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COURT DOCKET NO. CITATION NO.
CITY SALEM PD64 6 3
VIOLATION NOTICE
NAME(LAST,FIRST,INITIAL) ,
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STREETADDRESS CITYTrOWN STATE ZIP
lit a>~.SSca� S` �ae..ti5c.. crt�, a•.a���
LICENSE NO. LIC.EXP.DATE DATE OF BIRTH
OWNER'S NAME(LAST,FIRST,INITIAL)
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STREETADDRESS CITY/TOWN STATE ZIP
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REGISTRATION NO. STATE EXP.DATE MAKErYPE YEAR COLOR
I
DATE OF VIOLATION TIME DATE CITATION WRITTEN PERSONAL
AM n INJURY
L]YES
L � S'r• f ti'�3❑PMy �)) 1 i... ❑NO
LOCATION OF VIOLATION ENFORCING DEPT
1 ��
OFFENSE
T CHAP. SECT. FINES
A % 1 t-Z-�G�l�
B
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OFFICER I.D.NO. TOTAFINEL $ C�
DUE
OFFICER CERTIFIES COPY GIVEN TO VIOLATOR
7C IN HAND
X /// 4 �/UUttl � ❑ BY MAIL
DQ NOT_MAII.CASH—PAYONI_V_R.Y_PnSTAI_NnTF_h" Ui y
OI Do not mail cash-Pay only by postal note,money
Order or by check made payable to:
City Clerk-Mail to: Board of Health 120
Washington Street Salem,MA 01970-3523
I HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON
REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE
PAYMENT IN THE AMO NT OF
$ t) CAS
SIGNATURE-
SEE OTHER SIDE FOR FURTHER INFORMATION
ENCLOSE PAYMENT INTHIS ENVELOPE,PEEL AND SEAL
VIOLATION NOTICE Place
T'f)OFFENUER: -_ .. - Stamp
YOU FIAVI7 THE FOLLOWING ALTERNATIVES WITH REGARD TO Here
DISPOSITION OF THE M A TTER:_(1 You may elect to r either a Post Office
pay, y appearing in will not deliver
person at the board of health Mon Wed Sam-4pm,Thurs.gam—7pm,or Fri.gain without Stamp
—noon,legal holidays excepted,before:THE BOARD OF HEALTH—SALEM
CITY HALL ANNEX,or by mailings check or money order to the Hoard of Health
WITHIN TWENTY-ONE(21)DAYS OF THE DATE OFTHIS NOTICE.This
will operate as a final disposition of the matter,with no resulting criminal record.(2)
If you desire to contest this matter in a non-criminal proceeding,you may do so by
making a written request within 21 days to the Board of Health Cor a hearing.After ,
21 days you no longer have a right of appeal"the hearing will operate as a final
disposition of the matter,with no resulting criminal record,provided any fine _
imposed by the Hearings Officer is paid within the time specified.(3)If you Fail to
pay the imposed fine or to appear as specified a criminal complaint will be issued City of Salem
against you. Board of Health
120 Washington Street 4th floor
Salem, MA 01970
f
i
F[NA�ME
URT DOCKET NO. CITATION NO.
CITY OF SALEM PD 6 4 6 3
VIOLATION NOTICE
(LAST,FIRST QOINITIAL)
pwr 3 1fAEET ADDRESS CITV/TOWN $TATE ZIP
L �.Sci-�NSE NO. LIC.EXP.DATE DATE OF BIRTH
ER'S NAME(LAST,FIRSTINITIAL)STFETADDIIS Sr � 1 vCITY/TOWN
S STAT
E ZIP
1 11, t S( S SAL rnCA dl�
REGISTRATIONNO. STATE EXP GATE MAKE/TYPE YEAR COLOR
DyATE OF VIOLATION yTIIM�ES' DAI E CItTATION WRITTEN FERS6NAL
L -1�.1�L.. iF'9❑PM..... tet� I L iruua�YES
No
LOCATION OF VIOLATION ENFORCING DEPT
n,Lsr r €ec
OFFENSE CHAP. )S)ECT. FINES
A �", ���,Z,IO l- -'lay's'`, O'cq.. YS'2L 4 lf�
B
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OFFICER l.D.NO. TOTAL `Q�
FINE
OUE
OFFICER CERTIFIES COPY GIVEN TO VIOLATOR
IN HAND
X ❑ BY MAIL
DO NOT MAIL CASH-PA NLY BY POSTAL NOTE,MONEY
ORDER OR BY CHECK MADE PAYABLE TO:
CITY CLERK "
CITY HALL
93 WASHINGTON STREET
SALEM,MA G197D
TEL.(508)745.9595 X 251
1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON
REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE
PAYMENT IN THE AMOUNT OF
$ .— CASE#—_„__
SIGNATURE
SEE OTHER SIDE FOR FURTHER INFORMATION
ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL
/ ..-
1
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- � ����
COURT DOCKET NO. CITATION NO.
QCITY
O SALEM PD6 4 C 3
VIOLATION NOTICE U
NAME(LAST,FIRST,INITIAL)
CAFES v41-%'wqr*- Co t'� �HS�"fiA3
STREET ADDRESS CITY/TOWN STATE ZIP
1% essialuk 5' sows L M. x a�A�1v
LICENSE NO. LIC.EXP.DATE DATE OF BIRTH
OWNER'S NAME(LAST,FIRST,INITIAL)
YAL` Rv� ev")d N4k-Sots
STREETADDRESS CITY/TOWN STATE ZIP
1tib Li:SSz-- 5v v% d\5�
REGISTRATION NO. STATE EXP,DATE MAKIDTYPE YEAR COLOR
DATE OF VIOLATION TIM DATE CITATION WRITTEN veawly^�
f / /1 IWIIFY
L ��� IZ 2 ElPM 6�1�i12 ❑YES
❑NO
LOCATION OF VIOLATIONENF RQ CINO DEPT.
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OFFENSE CHAP. SECT.I FINES
A E�t�'�fL)atL Wean. a4t� '$ b-
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C
�. OFFICER LD.NO. TOTAL@ Ca
FINE $2,r,-
DUE
OFFICER CERTI IES COPY GIVEN TO VIOLATOR
IN HAND
X ❑ BY MAIL
DO NOT MAIL CASH-PA NLY BY POSTAL NOTE,MONEY
ORDER OR BY CHECK MADE PAYABLE TO:
CITY CLERK
CITY HALL
93 WASHINGTON STREET
SALEM,MA 01970
TEL.(508)765-9595 X 251
1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON
REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE
PAYMENT IN THE AMOUNT OF
$ CASE#
SIGNATURE
SEE OTHER SIDE FOR FURTHER INFORMATION
ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,0 Floor
Division of Food and Drugs Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT. Tel. (978) 741-1800 Fax(978) 745-0343
Name Date Tvoe of Ooeration(s) Tyoe of Inspection
❑ Food Service ❑ Routine
Address Risk ❑ Retail ❑ Re-inspection
Level ❑ Residential Kitchen Previous Inspection
Telephone ❑ Mobile Date:
Owner HACCP Y/N ❑ Temporary ❑ Pre-operation
❑ Caterer ❑ Suspect Illness
Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint
In, ❑ HACCP
Inspector 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... „ ❑ 12. Prevention of Contamination from Hands
1 PIC Assigned/Knowledgeable/Duties
[113. Handwash Facilities
EM_PLOYEEHEALTH pROTECTIONFROMCHEMICALS "'
El 2. Reporting of Diseases by Food Employee and PIC
El 14.Approved Food or Color Additives
El3. Personnel with Infections Restricted/Excluded
_ [:] 15.Toxic Chemicals
"FOOD FROM APPROVED SOURCE
-- TIME(TEMPERATURE CONTROLS Potentlall H
❑ 4 Food and Water from Approved Source ( y azardoue Footle)
❑ 5. Receiving/Condition [116.Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling
PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding
❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PLAT-OPUIONS_(N p
(]21. Food and Food Preparation for HSP
❑ 10. Proper Adequate Handwashing
❑ 11.Good Hygienic Practices [CONSUMER-AD WYA j.
❑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 x by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2) order of the Board of Health. Failure to correct violations
24. Food and Food Protection (Fc-3)(590.0so.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)(511.108) 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 ssoinyrer�a�a-ia.eoc
Inspector's Signature: Print:
PIC's Signature: Print: Page_of Pages
Violations Related to Foodborne Illness
Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION_
8 Cross-contamination
_ FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) ' Raw Animal Foods Separated from
1 590.003(A) Assignment of Res ionsibilit
Cooked and RTE Fads*
590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients
2-103:11. Person in charge-duties 3302.1 I(A)(2) Raw Animal Foods Separated from Each
Other*
EMPLOYEE HEALTH Contamination from the Environment
2 590.003(C) Responsibility of the person in charge to 3-302.11(.0} Food Protection*
require reporting by food employees and 3.302,15 ..WashingFruits and Vegetables
applicants* 3-304.11 Food Contact with Equipment and
590.003(F) Responsibility Of A Food Employee Or An *
Applicant To Report To The Person In Utensils
Contamination from the Consumer.
Charge*
590.003 G RepEting by Person in Charge*
3-306.14(A)(, ) Returned Food and Reservice of Food*
3 590.003(D) Exclusions and Restrictions* DisposPoon of Adulterated or Coniaminated
Food
590.003{F.) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Food*
4 - Food and Water From Regulated Sources 19 Food Contact Surfaces -
590.004(A-B) Compliance with Food Law* 4-501..111. Mutual Warewashing-Hot Water '
3-201.12 Food in a Hermetically Scaled Container* - Sanifization Temperatures*?
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hat 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.
4-60 1 A I(A) Equipment Food Contact'Surfaces,and
5-101.11 Drinkin Water from an Approved S tem* Utensils Clean* '
590.006(.0) BotWater Meet St Water 4-602.1.1 Cleaning Frequency ofEquipment Food
590.006(B) Water Meets Standards in 310 CMR 22.0* g q y
Shellfish and Fish From an Approved Source
.Contact Surfaces mid Utensils*
4702.11 Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan - _ Food Contact Surfaces of'E iii merit*
Shellfish* 4-703.11 Methods of Sanitiza_tipn-Hot Water and
3-201.15 Molluscan Shellfish from NSSP Listed Chemical*
Sources* 10 Proper,Adequate Handwashing -
Game and Wild Mushrooms Approved by 2-301.1.1 Clean Condition-Hands and Arms*
Re Malo AuthorR
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Proc dure*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201.17 Game Animals* 11 Good Hygienic Practices
5 Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco*
3=202.11, PHFs Received at Proper Tem eratures* 2-401.12 Discharges From the Eyes,Nose and
3-202.15 Package Integrity* Mouth*
3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting*
6 - Togs/Records:Shelistock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* - 590.004(E) Preventing Contamination from
3-203.12 Shellstoek Identification Mamtahud* Em to ees* - -
Tags/Records:'Fish Products 13 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(.1) 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 Methods* Devices
3-502.12 Reduced oxygen packaging,criteria* .6-301.11 Handwashm .Clcanser,.Availabilit
8-103.12 Conformance with Approved Procedures*
- 6-301.12 Hand Drying Provision
'
Denotes critical item in the federal 1999 Fool Code or 105 CMR 590.000. - -
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,0 Floor
Division of Food and Drugs Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343
Name Date Tvpe of Operation(s) Type of Inspection
❑ Food Service ❑ Routine
Address Risk ❑ Retail ❑ Re-inspection
Level [I Residential Kitchen Previous Inspection
Telephone ❑ Mobile Date:
Owner HACCP Y/N ❑ Temporary ❑ Pre-operation
❑ Caterer ❑Suspect Illness
Person in Charge(PIC) Time ❑ Bed&Breakfast ❑General Complaint
In: ❑ HACCP
Inspector 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.
FOODPROTECTION MANAGEMEN7= :.,, ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
El[EMPLOYEE HEALTH13. Handwash Facilities
---- - -- "� - .�w. s. PROTECTION FROM CHEMICALS
El2. Reporting of Diseases by Food Employee and PIC -
❑ 14.Approved Food or Color Additives
❑ 3 Personnel with Infections Restricted/Excluded
T_
, _� ❑ 15.Toxic Chemicals
LFOOD_FROM.APPROVED SOURCE,_
TIME/TEMPERATURE CONTROLS Potemlall Hazerdoua Foods
❑ 4 Food and Water from Approved Source (� _ Y .____
❑ 5. Receiving/Condition [:116.Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling
.a.�- C .__ 19. Hot and Cold Holding
P( ROTECTION ION-TFROM CONTAMINATION_ � ❑ 9
❑ 8.Separation/Segregation/Protection ❑20.Time As a Public Health Control
El9. Food Contact Surfaces Cleaning and Sanitizing - REQUIREMENTS FOR.HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
El21. Food and Food Preparation for HSP
El 10. Proper Adequate Handwashing
❑ 11. Good Hygienic Practices CONSUMER ADVISORYm_ ^ _�
❑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 x 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 suspe.sion 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:
559JIrupecffomi&IG.Coc , ..
Inspector's Signature: Print:
PIC's Signature: Print: Page_of_Pages
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT 8 Crass-contamination
1 590.003(A) Assignment of Res msibilit * - 3-302.1](A)(1) Raw Animal Foods Separated from
590.003(B) Demonstration of Kt owled e* Conked and RTE maxis*
Contamination from Raw ingredients
2-103.11 Person in charge-dut es 3-302.11(A)(2) Raw Animal Foals Separated from Each
Other*
EMPLOYEE HEALTH Contamination from the Environment
2 590.003(0) Responsibility of the person in charge to 3-302.11(A Food Protection*
require reporting by food employees and 3-302.1.5 WashingFruits and Vegetables
- applicants,* 3-30411 Food Contact with Equipment and
590.003(1') Responsibility Of A Food Employee Or An i.
Utensds*
Applicant To Report To The Person In Contamination from the Consumer
Charge" 3-306.14(A)(B) Returned Food and Reservice of Food*
590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated
3 590.003(D) Exclusions and Restrictions* Food
590.003(E) Removal of Exclusions and Restr c ions 3-101.11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Fad*
4 Food and Water From Regulated Sources F 9 Food Contact Surfaces -
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashmg-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-Slot Water
3-202.13 Shell Eggs* Sanitization Teat eratureO -
3-202.14 Eggs and Milk Products.Pasteurized* 4-501.11.4 Chemical Sanitization-temp.,pli,
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
Utensils Clean*
590.00(i(A) BotWater Meet St Water* 4-602.11 Cleanin Frequency of Equipment Food-
590.006(B) Water h Meets Standards in 3 10Approved
CMR 22ce Contact Surfaces and Utensils'r
Food-
Shellfish and Frsh From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of ui ment*
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 Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Aims*
Re ulato Author'
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* 11 Good Hygienic Practices
5 Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco*
3-20211PHFs Received at Proper Temperatures* 2-301.12 Discharges.From the Eyes,Nose and
3-202.1.5 Package Integrity* Mouth* - - -
3-101.11 Food Safe and Unadulterated* 3-30tA2 Preventing Contamination When Tasting*
6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* F590 004(E) Preventing Contamination from
3-203.12 Shellstock Identification Maintained* Employees* -
Tags/Records: Fish Products - 13 Handwash Facilities
3-302.11 Parasite Destruction*
Conveniently Located and Accessible
3-402.12 Records.Creation and Retention*
5-203.11 Numbers and Ca acities*
590.004(1) 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 Methods* Devices
3-502.12 - Reduced oxygen packaging,criteria* 6-301.11 Handwashin Cleanser,Availability
8-103.12 Conformance with Approved Procedures* 6`301-12 Hand-Drying Provision
*Denotes critical item in the federal 1999 food Code or 105 CMR 590.000.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: Date: Page: of
nem Code C-Cr@Ical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R-Red Rem Verified
PLEASE PRINT CLEARLY
Discussion With Person in Charge: Corrective Action Required: ❑ .Ni ❑ 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 Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
0 Voluntary Disposal 0 Other:
3-501.14(C) PHN Received at Temperatures
Violations Related to Foodborne Illness.Interventions and Risk: According to Law Cooled to
Factors(gems 1-22) (Cont.) 41'F/45°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* 3-501.16(B) Cold PHFs Maintained at or below
' 590,004(F) 410/450 F*
3-302.14' Protection from Unapproved Additives" -
15 Poisonous or Toxic Substances 3-501.16(A) Ha PHFs Maintained at or above
140
7-101,11 Identifying Information-Original .
3-501.16(.0) Roasts Held at or above 130°F.
Containers*
7-102.11. Common Name-Working Containers* Time as a Public Health Control
20
7-201.11 Separation-Stora t' 3-501.19 Time as a Public Health Control*
7-202.11 ,Restriction-Presenceand Use* 590,004H) Variance Requirement
7-202.12 Conditions of Use*
7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS HSP
7-204.12 Chemicals for WashingProduce,Criteria* 21 3-801.11(.0) Unpasteurized Pre-packaged Juices and
7-204.14 Drying Agents.Criteria* Beverages with Warning Labels*
7-205.11 Incidental Food Contact,Lubricants* 3-801.11(B) Use of Pasteurized Eggs*
7-206.11 Restricted Use Pesticides;Criteria* 3-801.11(D) Raw or Partially Cooked Animal Foal and
7-206.12 Rodent Bait Stations* Raw Seed Sprouts Not Served
3-801.11
7-206.13 Tracking Powders,Pest Control and C} Unopened Food Pack Not Re-served.
Monitorin * CONSUMER ADVISORY
TIMEITEMPERATURE CONTROLS 22 3-601'I I Consumer Advisory Posted for Consumption of
16 Proper Cooking Temperatures for - Animal Foods That are Raw.Undercooked or
PHFs Not Otherwise Processed to Eliminate
3-40L11A{1}(2) Eggs- I55°F 15 Sec.
pathogens.*E�D'.lo�t
Eggs-immediate Service 145'Fl5sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
3401.11(A)(2) Commiumed Fish.Meats&Game Eggs*
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 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 Fists,Meat, debited strider 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.
3-401.11(A)(1)(b) All Other PHFs-145'F 15 sec.
17 Retreating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3.403AI(A}&(D) PHFs 165°F 15 sec.* (Ifelms 23-30)
3-403.11(B) Microwave 165°F 2 Minute Standing Critical,and non-critical violations,which do not relate to the -
Time* - foodborne illness interventions and riskfactors listed above, can he
3-403A I(C) Commercially Processed RTE Food- found in the following sections of the Food Cade and 105 CMR
140°F* 590.000.
3-403.11(E) Remaining Unsticed Portions of Beefs Nem Good Retail Practices .FC 1 590.000
Rhe, 23. Management and Personnel FC-2 .003
18 Proper Cooling of PRFs - 24. Fool and Food Protection FC-3 _004
3-501.14(A) Coolie Cooked PHFs from 140°F to 25. Equipment and Utensils FC-4 .005
Cooling 26. Water.Plumbing and Waste FC-5 .008
70°F Within 2 Hours and From 70'F 27. P ical Facia 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 .003
Temperature Ingredients to 41°F/45°F Other _
Within 4 Hours*
°Denotes critical Item in the federal 1999 Food Code or 105 CMR MONO.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: Date: Page: of
Item Code C-Criticai item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Data-
No. Reference R-Red Rom Yenned
PLEASE PRINT CLEARLY
i
Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ .Yes
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
comply with all mandates of the Mass/Federal Food Code. I understand that ❑ Re-inspection Scheduled ❑ Emergency Suspension
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo u Emergency Closure
your food permit.
❑ Voluntary Disposal ❑ Other:
3-501.14(C) PHFs Received at Temperatures
Violations Related to Foodborne illness,interventions and Risk According to law Cooled to
Factors(Items 1.22) (Cont.) 41'F/45'F Within 4 Hours.
PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs
14 Food or Color Additives 19 PHF Hot and Cold"ding
3202.12 Additives*-
3-50L16(B) Cold PHFs Maintained at or below
_ 590.004(F) 41°145°F*
3-302.14 Protection from Unapproved Additives"
15140'F. *
Poisonous or Toxic Substances 3-501.16(A) Hot PRFs Maintained at or above
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
7-201,11 Separation-Storage* 3-501.19 Time as a Public Health Control*
7-202.11 .Restriction-Presenceand Use* 590.004(H) Variance Re uirement
7-202.12 Conditions of tise* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP
7-204.11 Sanitizers.Criteria-Chemicals*
7-204.12 Chemicals for Washin Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and
Beverages with Warning Labels*
7-204.14 Food
Criteria* 3-801.11(8) Use of Pasteurized E gs*
7-205.11 Incidental
Foa
ental Fl C tutee Lubricants* 3-80L I I(D) Raw or Partially Cooked Animal Food and
7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served *
7-206.12 Rodent Bait Stations* - 3-801.11 C) Unopened Food Package Not Re-seryed.
7-206.13 Tracking Powders,Pest Control and
Monitoring* CONSUMER ADVISORY
TIMEMEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
16 Proper Cooidng Temperatures for Ani mal Foods That are Raw,Undercooked or
PHFs Not Otherwise Processed to Eliminate
3 40LI lA(I)(2) Eggs- 155 'F 15 Sec. Patbo ns.*
Eggs-Immediate Service 145'F15sec* 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell
3d01.11(A)(2) Comminuted Fish.Meats&Game
E
Animals-155'F 15 sec. * -
3-401.11(13)(1)(2) Pork and Beef Roast- 1.30'F 121 min* SPECIAL REQUIREMENTS
3401.11(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 ilhtess
3.401.11(0)(3) Whole-muscle,intact Beef Steaks interventions and risk factors. Other
145OF* 590.009 violations relating to good retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165'F* Special Requirements. -
3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETA L PRACTICES
3-403,11(A)&(D) PHFs 165°F 15 sec. * (Items 23-30)
3-403.11(B) Microwave- 165°F 2 Minute Standing Critical,and non-critical violations,which do not relate to the
Time* foodborne illness interventions and risk factors listed above, can be
3-003A I(C) Commercially Processed RTE Food- found in the following sections-of the Food Cade and 105 CMR
1400F* 590.000,
3403.11(H) Remaining Unsliced Portions of Beef r Hem I Good Retail Practices I FC 590.0w
Roasts* 23. ' Management and Personnel FG-2 .003
18 Proper Cooling of PHFs 24. j Food and Food Protection FC-3 .004 I
25. Equipment and Utensils FC_-4 .005 J
3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Water.Plumbing and Waste i FC-5 .006
70'F Within 2 Hours and From 70'F 27. -Physical Facility FC-6 .007
to 4t°F/45'F)i ithin 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008
3-501.14(B) Cooling PHFs Made From Ambient 29. -Special Requirements
Temperature Ingredients to 41°F/45'F 30. Other
Within 4 Hairs* s:setr,;.,mser-.za
*Denotes critical item in the federal 1999 Food Code at 105 CMR 590.OW.
Commonwealth of Massachusetts
•'f` s e City of Salem
Board of Health Kimberley Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 12/29/2011
ESTABLISHMENT NAME: Cafe Valverde Coffee Roasters
File Number:BHF-2010-000009 196 Essex Street
SALEM MA 01970
LOCATED AT:
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
FOOD SERVICE BHP-2012-0209 Jan 1;2012 Dec 31,2012 $140.00
ESTABLISHMENT
Total Fees: . $140.00
PERMIT EXPIRES IDecember 31, 2012
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted
in a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,
all plans for.such must be submitted to and approved by the Salem Board of Health. page 1
CITY OF SALEM, MASSACHUSETTS
• r BOARD OF HEALTH
- 120 WASHINGTON STREET,4"'FLOCIR
TEL. (978) 741-1800
KIN43GRL.EY DRISCOLL FAX(978) 745-0343
MAYOR lramdint salcm.com
LARRY RANIDIN,RS/RHI IS,CI10,CP-FS
H 5ArriI A(il''.N'I'
201Q2APPLICATIIIION FOR PERMIT TO OPE/RATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT 04 OW0214 G'f dee /Z4S,kto ZIC TEL# �7a6J -7 I —I/PId
ADDRESS OF ESTABLISHMENT �l6 rS�ex 721[r?�- FAX# 363 /d,)�
MAILING ADDRESS(if different)
EMAIL- Business': 4WALCc�rdQ " I Website:
OWNER'S NAME pvu /�J ody l�/�Df��(a2 / TEL#�7��,
ADDRESS � l /D/ - �P o��2i G� 12t�, (Ll�— p/�c�
STREET CITY STATE ZIP
CERTIFIED FOOD MANAGER'S NAME(S)_TIZ12L CERTIFICATE#(S) (' 6 6JL-L
(Required in an establishment where potentially hazardous foodis repared) / G
EMERGENCY RESPONSE PERSON ��Gla l �/()�G7 e HOME TEL#
DAYS OF'OPERATION Monda Tuesda „Wednesda a Thursd Frida :=: Saturda Sunday
HOURS OF OPERATION j !
Please write in time of day. J° OU 1 / d) vU Ab n)(For example l lam-11 pm -7 ( v
i
_TYPE OF ESTABLISHMENT FEE check onl _
RETAIL STORE YES NO less than 1000sq.ft. =$ 70
1000-10,000sq.ft. =$280
more than 1 0,000sq.ft. =$420
----------------------------------------- -----------------------------------
- ES Tio n WE ni – – ,n
�... - iraa'G451`7'cSoeat•.'S"`"^h
(Outd "r Stationary Food Cart$210 25-99 seats =$280 ;
1 more than 99 seats =$420
------------------
BED/BREAKFAST/ -----------------YNO- ---------------------------------------------------------------- $100
--
CHILDCARE SERVICES/NURSING HOM---------------------------_----------------_-
------------------ - ------------------- ------- --------- --
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YESO $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.
Pursuopt,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
return a aid all statet es required F,der the law.
�J � �/i a -7/ass eV a-
SSiguhture Date Social Security or Federal Identification Number
---------------- —- ------ ------ -- _ -------------
Updated 5/23/11 FOODAP201 Laden Check#&Date
Massachusetts Department of Public Health Salem Board of Health
-120 Washington Street,0 Floor
Division of Food and Drugs Salem, MA 01970-352
FOOD.ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343
Name Date T e of Operation(s) Ne of Inspection
l Food ServiceRoutine
Address Risk Retail Ke-inspect on
Level ❑ Residential Kitchen Previous Inspection
TelephoneCME 161 ,3 ❑ Mobile Date:
OwnerC3Temporary ElPre-operation
EQ 0� d U HACCP Y/N ❑ Caterer ❑ Suspect Illness
Person in Charge(PIC) Time ❑ Bed&Breakfast ❑General Complaint
Inspector ln:a O" Permit No. ❑ HACCP
Out: ❑Other
Each violation checked requires an� lanabon 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) Nr 590.009(F)
action as determined by the Board of Health. R ^. /
--- - - - FI f Pel
FOOD PROTECTION MANAGEMENT- __ , ❑ 12. Prevention of Contamination from Han
❑ 1. PIC Assigned'/Knowledgeable/Duties
❑ 13. Handwash Facilities
EMPLOYEE HEALTH
PROTECTION FROM CHEMICALS '. *' _ _
❑ 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 Water
SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardoua FoodB
❑ 4 Food and Water from Approved Source � ( Y -_� )"
❑ 5.. Receiving/Condition ❑ 16.Cooking Temperatures
❑ 6._Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans [118.Cooling
PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding
❑ 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control
- �.
04 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR
I_HGHLY SUSCEPTIBLE POPULATIONS_(HSP).
El21. Food and Food Preparation for HSP
10. Proper Adequate Handwashing
❑ 11.Good Hygienic Practices [CONSUMER Y_ - r •
❑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
C7 r x by a Board of Health member or its agent constitutes an
23. Management and Personnel (Fc-2)(59..009) order of the Board of Health. Failure to correct violations
24. Food and Food Protection (Fc-9)(seo.00a) cited in this report may result in suspension or revocation of
I -vf 7 25. Equipment and Utensils (FC4)(590.005) the food establishment permit and cessation of food
I"U 26. Water, Plumbing and Waste (Fc-5)(590.006) establishment operations. If aggrieved by this order, you
U 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.
f, 30. Other„� DATE OF RE-INSPECTION:
S:S9J�nspacfFamb-ia.doc V� 11, ' V4�II
r Ill\
Inspector's Signature: Print: C
0
PIC'sSignature: Print \&VAfk a El
Page-1 of�ges
kv e- 6 O 4 ?, din44vs �oc� av,a i.vn R c�
e. �vs-r (N , twit F� u�S --°SSS e�fi _
c.
Violations Related to Foodborne Illness
interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION
8 Cross-contamination
FOOD PROTECTION MANAGEMENT
1 590.003(A) Asia mentofRes onsibilit * 3-302.1](A)(1) Raw Animal Foods Separated from
Cooked and RTE Foods*
590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients
2-103.11. - Person in charge-duties 3-302.1.1(A)(2) Raw Animal Foods Separated from Each
Other*
EMPLOYEE HEALTH Contamination from the Environment
2 590.003(C) Responsibility of the person in charge to 33U2.11(A) Food Protection*
require reporting by food employees and 3302.15 WashingFruits and Vegetables
applicants* - 3-304.1.1. FoodContactwith Equipment and
590.003(F) Responsibility Of A Foal Employee Or An
Utensils*
Applicant To Report To The Person In Contamination from the Consumer
Chau e*
590.003 G) Reporting b Person in Charge* 3-306.14(A)(B) Returned Food and Re Food*
Disposition of Adulterated
or Contaminated
or ontniaminefed
31 590.003(D) Exclusions and Restrictions* Food
590.003(E) Removal of Exclusions and Restri'etioas 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..1.11 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.)3 Shell Eggs* Sanitization Temperatures*
3-202,14
em eratures*3-202.14 Eggs and Milk Products,Pasteurized* 4-1501.114 Chemical.Sanitization-temp.,pH;
concentration and hardness.*
5-1U1.1 DrinkingWater from an Approved System*3-202.16 Ice Made From Potable Appro Water* 4-60 1 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 Focal Contact Surfaces of Equipment*
qp
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 Wild Mushrooms Approved by
Re MatoAuthorR 2301..1.1 - 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* it Good Hygienic Practices
3 Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco*
3-202.11 PHFs Received at Proper Temperatures* 2401.12 Discharges.From the Eyes,Nose and
3-202.15 Package Inte itv* mouth*
3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting*
6 Togs/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* Em 10 ees*
Tags/Records:Fish Products 13 Handwash Facilities
3-402.11 Parasite Destruction*
Conveniently Located and Accessible
.
5-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities*
Location and Placement*
'
590.004(1) Labeling of Ingredients*
7 Conformance with Approved Procedures 5-205.11 Accessibility,,0 eration and Maintenance
IHACCP Plans Supplied with Soap and Hand Drying
3-502.11 Specialized Processing Methods* Devices
3-502.1.2 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser, Availability
8-103.12 Conformance with Approved Procedures*
6-30112 Hand Drying Provision
Denotes critical item in the federal 1999 Foci Cade or 10 CMR 590.000.
I
I I
f ' I i +Ir/ / • •
•
RNg1� s uul .L._., KPIMS r to �_ . . i I 1u �.• �_. _ -. y�
3-501.14(0) PHFs Received at Temperatures
Viotatlons Related to Foodborne 111nes&Inter✓endons and Risk According to Law Cooled to
Factors(Items 1-22) (Cont.) 41'F/45`F Within 4 Hairs.
PROTECTION FROM CHEMICALS 3-501..15 CUOlin Methods for PHFs
14 rFood or Color Additives 19 CHF Hot and MainColdtained
Holding
3-202.12 Additives*' 3-501.4(Fl Cold PQIFs v4aintained at a below
3-302.14 Protection from Unapproved Additives* 3-50L 6( 41 t�15 F*
15 Poisonous or Toxic Substances 3-501.16(0) Hot PHFs Maintained at or above
I40'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*
Control
7-201.11 Separation-Storage* 3-501:19 Time as a Public Healt
7-202.11 .Restriction-Presence and Use* - �90.004(H) Variance Re uiremeM
7-202.12 Conditions of Use'
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Containers-Prohibitions*
7-204.1 I Sanitizers.Criteria-Chemicals* � P.1 18N5 HSP
7-204.12 Chemicals for WashingProduce,Criteria's 21 3-2301.117((0)A) Unpasteurized Pre-packaged Juices and
7-204.14 Drying Agents.Criteria* Beverages with Warning Labels*
3-801 A I(B) Use of Pasteurized Eggs*
7-205.11 Incidental Food Contact, ,Criteria'r 3-301..11(D) Raw or Partially Cooked Aniuial Food and
7-206.11 Restricted Use Pesticides;Criteria* Raw Seed Sprouts Not Served.*
7-206-12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served
7-206.13 Tracking Powders,Pest Control and
Monitorin * CONSUMER ADVISORY
TIMErTEMPERAT URE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or
PHFs Na Otherwise-Processed to Eliminate
Pathogens.'
3401.11A(l)(2) Eggs- 155F 15 See:
erre an, r
Ee-s-Immediate.Service 145'Fl5sec• 3-302.13 Pasteurized Eggs Substitute for Raw Shell
3-401.11(0)(2) Comminuted Fish.Meats&Game Eggs*
Animals-155'F 15 sec.
3.401.11(B)(1)(21 Pork and Beef Roast-130'F 121 mm* SPECIAL.REQUIREMENTSoof fSection
3-401.11(A)(2) Ratites,Injected Meats-155'F IS 590.004(0)-(D) Violations enn.590.4�9(A}- B}in
Sec.* catering,,mobile food,temporary and
3401.11(A)(3) Poultry,Wild Game,Stuffed PI117s, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-165017 15 see. * above if related to foodborne illness
3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
145'F" 590.009 violations relating to good retail
3401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165'F* Special Requirements.
3-401.11(A)(i)(b) Ali Other PI s-145'F 15 sea
lq Reheating for Hot Holding WOLA77ONS RELATED TO GOOD RETAIL PRACTICES
3-403AI(A)&(D) PHFs 165-F 15 sec. * (Items 23-30)
3-403A I(B) Microwave--165`F 2 Minute Standing -Critical,and non-critical violations, which do not relate to the
Time* - foodborne illness inten'entions and riskfactors listed above, can be
3-403.11(C) Commercially Processed RTE Food- found in the following sectionsofthe Food Codc and 145 CMR
1400P 590.000.
3-403.11(E) Remaining Unsliced Portions o£Beef - [ Itern i Good RetailPractices .FC 590.000
Roasts" 23. i Ivianapumant and Personnel FC-2 003-�
18 Proper Cooling of PHFs 24. i Food and Food Protection
25. i Equipment and Utensils
3-501.14(A) Cooling Cooked PHFs from 140'F to 26. 1 Water.Plumbing and Waste j FC-5 1 .006 r
70'F Within 2 Hours and From 70'F 27. 1 Physical Facility FC-6007
L
to 41'F/45'F Within 4 Hours.* 28. Poisonous or Toxic Materials FC--7 x008 i
3-501.14(H) Cooling PHFs Made From Ambient ( 29. S ecia!Requirements .009
Temperature Ingredients to 41'F1456F Othor _
Within 4 H(wrs s.
t ^Dmotes critical iu m in the federal 1999 Food Cale a'105 CMR 590.0()0.
f
j
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,0 Floor
Division of Food and Drugs Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978)741-1800 Fax (978) 745-0343
Nam ey� n /� / -�- Date Type of 0 eration(s) Tvoe of Insoection
C -.a , in Ql �/1 4c, I " "i l/ (LaPD -- d.SC-i ❑ Food Service ❑ Routine
Address (1 ` /M�^I o Risk ❑ Retail ❑ Re-inspection
vl Y Level ❑ Residential Kitchen Previous Inspection
Telephone /D f 3 I_ ❑ Mobile Date:
Owner (� 1 lJ HACCP Y/N El Temporary ElPre-operation
gponn< l _N� o P nim n ADA A,o ❑ Caterer ❑ Suspect Illness
Person in Charge(PIC) Time In: (}1M El Bed&Breakfast ❑ General Complaint
HACCP
inspector tiA R, Out �Ur 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) 590.909(F)�
action as determined by the Board of Health.
FOOD PROTECTION MANAGEMENT_ .. _ _ * . El12. Prevention of Contamination from Hands
/i 1. PIC Assigned/Knowledgeable/Duties `� y 13. Handwash Facilities
`J E EMPLOYEE „ ,"'i HEALTH :n y .. f..p
PROTECTION FROM CHEMICALS :
❑ 2. Reporting of Diseases by Food Employee and PIC
❑
❑ 3. Personnel with Infections Restricted/Excluded 14.Approved Food or Color Additives
❑ 15.Toxic Chemicals
FOOD FROM APPROVED SOURCE * - ` , ' , _' 1 . .
4. Food and Water from Approved Source TIMEMEMPERATURE CONTROLS.(Poternlally Hazardous Foo_da),
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling
PROTECTION FROM CONTAMINATION>,„: _ ❑ 19. Hot and Cold Holding
❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing - REQUIREMENTS FOR_HiGHLY SUSCEPTIBLE POPULATIoNS.(NSP)
El 10. Proper Adequate Handwashing
El21. Food and Food Preparation for HSP
❑ 11. Good Hygienic Practices CONSUMER ADVISORY' e
Posting of Consumer Advisories
Violations Related to Good Retail Practices v Number of Violated Provisions Related
Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions
immediate) or within 10 days as determined b the Board
Y Y Y i 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_ P 9
23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an
24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations
25. Equipment and Utensils (Fc-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-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)(590.008) 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: _
55901nspecYFwm6-14.tlx ��
U t 0 + /,1,d _(A
Inspector's Signature:
Print: Ci.3 h r_� CA..
_
PIC's Signature: I h ��J Print / I c y-) Page of ZPages
0 n
G t kl(,A- J)61 E
J
Y
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION
$ Cross-contamination
FOOD PROTECTION MANAGEMENT 3-302.1](A)(1) Raw Animal Foods Separated from
1 590.003(A) Assignment of Res oneibdlity* Cooked and RTE Foods*
590.003(B) Demonstration of Knowledge* Contamination from Raw ingredients
2-103.11 Person in charge-duties 3-302.1 l(A)(2) Raw Animal Folds Separated from Each
Other'
EMPLOYEE HEALTH Contamination from the Environment
2 590.003(C) Responsibility of the person in charge to 3-302.11(A) Food Protection*
require reporting by food employees and 3-302.1S Washing Fruits and Vegetables
applicants* 3-304.11. - Food Contact with Equipment and
590.003(F) Responsibility Of A Food Employee Or An
Utensils*
Applicant To Report To The Person In Contamination from the Consumer
Char e* 3-306.14(A)(B) Returned Food and Reservice of Food*
590.003(G) Reporting by Person in Charge*
31 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated
Food
590.003(E) Removal of Exclusions: Restrictions 3-701.11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Ford*
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 Seated Container* Sanitization Temperatures-
3-201.13
ent eratures-3.201.13 Fluid Milk and Milk Products" 4-501.11.2 Mechanical Warewashing-Hot Water
3-202.13 Shell Eggs* Sanitization Temperatures*
3-202.14 ERs 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 31.0 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food-
Shellfish and Fish From.an Approved Source Contact Surfaces and Utensils*
4-702.1 t Frequency of Sanitization of Utensils and
3-20.1.14 Fish and Recreationally Caught Molluscan
Shellfish* Food Contact Surfaces of Equipment*
4-703.11 Methods of Sanitization-Hot Water and
3-201.15 Molluscan Shellfish from NSSP Sated Chemical*
Sources* 10 Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Regulatory Author' 2-301.1.1 - Clean Condition-Hands and Arms*
3-202.18 Slrellstoek Identification Present* 2-301.1.2 Cleanin Procedure*
590.004(C) Wild Mushrooms" 2-301.14 When to Wash*
3-201.17 Game Ammals* 11 Good Hygienic Practices
g Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco*
3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges,From the Eyes,Nose and
3-202.15 Package Integrity* Mouth*
3-101.11 Food We and Unadulterated* 3-301.12 Preventing Contamination When Tas6n
6 TagslRecords:Shelistcck 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification * 590.004(E) Preventing Contamination from
3-203.1.2 Shellstoek ldentificat on Maintained* Employees*
Tags/Records:Fish Products 13 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(1) Labeling of Ingredients' 5-204.11 Location and Placement*
q 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 packagmg,criteria* 6-301.11 Handwashing Cleanser,Availability
8-103.12 Conformance with A. roved Procedures*
6-301.12 Hand Drying Provision
Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
CITY OF SALEM 1
I _ ''B)OARD OF HEALTH
Establishment Name:P4 D 1 �Q ! )PA Q O��a 1 \aa�Tt-i n ,� Date: — b �-_ U Page:_ of �Q
Rem code c-critical nevi! U IbESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date,.
No. R erence R-Red nem , 11 1' Verified
0`. PLEASE PRINT CLEARLY
1 N n a. a ��+F��C i ��✓'G,epi l)VQz�4 I' - a o
ll _.rrin ) ()
it ! it
0000"' ,
r
11A1 ,1 10 )r, 1f0 \ , . - rA e, n.._ A441 .PA nnn />, P`Bnn , nn.i. r
l L {�Yy�n `^^ f 1 ""q pv'k.
I T' '. !L� -!"A'^ ?n� �A n•� ,.+/lJ f4A
1o p
Discussion With Person in Charge: Corrective Action Required: ❑ No Yes
t
A I have read this report, have had the opportunity to ask questions and agree to correct all O Voluntary Compliance ❑ Employee Restriction/
violations before the next inspection, to observe all conditions as described, and to / Exclusion
o Re-inspection Scheduled ElEmergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that ( uti�,�
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of C) Embargo ❑ Emergency Closure
your food permit.
'X ` ❑ Voluntary Disposal ❑ Other:
v
3-501.14(C) PHFs Received at Temperatures
Violations Related to Foodborne fitness.Interventions and Risk According to Law Cooled to
Factors(Hems 1-22) (Cont) 4l'F/45'F Within 4 Hours.
PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs
14 Food or Color Additives 19 PHF Hot and Cold Holding
3-501.16(B) Cold PHFs Maintained at or below
3-202.12 Additives* 590,()04(17) 410/450 F*
3_302.14 Protection from.Unapproved Additives*
15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above
140°17.*
7-101..11 Identifying Information-Original
3501.16(A) Roasts Held at or above 1300F.
Containers*
7-102.11. Common Name-Working Containers* 20 Time as a Public Health Control
7-201.11 1 Separation-Storage* 3-501.19 Time as a Public Health Control'
7-202.11 .Restriction-Presenc:eandUse* 590.004(H) Variance Requirement
7-202.12 Conditions of Use*
7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11 Sanidners.Criteria-Chemicals* POPULATIONS HSP
7-204.12 Chemicals for Washin Produce,Criteris* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and
7-204.14 Drying Agents.Criteria* Beverages with Wanting Labels*
7-205.11 Incidental Foal Contact,Lubricants* 3-801.11(B) Use of Pasteurized Eggs*
7-206.11 Restricted Use Pesticides,Criteria* 3-80L I1(D) Raw or Partially Cooked Animal Food and
Raw Seed Sprouts Not Served *
7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.
7-206.13 Tracking Powders,Pest Control and
Monitoring* CONSUMER ADVISORY
TIMEITEMPERATURE 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
3-401AIA(l)(2) Eggs- 155'1715 Sec.
Patho ns.*
-Eggs-Immediate Service 145'F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
3-401.11(A)(2) Comminuted Fish.Meats&Game E *
Animals-155'F 15 sec.*
3401.11(8)(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
3401.11(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 we. * above if related to foodborne illness
3-401,11(C)(3) Whole-muscle,intact Beef Steaks interventions and risk factors. Other
145OF* 590.009 violations relating to good retail
3-401.12 Raw Animal Fails Cooked in a practices should be debited under#29-
Microwave 165'F* Special Requirements.
3-401:11(A)(1)(6) All Other PHFs- 145'F 15 sec. *
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3403,81(A)&(D) PHFs 1657 15 sec.* (Items 23-30)
3403.11(B) Microwave 165'F 2 Minute Standing Critical.and non-critical violations,which do not relale to the
Time* foodborne illness interventions and risk factors listed above,can be
3-303.11(C) Commercially Processed RTE Food- found in the following sectionsof the Food Code and 105 CMR
1400F* 590.000.
.
3-409.11(E) - Remaining Uns[iced Portions Good Retail Practices FC 590.000
,ons of Beef � fJ-
Roasts+' i 23. ( Management and Personnel FC-2 _003 .I
18 Proper Cooling of PHFs i 24. Food and Food Protection FC-3 .004
25. Equipment and Utensils FC-4 .005 {
3-501.14(A) Cooling Cooked PHFs from 140'17 to 26. Water.Plumbing and_Waste FC-5 .008
70'F Within 2 Hours and From 70'17 27. Physical Facility
FC-6 D07 f)
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. S ial Requirements I .009
Temperature Ingredients to 41*F/4.5'F 30. Other
Within 4 Hours*
*Denotes critical item in the federal 1999 Fwd Cade or 105 CMR 590.000.
i Commonwealth of Massachusetts
e City of Salem
b 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 Va_lverde_Coffee_Rog as�ters
File Number:BHF-2010-000009 196 Essex Street
SALEM MA 01970
LOCATED AT:
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
FOOD SERVICE BHP-2011-0177 Jan 1, 2011 Dec 31,2011 $140.00
ESTABLISHMENT
Total Fees: $140.00
PERMIT EXPIRES IDecember3l, 2011
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted
in a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,
all plans for such must be submitted to and approved by the Salem Board of Health. Page 1
r
• CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET,4`FLOOR
TEL. (978) 741-1800
KINIBERLEY DRISCOLL FAX(978) 745-0343
MAYOR DG1a3r1y6AUNI@SA1,LN1.COM
DAVID GREENBAum,RS
ACTING HEALTH AGENT
2011 APPLICATION,FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT-C4 (�'!/ jcL(f')/26 e_I[ j. _ �_gS�Ec.o__TEL#_—J 70'- 0
ADDRESS OFESTABLISHMENT�I!IG, &'SLoX �` l/ LcC FAX#
MAILING ADDRESS(if different)
EMAIL- Business': -* /Ie4( '.(/�deAaL c- / Website:
OWNER'S NAME�l`Pvu_ Lzkge�,l [�2�/J�c d� II TEL# 970p
ADDRESS 1-/,)-D1-/,)-D /
D YY1P/11 Z2),eCT- eZ4Jl Lj✓ A �
STREET CITY STATE / ZIP.
CERTIFIED FOOD MANAGER'S NAME(S) I bQAC f CERTIFICATE#(S)
(Required in an establishment where potentially hazardous food is prepared) /,, q p a
EMERGENCY RESPONSE PERSON Fl-e Pl, 0411/022 ' HOME TEL#
c
DAYS"OFOPER4TION= ., ,Monday `;_ x.�Tuesday:: ;;-��Wed_iesday� �z,gThursday,k : :,Friday)
HOURS OF OPERATION
Please write in time of day. da 'M � � #D � sU,�� ig� 6�
For example Ilam-11 pm j /
TYPE OF ESTABLISHMENT FEE (check only)
RETAIL STORE less than 1000sq.ft. =$ 70
1000-10,000sq.ft. =$280
more than I0,000sq.ft. =$420
-----------------------------------------------------------------------------------------------------------------------------------------------------_
RESTAURANT NO less than 25 seats $14
(Outdoor Stationary Food Cart$210) 25-99 seats =$280
more than 99 seats =$420
-------------------------------------------------------------- ------ -------------------------------------------------------------------------------------------
BED/BREAKFAST/ YES NO $100
CHILDCARESERVICES/NURSING HOM---------------------------------------------------------------------------------------------------------------------------------
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES %00
$25
TOBACCO VENDOR YES $135
ALL NON-PROFIT(such as church kitchens) YES $25
'Please pay total with one check payable to the City of Salem.
This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location
in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for
such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax
ret s nd paid all s e taxes required under the law.
Si ature Date Social Security or Federal Identification Number
Revised ionli I FOODAP201 Ladm Check#&Date
L
t
CITY OF SALEM _
BOARD OF HEALTH / /
Establishment Name: .k; �� l� V E'� Date: CJI C�� I I� Page: of /
Item Code C—critical Itenti -
DESCRIPTION OF VIOLATION/PLAN OF CORRECTION
No. Reference R—Red Item
f PLEASE PRINT CLEARLY
M) c)ney1lYlc?
lr�_ yr(5 -tk(2, SII oiA�rnu intet^e n0+er6
f I J
v�� wa�h �I�K -ro he (a-bPleci (na��c�wa�l.7
� on its
I� `1
f �
k
y
J Poll ttiil v�.ev�1-s 4-o � wctt � -(te l .��.rv;
i
I
Discussion With Person in Charge: Corrective Action Required: ❑ No7 Yes
's
` 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 twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. _ - J l � -
��nAu ( /Q /�0 n Voluntary Disposal 0 Other:
f
PHFs Received at Temperatures
Violations Related to Foodborne illness Interventions and Risk Amaoding to Isix Cooled to
Factors(Itents 1-22) (Cont) 41`:F/45"F Within 4 Houp,,
PROTECTION FROM CHEMICALS — 3-501A5 C–oolin.-I-Me-1-hods.for-PHFs
E-14 Food or Color Additives 19 PHF Hot and Cold Holding
3-202,12 Additives* 3-50IA6(B) Cold PHFs Maintained at or below
59(1.0(9(F) 41 /45°P`
3-302.14 Pnitectim)from :1 Addinves� 3-501,16( 3) lint 11HFq.%1aunamed at�orabove
1.5 Poisonous or Toxic Substances I 140'F.
101.11 Ideruffy lig info)mation Original —
3-501 INA) Rout;.Held at or above 1300F,
contaole's I t I I
i 2t) i Time as a Public Health Control
102,11 CcannionNarn, L
Fimw,as a Public Health(,onirt)p
V��riapce Reottucillent—
�_7-202A2 Coratition,,of lisc, i
�-203 H To
("Ajmaincf� -Prohibvmil� REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS
H-204.17---Sdn67ers,Criieria-Chu mical.0
7.`04.12 (1willical.,for 'Aa,hwg Proditce,Criteliall 217 ;-80 1�1 It,%,) ll'apmcuritcd fire-packaged Joices and
Rei-toes with wamima
2o.I I bnci&ntal Fi,xl Cownci,lAtbiwa;tW
ljs,�of Pastomized E
1-S01.II(D) Fl,i<t or RuIiAl,, OK�Kcd Animal F(x'd and
7-2F6.11 RO:I Vw fle"11 Ide, 01.U-1.1 9 Ro%� Su'tl Sprout, set 9 V�I
1 -206.12 Roclim, 13mf toatlon'�
901 1 1(c) kji�z)pcfled y"Xci pjcka�- No W-w-—c19
CODTTO! and
�06.1 ......
CONSUMER ADVISORY
onsumor PfAt"d kor
TIMErrEP41PERATURE CONTROLS 2
3 odis T;ia,,:uv Rnw, Uralet�A'td o;
Proper Temperate: for
L---T
1 3 f9IAiA(I)(2;! 1. 5�K I
iri + Pair SItell I
,l.417I I It A?(2) Filb—%ieX & C
SPECIAL REQUIREtMENTS
1!(B)f 1'�'! P�llk Rod V�'C! kkj;tq 1 121 min, 1
. .... ... 9-�------I- ---_�- - -- 1 �9")0 1 vk!"fi��'I"6
t 0 i-1 I(A)I R:ooc, Iiii,mt;,i Mc A� I�5 F I` 1 1
it lila:. [�"xl. temporal., and
3 411.1 HAY 6 I Potfit",wdd t;a13"- swi!'cd romdw;."al Utchel opvi"licitis Atouto tit"
l.c(or!fic ap' ruilrlatc ic,iion�
k" fwc" 't:ld as, Otli(T
r:
-------------- -
Ptohcatinj 10,Hot Holdinq
VIOLA710N5 RELA TEV- TO (,00D
3-40311(A)&(O� r(ll to:F 1 (Itew�i 23-30)
C1 qi("-fi�"?Id twn-�? nw !'late:')l'Or
.-#Q3.21 rh� I F 2, %1 nul"Standing I
i q)()dh? n eat 7t md i i�k)v ior,liywd ai�mw art b,'
T-403.1:1 111(i,01.scd R IF Maw "'Um11 7i7t o4;h" Lood e'ode s 105 (".'VK
3403.11 IF) 1 Rcviaomq, Lnakced Tlooicin,of Beef Item I Good Reta4Prartices FC_ rbfJD 00O
2,39 MaLmgorml-ni and Pei:
R; 9 103�
24 1 Folrt;)nd Food P PC �M4
1 Prufm noting of PHFs
25 guypmeet and Utes s,i3
3 501.14(A) C(x4fag Ccuokixi 111-11-'s how IWl'to
Viater,Pk�ribji��c�V�istk, a
701Y Waiun 2 Hrairq and From IS Flivsical Fa�'ill) FC- 6 007 1
I,off I I�-p Within.1 How 0��o'ois or Kitef'nL� PC -7 1 008
r ......... .
Sc'q(;.aI P��ouirewry 1f9-
:..501.14B1 Cta-titw flifF, M;& From Ambient
to 4j�B'45'F 3o ottlw'
'Withiji'l
i
DEC-23-2009 10;48 AM GreenNet-Invalsa Coffee 9783631225 P. 2
E.w corm Ne.-079
Can.No 6011039 S0CMTi9h
s• -
$eiv*afe`Certtfieetian
io ELENI VALV€RDE
baKtaNegavWnplMtN��de MlgpA4a4v�rvrRtunw Mma4unG.mroel '
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VOM NtienelMerv<enLLNMlPrei EPY0.nWmlYevMMee,n9' Nrourw!
DEC-23-2009 10;47 AM GreenNel—Invalsa Coffee 9783631225 P. 1
ELENI VALVERDE
INVALSA COFFEE ** CAFt VALVERDE
420 MAIN STREET
WEST NEWBURY,MA 01985
979-363-1513.
FAX TRANSMITTAL FORM
FAXNUMBER / 7f
COMPANY
DATE
NUMBER OF PAGES
COMMENTS: 1I_ f k,
CITY OF SALEM
BOARD OF HEALTH
Date: December 22, 2009
Name of Establishment: Cafe Valverde Coffee Roasters
Address: 196 Essex Street
Owner: Eleni and Nelson Valverde
Phone: 978-363-1513
The proposed owners of this establishment Eleni and Nelson Valverde 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. Eleni Valverde is Serve Safe Certified and will fax a copy of her
Certificate to the Board of Health
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 commercial dishwasher will be used for washing, rinsing and sanitizing all dishes and
utensils. The dishwasher to be used 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 and the dishwasher must be NSF certified.
MENU/FOOD 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 consumer advisory regarding the consumption of raw or under cooked foods must
be added to the menu should this establishment add any menu items that would served
to order.
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`" 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.
Please call one week prior to opening to schedule and opening inspection.
A �14�IJL 1Z- Zz-�
id Greenb um Date
Acting Health Agent
/ aa�
Eleni Valverde LL-�—& Date 0
C d9-6 12-
jelson Valverde
CAFt VALVERDE
MENU
BREWED COFFEE (Hot and Iced)
ESPRESSO DRINKS, Including basic Espresso, Latte, and other variations
SMOOTHIES
JUICES
WATER
TEA & CHAI
HOT CHOCOLATE
HIGH QUALITY BAKED GOODS & FANCY PASTRIES
SOUP
Other specialty food choices, such as spinach pie, quiche,that require only par-baking or heating.
We will also be selling bags of roasted coffee, as well as green unroasted coffee for home
roasting, and coffee and tea equipment and supplies.
Commonwealth of;Massachusetts
City of Salem
Board of Health
120 Washington Street,4th Floor Kimberley Driscoll
Mayor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 03/25/2010
ESTABLISHMENT NAME: Cafe Valverde Coffee Roasters
File Number:BHF-2010-000009 196 Essex Street
SALEM MA 01970
LOCATED AT:
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
FOOD SERVICE BHP-2010-0390 Mar 25,2010 Dec 31,2010 $140.00
ESTABLISHMENT
Total Fees: $140.00
PERMIT EXPIRES IDecember3l, 2010
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all
plans for such must be submitted to and approved by the Salem Board of Health. Page 1
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET,4"'FLOOR
TEL. (978)741-1800
KIMBERLEY DRISCOLL FAX(978) 745-0343
MAYOR 136,11EENBAUM(17 ALEM.COM
DANT ID GREENBAU➢4,
ACTING HEALTH AGENT
2009 APPLICATION FOR PERMIT TTO� OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT TEL#
ADDRESS OF ESTABLISHMENT FAX#
MAILING ADDRESS(if different)
EMAIL-Business': ej& J �4 ?2 d q Cern Website:
OWNER'S NAME ///oi2i TEL# 3
f7d',16
/
STREET Q` CITY STATE ZIP
CERTIFIED FOOD MANAGER'S NAME(Sb/ 7e)>C CERTIFICATE#(S) 9 0I l®C� 6
(Required in an establishment where potentially hazardous
fo/qd is prepared)
C�7 36/
EMERGENCY RESPONSE PERSON esh/ VrO (� 9 HOME TEL# ` �S/�
Fl
DAYS OF OPERATION Monday 1 Tuesday Wednesday I Thursday Friday Saturday Sunda
HOURS OF OPERATION
Please write in time of day.
/ 7iK(For example l lam-11 pm) 7,1-7,1 74 // i74A /P,N pK( w7� -//�ore4
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€S) NO less than 25 seats
(Outdoor Stationary Food Cart$210 25-99 seats li—$280
more than 99 seats =$420
------------------- ----- ---- ------------------------------------------------------------
BED/BREAKFAST/ YES NO $100
CHILDCARE SERVICES/NURSING HO
M - - -- - ------------ --------.-.-.
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES qg:D $25
TOBACCO VENDOR YES $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.
Pursuan MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax
returns n pard all state taxe required unde the law.
/ -2 113J
Signature Date Social Security or Federal Identification Number
r'
CITY OF SALEM, MASSACHUSETTS
+ BOARD OF HEALTFI
120 WA5HNGTON STREET,4"'FLOOR
TEL. (978) 741-1800
KIMBERLEY DRISCOLL FAY(978) 745-0343
MAYOR DGREENBAUM@SALEM.COM
DANT ID GREENBAUM,
ACTING HEALTFI AGENT
Revised 4/24/07 FOODAP2008.adm Check#&Date $