1 Exterminators PLEASE REMIT PAYMENT TO: 183 SHEPARD STREET,LYNN,MA 019024597 INVOICE P.O. Box 310, Lynn, MA 01903-0310 0 781-592-2731 1-800-525-4825 FAX 781-592-7641 CURRENT 30 DAYS I 60 DAYS 90 DAYS CC`S8 Pest and Termite Control Professionals U RT DATE DAY TYPE DATE COD ACCT.NO.123980 TECH:005// 0522 Tr_te 101 05/20/07 CAFE JEFFERSON CONTROLFOR REGULAR FEST CONTROL SERVICECHARGE 40. 1293 JEFFERSON AVE NUMBER UNITPRICE AMOUI SALEM MA 01970 MOUSE GL BD 978-744-2488 03/30/07 0600AM ^� MULTI-CT TRAP DATE r1Y 2 .d� PROTECTA �,I CHECK NO. PROTECTA LP RTU BAIT STA COMMENTS ❑ MC ❑ VISA ❑ DISCOVER RAT GLUE BD KITCHEN/PREP/DINING AREA/RR AS ACCT# NEEDED EXP DATE - SALES TAX C.Q.O.❑ CHG❑ NrC❑ TOTAL DUE TOTAL AMOUNT PD -0 DIRECTIONS CONT:GEORGE / DINO (617) 728-7307 ADDITIONAL COMMENTS. COMMERCIAL SANITATION REPORT YES NO Floors-Clean ................................................................ ❑ ❑ Counter Surfaces-Clean ............................................ ❑ ❑ Drain Areas-Clean ....................................................... ❑ ❑ Rest Rooms-Clean ..................................................... ❑ ❑ Dining Areas-Clean ..................................................... ❑ ❑ EmployeeAreas-Clean .............................................. ❑ ❑ RESIDENTIAL WARRANTY INFORMATION Locker Areas-Clean ...........................-..................... ❑ ❑ DWELLING TYPE WARRANTY YES El NO❑ Storage Areas-Organized .•....................................... ❑ ❑ 1Family ❑ 3Family ❑ 30 Days ❑ 60 Days ❑ Comments 2 Family ❑ 6 Family ❑ 90 Days ❑ _ 6 Mos. ❑ REASON FOR NO WARRANTY • Partial service requested ..................................................................................❑ • Poor sanitation ...................................................................................................❑ POST APPLICATION REQUIREMENTS •Kitchen/bathroom cabinets not prepared ......................................................❑ OCCUPIED AREAS MUST BE VACATED FOR HOURS. •Closets/furniture not prepared..........................................................................❑ ,THOROUGHLY VENTILATE TREATED AREAS BEFORE THEY ARE • Rodent proofing needed...................................................................................❑ REOCCUPIED. DO NOT ALLOW ADULTS, CHILDREN, OR PETS ON •Other TREATED SURFACES UNTIL DRY. CONTRACTING ENTITIES HAVE RECEIVED ALL MASSACHUSETTS DEPARTMENT OF FOOD&AGRICULTURE'S PESTICIDE TIME IN TIME OUT BUREAU CONSUMER SHEETS,WRITTEN STATEMENTS,POSTING NOTICES AND HAVE AGREED TO NOTIFY TENANTS 2-7 DAYS PRIOR TO APPLICATION TIME.THE ABOVE SERVICE HAS BEEN SATISFACTORILY COMPLETED. iNs 5-1 C TOMER SIGNATURE LIC # CH SIGNATURE TECH P 6y a 0 SEE REVERSE SIDE FOR PERTINENT INFORMATION White-OniceCopy Canary-Customer Copy Pink-Remittance C AA-1 Exterminators PLEASE REMIT PAYMENT TO: 183 SHEPARD STREET,LYNN,MA 019024597 INVOICE P.O. Box 310,Lynn,MA 01903.0310 781-592-2731 1.800-525-4825 FAX 781-592-7641 ;34.0678 CURRENT 30 DAYS 60 DAYS 90 DAYS Pest and Termite Control Professionals 40. 00 I 0. O� I O 00 0. 00 F I� 1 RT. DATE DAY TYPE DATE G9'9 ACCT NO.'— " ""�"" ` ` OG26 Trae 101 06/26/07 CAFE JEFFERSON CONTROL FOR REGULAR FEST CONTROL. SERVICE CHARGE 3 AVE' 29 .rEFFERSON SALEM MA 11970_ NUMBER UNIT PRICE AMOUNT �- MOUSE-OL BD 978-744-2488 05/22/07 0600AM MULTI-CT TRAP 617--728-73.07 — DING DATE O7 PROTECTA �4 PROTECTALP CHECK NO. RTU BAIT STA - 1 COMMENTS ❑ MC ❑ VISA ❑ DISCOVER RAT GLUE BD KITCHEN/ 'REF/DINING AREA/RR AS NEEDED ACCT n EXP DATE SALES TAX L a�( C.oX.D.❑ CHG ElNiC EJTOTALTOTAL DUE MTOTAL AMOUNT PD A. ADDITIONAL COMMENTS COMMERCIAL SANITATION REPORT YES NO Floors—Clean ................................................................ 0 ❑ Counter Surfaces—Clean ............................................ ❑ ❑ Drain Areas—Clean ....................................................... ❑ ❑ RestRooms—Clean ..................................................... ❑ ❑ Dining Areas—Clean ..................................................... ❑ ❑ Employee Areas—Clean .............................................. ❑ ❑ RESIDENTIAL WARRANTY INFORMATION Locker Areas—Clean •••••••.......................................... ❑ ❑ Storage Areas—OrganizedDWELLING TYPE WARRANTY YES❑ NO❑ W" LJ Family ❑ 3 Family ❑ 30 Days ❑ 60 Days ❑ Comments 2 Family ❑ 6 Family ❑ 90 Days ❑ 6 Mos. El REASON FOR NO WARRANTY . Partial service requested .........................,.......................................................❑ • Poor sanitation ...................................................................................................❑ POST APPLICATION REOUIREMENTS • Kitchen/bathroom cabinets not prepared ......................................................❑ OCCUPIED AREAS MUST BE VACATED FOR HOURS. •Closets/furniture not prepared...................................................................:......❑ THOROUGHLY VENTILATE TREATED AREAS BEFORE THEY ARE •Rodent proofing needed...................................................................................❑ REOCCUPIED. DO NOT ALLOW ADULTS, CHILDREN, OR PETS ON •Other TREATED SURFACES UNTIL DRY. CONTRACTING ENTITIES HAVE RECEIVED ALL MASSACHUSETTS DEPARTMENT OF FOOD&AGRICULTURE'S PESTICIDE TIME IN � BUREAU CONSUMER SHEETS,WRITTEN STATEMENTS,POSTING NOTICES AND HAVE AGREED TO NOTIFY TENANTS 2-7 DAYS PRIOR TO APPLICATION TIME.1!j- BOVE 10 HAS,BEEN SATISFACTORILY COMPLETE Ns s-r CUSTOMEg,SIGNATTJ E LI - H SIGNATURE CH NO. �� SEE REVERS SIDEFORPERTINENTINFORMATION White—CllliceCopy Canary—Customer Copy Pink—Remittance Copy V CHECK THE CONCENTRATION OF EPA REG NO. LIST CODE TOTAL AMOTINT OF MATERIALS [ ],MATERIALS USED MATERIAL USED USED:(oz.,gal.,lbs.) [ ] Advance Dual Choice 0.500% 499-459 _ - ( I Avitrol Concentrate 25% 11649-10 - [ .]Avitrol.Whole Corn 5°,0+- -, -11649-7 _ [ ]BP-100 See Label 449-452 - [ ]CB-80 Extra See Label 9444-.175 [ ]Conquer .027%or.05% 1021-1641-57076 [ ]Conran Slox .005% 12455-79 •• [ I Drax Sugar 5% 9444-131 - ( I Drione Dust See Label 435-_4j2 [ 'TGentrol IGR Concentrate 9% '\ - 272/4381 - [ I Intruder HPX see Label 9444-183 [ ]Larva Lur 2% 655-802 [ ]Maxforce Ant Bait Gel .001% 432-1264 [ )Maxforce FC Bait Station .05% 432-1256 [ ]Maxforce FC Gel '01% 432-1259 [ ]Maxforce FC Select .01% 432-1259 - r6, ' [ I Maxforce Gel See Label 432-1254 I ]Maxforce Tick System .70% 432-1248 [ j Nylar Carpet Spray See Label 4758-169-57076 t [ ]Phantom - .35 w.5%,.125%• 241-992. [ -],Purge 711_ •' _ ` S!st1abel 9444-33 ,. ' e .._.- .. ...J' [ J Precor 1,27 2724-352 - I ),Pro Control Fogger - See Label 499-465 - [ ]Recruit IV AG - .514, . 82719-454 - - 1 [ ]Recruit IV .5% 62719,453 ( ]Rozol Tracking Powder - .02% 7173-113 ( - [ ]Suspend SC - .01%.or.03% 432-763 - - f •� 1 y , h - 9 [ Tempo - 1%Dust 3125-559 I ]Termidor SC - (J6%or.125% 7969-210It . nIt [ ITim-bor 9846 64405-8 - r [ ]Wasp Freeze . See Label 499-362 [ ]Weather Bfok .005% 100-1055 t - t .«, 'y •i ( ]Whitmire[ ] See Label r [ )ZP Tracking Powder 10% 12455-16 ,;\ it [ ]Other TARGET PESTS METHOD APPLICATION, BAIT STATION APPLICATION CODE _ PLACEMENT CODE [ ] Ants [ J Mice [ I Spiders Balt Station <es Under Sink US [ ]Bed Bugs [ I Millipedes [ ]Squirrels Broadcast -BC Behind Stove es ( ]Bees-- - r[ ]•Mltes ; - [ ]Termites - - - Brush -BR Behind Refrigerator BFR [ I Birds [ ]Powder Post Beetles - -( I Ticks Crack-a Crevice -CC Closet C [ I Centipedes [ ]Raccgon ( ]Wasps Duster -D Floor F. ( I Crickets [ I Rats [ )Wood Boring trip. Foam -FM Sill S [ ]Roaches Fog -F Cabinet Ce [ ]Earwigs [ ]Other InI j -M [ I Fleas [ I Silverfish [ I Inspection Only Micro ector Slab Injector -M - [ ]Flies [" ]skunk [, ]-Other Ultra Low Volume -ULV ( Sj I Hornets [ ]Sowbugs [ ].Other - ---- Be A-1 EXTERMINATORS MISSION&GOOD PRACTICE STATEMENT ' A-1 Exterminators adheres to all.Federal and State regufaYiQns pertaining tothe use of pesticides.Our mission is to provide.our clients with.satisfactiort through reliable pest•control.Services.On occasions,.we shah insUuct'.you to vacate the area of treatment of to remaiii off of treated surfaces will they have dried.,Your family,clients;employees,and pets are always our first priority.Labels and MSDS sheets are available.upon request.Commercial property and public buildings sFia(Lb' poSS"to r ify you of the pest control servicesbeing prdvided at your location.On file in the conlracitng,errfily'sioffoe is a list of"Materials In Common Use`-Gen 'a[pest Centro]."Please aefer to this notice Tar information required should you have questions,Do not Hesitate to contact'our office for pest control - gtlestigns�needs. 1"11 •,x r � r u�``�- ` f I'I EXIerI�IC�C�LOrS PLEASE REMIT PAYMENT TO: �jj INVOICE P.O. Box 310,Lynn,MA 01903-0310. - «• 183 SHEPARD STREET,LYNN,MA 01902-4597 781-592-2731 1-800-525-4825 FAX 781-592-7641 3'7� 305 CURRENT 30 DAYS 60 DAYS 90 DAYS Pest and Termite Control Professionals � � r RT DATE DAY TYPE DATE L.UU ACCT.N01 C!,6JbV1 tU :ILIIGJ { 1023 Tue 101 10/23/07 CAFE JEFFERSON CONTROLFOR REGULAR PEST CONTROL' s—EAV4ceCHARGE 40. 00 293 JEFFERSON AVE - NUMBE UNITP IC AMOUNT SALEM MA 01970 MOUSE GL BID 978-744-2488 06/26/07 0600AM MULTI-CTTRAP 617-728-7307 - DINO DATE Jo r .p PFZTECTA P CHECK NO. PROTECTA L t RTU BAIT STA - COMMENTS ❑ MC ❑ VISA ❑ DISCOVER RAT GLUE BD KITCHEN/PREP/DINING AREA/RR AS NEEDED aX ACCT# EXP DATE SALES TAX - C.O ❑❑ DUE CHGNIC TOTAL DUE TOTAL-AMOUNT PD Dao-, f - �Qe�.�.-'�-a�-a�-oma-.. - r r r I r r r R MIME=- i c ADDITIONAL COMMENTS ' �Sl Li K I Y ; l COMMERCIAL SANITATION REPORT YES NO Floors-Clean .................:.............................................. ❑ ❑ Counter Surfaces-Clean ......................................: ❑ ❑ Drain Areas-Clean ....................................................... ❑ ❑ ., .. ., Rest Rooms-Clean ..................................................... ❑ ❑ Dining Areas-Clean .............................':...................... ❑ ❑ Employee Areas-Clean •-•• ........• ................... ❑ ❑ RESIDENTIAL WARRANTY INFORMATION LockerAreas-Clean .................................. ••--•••••. ❑ ❑ DWELLING TYPE WARRANTY YES El NO❑ Storage Areas-Organized ....................A................... ❑ ❑ 1 Family ❑ 3 Family ❑ 30 Days ❑ 60 Days ❑ Comments 2 Family ❑ 6 Family ❑ 90 Days ❑ 6 Mos. ❑ REASON FOR NO WARRANTY - Partial Partial service requested ..................................................................................❑ • Poor sanitation ...................................................................................................❑ POST APPLICATION REQUIREMENTS •Kitchen/bathroom cabinets not prepared ......................................................❑ OCCUPIED AREAS MUST BE VACATED FOR HOURS. •Closets/furniture not prepared...................................::.....................................❑ THOROUGHLY VENTILATE TREATED AREAS BEFORE THEY ARE • Rodent proofing needed...................................................................................❑ REOCCUPIED. DO NOT ALLOW ADULTS, CHILDREN, OR PETS ON .Other TREATED SURFACES UNTIL DRY. CONTRACTING ENTITIES HAVE RECEIVED ALL MASSACHUSETTS DEPARTMENT OF FOOD&AGRICULTURE'S PESTICIDE TIME IN9 BUREAU CONSUMER SHEETS,WRITTEN STATEMENTS,POSTING NOTICES AND HAVE AGREED TO NOTIFY TENANTS 2-7 DAYS PRIOR TO APPLICATION TIME.THE ABOVE SERVICE HAS BEEN SATISFACTORILY COMPLETED. ws sr / V' USTOMER SIGNATURES X� LIC.# A TECH SIGNATURE , TECH NO. SEE REVERSE SIDE FOR PE INENTINFORMATION White-Office Copy Canary-Customer Copy Pink,Remittance Copy F J I CHECK THE CONCENTRATION OF EPA REG NO. LIST CGDE G TOTAL AMOUNT Or MATERIALS [ ] MATERIALS USED MATERIAL USED � USED(az.,gal.,.lbs.) [ ] Advance Dual Choice 0.500% 499-459. [ ]Avitrol Concentrate 25% 11649-10 - - ( ]Avitrol Whole Corn - �.5% 11649-7 - - [ ]BP-100 See Label 449-452 [ ]CB-80 Extra See Label 9444475 [ ]Conquer .027%or.05% 1021-1641-57076 [ )Contras Blox ,005% 12455-79 [ ]Drax Sugar r 5% 9444-131 ( ]Drione Dust See,Label k 435,992. [ ]Gentrol IGR Concentrate 9% 2724-1351 [ ]Intruder HPX _ See Label ' 9444-18$ [ ]Larva Lur ii 2% 655-802 [ ]Maxforce Ant Bait Gel .001% 432-1264 ] ]Maxforce FC Bait Station - .05% 432-1256 ' ]Maxforce FC Get r .01% 432-1259 1 [ J Maxforce FC Select .01% 432-1259 ' [ j Maxforce Gel See Label 432-1254 ( ]Maxforce Tick System .70% 432-1248 - # - [ ]Nylar Carpet Spray-t- ' See Label 4758-169-57076 - - [ ]Phantom 25-/6_5%,.125% 241392 [ J Purge III - - - See iabei 9444-33 [ ].Precor - 12% '2724.352 - [ ]Pro Control Fogger See Label. 499-465 ( ]Recruit IV AG" '_` .5.6 ,62719.454. ' ( ]Recruit IV r, .5% 1527f8.453 Rozot.Tracking Powder' _ .0g 7473413 ( ]Suspend SC' .Oi,Y or.03.96 '432-763 u I 1 Tempo 1%Dust 3145.,-569 ( ]Termidor SC r .06%ci.125% 7969"210 [ ]Tim-bor 98% 64405-8 - - — C [ J Wasp Freeze See Label 499-362 [ I Weather Blok .005% 100-1055 [ j Whitmire[ ] See Label % \ A, [ I ZP Tracking Powder 10% - 12455.16-• { it r [ ]Other [ 1 ' TARGET PESTS METHOD APPLICATION BAIT STATION APPLICATION CODE PLACEMENT CODE [ j Ants [ ]Mice ( J Spiders Bait Station -BB Under Sink us [ ]Bed Bugs, [ ]Millipedes [ ]Squirrels Broadcast •Be Behind Stove BS [ ]Bees [ ]Mites { ];Termites - -Brush -BR Behind Refrigerator SR [ ]Birds - [ );Powder Post Beetles [ - ]Ticks - -Crack&Crevice -CC Closet C [ ]Centipedes [ ]Raccoon, ( ]Wasps Ouster -D Floor F [ ]Crickets ( j Rats ( J Wood Boring Insp. Poem -FM Sill S Fog -F Cabinet CB [ J Earwigs ( j Roaches ( ]Other_- - Micro Injector -MI [ I Fleas ( ]Silverfish ( ]Inspection Only, Slab Injector -SI ( jFlies [ ]Skunk [ ]Other_ Ultra Low Volume -ULV ( j Hornets ..[ J Sowbugs ( ]Other� Rod -4R A-1 EXTERMINATORS MISSION&GOOD PRACTICE STATEMENT - A-1 Exterminators adheres to.all Federal and State regulations-pertaining to the useof.pesticides.Our mission.isao provide our clients with satisfaction through. reliable pest control services.On occasions,we shall instruct you to vacate the area of,treatment or to remainoffof treated surfaces until they h8be dried.Your family,clients,employees,and pets are always our first priority.Labels and_MSDS sheets are available upon request.Commercial property and public buildings shall be posted to notify you of the pest control services being provided at your location.On file in the'contracting entity's office Is a fist o"F"'Materials In Common Use-General Pest Control."Please refer to this notice for information required should you have questions. Do not hesitate to contact our office for pestContfoi questions'or needs. T 0293 JEFFERSON AVENUE Cafe Jefferson City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION (617) 347-2439 Food Contact Surfaces.Cleaning and Sanitizing FAIL Critical RED Owner: Comment:There is no sanitizing available in this establishment. Sanitizing sokution of proper concentration must be readily George & Dino Papagiannis available at all work stations at all times. PIC: Handwash Facilities FAIL Critical 0 RED George Papagiannia 11� Comment:The kitchen habd wash sink found obstructed with dishes. Keep hand wash sinks clear and accessible at all times and Inspector: df -hand washing only. David Greenbaum The eat slicer needs a thorough cleaning and sanitizing. Date Inspected:Correct By: � 10/1/2007 Risk Level: I Permit Number: BHP-2007-0367 Status: VIOLATION #of Critical Violations: 3 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Oct 03,2007 ) Page 1 oft Item Status Violation Critical Urgency RED: Violations Related to.Good Retail Practices (Blue Items) Violations Related to Food and Food fotection FAIL Critical BLUE Foodborne Illness Interventions and Risk Factors (Require mment:There are paper products stored directly on the basement Floor. Store all paper products at least 6.8 inches off the floor. immediate corrective action) Equipment a tensils FAIL Non-Critical BLUE Comment:The Hobart oven in the kitchen needs a thorough cleaning. �T.fie kitchen True reach in needs a general cleaning. ( Theoto"of the front True deli unit has an accumulation of food debris. Thoroughly clean this unit. ,l Tvl e/front display case needs a thorough cleaning, including the door tracks. The eiice scoop on the side of the ice machine needs a thorough cleaning. LKe Maytag freezer in the basement needs a general cleaning. VVV Frigid 're freezer in the basement needs a visible,accurate thermometer. Physical Facili FAIL Non-Critical BLUE mment:The basement lights need protective covers. ` There are open areas on the basement ceiling. Repair all open areas. Other-See Notes FAIL BLUE Comment:There are no extermination invoices for inspecto to review. Owner to provide 6 consecutive months of extermination invoices for review by the inspector. GENERAL COMMENTS: Reinspection on 10/9/07, all violations to be corrected. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMSO 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Oct 03,2007 ) Page 2 of 0293 JEFFERSON AVENUE Cafe Jefferson City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP:- ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION (617) 347-2439 Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑d RED Owner: Comment:There is no sanitizing available in this establishment. Sanitizing sokution of proper concentration must be readily George & Dino Papagiannis I available at all work stations at all times. PIC: Violations Related to Good Retail Practices (Blue Items) George Papagiannia Equipment and Utensils FAIL Non-Critical BLUE Inspector: Comment:The ice scoop on the side of the ice machine needs a thorough cleaning. David Greenbaum Date Inspected:Correct By: Physical Facility FAIL Non-Critical BLUE 10/9/2007 Comment:There are open areas on the basement ceiling. Repair all open areas. Risk Level: Other-See Notes FAIL BLUE Permit Number: Comment: It appears that extermination is only being done every 3 months. Owner must provide an extermination contract to the BHP-2007-0367 Board of Health showing that monthly extermination is being conducted. Owner to provide six consecutive months of extermination invoices to the Board of Health. Status: GENERAL COMMENTS: PARTIAL COMPLY #of Critical Violations: All other violations cited in the 10/1/07 inspection report have been corrected. 1 Time IN: Time OUT: I Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Oct 09,2007 ) Page 1 oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Oct 09,2007 ) Page 2 oft ;293 JEFFERSON AVENUE Cafe Jefferson City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) (617) 347-2439 Equipment and Utensils FAIL Non-Critical BLUE Owner: Comment:The Hobart oven has an accumulation of grime and food debris. Thoroughly clean the oven. George & Dino Papagiannis PIC: Physical Facility FAIL Non-Critical BLUE George Papagiannia Comment:There is a gap around the back screen door. Seal all gaps. Inspector: David Greenbaum Basement ceiling in disrepair. Repair basement ceiling. Date Inspected:Correct By: GENERAL COMMENTS: 3/12/2007 All other violations cited in the 3/5/07 inspection report have been corrected. Risk Level: Permit Number: BHP-2007-0367 Status: SIGNED OFF #of Critical Violations: 0 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 12,2007 ) Page 1 of Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 12,2007 ) Page 2 oft 0293 JEFFERSON AVENUE Cafe Jefferson City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: ', PROTECTION FROM CONTAMINATION (617) 347-2439 Separation/Segre on/Protection FAIL Critical ❑d RED Owner: I c ment:The back True reach in has potentially hazardous foods stored with ready to eat food. Organize this unit so PHF is George & Dino Papagiannis eparale f RTE food to prevent cross contamination. PIC: T ack True freezer has PHF stored above RTE food. Store PHF below RTE food to prevent cross contamination. George PapaglaMld Food ontact Surfaces Cleaning and Sanitizing FAIL Critical RED Inspector: David Greenbaum Comment:There is no sanitizing solution available in the back prep area. Sanitizing solution of proper concentration must be readilyavail le at all work stations at all times. Date Inspected:Correct By: 3/5/2007 T eat slicer has an accumulation of grime and food debris. Properly clean and sanitize the meat slicer after each use. Risk Level: Th mall front c' ng board and the cuttin n on the True deli unit are stained and scored. Resurface or replace both cutting boa Permit Number: Handwash Facilities FAIL Critical ❑d RED BHP-2007-0367 / Co nt:The front hand wash sink missing paper towels. Provide disposable paper towels at this hand wash sink at all times. Status: ON Violation Related to Good Retail Practices (Blue Items) V Equipment and Utensils FAIL Non-Critical BLUE -Wof Critical Violations: 3 T®Comment:jhe Hobart oven has an accumulation of grime and food debris. Thoroughly clean the oven. Time IN: Time OUT: Th ont True deli unit needs a thorough cleaning. Urgency Description(s): Th ont display case needs a thorough cleaning including the door tracks. BLUE: Violations Related to Good th freezers in the basement need a general cleaning. Retail Practices (Critical T basement needs a thorough cleaning. violations must be corrected immediately or within 10 Physical Facility FAIL Non-Critical BLUE days)(Non-critical Violations „ Comment:There is a gap at the bottom of the back screen door. Provide a sweep on the bottom of this door. must be corrected immediately or within 90 days) o The basement ceiling is in disrepair. Repair the basement ceiling. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeOTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 05,2007 ) Page 1 oft Item Status Violation Critical Urgency RED: GENERAL COMMENTS: Violations Related to Reinspection in one week, all violations to be corrected. Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 05,2007 ) Page 2 oft COURT DOCKET NO. Q CITATION NO. CITY OF SALEM Q VIOLATION NOTICE A i89 NAME j((LAST,FIRST,INITIAL) / 1W ADDRF S N�s i CJG ✓ n STBEE �Ss "� CITY/T6WSTATE ZIP a� ' - IvA 6) 70 LICEN 'e .EXP.DATE DATE OF BIRTH D OWNE A E FI - IN 6ti 4 G STREET"ADD.DRRESS CIT'r OW STATE ZIP d cll7GGl7 oc'r't" C dA 7 REGISTRATION NOT STATE EXP.DATE MAKET/PE YEAR COLOR DATE OF VIOLATION TIME DATE CITATION WRITTEN PERSONAL El AM ❑VES ❑PM ❑NO LOCATION OF VIOLATION A V t -y �„{� ENFORCCIING DEPT. ,L �-. . . I tale V* OFFENSE / CHAP. SECT. FINES 4 j G.:& [K r(5 G - iii 'Ira I 4'607 F6od Pcow li B D10-7) C OFFICER ( I.D.NO. TDUEL FINE FIGER CERTIFIES ''COPY GIVEN TO VIOLATOR X C-61 / // ElIN HAND „L=h(BV MAIL DO NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY ORDER OR BY CHECK MADE PAYABLE TO: CITY CLERK CITY HALL 93 WASHINGTON STREET SALEM,MA 01970 TEL.(508)745-9595 X 251 I HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE. PAYMENT IN THE AMOUNT OF $ CASE# SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL e � C' z Mx IN r :�,+ nav1+•^3F'c�, x n*x ,Y{: a.; rc.y..,p'" 3S..r�c3 t.>T * �..'� "' -"F' n I f uocKerNa SALEM ,A pp (, t �o ' s h.' 1 t', VIOLA710N NO710E X i ., i!� �t 1/4 V �( It (l )a f t i t t i C�• r Yr NAME FlRSTtW(fIAU r t 1• (�`` �. ��. r 7 `S�Tt 19t. i�f�` k A _ 'JI�IyS.4�gfQ p: D - '-CITY '�5fATE 21P -�� °` tn� - 1o�r',y� V oa ._ 6h70- 9 "I o00 UCENSE P.DATE DATE OF 6IRTHPi _ CI OWNER'S,NAME(LAST,FIRST,INITIAL) n o L1 STREWADDREA CIT'ROWY STATE 2IP - REGISTRATION NO STATE EXP.DATE MAKET'PE YEAR COLOR f , I DATE OF VIOLATION TIME DATE CITATION WRITTEN L O WURY OAM IWUFY I ❑T-PM ❑YES LOCATION OF VIOLATIONENFORCING DEP❑T,NO 4 OFFENSE CHAP. SECT FINES GD ri.l I A FG?I P< 6 O ) I < ^� f 66W Foed Q<rM 4L` I c Con7tqm �n I, C ER b S _. OFF ER � J I.D.NO.PFNE L C7 t �7' — C. R CERTIFIES COPY GIVEN TO VIOLATOR El IN HAND 0 X rL m . 4.. R i -� /� LCJ,BV MAIL i .-• r, DO NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY ! !, ORDER OR BY CHECK MADE PAYABLE TO: U CITY CLERK - Z ^� CITY HALL Z 93 WASHINGTON STREET r SALEM,MA 01970 b O • 1' TEL.(508)745-9595 X 251 yg !n I HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON 1 > d' a REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE W Q a o < S rf1 PAYMENT IN THE AMOUNT OF �I LL z rn Q LU $ CASE n "'7 r¢j F Z Lij p LL SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL 0 <om aop OI % R, -j'441 Commonwealth of Massachusetts , City of Salem Board of Health. Iftberley D I risooll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Temporary Food Permit DATE PRINTED: 01/08/2007 ESTABLISHMENT NAME: Cafe Jefferson File Number:BHF-2005-000043 293 Jefferson Avenue SALEM MA 01970 LOCATED AT: 0293 JEFFERSON AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions Notes FOOD SERVICE BHP-2007-0367 Jan 8,2007 Dec 31,2007 $100.00 ESTABLISHMENT Total Fees: $100.00 PERMIT EXPIRES December 31, 2007 r Of Board of Health Page 1 of 1 • CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741.1800 FAx 978-745-0343 Kimberley Driscoll WWW.SALEM.COM Mayor JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT i<I� l�/> >�.S O TEL# g7S 7y9' � ADDRESS OF ESTABLISHMENT„ „ �� 1� SU'� Alf- FAX# MAILING ADDRESS(if different) _ EMAIL--Business':_ Owner's: OWNER'S NAME Q 5l�qu� 5 TEL# ADDRESS ( (IC ��Ir AJ,-) STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S N, E(�) `��' � . „r/v�%1 CERTIFICATE#(S) cw i (Required in an establishment where potentially hazardous food is pared) EMERGENCY RESPONSE PERSON HOME TEL# BAYS Of OPERATION Monday Tuesday Wednesday Thursday Friday Saturday SondaY NOURS OF OPMATION Please write in time of day. (for example ttam41nm) i TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 NO - ------ ----...---- --- ------ ---------- - ---less--than a"n-25.. s.--eat....s 100 ------ RESTAURANT YES 25-99 seats =$150 more than 99 seats =$200 BEDIBREA_KFAST.--- -YES.-._NO- ---- --. .............._.--..-..-..-- -$..1.0- 0- -------------- --- - ------ - ... ----------- ------ ---- ---- _--....--..--------... ..... .... ....._....._...._-........._.-.......... - ----.---- ADDITIONAL PERMITS j MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 `Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant L Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, ;ha&veda#I a paid all state t es required under the law. `__ ar Signature a e Social Security or Federal Identification Number - -- — - --- ------ --------,-- - - --------------- -- ------------- - - - ------------ Revised t 1113/O(i FOODAP2007.adm Check#8 Datet�j''A�la �V �� 5/.{[�_ ', 029.?JEFFERSON AVENUE Cafe City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Item Status Violation Type Urgency PROTECTION FROM CONTAMINATION Address: 0293 JEFFERSON AVENUE Good Hygienic Practices FAIL Critical RED COMMENTS: Employees drinks observed in the kitchen and food prep areas. Employees Telephone: (617) 347-2439 must eat and drink in the dining room to prevent cross contamination. Owner: George&Dino Papagiannis Violations Related to Good Retail Practices PIC: (Blue Items) Food and Food Protection FAIL Critical BLUE Inspector: David Greenbaum COMMENTS: There is paper goods stored directly on the basement floor. Store all food Date: 9/22/06 and paper products at least 6-8 inches off the floor. Risk Level: HACCP: No Correct By: Equipment and Utensils FAIL Non-Critical BLUE Permit Number: BHP-2006-0243 COMMENTS: The Hobart oven needs a thorough cleaning. Status: PARTIAL COMPLY # of Critical Violations: 2 The front display case has an accumulation of food debris. Thoroughly clean the display case. Physical Facility FAIL BLUE Time IN: OUT: COMMENTS: The floors and walls have food spills and splatter. Thoroughly clean all floors and walls. Urgency Description(s): GENERAL COMMENTS: Owner must notify the Board of Health by Monday, September 25, 2006 that al BLUE: outstanding violations hav been corrected. Violations Related to Good Retail Practices(Critical violations must be All other violations cited in the 9/15/06 inspection reprot have been corrected. corrected immediately or within 10 days)(Non-critical violations must be City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970 (978)741-1800 GeoTMS2005 Des LaurieMunkipal so ns,.Inc. COMMONWEALTH OF MASSACHUSETTS Paget ® m 029.31EFFERSiONAVENUE Cafe jet&"0 City ofSWem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Item Status Violation Type Urgency corrected immediately or within 90 days) RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) Inspector Signature rnidife V- 41--) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970 (978)741- 0 GeoTMS0200S oes Lauriers MunhAPal soiaona,Inc. COMMONWEALTH OF MASSACHUSETTS page 2 0293 JEFFERSON AVENUE Cafe Jefferson City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone - PROTECTION FROM CqXTAMINATION (617)347-'2439,,. Food Contact Su ces Cleaning and Sanitizing FAIL Critical ❑J RED Owner: fi C mefnta The ice scoop found laying in the ice machine. Store ice scoop handle side up in ice to prevent cross contamination. George&Dino Papagiannis / PIC: - Tb€m slicer has an accumulation of food debris and grime. Thoroughly clean and sanitize the meat slicer after each use. George Papagiannia re plastic table ware going in one direction. Inspector: Good Hygienic Practices FAIL Critical ❑J RED David Greenbaum Comment:Employees drinks observed in the kitchen and food prep areas. Employees must eat and drink in the dining room to Date Inspected: Correct By: r-- prevent cross contamination. 9/1$/2006 Handwash Faciliti FAIL Critical d❑ RED Risk Level:' menta The soap dispenser at the fron hand wash sink is not working. Repair the soap dispenser to good working order. Permit Number: BHP-2006-0243 Status: VIOLATION #of Critical Violations: 4 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practiced(Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 18,2006 ) Page I oft I.r Item Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Food Protection FAIL Critical BLUE Foodborrie Illness Interventions /� and Risk Factors(Require' �/Comment:There is paper goods and food stored directly on the basement floor. Store all food and paper products at least 6.8 inches off the floor. immediate corrective action) " matow stored on the mop sink. Store all ready to eat foods in an appropriate storage area do prevent cross contamination. Equipment and ensils FAIL Non-Critical BLUE menta The True freezer in back has an accumulation of food spills and splatter. Thoroughly clean this unit inside and out. t� The Hoba ven needs a thorough cleaning. Th rue refrigerator in front needs a thorough cleaning. T True unit needs a thoroughcleaning. he am�e t needs a visible,accurate thermometer. �Th�ldaire freezer in the basement needs a visible,accurate thermometer. freezer in the basement needs a visible,accurate thermometer. LThe front display case has an accumulation of food debris. Thoroughly clean the display case. Physical Facility FAIL BLUE Com nt:The floors and walls have food spills and splatter. Thoroughly clean all floors and walls. GENE L COMMENTS: 829:Reinspection will be in one week. All violations to be corrected. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 18,2006 ) Page 2 oft 08/19/06 10:12 FAX 6177377851 FIRST TRADE BANK X001 — ------ CAFE JEFFERSON 293 Jefferson Avenue Salem,MA 01970 1-978.744-2486 Fm To: 9oard of Heafth Frorm CAFE JEFFERSQN Inspeclion Dino Papagiannis George Papagfannis Fax. 1-978-745-0343 Date: June.19,2006 Phone: Pages:... 3.. Re: CC. - 0 Urgent 0 For.Re/7lew 0 Please Comment ❑Please Reply 13 Please Recycle -Comments: Here is the executed contract for the pest control service. Thank you. 06/19/06 10:12 FAR 6177377051 FIRST TRADE BANK p� • — ,06 10:86 7815927641 Al EXTERMINATORS _ FA[�E'_',Dd[jst?< . ! ®yam r of1183 a Headquarters 2 Main Cad 1 a9 Shepard Street. 72 aleln Sveet Lynn,MA 61982 :lune 7 (181)64122731 W:Harwich,MA 02671 A-1 i Exterminators 800-525-482S (506-432-5M Fax(781)692.7841 800.499.6866 www.ai exterminatorscam Commercial, Industrial Fest Control Service Agreement aiIz^toy j Dasa: ContomarW _1 ..AA� Tele `F'x- Addrece — elQr•,f�reo ,�I c _ CRY 51ata _ IM I+ - i=,s Code sotvice information and location Customer-- Address ustomer —Address GAr Sraee zill Cede M DIa tocaliens(sae attldhmam) C ftrob Tfds agroament is far VTontrot of m4 follow rill-pasoL 'DoesIRea t include C t •?- (>'}data t XMke 4. )•.Otnar Pharoah Ants. "Does not Include Ta�lfnllas,Wood Owing 1hwrJ&or.Fi �! ylhg.InseCis.unlass sperJflcelly rnentlened. Area:The( rf mledar ( )av aror araas of the bullding(s)to be SoMced include the following: special lnstn,CTiona: 6ervke 8ehedub:A-1 Ezlemirurtgn will Droutda �"" Inionsfva Sarvfos and will also pmNdo Rataa+r per!aanbot aetvtoeS (.ry txmonih ( 2x month ( } Extaddr Roden!Control: It )t ix monrt tl+ if -2x gnth ( ).waakiy' Exterior Insect Control: lx month 2x mondr ( )weekly. . Paymenc In consideration of sia.temice prowtled by Aa 6xm0ninatars,.tho ewfonv r ap�00110 pay A-1 Exh urninatora,its successor or as. slgns the wmh of S for each inlarwlva sorvloa and for each regWu 8enrice. .. Payment Terra:( COD ( )�harga.P9ymenl due upon receiptpf.inwloe. 4 Total Arrival Payment A/wrlaws ton _1. .. �,;,_,%diaetwmS .. '` I S IGS ilii eiNt iateraim'iti.lce. ,�fTttt?�c•/'.. --------• .,..-.-.. „� . .. 1 S--" far each regular rstvice. /K"o•� �s1fh'•.. �� l,; I+.r L! S-2—for each exterior rodent cervica. S ' for pelt (seder Inge"cute)wrvlce .Cuseamer obligation:The cusich oragraea wpliq emit ira{ywilh A 1 Extearanators,Whenerar eonG6ans canduGvs to the brecNrrg �ssfbaary asgupO io corre d by thin M UW'"hapartod M writrng by A-1 Extermmalars ro the cuseu me.ma.cusiomef x01t.lata.the. post Deouge:The customer atpaes Sao k-l.6darmi mtare 19 net ne3100119ID14 for any bU$4* "*rvpeash or dameea caused by insects and/or rodents,on,or to ft customers protobes or as contents,and the customer specifically releatees C-I Exa minafora from liability for any ouch Jahns. . Additional No Cost 6CreICe:A•t Exterminates sganpromptly prrx4de'atldlUaltal sarvicabaavaan reguiaty-Scheduled vlshegs.h ls- d48"ll necossary by A-1 ExferrNtutsors. Sehlwa: 3efvicelotmml eM/at epptkadan Of paeCciOex torths etnbWel-amsabuvo manaoned peals. Aa aervtcea xhan ba I rmad M aceoidence with Federal and Sells requirements,end EPA and USDA Standards. Metetlere: AN matStWS tssd.la/x+11t0 pasta Sftaa nowtet la Fadeel,:Sls19 unit local laws and reg"o ns. A-1 Exterminators reserve the fightree to • hat cusmmpremiums ets prems and.nerve any chemieets lndu,tirtg.rodan,am... b+sact halts upon termination of:fill"arrant. Equipment and Produeu:.,�ha customer trgrea610 All Extermihblms.lor eery equipment irlxlsaed ar placed on the Customers propety necsasahy Mr ma d8na<M or the abase mw/8rmed pasta. Insumnat:Upon request,A4 8xlunrinsk wla hxrtaftm thaauslamsr a oaN6cela of IffourancattMwlret coverago In efloct. Terms of COnmact•. •This Contract&hell be 9UitcW8 for an od8inetpedod of one year.Thoroaaai,ads Contract shall renew INrtlf from month to month unit fenranseed by alerer party Won#*I$Geye.Written n*JQ$-.Rate.au01e0.M Periodic tavisw and;nCreasa by A•I existminawrs after Initial 12 month period. •Tha cV m further agreaa�additionally pay tar any ceepdnarear beat 6ic'is ordered or hasu ut an per GtMlwmer'3 plEmisee tie dstor rhed M be not oasay as q-1 Exramdnatara,p0,gel.cw=t of-Me Ob0va.rtmMionadptsts-Sieh Ifmn1 may InCI1We,but not be a,dtod to me tellovMti:aaa g6AxAs.Glue Tfaps,Muldpla Ketch Traps,fly spray,9%. 1 A•1 E cormi Araoptad , Dale I•' a� sy atm.-_.. ey +�1i! �a a , �affiLetc RxY Mmq., -. axe Tao �,_rs:y7311.�4•'. ' .:wseway.cipj' vY s.gt�q. PaewornlPYnh 8Y' I � ..i ueT"• ' 1 l IMPORTANT MESSAGE FOR DATE `7�[.2— TIME M OF PHONE AREA CODE nGNUMBER�/ EXTENSION O FAX ((rr'_ ❑ MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE k-)0 7LL--0147 7 re4 elbr 1021 rhqp' If �h v SIGNS FORM 404 MARE IN U.S.A. NOTES ~` IMPGRTANT MESSAGE FOR DaI7// 'i"q DATE _r / TIME / M Co OF PHONE / 7 a�� AREA CUUE UMBER E " SION ❑ FAX ❑ MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE '' C3 7 SIGNED WropiFORM 09 MADE I .S.A. NOTES I IMPORTANT MESSAGE FOR �AL2 DATE t)`1 S I TIME ILLL .M. M OF PHONE AREA CODE NUMBER EXTENSION U FAX U MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED ,': PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH ' RETURNEE)YOUR CALL WILL FAX TO YOU MESSAGE YI 5 - SIGNED Ra 4009 a MA E IN U.S.A. NOTES ___ _ i; i! 1 � � , i � � � � � � � � 1 1 � �.-----= . � � 1 1 � , � : � � i, � , 1 1 � , � � � �, 1 1 � i � � '. � , � � � � � �, 1 � � � � ; � � . 0 1 � � � i , 1 ,, 1 � 1 , � 1 � i � � i , . 1 �� 1 1 . � , , � � � 1 _ � , � r Massachusetts Department of kPubl" ealth Salem Board of Health p k.. 120 Washington Street,4'" Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Dae ( Type of Operation(s) Type of Inspection I iFood Service EJRoutine Address % js N-Retail ® Re-inspection Level ❑ Residential Kitchen Previous I spection Telephone ❑ Mobile Date: C 1a log, Owner tP HACCP YM ❑ Temporary ❑ Pre-operation ❑ Caterer ❑ Suspect Illness Person in Chaige L 1 Time ❑ Bed& Breakfast ❑ General Complaint In: / ❑ HACCP Inspector ` Out. Permit No. ❑Other Each violation chec ed 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 Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. ;FOOD PROTECTION MANAGEMENT, � �.`�-"r ,k»� �t _. t El 12. Prevention of Contamination from Hands F11. PIC Assigned/Knowledgeable/Duties ❑ 13 Handwash Facilities "EMPLOYEE HEALTH :-7,�`�'a ` `5 �g PROTECTION FROMCHEMICALs ❑ 2. Reporting of Diseases by Food Employee and PIC r - � _ r " __ •� lle _ •_ ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals ^FOODFROMAPPROVEDSOUACE>�` v= .,,„m.,; . ❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) #� f+}^ [1 5.5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements [117. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION i - ❑ 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 SUS$EPTIBLE POPULATIONS(HSP),- ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices 1,,'CONSUMERADVISORY: �, ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected $ To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (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 ' N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(sso.00a) 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-4)(590:005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 7. Physical Facility (FC-6)(590.007)' have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (Fc-7)(590.008) 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: S:590In5 IFO/ 14.E a2 Inspector's Signature: \ Print: PIC's Signature: Print: Y Page+of2Pages l n _ / y Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 590.003(A) Assignment of Responsibility* 3-302.1.1(A)0) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* - Cooked and RTE Foods* 2-1.03.11. Person in charge-duties Contamination from Raw ingredients - 3-302.11(A)(2) Raw Anumd Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* applicants* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.1 l Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Fo cs 3 590.0030 Exclusions and Restrictions* Disposition of Adulterated or Contaminated - 590.003(E) Removal of Exclusions and Restrictions Food - 3-701.1.1 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 t 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 Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Tem eratures* 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. 'K 5-101.1.1 Donkin Water from an Approved System* 4-601.1 I(A) Equipment Food Contact Surfaces and 590.006(A) Bottled DrinkingWater* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.04' 4-602.11 Cleaning Frequency of Equipment Food- Shetflisfr and Fish From an Approved Source - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and 3-20114 Fish and Recreationally Caught Molluscan Foci Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201-15 Molluscan Shellfish from NSSP Listed Chemical* Sources* Game and Wild Mushrooms Approved by 10 Proper,Adequate Handwashing Regulatory Authority 2-301.11. Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present* 2-301.1.2 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.1.7 Game Animals* 1.1 Good Hygienic Practices 5 Receiving/Condition 2-401.11 Eating,Drinkm or Using Tobacco* - 3-202.11 PHFs Received at Proper Temperatures* 2-401.1.2 Discharges From the Eyes, Nose and 3-202.15 Packa e hite it * Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 reventing Contamination When Tasting" 6 Tags/Records:Shellstock 1.2 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employees* Tags/Records:Fish Products 13 Handwash Facilities 3-40211 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(7) Labeling of Ingredients' 5-204.11 Location and Placement* q Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Pians - Suppled with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.1 •ge .2 Reduced ox n acka 'ng.criteria* 6-301.11 HandwashipE Cleanser,Availability 8-103.12 Conformance with A roved Procedures* 6-301.12 Hand Dr hg Provision Denotes critical item in the federal 1999 Pail Cale ur 105 CMR 590.000. - i CITY OF SALEM `# BOARD OF HEALTH l Establishment Name: C� o �,.. Date: Pager of 9 F Item Code C-Critical nem -DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date :y No. Reference R—Red Item p;=.�•�: Verified EASE PRINT CLEARLY Ski—c- a'a le I' 1-I QC, l / Ilk ` ;qq I � LF Li 1.1 +l s �s a s ,i p l s Discussion With Person in Charge: Corrective Action Required: ❑ No Yes b ntary Compliance ❑ Employee Restriction/ 'f I have read this report, have had the opportunity to ask questions and agree to correct all [au 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 ollars r sus cation of ❑ Embargo �'I ❑ Emergency Closure your food permit. I F ❑ Voluntary,Disposal � El Other: '# 3-501.14(C) PHFs Received it'relinicratures Violations Related to Foodborne Illness Interventions and Risk Accordiro,to Law Cooled to Factors(items 1-22) (Cont.) 41'F/45`F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501,15 Cooling=Meonxis for PHFS 1=4 _Food or—Color Additives Ftq - PHF Hot and Cold Holding 3202.12 Additives* 3-501.16(b) Cold PHFs Maintained at or below 590.004(1`) 410145' FA 1-302.14 Protection froul Unapproved Triic Substances Additives* L�-L Poisonous or Tox3-501,16(A) Not PHFs Maintained at or above 7-101..11 Identifying Inforawflon-Orianial — 14WF � 1- Roasts Heid atorabove Contmite S" 3-501 16(A) 7-102,11 Conarnon Narnt Workin.-Containers, 2=0 --Tare as a Public Health Control 7-201.11 Separation-StoraEel, 3-507.19 Time as a Public fitarah Control* 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Recituretrent 7-202.,12 Conditions of t so- 7-20111 Toxic Containers-ProbibiLrOTIS" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sannizers,Criteria-Chemicals* POPULATIONS(HSP) �-80 I�I I(A) Unpasteurized Pre-palckaged Juices and -T20-1 12 Chemicals to, WashmL Produce.Criteria''' 21 7204 11 A2cw.Criteria' Beverages with ,,a.mtng labels* E'_4�"` � 3 Use 2 Incidental Food Contact, Lubricants,* 3-80 Ll I(B) of Pasteurized f�?ga _1 I I Restricted Use Pesticides.Criteria* 3-801 11(D) Raw or Partially Cooked Animal Food and 7 Raw Sccd S roues Not Served. 2O6 1'j"2 Rodent Bait Stations" 3-80L 11 7__()6 3 Tracking Powders,Pest Control and - -(C) CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal lWids That are Raw. Undercooked sn PHFs Not Otherwise Processedto Eliminate 3401.11 A(l)(2) Eggs- 155°F 15 Sec. Path�_Igcm "aco�f r our __]2-102 13 PaSts!Urifed F9gF Substitute for Raw Shell 3-401.11.(A)(2) Comminuted Fish, Meats&Game — Eggs* Animals- 155'1` 15 see. * 3-401.1 413)(1)(2) Pork and Beef Roast- 130'F 121 mil.. SPECIAL REQUIREMENTS 3-401.11(A)f2) Rattles, ejected Meats-155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in h sec, catering, mobile food, temporary and 3-401.1 I(A)(3) Poultry, Wild Game, Stuffed PHFs, residential kitchen operations should be Sniffing Containing,Fish, Meat, debited under the appropriate sections It tr r or Ratites-165`F 15 sec. above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beet Steaks interventions and risk factors. Other 1451117* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under 7629- Microwave 165'F* Special Requirements. 3-401,11(AI(l)(h) All Other PHFs- 145'F 15 sec. 17 Reheating for Hot Holding -VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(I)) PHFs 165'1`15 sec, (items 23-30) 3-403.11(B) Microwave- 165' F 2 Minute Standing Critical and non-ci itical violations, which do not relate to the — Time" foodborne illness haerrenl'Ons and risk joctors listed above can be 3-403.11(C) Commercially Processed RTE Food- found at the following sections of the Food Code and 105 C.9R 140"Ft 590.000 ------- 3-40111(E) Remaining Unsliced Portions of Beef Item Good Retail Practices I FC 580.000 Roasts* r2-3--M—anaqem—entan-d-P-e--r-s--o-i-mei-- FC-2 .003 Proper Cooling of PHFs 24, Food and Food Protection FC�-3 091_ — 25. __E�l Utensils FO-4 005 3-501..1.4(11) Cooling Cooked PHFs from 140'F to 26 Water PlumbLing and Waste F-C T 70'F Within 2 Hours and From 70"F 2PhKical Facility, _TC_-6 -1--.067 to 41"F/45'F Within 4 Hours. ' 28. Poisonous or Toxic.Materials __ FC-7 1 .008 3-501.14(13) Cooling PHFs Made FroniAmbient— - .009 ------------- Temperature Ingredients to 41'F/45'F 30, Other Within 4 Hours,t a-'-du, Denotes critical item in the 12deral 1999 Food Codoor 105 CNIR 590 000, Massachusetts DepartmSalem Board of Health ent of Public Health 1h Division of Food and Drugs Sal m, MA 01970-352 4 Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Dat Tvne of Ionia, T e of Inspection l �) S Food Service Routine Address Risk ❑ Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone 4�-:? ❑ Mobile Date: 4/13(,<-- Owner ❑ Temporary ❑ Pre-operation `,2 1.;' HACCP YM ❑ Caterer ❑Suspect Illness Person in C arger IC) Time ❑ Bed&Breakfast ❑ General Complaint `e to Ina- �� ❑ HACCP Inspector Oui8H, Permit No. ❑ 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 Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT„" W;,� €,�a,�„gGnl ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties El 13. Handwash Facilities EMPLOYEE HEALTH r ;�' 'i"A v yPRDTECTIQN FROM CHEMICALS y o j", ❑�2.Reporting of Diseases by Food Employee and PIC j_.'t - - tae =AM4, ';=�r .u�� _ ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15 Toxic Chemicals w ;_ a . .FOOD FROM and Water SOURCE FUTIMErrEMPERATURE CONTROLS Pptenhall H. ardoua Fids ❑ 4. Food and Water from ApprovedSource ( , y � ) , ❑ 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 -`- '. """`�"" "'�"' El 19. Hot and Cold Holding F - _rat_ :_.:;a .,tea,..-„ ',� .�s�.,�.,n.•d,�A E38.Sepaion/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing - I''REoUIREMENTS FORHIGHLY SUSCEPTIBLE POPULATIONS(HSP)".,y ❑21. Food and Food Preparation for HSP El 10. Proper Adequate Handwashing �- �, ;,---' R,`GONSU,MER,ADVISORY.'" w El 11. Good Hygienic Practices = ❑22. Posting of Consumer Advisories 4 Violations Related to Good Retail Practices ( Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board. and Risk Factors(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" by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(sso.00a) _x 25. Equipment and Utensils (Fc-a)(sso.00s) 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-9)(990.009) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007)' have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(59o.00a) 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: S:590Mn OFar 14.0 ^ �n •e 1( p"7 1 Inspector's Signature: Print: I I PIC's Signature: Print: � ) Page of Pages V � ' ,7 Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Crass-contamination I 596.003(A) I Assignment of Responsibility* 3-302.11(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* 2-103.11 Person in charge-duties Contamination from Raw ingredients 3-302.1.1(A)(2) Raw Animal foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.1](A) Food Protection* a 3lieants* _ 3-30215 Washing Fruits and Vecetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003((]) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Re-strictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources F 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 Tem eratures* - 3-20113 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashind Hot Water Sanitization Tem eratures* 3-202.13 Shell Eggs* Y, 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.11.4 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. * 5-101.1.1 Drinking Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0" 4-602.11 Cleaning Frequency of Equipment Food- Contact Surfaces and Utensils* Shellfish and Fish Froman Approved Source 4-702.11. Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* t0 Proper.Adequate Handwashing Regulatory Authority Game and uMushrooms Approved by 2-301.11 Clean Condition-Hands and Arms" 3-202.18 Shellstock Identification Present* 2-301.1.2 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* Il Good Hygienic Practices g Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Pro r Temperatures* 2-401.12 Discharges From the Eyes,Nose and - 3-202.15 Packa e Inte it * Mouth* 3-101.11. Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained` Employees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible I - 3-402.12 Records,Creation and Retention" 5-203.11 Numbers and Capacifies* 590.004(7) Labeling of Ingredients' 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility.Operation and Maintenance /HACCP Pians Supplied with Soap and Hand Drying Devices 3-502.11 S duce ox gen pack Methods* 6-301.11 Handwashin Cleanser, Availability 3-502.12 Reduced oxygen tacka 'nom,criteria* - 6-301.12 Hand Drying Provision 8-103.12 Conformance with App roved Procedures* Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. - CITY OF SALEM BOARD OF HEALTH Establishment Name:�Lc '2?7 ei��i' Date: C, 6 Pager of Item Code C-Critical Rem v DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified. PLEASE PRINT CLEARLY r}t. 0411 �-✓i Gn Cr F I r } S f o � 1 A�CIS ( J pi-P2fi -4-v'ZJilor io 1 D ).4CA i d AIA JArlo I :1 r X ) Vol I. n 3 Discussion With Person in Charge: Corrective Action Required: ❑ No es have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ t violations before the next inspection, to observe all conditions as described, and to Exclusion � p e-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 our food permit. �U ` t ❑ Voluntary Disposal ❑ Other: Y p r� �� '. 'CGnn ,5 F . Violations Related to Foodborne Illness Interventions 14(C) PHFs Received at Temperatures ions end Risk According to Law Cooled to Factors(items 1-22) (Cont.) 41°F145`F Within 4 Homs. PROTECTION FROM_CHEMICALS3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding t x "--- 3-501.168) Cold PtIFs Maintained at or below 3-302.12 Addmscs - 590.004(F) 41 V45"F" 3-302.14 Protea ouion from xic Substances Addltives'w 3-501,16(A) Hot PRFs Maintained at or above 15 Poisonous or Toxic Substances 140'F. * 7-101.11 Cojgtiners Intonn2nuan-Original 3-501.16(A) Roasts Held at or above 130'F. Containers`_ 7-102.11. Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Se aration-Storal 3-50I A9 Time as a Public Health Contnroi* 7-202.11 Restriction-Presence and Use'r 590.004(Ii) hxriance Re uirement 7-202.12 Conditions of Use* 7-203.11 Paxic Containers-Prahihi ons* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11. Samuccts,Chi cria-Chemicals," POPULATIONS(HSP) 7-204.12 Guquicals for W ashine Produce Criteria" 2fl 3-&01.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Dr mg A>?ents,Criteria' B averages with W ar ninq Labels^ 7-205.11 incidental Food Contact.Lubricants* 3-801.11(B) Use of Pasteurized l ses* 7-206.11 Restricted Use Pesticides.Criteria* 3-801.11(D) Raw or Partially Cooked Animal Faxl and Raw Seed Sprouts Not Served. 7-206.12 Rodent Bait Stations* 3-h01.11(C) UnoenedFoodPacka=eNotRe-served, "` 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 3-"3.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw. Undercooked w' 1S Proper Cooking Temperatures for Not Otherwise Processed to Eliminate PHFs 3-401.11A(1)(2) fs- 155't I5Sec. I'athoaens.`Errece�e,n"'M Eves-Immediate Service 145'Fl5sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.1 I(A)(2) Comminuted Fish,Meats&Game figs* Animals- 155°F 15 sec.'s 3-401.1 l(B)(1)(2) Pork and Beef Roast -130'P 121 renin* SPECIAL REQUIREMENTS 3-401,11(A)(2) Ratites, Injected Meats-155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 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 3-4011I(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 Cooked in a practices should be debited under#29- Micmwave 165'F* Special Requirements. 140 1,111 All OtherPHFs-- 145'F15see, I7 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&Q7) PHFs 165'F 15 sec. t` (Items 23-30) 3-403.11(B) Microwave-165'17 2 Minute Standing Critical and non-critical viobvion,s, which do nor relate io the Tints* foodborne tllness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTF Ford- ,found in the following sec tions of the Food Code and 105 CNIR 1.40°F* 590.00(f 3-40111(E) Remaining Unsliced Portions of Beef Item I Good Retail Practices FC 599.p00 � -- Roasts* 23. Management and Personnel FC_2 .00& Ig Proper Cooling of PRFs 24. Food and Food Protection _ - FC---3 .004 25 __Equipment and Utensils FC 4 .005 _ ___ r) Cooling Cooked PHFs from 140'F to 26 W ater`Plombinq and Waste FC_5 006_ 70'1-Within 2 Hours and From 70'F 27. Ph slcal_Facili FC-6 .007 to 41.°17/457 Within 4 Houts'. * 28. Poisonous or Toxic Materials FC-7 .Cos 3-50114(B) Cooling PHFs Made Front Ambient 29. S ectal Re ulremants _ .009 - - Temperature Ingredients to 41'F/45'F _30. __ Within 4 Hours" "Denotes critical item in f he.Wood 1999 Ford Code or 105 CMR 590.000. r CITY OF SALEM BOARD OF HEALTH } Establishment Name: Date: G Page:_ of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date t No. Reference R—Red Item Verified PLEASE PRINT CLEARLY o ., G ti Ice w e\ a 4.-,c ` , i6e L f t 4 r t p4 is .' a C. 4 •g Discussion With Person in Charge: corrective Action Required: ❑ No 2s`LYes r i I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to -111 Exclusion + P y( Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that r \ noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. C :fix, ceUre (an V')t1 > 0 Voluntary Disposal 0 Other: 3-501 14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness interventions and Risk According to Law Cooled to Factors fltems 1-22) (Cont.) 41`F/45'F Rahin 4 Howl. * PROTECTION FROM CHEMICALS 3507.15 Coaling Methods for PHFs 14 Food or Color Additives 14 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or belava 3-302.14 Protection from Unaf�proved AddiCives* 590.004(F) 41°/45° F' 4-501.I6(A) ,HrC PHFs Maintained at or above 15 Poisonous or Toxic Substances 240'F. 7-101..1 J I ontine Intonnation-Original 3-501.16(A) Roasts Held at or above 130°F. Containers'" 7-102.11 Common N2ame-Working Containers* Time as a Public Health Control 7-201.17 Se.aration-Stora e" 3-50719 Time as a Public Health Control* 7-20211 Restriction-Presence and IJse'6 590.004(H) Variance Requirement 7-202.12 Conditions of Use* - 7-20111 Toxic Containers-Prohibitions*' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals" POPULATIONS(HSP) 7-204.12 Chemicals for Washing Rndnce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with W'arnin>I.abek- 7-204.14 Dr �in A eats,C riteria* -- -- - 7-205.11 Incidental Food Contact,Lubricants** 3-801.11(B} Use of Pasteuli7ed Eggs' 7-206.7 1. Restricted Use Pesticides, Criteria* 3-801,11(D) Raw or Partially Cooked Animal Food and 7-206.72 1 Rodcor Bait Station", Raw Seed S trouts Not Served. * 7-206.13 "frackinb Powders,Pest Control and ?-801.17(C) Una.erred Food Peckage Not Re-served. Monitorinl"' CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Auroral F-xxts'1'hat are Raw.Undercooked or 15 Proper Conking Temperatures for PHFsNot Otherwise Processed to Eliminate 3-401.11A(7)(2) Eggs- wis 7.55F1SSec. Pathogens.'E's"ob tr'.zam E gs-Imunedt ate Service 145°Fl5sec* 3-302.13 1Pasteurized Eggs Substitute for Raw Shell 3-101.11(A)(2) Comminuted Fish, Meats&Game Animals- 155`F 15 sec. * 3-401.11(B)(1.)(2) Pork and Beef Roast- 130`F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites, Injected Meats-155°F 1.5 590,009(A)-(D) Violations of Section 590.009(A)413)in sec. * catering, mobile foil, temporary and 3-401.11(A)(3) Poultry, Wild Game,Stuffed PI-IFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Rafrtes-165°F 15 sec.;- above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and tisk factors. Other 1450F* 590.009 violations relating to good retail 3-407.12 Raw Animal Foods Cooked in a practices should be debited under/129- Microwave 165°F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs-- 145°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.II(A)&(D) PHFs 165°P 15 sks. * (items 23-30) 3-403.11(B) Microwave- 165°F 2 Minute Standing Critical and non-critical violatioxs, which do nor relate to the Time` ,foodborne illness onernenoons and riskfaetars listed above, con be 3-403.11(C) Commercially,Processed R'rE Food- Inand in the-following sections of the Food Cade real 165 CMR 140°F* 590.600, 3-401 11(E) Remain ng Unsficed Portions of Beef Item Good Retail Practices FC 590.000 Roosts* 23. Mona ement and Personnel FC-2 .003 Ig Proper Cooling of PHFs 24. Food and Food Prosection _-_.. FC-3 1 .004 25 _ E ui ment and Utensils _FC 4 _I .005 3-50L14(A) Cooling Cooked PRFs from 140°F to 26 Water, Plumbin and Waste FC-5 006- 70°F Within 2,Hours and From 70°F 27. Ph sisal Facifi FC-6 � .007 -ry-- to 4L'F145°F Within 4 Hours. " 28. Poisonous or Toxle Materials FC-7 I .008 3-501.14(B) Cooling PHFs Made Front Ambient 29_ Special Re ulrements _ _ .009 Temperature Ingredients to 41cF/45°F 30 _ -4fher L Within d Hours* ""Denotes critical stern in tier todend 1999 Food Code or 105 CNIR 590.000. 0293 JEFFERSON AVENUE Cafe Jefferson City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Telephone: � Item Status Violation Critical Urgency Nature of problem or correction x(617) 347-2439 - *' '" Non-compliance with: Done Owner:- a Anti-Choking PASS ❑ George &'DinoPapagiannis:= Tobacco PASS ❑ PIC. George PapaglaMla .- FOOD PROTECTION MANAGEMENT Done Inspector: - PIC Assigned/Knowledgeable/Duties PASS ❑J RED =David Greenbaum - -5 EMPLOYEE HEALTH Done Date Inspected: Correct By.- Reporting of Diseases by Food Employee and PIC PASS ❑J RED 9/13/2005 Personnel with Infections Restricted/Excluded PASS ❑d RED Risk Level: �- � =r• ^? FOOD FROM APPROVED SOURCE Done I Permit Number:. _,-r" Food and Water from Approved Source PASS ❑d RED BHP-2005-0503 Receiving/Condition PASSd❑ RED Status: Tags/Records/Accuracy of Ingredient Statements PASS ❑ RED SIGNED OFF Conformance with Approved Procedures/HACCP PASSd❑ RED #of Critical Violations Plans } PROTECTION FROM CONTAMINATION Done Time IN: Time OUT: - Separation/Segregation/Protection PASS ❑Q RED Notes: " Food Contact Surfaces Cleaning and Sanitizing PASS RED 286. Proper Adequate Handwashing PASS ❑d RED Urgency Description(s): Good Hygienic Practices PASS ❑/ RED BLUE: - I & Prevention of Contamination from Hands PASS RED Violations Related to Good, y Retail Practices (Critical Handwash Facilities PASS ❑d RED violations must be corrected immediately or within 10 days)(Non-critical violations GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 14,2005 ) Page / of 0293 JEFFERSON AVENUE Cafe Jefferson must be corrected immediately°- PROTECTION FROM CHEMICALS Done or within 90 days) Approved Food or Color Additives PASS 91 RED RED: Violations Related to Toxic Chemicals PASS ❑o RED Foodborne Illness Interventions TIME/TEMPERATURE CONTROLS(Potentially Haz Done and Risk Factors (Requite_ a Cooking Temperatures PASS RED immediate corrective action) Reheating PASS ❑J RED Cooling PASS RED Hot and Cold Holding PASS 0 RED Time As a Public Health Control PASSd❑ RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Done Food and Food Preparation for HSP PASS Q RED CONSUMER ADVISORY Done Posting of Consumer Advisories PASS 0 RED Violations Related to Good Retail Practices (Blue Done Management and Personnel PASS ❑ BLUE Food and Food Protection PASS ❑ BLUE Equipment and Utensils PASS ❑ BLUE Water, Plumbing and Waste PASS ❑ BLUE Physical Facility PASS ❑ BLUE Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other-See Notes PASS ❑ BLUE Provide a barrier at the front handwash sink near the coffee station. In accordance with the Federal Food Code and the State Sanitary Code this establishment has met all requirements to operate a food establishment. GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 14,2005 ) Page 2 of 0293 JEFFERSON AVENUE Cafe Jefferson GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 14,2005 ) Page 3 of J Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street,4th Floor dyt� SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2006 WHO'S PLACE OF BUSINESS IS: Cafe Jefferson File Number:BHF-2005-0043 293 Jefferson Avenue SALEM MA 01970 LOCATED AT: 0293 JEFFERSON AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2006-0243 Jan 3,2006 Dec 31,2006 $100.00 ESTABLISHMENT Total Fees: $100.00 PERMIT EXPIRES December 31, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page t of 10 ✓ CITY OF SALEM, MASSACHUSETTS n BOARD HEALTH S c g p J +� 120 WASHINGTON STREET, 4TH FLOOR R �O SALEM, MA 01970 dIl/Itlu' TEL. 978-741-1800 DEC 282005 STANLEY J. USOVICZ, JR. FAx 978-745-0343 MAYOR WWW.SALEM.COM SALEM CITY OF JOANNE SCOTT, MPH, RS, CHO BOARD F HEALTH AGENT HEALTH 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Ca f e �p f /��[�f�n 3n c . �TIEL# ::! — 9V Y- 0 ADDRESS OF ESTABLISHMENT Z 3 Te-TT e yo ✓2 MAILING ADDRESS (if different) OWNER'S NAME ADDRESS A,a-Q" a�' C' CITY a ¢ w STATE M - ZIP 0'2-V 9 z CERTIFIED FOOD MANAGER'S NAME(S) Pa � .a tw `/ CERTIFICATE#(s) n Q -�e BVe. S-A C eg- T C (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON 0"° I (^P(c±1 k4,1� HOME TEL# HOURS OF OPERATION: Mon""Tue.L '?Pa Wed.L-3e±2 Thu. n Fri. -3 n, Sat. Sun. -3e^, TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 - ............................... ............................................................ .........--------.._-----------------....- RESTAURANT E NO �1 / less than 25 seats 100 25-99 seats =$150 v �Y more than 99 seats =$200 - ---------- --------- ------N-----O --------------- ------........-----------.......------------------------------------$00-6—-------- --- BED/BREAKFAST YES -----------------------------------------------------------------------------------------------------*----------------------- ADDITIONAL PERMITS tnp_Kr_ (slot ju-t sen/e) ICE CREAM, YOGURT, SOFT SERVE YES (� $5 TOBACCO VENDOR YES $50 ALL NON-PROFIT(such as church kitchens) YES N $25 'Please pay total with one check payable to the City of Salem . This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filedII state tax returns and paid all state taxes required under the law. 8 3 OL131 9 )3 Signature Date Social Security or Federal Identification Number --- --------------------------------------------------------------------------------------------------------------------------------- Revised 11/03/05 FOODAP2.adm Check#&Date a X00 - L CITY OF SALEM, MASSACHUSETTS $ BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT Facsimile Transmittal To: C4&o,rge i -Doti /G�a yi �dn �i5 Fax # 619- '739- '285-/ RE: 160 &' Lo Date : ,9- 17- o57 Page(s): including this cover# Message: f / rro �Ci✓l,e LlO�I �1dv✓ �Q�ipi'/CQ dGC�-G✓d�✓�9 �/�i5 ✓P�Gv�- �leC[S[ Siyvi Y� /a-�f Po /}mid �Bfl jl IJaPt �.� ,v+Ll ✓P[� vrd > Board of Health News ----------------------------------------------------------------For Your Information Office Hours: Effective September 12, 2003 Monday, Tuesday, Wednesday 8:00 AM to 4:00 PM Thursday 8:00 AM to 7:00 PM Friday 8:00 AM to 12:00 NOON Do Salem Residents Know ? - The Board of Health meetings are held the second Tuesday of the Month. 4 Y CITY OF SALEM BOARD OF HEALTH Name of Establishment: Salem Caf6 Address: 293 Jefferson Avenue Owner(s): George & Dino Papagiannis Phone: 617-728-7303 Fax: 617-737-7851 The owners of this establishment presented a Floor Plan and Menu for review in accordance with the State Food Code. This establishment will be open for breakfast and lunch. FLOOR PLAN A Hand Sink must be located in each food prep and service area. Therefore there must be a hand sink in both the front and rear prep areas. Hand sinks must have wall hung soap and paper towel dispensers. These must be stocked at all times. Hand sinks must be used for hand washing only. All floors, walls, and ceilings where food, utensils, paper products, etc, are stored, prepared or served must be intact, impervious, and easily cleanable. MENU/FOOD PREP Any pre-made items must be purchased from a wholesaler licensed by the State. Fruits and vegetables must be washed prior to preparation. This may be done in the 3`d bay of the 3-bay sink. This bay must be sanitized before and after washing. All food must be held at 41°F or lower, or 140°F or higher, at all times. Therefore, soup should be brought to boiling before being held hot. Salad display items, such as tuna fish, must be cold prior to being held cold in the salad unit. Food may not be added to containers in salad unit. Instead, a sanitized container with new product may replace the existing container and the old product may be placed on top of the new product. There may be no bare hand contact of ready-to-eat foods. Gloves, tongs, or tissues must be used when handling such food. l CERTIFICATION There must be a Certified Food Manager working at this establishment full time. Information regarding upcoming classes was given to the owners. Both will become certified. When a CFM is not onsite there must be a Person-in-Charge (PIC) who is fully trained in sanitation techniques and has a thorough understanding of the operation. UNDERCOOKED FOODS If you plan to sell undercooked eggs or meat, you must place a notice on your menu warning of the increased possibility of food borne illness. Please call this office, if undercooked foods will be served, to receive more information. EXTERMINATION Monthly services of a Licensed Pest Control Operator are required. Please keep receipts for inspections. SANITIZING SOLUTION Sanitizing Solution must be accessible at each prep station and for the patrons' tables. Test strips corresponding to the kind of sanitizer, must be on hand to check concentration of solution. Solution must be made daily, tested, and the results recorded on a log sheet for examination by Board of Health inspectors. Solution may be prepared in the 3`d bay of the 3-bay sink and spray bottles may be filled there. Spray bottles with clean paper towels may be used, as well as wiping pails with wiping clothes always held in the solution in the pail. Please check with the Building Department regarding the two foot passage at the end of the refrigerator display case. 978-745-9595 x 386 Please contact the Licensing Board to determine if a Common Victualler's License is required because you have seating. Outside area of premises, including the dumpster area, must be kept clean and sanitary. Please call one week prior to opening to schedule an opening inspection. ACc4��( Janne Scott Date Health Agent Owner(s) Date HP Fax Series 900 Fax History Report for Plain Paper Fax/Copier Joanne Scott Salem BOH 978 745 0343 Feb 17 2005 2:02pm Last Fax Date Time Twe Identification Duration Paees Rpidt Feb 17 2:01pm Sent 916177377851 1:00 4 OK Result: OK - black and white fax February 10,2004 PRELIMINARY MENU 293 Jefferson Avenue, Salem, MA George & Dino Papagiannis- Business Owners Mornin¢/All Day Muffins Bagels Croissants Pastries (Danish, Scones) Fruit Cups Yogurts Breakfast sandwiches (on a toasted bagel with egg & cheese, & Canadian bacon) Lunchtime Soups Salads Sandwiches (Turkey, Roast Beef, Ham, Tuna, Chicken Salad) Panini Grilled Sandwiches Bagged Chips, etc. Eeveraees Coffee Tea Espresso 1p Cappachino Hot Chocolate Sodas—bottles, cans (NOT fountain) Iced Coffee Juices- bottled 730•'7 rug( 37- -78sy1 ' - 37 O O U 1 �2 � ` y O ,V O V L ❑❑ 3 O^ m 16 O� I I \N1 O EQUIPMENT LIST mO ELECTRICALPLUMBING K� DESCRIPTION AMP VOLTS BTUS INLE REMARKS 1 MOP SINK 2 3 BAY SINK W/DRAINSOARD 3 HOT PLATE 18,8 208 HARD WIRE 4 CONVECTION OVEN 40 208 3/4" HARD WIRE $ 515 TABLE ] SALAD UNIT 7 115 $ 1 WORK TOP FREEZER 6 115 NEMA 5-15P 9 2 PANINI GRILL 2/15 115 NEMA 5.15P 1D TOASTER 14 115 NEMA 5-15P 11 12 13 COFFEE MACHINE 20 _20B 14 (WORK TOP REFRIG 12 15 NEMA 5-15P 15 REFRIG.OISPLAY CASE 12 116 HARDWIRE 18 JDAY DISPLAY CASE 116 HARD WIRE 17 HAND SINK 18 SLICER 5 115 19 20 O S 21 pq /o " 22 23 24 25 DRAWN BY KARPOUZIS&SONS COMMERCIAL REFRIGERATION PROJECT SCALE 293 JEFERSON AVE. 1!4"=A' SALEM MA DATE _ APPROVED BY Z0 3Jtid UNI bU� BTTVZL8809 8Z :9T 500Z/ZT/T0 I CITY OF SALEM BOARD OF HEALTH s Establishment Name: CAre JEFFC-ksON Date: S• 3/ oS Page: f of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION bate No. Reference R—Red Item Verified 'PLEASE PRINT CLEARLY CP ✓ 7 no a a n vw P s is �Sa/� isl nv,L ✓� P S Pct n f ye D PO i n `-moi .6Cz 0 L1 S1 Jab Pd WG A ' " ,f 4 ,„ '' le 4ev o,Ielhal o ratr) Jahe1 mo s _7K ' " o/i ly t Se e n-t ac h iii e. - -kh e_ se 1" 054 be- Ae44 W1441,, M&C k iw a,- in o ala,. s d . O ✓ ✓ S 4- V S /e Ursa -1 w r lj24 �f f ~.5 `lave- 4PW.1a o! ( °r ar owP" — rP�Lev n-t�sl l�avc. v/st � ltQ. �isr� ict-o vj a-vl n huf ewes ae i / d a ✓eu i r 0.14 cti �4 b'L-s de o 4- a--P co 10se4 We " a2L ( IP SL C'Q l one U S rt" -/v 6 (`- Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to'C rrect all C3Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P Ll Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. _.__--- �� ❑ Voluntary Disposal ❑ Other: 3-541.14(C) , PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to law Cooled to Factors(Items 1-22) (Cont.) 41'F/=44 Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Coolinn Methods for PHFe 14 u Food or Calor Additives 19 PHF Hot and Cold Holding ------ 3-202.12 Additives" 3-501.16(B) Cold KIN Mainuoned at or below 3-302.14 ProtecimIn from Unapproved proved Additives590.t}04" (L� 41°145° F" l t- IS Poisonous or Toxic Substances - 3-501,16(A) Hot P1IFs Maintained at or above 140°F. * 7-101.11 ldeContainers* lnforma6on-Original 3-501.1.6(A) Roasts Held at or above 130'F. Conhainers* 7-102.11 Common Name- Working*Containers* Time as a Public Health Cartrol 1-201.11 Separation-Sksaee* 3-501.19 TimeasaPub(9cHealthControl* 590.004(H} 7-202.11 Restriction-Presence mid Use'k variance Ruirement 7-20212 Conditions of Use` 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sazntrzets,Crites n Chemicals" POPULATIONS(HSP) 7-204.12 Chemicals for W tshing Product. Criteria* 21 3-801.11(A) Unpasteurized Pxc packaged Juices and 7 iteria* Beverages with Warning Labels* 204.14 Dr tit A eats.Cr 7-205-11 Incidental Food Contact.Lubricants* 3-801 I l(B) Use 01 Pasteurized F s* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides.Criteria* Raw Seed Sprouts Not Served. 'x 7-206.12 Rodent Bait Stations* 7-306.13 ;-801.11(C) Unopened Fmxi Package Not Re-served 'frac-kmg Powders,Pest Control and Monitoring* . CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of IS Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.1.IA(1)(2) Fggs 155'F '15 Sec. Pathogens- ""6 aaooi Eggs-Immediate Service 145°1715sec* 3-302.13 Pasteurized Fggs Substitufe for Raw Shelf 3-401.11(A)(2) Comminuted Fish,Meati<&Game Egg,,* Animals- 155'F 15 sec * 3-401.1l(B)(1)(2) Pork.and Beef Roast - 130°F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats- 155'F 15 590.009(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, residentialkitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Pouler or Ratites-165'F IS sec.* above it related to foodborne illness 3-401.11(C)(3) Whole-nmscie,Intact Beef Steaks interventions and tisk factors. Other 145'F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under 1129- Mlcrowave 165T* Special Requirements, 3-401.11(A)(1)(b) All Other PHFs-1.45'F'15 sec. I1 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)<&(D) PHFs 1650F 15 sec. "` (Itetrns 23-30) 3-403.11(B) Micanwave-165'F 2;Minute Standing Critical and non-critical violations, irohich do not relate to the Time* foodborne il0ies.s interventions and risk factors listed above,, can be 3-403.11(C:) Commercially,Processed RTE Food- ,found in the following seceions of the Food Cade and 105 CVR 140'14* _590.0(10 3-403.1.1(E) Remaining Unslieed Portions of Beef Item Good Retail Practices ( FC 0-0.150-0-_ Roasts* 23. Management and Personnel FC -2 .003 1g Proper Cooling of PHFs 24. Food and Food Protection FC-3 .004 25 Equi2ment and Utensils FC 4 f_.005 3-501.14(A) Coniine Conked PHFs f om 140'It to 26 Water, Plumbing and Waste FC-5 .006 70°F Within 2 Hours arid From 70°F 2'7. Physical Facility FC-6 ; .007 to 41.'F/45°'.F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) CoolinguPFlFs Ingredients om dlient 29, Temper30 __.._Oiheral ......---------- Within 4I-Iours'x Denotes Unocal item in tic rMeral 1999 Find Cade or 105 CNIR 590.000- 4 xy CITY OF SALEM9jMASSACHUSETTSV- "'y� A' - BOARD OF HEALTH 120 WASHINGTON STREET 4TH FLOOR g - SALEM, MA 01970 .- TEL. 978-741-1800 - FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: FOOD SERVICE ' Name of Establishment: Cafe Jefferson Address of Establishment: 293 Jefferson Avenue Owner's Name: George & Dino Papagiannis Restrictions: Application Date: 9/8/05 Permit for Food Establishment 321-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the SaleB a d of Healt . HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT CC,fC 5e-9�e r son TEL# 6/ ADDRESS OF ESTABLISHMENT A 1 3 JTe P�?rSon /dye . MAILING ADDRESS (if different) 2� P �5��6. Ry& /7 61 � .3y? /� /� nv a �tann� gEL# (17 - 67FV -0/Y9 OWNER'S NAME Lj2ol��e �G(Jc.yi"pnn;st ( � (k`- ADDRESS P� M6PCAu) 6-),r r CITY L)c--er+uwN STATE AAA zip C6Z-(9 CERTIFIED FOOD MANAGER'S NAME(S) <1 na CERTIFICATE#(s) gi1-�tct�60"l I v: 7 c e r-E (required in an establishment where potentially hazarrclous food is prepared.) 9i78 7.Q&y Coq EMERGENCY RESPONSE PERSON h?Ve CA ins HOME TEL#7�( X33"o)0 u HOURS OF OPERATION: Mon`—' Tue.-)-3 Wed(-"3 Thu.(,-3 Fri.6-3 Sat.( -�- Sunk-3 TYPE OF ESTABLISHMENT\ FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 D�� n more than 10,000sq.ft. =$250 RESTAURANT YE NO v✓ less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my besto ee and e fi d all state Qturns and paid all state taxes required under the law. SignatuW` Dae Social Security or Federal Identification Number ------------------------------------------------------------- -- ------ --------- Revised 11/03/03 FOODAP2.adm Check#8 Date / 7// /OD r