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CHIPS VARIETY NOW JOSHS PLACE - ESTABLISHMENTS CHIP'S VARIETY 72 WHARF STREET ,I 0 0 e i �� I IMPORTANT MESSAGE FOR DATE 9/�3 TIME _ M OF n Jo 5 PHONE 9-7 ? 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 SIGNED MAAU N UC09 i S310N ,��,�S .�-�'' �` 2( `�� f �� ,y,,,,-- �,/ ,�� 1 _---,'�1 '', 1 ....---'�� J��/ ..�--fes /��' flit I 0072 Wharf Street Chip's Variety City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ `Telephone: Item Status Violation Critical Urgency Nature of problem or correction 745-6659 Non-compliance with: Done Owner: Anti-Choking PASS ❑ Chester& Lisa Hincman Tobacco PASS ❑ PIC: - ` `- _ - a " � =Chester.HlncmanFOOD PROTECTION MANAGEMENT Done Inspector: - PIC Assigned/Knowledgeable/Duties PASS ❑d RED David Greenbaum M' -, EMPLOYEE HEALTH Done Date Inspected: Correct By:v Reporting of Diseases by Food Employee and PIC PASS RED 9/26/2005 Personnel with Infections Restricted/Excluded PASS 0 RED Risk Level - y= FOOD FROM APPROVED SOURCE Done Permit Number Food and Water from Approved Source PASS RED BHP-2005-0174 Receiving/Condition PASS ❑d RED Status: - Tags/Records/Accuracy of Ingredient Statements PASS ❑J RED SIGNED OFF Conformance with Approved Procedures/HACCP PASS ❑d RED #of Critical Violations. Plans PROTECTION FROM CONTAMINATION Done Time IN. ''4-= `-.Time OUT Separation/Segregation/Protection PASS ❑O RED Notes' Food Contact Surfaces Cleaning and Sanitizing PASS ❑d RED 321.' Proper Adequate Handwashing PASS ❑Q RED Urgency Description(s): Good Hygienic Practices - PASSd❑ RED BLUE: Prevention of Contamination from Hands PASSd❑ RED Violations Related to Good' Retail Practices (Critical Handwash Facilities PASSd❑ RED violations must be corrected immediately or within 10 days)(Non-critical violations GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 26,2005 ) Page 1 of 0072 Wharf Street Chip's Variety must be corrected immediately PROTECTION FROM CHEMICALS Done or within 90 days) Approved Food or Color Additives PASS ❑d RED RED: ` Violations Relatedto Toxic Chemicals PASS ❑d RED . Foodborne Illness Interventions TIMEITEMPERATURE CONTROLS(Potentially Haz Done and Risk Factors (Require µ Cooking Temperatures PASSJ❑ RED immediate corrective action) Reheating PASS F/-] RED Cooling PASS 7 RED Hot and Cold Holding PASS RED Time As a Public Health Control PASS RED - REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Done Food and Food Preparation for HSP PASS 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 FAIL ❑ BLUE Repair screen door. Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other-See Notes PASS ❑ BLUE Owner will notify the Board of Health prior to any change in the menu or to the establishment. Owner will forward a copy of the new certified food managers certificate to the board of health. 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 26,2005 ) PaAe 2 of .`\ r 0072 Wharf Street Chip's Variety GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 26,2005 ) Page 3 of p CITY OF SALEM, MASSACHUSETTS �! BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR o' SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Chip's Variety Address of Establishment: 72 Wharf Street Owner's Name: Chester & Lisa Hincman Restrictions: Application Date: 12/01/2004 Permit for Food Establishment 101-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 26-05 These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT T, I D g a " V CITY OF SALEM, MASSACHUS �7 BOARD OF HEALTH NOV-9 0 9004 04i) 120 WASHINGTON STREET, 4TH FLOOR �`1UY J L 'tiSALEM, MA 01970 TEL. 978-741-1800CITY OF SALEM FAx 978-745-0343 BOARD OF HEALTH STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT C h t'�S I OsevC,1 Y TEL# /Jp 7 YSJ� S ` ADDRESS OF ESTABLISHMENT 70( Ly,"Ac: e F 5- MAILING MAILING ADDRESS (if different) // eo- OWNER'S NAME 11eS 'hC ✓� C/#+'iG✓) TEL# y7�717" L ADD SS ;] 4arXWL.3 L✓V+y CiTy oyl vey'—.S STATE a _ ZIP CERTIFIED FOOD MANAGER'S NAME(S)CAesi-c,/ ,yt /itv,e:inCERTIFICATE#(s) aY ,,�-/ (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON/—/S,a /fYy% Cwr e'v) HOME TEL HOURS OF OPERATION: Mon77"ZTud 3"Wed.7-6 Thu.?-lo Fri. 7-G Sat.?-G Sun.I-5 TYPE OF ESTABLISHMEUI FEE check only RETAIL STORE YE NO less than 1000sq.ft. _$ 50 1000-10,000sq.ft. 100 / 6 j more than 10,000sq.ft. =$250 RESTAURANT YESNO G / / less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BEDIBREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVEZNO $_ TOBACCO VENDOR a�p— j ES $50 ALL ATOM-PROFIT(such as church kitchens) S $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 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Signatur ` Social Security or Fe r I, en f � ' j y ------ t- Revised 11/03/03 FOODAP2.adm Check# ate '_4 v-0 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL..978-741.1800 FAX 978-745.0343 STANLEY J. USOVICZ, JR. .JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Chip's Variety Address of Establishment: 72 Wharf Street Owner's Name: Chester& Lisa Hincman Restrictions: Application Date: 1/8/2004 Permit for Food Establishment 251-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 57-04 These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health,.. HEALTH AGENT CITY OF SALEM, MASSACHUSETTS yup) ^« Lt 1 f BOARD OF HEALTH �II • 120 WASHINGTON STREET, 4TH FLOOR VV Y SALEM, MA 01970 JAN 082004 TEL. 978-741-1800 FAX 978-745-0343 BOARD OF SALEM STANLEY USOVICZ, JR. ,JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT T7 OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT TEL#2?��/�7 &U.S ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different) r/ OWNER'SNAMELJ TEL# T ADDRESS SAC M J-S a CITY ` S TE ZIP CERTIFIED FOOD MANAGER'S NAME(S)rht ERTIFICATE#(s) (required in an establishment where potentially hazar ous food is prep ed.) gyp EMERGENCY RESPONSE PERSON HOME TEL# � Nil— MIL— HOURS OF OPERATION: Mon ue. r1 Wed. 1 Thu. 11 Fri. 1/ Sat. w� Sun. TYPE OF ESTABLISHMENT,- �I p FEE check only RETAIL STORE ES NO less than 1000sq.ft. _$ 50 1000-10,000sq.ft. =$100 �� more than 10,000sq.ft. =$250 RESTAURANT YES N( O\ 1 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 SE VE YES NO $5 TOBACCO VENDOR 15'J-6f (fEED NQ $50 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, ection 49A, I certify under the pains and penalties of perjury that I, to my best kno d e and belief, .a e filed all state tax returns and paid all sta.tQxes 2uired under the law. Signat re / ( t5Social Security or Federal Identifi ation Number -------- -- -- ------ -------- - - ------ -- --------------------------------------------------------------- Revised 11/03/03 FOODAP2.a m Check#&Date I� ...��— /�/ O 3 IMPORTANT MESSAGE FOR A�J/* /]y DAT(E'm ` r ()"� TIME M v' 1 l \f OF Chip-I Y u l�'�i� PHONE D 7'117 LO &51 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 RETURNED YOUR CALL WILL FAX TO YOU MESSAGE 4 SIGNED '.Yrs. FORM 4009 MARE IN LLS. - SJK/5�1��72� SS10N 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 �/ Type of Operation(s) Tvpe of Inspection Address S Y/ g �� 7 Food Service ❑ Routine Risk b2Retail Ike-inspection Q.V Level ❑ Residential Kitchen Previous Inspection Telephone _ _ 5 ❑ Mobile Date:&.,5.,04.4 OwnerHACCP YIN ElTemporary ❑ Pre-operation ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed& Breakfast ❑ General Complaint In: ElHACCP Inspector /[( J Out: Permit No. ElOther Each violation checked req Ires 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 ` _ El12. Prevention of Contamination from Hands El1. PIC Assigned/Knowledgeable/Duties EMPLOYEE HEALTH El 13. Handwash Facilities `�`�- _ "_. PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC El3. Personnel with Infections Restricted/Excluded El 14.Approved Food or Color Additives _FOOD FROM APPROVED SOURCE ❑ 15.Toxic Chemicals `-' "9"""'_ ' E] 4. Food and Water from ApprovedSource .ems_ - TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods).�w ;i ❑ 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', ❑ 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(HSP) 10. Proper Adequate Handwashing [:121. Food and Food Preparation for HSP ❑ ❑ 11. Good Hygienic Practices CONSUMER 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 j] immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): V 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 C3, "s , 590.000/federal Food Code. This report, when signed below 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-4)(590.005) cited in this report may result in suspension or revocation of., 26. Water, Plumbing and Waste (FC-5)(590.006) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you J 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: S:5soM /CtFome-1a.mo P 1' 17,f'S#PeC 1 r' Si n(a6 a Print: {4 / PI �Is Sig u e: Print: Pagel of CJ Pages �/IE •/1 H1Gt� Violations Belated to Foodborne Illness �. Interventions and Disk Factors(Items 1-22) PROTECTION FROM CONTAMINATION _ FOOD PROTECTION MANAGEMENT K Cross-contamination 1 590.003(A) Assiument afkespmrstbrlity* 3-302.11(A)(1) Raw Animal Pools Separated from 590.003(B) Demonstration of Knowledge Cooked and RTEFoods* 2403,11 Person in charge-duties Contamination from Raw ingredionts 3-3 0 Tf I(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 repealing by food employees and 3-302.11(A) FMI protect)oil a -rliumts* 3-302.15 Waahin Fruitsxnd Veetables 590 003(F) Responsibility Of AFund Earployee Or An 3-3tY1.11 Food Contact with Equipment and Applicant To Report To The Person in Utensils* Charge* Contamination from the Consumer 590.00.1 Re ronin b Person m Char£e* 3-306.14(A)(B) Returned Food and Reser-rice of Food* .31 590.003(D) Exclusions and Restrictions^ I Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions - Food :-701.11 Discarding a,Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food„ 4 Food and Water From Reguiated Sources ) Food Contact Surfaces 590.004(A-$} Cam rtiance with Eood Law`k 4-501.I1 l Manual Warewashing-Hot Writer 3-201.12 _ Pood in a He:,metically Sealed Container" Sarutizatlon Tem eratares* 3-201.13 Fluid Milk and Milk Products* 4-501.1}2 MeiUmcai W treuashin= Hot Water 3-202.13 _ Shell fines' Temperatures` 3-202.14 Eggs and Milk Priducte.Pasteurized* 4-501A 14 C hemtcal Sanitization-tamp.,pH, 3-2.02.]6 Ice Made From Potable Drinking,Water* concentration and hardness. 4-601A I(A) Equipment Food Contact Surfac nand 5-101.11 Drinking Water front an A r icved System` _ Utensils Chan" 590.006(A) 'Bottled Dnnkme Water 4-602.11. Cleaning Frequenev of Equipment 590.000(H) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Shel-Ifish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.74 lash and Recreationally Ca ,ht Molluscan Food Contac-Surfaces of Er ui menf" Shellfish'- ' 4-703.11 Methods of San9nz tion-llot Water rad 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* Ip Proper,,Adequate Handwashing Game and Isoid Mushrooms Approved by iqp�;tbjafory Authority 2.301.11 Clean Condition-Hands and Arnts"` 3-202.1 S S_heilstock identification Present* 2-30(.12 Cleaning Prtpcedurc* _ 590.004(C) Ami d Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* L1 ___ Good Hygienic Practices g ReeelvingiConciftion 2-401.11 Erten ,Drinkinn or Usin Tobacco" 3-202.11. PI1Fs Received at Proper Tem eratures* 2401-12 � Discharges From the Eyes, Nose and 3-202.1$ 4loutV 3-101.11. Food Safe arid Unadulterated 3-301.12 1 Preventing Contmatinalion Wltert'Castina* ry TagslReeords:Sheilstock 12 Prevention of Contaminationfrom Hands 1-202.IS Shellstock Identification* 590.004(E) preventing Contamination from 3-203.12 Shellstockidentification Maintained" Empl<p)`>es" Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction' Conveniently Located and Accessible �. -- 35-203.17 umbers and Capacities* -40?.12 Recurds.Creationand t " 590.0040) Labeling of Ingredients" 5-2fla.11 Location and Placement*` 7 Conformance with Approved Procedures 5-2-05.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Nand Drying Devices 3-502.11 5 ccialized Processin£Methods* 3-502.12_ Reduced oxv yen 7acka rims.criteria* 6-301.11 Handwashina Cleanser,Availabihty 5-103.12 Conformance with Ar roved Procedures* 6-301.12 Hand Dryine,Provision s Denotes eruical inm in the[vJeral 1999 Food Code or 105 CAIUM000. A CITY OF SALEM / BOARD OF HEALTH Establishment Name: S // /P Date: /a 6 Page: oZ of oZ Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date _ No. Reference R—Red Item Verified _.... PLEAS PRINT CLEARLY Z2 3rl -0 1z;-110M)1fia /I 'D- _'ih r'v of) 76wak LIZS061=ed r 0ezY / ill / J Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes ❑ voluntary Compliance ❑ I have read this report, have had the opportunity to ask questions and agree to correct all Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension ,t 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 r your food permit. ❑ Voluntary Disposal ❑ Other: 3-507.14(Ci) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Ia Cooled to Factors(items 1.22) (Cont.) 41'.F/45`F Within 4 Hour . PROTECTION FROM CHEMICALS 3-501.15 C winos11 Methods for PHFs 14 v Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives" 3-501.16(B) Cold PHFs Maintained at or below 590.004(F) 41`145°F* Poisonoisonous or Toxic Substances 3-3(Y2.14 Pofrom Unapproved Additives* 'i-501.16(4) Hot PHFs Maintained at or above ]5 u - 4WE* 7-101.11 Continerstnfrn'matiou-Original 3-50I16(A) Roasts Held at or above130'F. Containers"` 7-10111 Common Name-Warkin�}T Containers* 24 Time as a Public Health Control 7-201.11 Separation-StontRo. 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use* 590-004(1-) Variance Re Inent 7-202.12 Conditions of Use` 7-203.1.1 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers,Criteria-Chemicals* POPULATIONS(NSP) 7-204..2 Chemicals for Washine Produce,Criteria* 21 3-W1.i1(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drinv A cots,Criteria* Bevertt¢es with 1k`ammg labels* 7-205.11 Incidental Food Contact,Lubricants* 3-801..11(B) Use of Pastenuzed ET 3-80 1 A I(D) Raw or Partially Caked Ani mal Faxi and 7-206.1 L Restricted Use Pesticides.Criteria* Raw Seed S xrouts Not Served. 'a 7-206.12 Rodmi Bait Stations* 3-$01.11(C) Uno caned Food Packa=e Not Re-served. 7-206.13 Tnickmg Powders,Pest Control and Monitorinn* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-60111 Consumer Advisory Posted for Consumption of Animal Foods That are Raw.Undercooked of 16 Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate �;-401.11A(t)(2) Eggs- 15517 15 Sec. Patho,-ru ''``n� -sol E ,s-Immediate Service 145'F75see* 3-302.13 Pasteunrea F ggs SubStiurte for Raw Shell 3-401.11(A)(2) Comminuted Fish,Means&Game Animals-15-5'F 15 sec. 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)t2) Ratites,Injected Meats- 1.55'F IS 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. * catering, mobile food,temporary and 3-401.11(A)(3) Poaltr),Wild Game, Stuffed PFIFs, residential kitchen operations should be Slotting Containin,Fish,Meat, debited under the appropriate sections Poultry or Ratites-I65`F 15 sec. _ above if related to foodborne illness 3-401A 1(C)(3) Whole-muscle,haact Beef Steaks interventions and tisk factors. Other 145'F* 590.009 violations relating to good retail 3-=01.12 Raw Animal Foods Cooked in a practices should be debited under 7)29- Microwave Itis°F* Special Requirements. 3-40LII(A)(I)(b) All Other PHFs-1.45'F15see, 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165'F 15 sec. * (Items 23-30) 3-403.11(B) Microwave-165'F 2 AMnute Standing Cuical and non-criticai violalions, which do not relate to the Time* foodborne iilnes.s intervenriom and risk factors listed above, can be 3-403.1 l(C) Commercially Processed RTE Food- foamd in rhe fotlotving sections q1 the Food Code and 105 CMR 140"F* 590.000. 3-40111(E) Remaining Unshced Portions of Beef Item Good Retail Practices R 590.000 Roasts* 23. Mona ement and Personnel _ FC-2 .003 i& Proper Cooling of PHFs 24, _ Food and Food ProtectionL-iFC_3 .004 25Equi menu and Utensils FC 4 .005 3-501.14(.A) Coo nig Cooked PHFs from 140'F to ----ate -- -------- 26 Wr, ambiand Waste FC 5 .006 70'F Within 2 Hatrrs and From 70'F 27, Physical Facilltv FC-6 . .007 to 41'F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 ` .008 3-501.14(B) Coolin,PHFs Made From Ambient 28. S conal Re ulrements _ .009 Temperature Ingredients to 41'F/45'F 30.... Other Within 4I-Iours'" "Denotes critical item in the Lateral 1999 FoodCode or 105 CMR 590.000_ - . .. �,^-.-._r rxs "1"Mi:.:'��"`"�""s x+-.i.y..n._ryMi.�+rr=.,, r.'gkaty b� ., .r^... • v, - - ,. t;r, Masacichusetfs Department of Public Health Salem Board of Health DiViiSion of Food and Drugs 120 Washington Street,4t" Floor Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date Tvoe of Ooeration(s) Type of Inspection 0 ❑ Food Service outine Address R sk H"Retail ❑ Re-inspection Telephone Level ❑ Residential Kitchen Previous Inspection _ CJ q Mobile Date: OwnerHACCP V/-N-- ❑ Temporary ❑ Pre-operation ❑ Caterer ❑ Suspect Illness Person 1n harge(PIC)' ( Time ❑ Bed& Breakfast ❑ General Complaint InspectorOut: In. Permit No. ElHACCP Other Each violation cTi6ckid 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 E] 12. Prevention of Contamination from Hands [1 1. PIC Assigned/Knowledgeable/Duties EMPLOYEE HEALTH ' """. ,. . .,_.. _ ., _. [ 3. Handwash Facilities PROTECTION FROM CHEMICALS- ❑ 2. Reporting of Diseases by Food Employee and PIC El3. Personnel with Infections Restricted/Excluded E] 14.Approved Food or Color Additives FOOD FROM APPROVED SOURCE El 15.Toxic Chemicals - �� - _ "- ❑ 4. Food and Water from Approved Source TIMEITEMPERATURE CONTROLS(Potentially Haiardous Foods) ❑ 5. Receiving/Condition El 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACOP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION " 2'2'19. Hot and Cold Holding(a) ❑ 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control EOX Food Contact Surfaces Cleaning and SanitiziV ng. REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)': / ❑ 10. Proper Adequate Handwashing El 21. Food and Food Preparation for HSP ,�� „1 % `CONSUMER ADVISORY,' ❑ 11. Good Hygienic Practices nu r / ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices 4/ Number of Violated Provisions Related Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board To Foodborne Illnesses Interventions �G and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected t Official Order for Correction: Based on an inspection immediately or within 90'days}as determined by the.Board of Health. today, the items checked indicate violations of 105 CMR r� n y, -w- 590.000/federal Food Code. This report, when signed below y 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 cited in this report may result in suspension or revocation of (FC-4)(590.005) �a 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: s:ssoinsnec�Forms-ie.aoc // 0-4 OCll 4 ti .. t/ t q s r'gn).' IA tur •" I Print: - EI Sr latuure: Print: / Page of ages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT F-8 Gross-contarriinatmn Assig onem of Responsibility" � 3-302.1 (A)(1) Raw Animal Foods Separated from 590. I,- Denu>nsn mo on f Ml Knoed e" Cooked and RTE Foals* 2-103.1 1. Person in charge--duties � Contamination from Raw Ingredients 3-302-11(.A)(2) Raw Animal Fouls Separated from Each EMPLOYEE HEALTH Other* 2 590.003(0) Responsibilityof the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11{A) Food Protection* a �lic:utts* 3-302.15 Washing Fruits and Veetables 590.003(F) Responsibility Of A Food 6mpioyee Or An 3-304.11 Fo(rComact with Equipment and Applicant To Report'ro The Person In Ukensils* Charee' Contamination from the Consurrer .590.003(G) Re>or ng b Person in Charge* 3-306.14(A){Bj Returned Food and Reserticc of Feu 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(P,) Removal of Fixclusionsand Restrictions Food 3-701.11 Discarding or Reconditioning Unsate FOOD FROM APPROVED SOURCEFonda 4 Food and Water From Regulated Sources IF9 Food Contact Surfaces 590.004(A-B) Com Aiancc with Food Law't 4-501.211 Manual tin Tem Temperatures* 3-201.12 es* Water 3-201.12 Food in a Hermetrcall Scaled Container* Samuzation Temperatures' 3-201.13 Fluid Mil k and Milk Products * 4-501.112 Mcch nical Ware-washing Hot Water 3-202.13 Shell Lggs* Sanitization Tem erature�* 3-202.1.4 E<>rs and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, concentration and hardness. * 3-202.16 Ice Made From Potable Dririrc ng Water* 4-601.11(A) Equipment Food Contact Surfaces and 5-201.11 llrinkin Water fn'>m an A roved S Stem* - Utensils Clean* 590.006(,4) Bottled Dr akin Water 4-602.11 Cleaning Frequency otEquipmentFood- 590.0(16(8) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Shellfish arid Fish From an Approved Source q-702.1 I Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of ui stent* Shellfish' 4703.1 I 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 Authorrt 2-301.11 Clean Condition-Hands and Arms" Reou{ato - 3-202.18 Shellstoek Identification Presem* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Came Animals* 11 Good Hygienic Practices g ReceivingiCondition 2-401.11 Eating,Drinking or Usin Tobacco" 3-202.1 1 PHFs Received at Pro ler Tem eratures* ?-401.12 Discharges From the Eyes, Nose and Pucka elute it"` Mouth' 3-202.15 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventin Contaminatiat iYiten fasting"' 6 TagstRecords:Shelistock 12 Prevention of Contamination from Hands 3-202.18 Shetlstock Identification * 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained" Em tlovees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite ords:Fish Conveniently Located and Accessible 3-402.12 Records-Creation and Retention* 5-203.11 N cation and Ca iement" 590.0(4(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 3-502.13 S ecializett Processing Methods 6-301.11 Haadwashin Cleanser,Availability 3-502.12 Reduced ax en taeka nng,criteria`' 6-103.12 Collrennance wah A roved Procerhnes* 6-301.12 Hand Drviro,Provision *Denotes critical item in the Wesal 1999 Fond Cone or 10i CNIP 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: hi 1A I, I C 17,1 Date: Js' 6 Page: a of Item Code C-Critical item t DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date } No. Reference R—Red Item ` O�-P /, se PRINT c�enaw - �... lU/ Verified' , d 7Y79 1 �P- � S 141 AOM41 IV49 11IT t`'S ll _ l /IP s ✓ C m F S / a /7 c� 4 /?G U _a ek '' ;ink h _ d lcl'1 n) " '' - rvodv S i ne� h IVZPbfl�, 1/t Sf �Y DS m . 1LeI n V . f a6 US Y'll�i Li v '-I t n 1 Ee 2 rnQ Ln 1 oc o 0FP d S ad K D 2whiotniklod at .t OY s 4F t � , Discussion With Person in Charge: Corrective Action Required: - ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ voluntary compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion p Cl 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 dSoars r s pe sio revocation of ❑ Embargo Ll Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: 3-5()I.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°F145°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-5(31.'15 Coolinn Me hods for PHFs 14 14 Food or Color Additives PHF Hot and Cold Holding 3-50 E M(B) Cold PHFs Maintained at or below '3-202.12 AUdttiFoc' 590.004(F) 41'!45°P'* 3-302.14 Pmtutton from Una r»roved .Additives* 3-501.16(A) Hot PHFi Maintained at or above IS Poisonous or Texic Substances 40'F. * 7-1011! Iontifyingln'}or5itatioir-Original Qvttainers* F.3-50I16(A) Roasts Held at or above )30° '" 7-1()2.11 Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Se-.amnion-Sturaee", 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Re airentent 7-202.12 Conditions of Use* 7.203.11 'toxic Containers-Prohibitions»` REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Satntizers,Criteria-Chemicals* POPULATIONS(HSP) 7-20-1.12 Chemicals for Washing Produce Criteria* 21 3-801.1 1(A) Unpasteurized Pre-packaged Juices and Beverages with Warnme labels* 7-204.14 Urvin Agents.Criteria* 3-801.11(13) Use of Pasteurized Bees" 7-205.11 Incidental Food Contact. Cttbricants* 7-206.1 1 Restricted Use Pesticides. Criteria* 3-801A 1(D) Raw,or Partially Cooked Animal Food and 7-206.12 Rodent Bait stations- Raw Seed S gouts Not Served. :' 3-801.11(C) Uno ened Food Package Not Re-served. " 7-206.13 'tracking Powders,Pest Control and Monrtorina* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods Tltat are Raw, Undercooked or 16 Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate 3-401.1 IA(1)(2) Eggs- 155'F 15 Sec. Patho ens ` " E es-Lnmedtate Service 145°1715sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 33-401.11(A)(2) ('omminuted Fish, 6Meats&Game L Animaals- 155°F 15 se 3-401.)1($)(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, It 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 Ratite065-F 35 sec. * above if related to foodborne illness 3-401.1I(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 Crooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3-401.11(A)(1)(b) .All CJtber PHFs-145°F '15 see. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403._11(A)&(D) ` PHFs 1650F 15 sec. * (ltetrr,23-30) 3-403ATE) Microwave-165°172 Minute Standing Critical and non-critical violations, which do not relate to the Tone* _foodborne illness interventions and risk firctors listed above, can be 1403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140°F* 590.000. _ 3-103.11(E) Rernaotine Uusiiced Portions of Beef item Good Retail Practices FC 590.000 Roasts* 23. Marra ement and Personnel _ FC-2 .003 -- 1g Proper Cooling of PHFs 24 Food and Food Protection _ FC 3 , .004 3-5O1.14(A) Cool25 Equipment and Utensils ing Cooked PHFs from t40°F to - - - 26 Water,Plumbin and Waste FC-5 x_006 ---- - 7 'F Within 2I-tour and From 70°F. 7T ph sical Faculty _ FC-6 I .007 to 41°F/45°F Within 4 Hours. " 28. Poisonous or Toxic Materials_ FC-7 .008 3-50114(B) Cooling PHFs Made From Ambient 29. S eeial Re ulrements _ .009 Temperature hig ediems to 41°F(45°F 30.___ .Other __L..... Within 4I-Iours" Denotes critical ilcm 3n tiro foderal 1999 Food Code or 105 CMR 590.WO. r CITY OF SALEM BOARD OF HEALTH Establishment Name: ah Date:Date: Page: of Item Code C-Critical nem ? DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified' ., PLEASE PRINT CLEARLY oS`E RoaYl) ak Mau u Kef -qer/rfDys Dave cv o Ier2s a rFra a� OC41 Qy Y n Qndtc�ash c s-, �� Q Moues+ CCeI.� 2 N f Sa (C - C I � - t t. Discussion With Person in Charge: Corrective Action Required: ❑ No O Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand thay� noncompliance may result in daily fines of twenty-five d I s r •spe s'66/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: 3-50L14(C) PRFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Iatw Cooled to Factors(items 1.22) (Cont.) 4FF(45`F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501-'15 Coolinn Methods for PHFs 14 Food or Color Additives 1g PHF Hot and Cold Holding - 3-501.16(B) Cold PHFs Maintained at or below, 3-202.12 Adddises'.... 590.004(F) 41'!45°F* 3-302.14 Protection front Uta a roved Additives* 3-501.16(A) Hot PHFs Maintained at or above 1j Poisonous or Toxic Substances 40'F. * 7-101.11 Identifying Information-Original 3-50116(A) Roasts Held at or above 130'F. Canainers* 7-102.11 Common Name-Workinn Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storage" 3-501-19 Time as a Public Health Control* 7-20211 Restriction-Presence,tad User 590.004(H) V<'ariance Re uirement 7-20212 Conditions of Use" 7-203.11 Toxic Containers-Prohibitions% REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanrozets,Criteria-Chemicals* POPULATIONS(HSP) 7-20312 Chemicals for Washing Produce,Criteria* 21 mo 1.1 1(A) Unpasteurized Pre-packaged Juices and 7-204.14 Beverages with Warning I..abels* D 9na. ents.Criteria' -- �- 3-801_11 B) Use of Pasteurized Eggs* 7-2( 11 Incidental Food Contact.Lubricantfl* 7-206.1 1 Restricted Use Pesticides.Criteria* 3-801,11(D) Raw or Partially Cooked Animal Food and Raw Seed S grouts Not Served. .F 7-206.12 Rodent Bait Stations* 3-80'1.1I(C) Uno ened Food Package Not Re-served. 7-206.13 'Prack'ing Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.71 Consumer Advisory Posted for Consumption of Animal Foods'Ifiat are Raw.Undercooked or I6 Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate erra�y�e 3-401.11A(t)(2) Eggs- 155"F 15 Sec. I alto ins.* 1111,2eor E ts-bnn)ediate Serwicc 14VF=15sec. 3-302.14 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish, Meats&Game E gg* Animals- 155°F 15 sec. " 3-401.11(B)(1)(2) Fork and Beef Roast- 130°F 121 min* SPECIAL REQUIREMENTS 3-401.11(A){2) Re�tites,Injected Meats-155°F 1.5 590.009(A)-(D) Violations of Section 590.009(A)-(D)in ,we.' catering, mobile food,temporary mid 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultr,or Radres-165°F 15 s� 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)(I)(b) All Other PHFs--145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.1 l(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 he 3-403.11(C) Commercially Processed RTE Food- ,tound in the following sections Qf the Food Code and JOS CMR 140'F` 590.000- 3-403.t 1(E) Remaining U'nsliced Portions of Beef Item Good Retail Practices FC 590.000 Roasts* 23. Mena ement and Personnel FC-2 .003 I8 Proper Cooling of PHFs 24. _ Food and Food Protection _ _F_C--3 .o04 25 ___Equipment and Utensils _ FC4 ._005 3-5(}1.1.4(A) Cooling Cooked PHFs from 140`P to 26 _ Water, Plumbing and Wasto FC 5 .006 70`F Within 2 Hours and From 70'F 27. Physical FacilityFC-B 007 - to 41'F/45'F Within 4 Hours. * 28Mat. Poisonous or Toxic Materials FC=7 .008 3-SOL 148) Cooling PHFs MadeFrom Ambient 29 S eciaiRe utremonts _ 009 Temperature ingredients to 41 OF/45'F 30 _ Other �- Within 4 Hours'" ssoon,m.n-Hsxm,� Denotes critical nein in The Federal 1999 Food Cod:or 105 CMR 5905700. � a- . CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH,RS,CHO NINE NORTH STREET HEALTH AGENT Tel:(978)741-1800 Fax:(978)740-9705 NOTICE OF VIOLATION STATE SANITARY CODE CHAPTER X 105CMR 590.021 The Salem Board of Health will be Strictly enforcing the regulation stating that all openings to the outside shall be effectively protected against rodents, flies, cockroaches, and other insects. Included in this mailing is a copy of that notice. Recently, your establishment was conducting business in violation of the State Sanitary Code due to; Reason: DOOR IN OPEN POSITION Date: 5/5/04 Please remedy this situation by keeping your doors and/or windows closed or by affixing appropriate protection to these outer openings. If you are seen violating this regulation again you will be issued a fine for each day the violation exists. Establishment: CHIPS VARIETY Address: 72 WHARF ST. , SALEM Reply to: Owner: CHESTER & LISA HINCMAN D. GREENBAUM V. MOUSTAKIS SANITARIANS jvvio-sc.wpd P 1 M1 R CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH, RS,CHO NINE NORTH STREET HEALTH AGENT Tel:(978)741-1800 Fax:(978)740-9705 NOTICE TO ALL FOOD SERVICE ESTABLISHMENTS Insect and Rodent Control The Salem Board of Health strictly enforces the Commonwealth of Massachusetts Regulation 590.021 : Insect and Rodent Control A) General. Effective measures shall be utilized to minimize the entry, presence, and propagation of rodents or of flies, cockroaches, and other insects. The premises shall be maintained in a condition that prevents the harborage or feeding of insects or rodents. B) Openings. Openings to the outside shall be effectively protected against the entry of rodents. Outside openings shall be protected against the entry of insects by tight-fitting, self-closing doors, closed windows, screening, controlled air currents, or other means. Screen doors shall be self-closing, and screens for windows, skylights, transoms, intake and exhaust air ducts, and other openings to the outside shall be tight-fitting and free of breaks. Screening material shall not be less than 16 mesh to the inch. Furthermore, if doors to your establishment are noticed open without the protection of a self- closing screen door or other effective means of protection you will be ordered to appear for a hearing before the city Health Agent and the Board of Health or be issued a fine. If you have any questions, please callus at (508) 741-1800. Reply to: DAVID GREENBAUM VIRGINIA MOUSTAKIS SANITARIANS jvscreen.wpd I I • i � M1 1� �F CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH,RS,CHO NINE NORTH STREET HEALTH AGENT Tel:(978)741-1800 Fax:(978)740-9705 NOTICE OF VIOLATION STATE SANITARY CODE CHAPTER X 105CMR 590.021 The Salem Board of Health will be strictly enforcing the regulation stating that all openings to the outside shall be effectively protected against rodents, flies, cockroaches, and other insects. Included in this mailing is a copy of that notice. Recently, your establishment was conducting business in violation of the State Sanitary Code due to; Reason: DOOR IN OPEN POSITION Date: 5/5/04 Please remedy this situation by keeping your doors and/or windows closed or by affixing appropriate protection to these outer openings. If you are seen violating this regulation again you will be issued a fine for each day the violation exists. Establishment: CHIPS VARIETY Address: 72 WHARF ST. , SALEM Reply to: Owner: CHESTER & LISA HINCMAN D. GREENBAUM V. MOUSTAKIS SANITARIANS jvvio-sc.wpd 3 gl 11jIF 4 CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH, RS,CHO NINE NORTH STREET HEALTH AGENT Tel:(978)741-1800 Fax:(978)740-9705 NOTICE TO ALL FOOD SERVICE ESTABLISHMENTS Insect and Rodent Control The Salem Board of Health strictly enforces the Commonwealth of Massachusetts Regulation 590.021 : Insect and Rodent Control A) General. Effective measures shall be utilized to minimize the entry, presence, and propagation of rodents or of flies, cockroaches, and other insects. The premises shall be maintained in a condition that prevents the harborage or feeding of insects or rodents. B) Openings. Openings to the outside shall be effectively protected against the entry of rodents. Outside openings shall be protected against the entry of insects by tight-fitting, self-closing doors, closed windows, screening, controlled air currents, or other means. Screen doors shall be self-closing, and screens for windows, skylights, transoms, intake and exhaust air ducts, and other openings to the outside shall be tight-fitting and free of breaks. Screening material shall not be less than 16 mesh to the inch. Furthermore, if doors to your establishment are noticed open without the protection of a self- closing screen door or other effective means of protection you will be ordered to appear for a hearing before the city Health Agent and the Board of Health or be issued a fine. If you have any questions, please call us at (508) 741-1800. Reply to: DAVID GREENBAUM VIRGINIA MOUSTAKIS SANITARIANS jvscreen.wpd COURT DOCKET NO. S CITATION NO. CITY OF SALEM D pq 1 c c 5 VIOLATION NOTICE.r V NAME(LAST,FIRST,INITIAL) STREETADDRESS CITY/TOWN STATE ZIP > S Sdin 0 a LICENSE NO. LIC.EXP.DATE DATE OF BIRTH OWNERS NAME(LAST,FIRST,INITIAL) t 9 f�/(S STflEETAD/D'R'ESS CITY/TOWN STATE ZIP W REGISTRATION NO. STATE EXP.DATE MAKE?1'PE I YEAR COLOR i DATE OF VIOLATION TIME DATE CITATION WRITTEN PERSONAL ❑AM WuRr ❑YES ..! ❑PM `-07`-O El NO LOCATfON OS Vty IOIAA'TION*'c 0414a& NFORCING DEPT Gil L' '$ a z7�1 OFFENSE/ T_ eg> /;tJ CH . SECT JEWjE]S A Q O G aim �b B C OFFICER I.D.NO. TOTAL /S NE DIUE OFFFhCEE]RR CERTIFIES COPY GIVEN TO VIOLATOR IN PANID X !/ Q�� -r�J El Y 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 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 �60URT DOCKET NO. , CITATION NO. CITY OF SALEM nDAti 0O VIOLATION NOTICE r NAME(LAST,FIRST INITI'A'L``). STREET ADDRESS %Y WN //STATE -� ZIP 7R >li%aoR, S7'• _ ;lir ;;y(4 LICENSE NO. LIC.EXP.DATE DATE OF BIRTH OWNER'S NAME(LAST,FIRST,INITIAL) STREETADDRESSCITYROWN STATE ZIP cc REGISTRATION NO. STATE EXP.DATE MAKETYPE YEAR COLOR DATE OF VIOLATION TIME T/ DATE CITATION WRITTEN PERSONAL El AMs�� I INJURY El PM E]NO LOCATION OF VIOLATION ENFO ING DEPT_ 'A,Air //7�f°/P 1�s-/'7r f��l�'QF.�1 d4}` OFFENSE // ' CHeP. S,ECi FINES A oc'''wl /Kl 'O lrJ�Y/J_'IN A Q7� '. B C OFFICER yyJ I.D.NO. TOTAL@ CY FINE ✓ /'/GLIAS fcY�'S/� DUE W /'^V• OFFICER CERTIFIES COPY GIVEN TO VIOLATOR ��') }�• ❑ IN HAND X ❑ BY 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 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 ' CITY OF SALEM, MASSACHUSETTS �o r BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR �S SALEM, MA 01970 ✓,y�, TEL. 978-74 1-1800 FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH. RS. CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94 , Section 305A and Chapter III , Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to : Owner ' s Name : Chester & Lisa Hincman Name of Establishment : Chip ' s Variety Address of Establishment : 72 Wharf Street Type of Establishment : RETAIL FOOD Application Date : 01/10/2003 Restrictions : Permit for Food Establishment 252-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 57-03 These Permits Expire December 31, 2003 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. 1 Al (((( HEALTH AGENT i I CITY OF SALEM, MASSACHUSETTS �. e}v BOARD OF HEALTH JAN 0 9 2003 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 -�.a, - _L TEL. 978-741-1e00 BOAR1 L.i %1� HEALTH FAX 978-745-0343 STANLEY USOVICZ, JR, JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2003 APPLICATION FOR PERMIT TO O ERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT--� TEL#� � �' ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different) OWNER'S NAME r91�""'q ADDRESS (hqq3 CITY U STATE ZIP CERTIFIED FO MANAGER'S NAMES} CERTIFICATE#(s) (required in an establishment where potentially hazMds food is prepared.) EMERGENCY RESPONSE PERSONJ�dt$ (..JU) HOME TEL#gye l F} / J l HOURS OF OPERATION: Mon. Tue 't Wed. r` Thu. `` Fri. " Sat.--(O Sun.Z ry� TYPE OF ESTABLISH FEE check only RETAIL STORE YE ) NO less than 1000sq.ft. =$ 50 a 1000-10000sq.ft. =$104 more than 10,000sq.ft. =$250 RESTAURANT YES NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES M $100 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVE NO $5 TOBACCO VENDOR �YE,SI NO s�� $50 , ALL NON-PROFIT(such as church kitchens) YES /�'�� $25 / Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that 1, to my best knowledge and belie , have filed all state tax returns and paid all state taxes required under the law. Signature Date �� Social Security or Federal Identificakion Number Revi ed 11 0 FOODA .adm Check#&Dated —'0 3 � THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 120 Washington Street, 4th Floor BOARD OF HEALTH Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 745-0343 Namen `�• - / / D IV, T f i n T f In i n l/ 0 Food Service Routine Address p ,� �..P_ Risk ❑ Retail Re-inspection W 1 _ Level ❑ Residential Kitchen Previous Inspection Telephone /_ ❑ Mobile Date: Owner HACCP Y/N El Temporary ElPre-operation ZL 1K6 ❑ Caterer ElSuspect Illness Person in Charge(PIC) /Q - Time ❑ Bed&Breakfast El General Complaint - /'� In: ❑ HACCP Inspector- Out: Permit No. ElOther Each violation che6kea requires an explanation on the narrative page(s) and a citation of specific provisions) violated. Mon-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) 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. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 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 SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) F-1 4. Food and Water from Approved Source El16. Cooking Temperatures El 5. Receiving/Condition 17. Reheating El6. Tags/ Records/Accuracy of Ingredient Statements El .,_ 7. Conformance with Approved Procedures/ HACCP Plans PROTECTION FROM CONTAMINATION ❑ 18. Cooling 19. Hot and Cold Holding ❑ 20. Time as a Public Health Control ❑ Separation/Segregation/ Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 9. Food CAdequate Handwashing Contact Surfaces Cleaning and Sanitizing El 10. Proper El21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 11. Good Hygienic Practices { ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related Items) Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/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)(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)(590.008) 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: V Y � PIC's Signature: Print: Pag,of Zpages FORM 734A HOBBS&WARREN - BOSTON Violations Related to Foodborne Illness 4 Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION "8- Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 590.003(A) Assi nment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11 Person in Charge-Duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment r'2r. 590.003(C) Responsibility of the Person in Charge to 3-302.1](A) Food Protection* require reporting by Food Employees and 3-302.15 Washing Fruits and Vegetables ..,,R. 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 Charge* Contamination from the Consumer -3-306.t4(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated 3t' 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE 4 Food Contact Sulfates Food and Water From Regulated Sources 4-501.111 Manual Warewashing-Hot Water 590.004(A-B) Compliance with Food Law* Sanitization Temperatures* 3-201.12 Food in a Hermetically Sealed Container* 4-501.112 Mechanical Warewashing-Hot Water 3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures* 3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.14 Eggs and Milk Products, Pasteurized* Concentration and Hardness* 3-202.16 Ice Made from Potable Drinking Water* 4-601.11(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved System* Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Shellfish and Fish 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 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 Wild Mushrooms Approved by Regulatory Authority 2-301.11 Clean Condition-Hands and Arms*3.202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* 11 Good Hygienic Practices 3-201.17 Game Animals* 2-401.11 Eating,Drinking or Using Tobacco* '.5 Receiving/Condition 2-401.12 Discharges From the Eyes.Nose and 3-202.11 PHFs Received at Proper Temperatures* Mouth* 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-101.11 Food Safe and Unadulterated* ;.t2;. Prevention of Contamination from Hands 6' Tags/Records:Shellstock 590.004(E) Preventing Contamination from 3-202.18 Shellstock Identification* Employees* 3-203.12 Shellstock Identification Maintained* F1 Handwash Facilities Tags/Records: Fish Products Conveniently Located and Accessible 3-402.11 Parasite Destruction* 5-203.11 Numbers and Capacities* 3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement* 590.004(1) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance J: Conformance with Approved Procedures Supplied with Soap and Hand Drying /HACCP Plans Devices 3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability 3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision 8-103.12 Conformance with Approved Procedures* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: C_ �` Date: P- Page: of Z Item Code C-Critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY/r�J P 42, �� b U�i /fitcc Lac % OR k t� }4 ,f S ^ ", :f S i TTaY Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes i have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension 3 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: i 3-501.14(0 PHFs)received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According*to Taw Cooled to Factors(items 1-22) (Cont.) _ 41°F/45°F Within 4 Hours, M PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs I4 Food or Color Additives 19 PHF Hot and Cold Holding 3-501.16(B) Cold PHFs Maintained at or 6111111 3-202.12 Additives* 590.004(F) 4l !450 F* 1-30114 Protection from Unapproved )ak hives* 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 140'17' 7-101.I] klentifying Information-Orignnai 3-501.16(A) Roasts Held at or above 1.30'F. Containers" 7-102,11 Common Native-Working Containers* 20 Time as a Public Health Control 7-201.1.1 Se oration-Biota e* 3-901.19 Time as aPub]ic Health Control* 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanifizeis.Criteria-Chendcals* POPULATIONS(HSP) 7-204.12 Chemicats for Washing Produce, Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drying Agents.Criteria` _. Beverages with Waiting Labels* 7-201.1.t Incidental Food Contact,Lubricants* 3-801.11(13) Use of Pasteurized Eggs* 7-206.11 Restricted Use Pesticides,Criteria" 3-301 1.1(D) Raw of Partially Cooked Annual Food and Raw Seed S rrout'a Not Served 7-206.13 Trac.km- Powdderss,, Pest Control and 7-206.12 Rodent Batt r3-801.tI(C) Unopened Food Package Not Rei-servedd P Monitoring* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consurner Advisory Posted for Consumption of Animal Foils That are Raw, Undercooked or Ib Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate 3-401.11.A(t)(2) Eggs- 155'F 15 Sec. Patho<e,ns' 1 gas-Immediate Service 145gFl5sec.k 3-302.13 1 Pasteurized Eggs Substitute for Raw She11 3-401.11(A)(2) Comminuted Fish.Meats&Game Eggs* A ihnals- 155'F 15 see." SPECIAL REQUIREMENTS _ 3-40l I(B)(1)(2) Port and Beef Roast- 13055 121 min* 590.009(A)-(D) Violations of Section-590.009(A)-(D)in 3-401.L 1 (A)(2) Ratites, Injected Meats- 159'1^ IS see. * catering, mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should he Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sec. * above if related to foodborne illness -T--401 1 1(0)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145'17 1 _ 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. I7 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-10111(A)&(D) PtIFs 165'F 15 see. " (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 i tsk,factonc listed above, can be 3-40)3,1.1(C) Commercially Processed RTE Food- found in the follmving sections of the Wood Code and 105 CMR 1400F* 590.000. 3-403.11(E) Remaining Unshced Portions of Beef I Item I Good Retail Practices ; FC 590.000 - Roast.%* 123 1 Management and Personnel , FC-2 ,003 24. Food and Food_Protection FC-3 .004 1g Proper Cooling of PRFs - 25 ; Equipment and Utensils _ FC 4 _.005 __.-- 3-501.14(1) Cooling Cooked PF{1^s from 740°F to 26. Water,Plumbing and Waste1_FC-5 .006 70'F Within 2 Hours and From 70'17 ` 27. Physical Facility _FC-6 .007 to 41"F/45"I Within 4 Hours. * _28 Poisonous or Toxic Materials FG-7 .008 3-501.14(8} Cooling PHFs Made From Ambient 29 i-Special Requirements _ .009 _I Temperature ingredients to 41'F745'F 30 Other Within 4 Hours" .asmimnnaac-r o-� *Denoros crnicat iters in the federal 1999 food Code of U)5 CNIR 590.000. RE "'" �}� � • 4^ .,{�A .rte� x + -1�� '�X��,� fi"'� � i�` I P�i•� i.'!gy-�<{}� �P� ,4 R Wk, s ,' r ':#4' a - r YI -viy:x�•i`' ay, R w'k .:p it � �'r'• t'h ' 3s.�J`r ` x: i ' t*Ts'a ra'?r ..p?X 45�, "•k g13 ' �A( "•Y3. yy_,yyate�L�..[ }$y Pm' M * S ah !f p .Y rYg3,�1'l6•yi N �`^S nu � '- x' rFa' ' .G x •qa aty' g#;(tom ., �y^ �e 'tr r a r "Dfs, vfir .✓�,'+{sr�,.,. as•x .1xFY1•S•` �+ '�,. +zf� aq A•<nsu.otio��ntis osuoas�dsusseedas�o;2aqx•�a�apo�a��se?s3aF5s�uega�o�5yua stdasnb.9 sat3simo ;as.um2RpkJ{'Fx{�sIP"ao{Wa�3oa12!1.x„�uqsquauewosd =,yr �i 4 uoi 2 0 . •ua ttISos E Lt pa o a ssuII a 'Etaxa a u -s s;oo : so dis�ssasuyo oa uo ansa az aq nus , aygesa auQs �ou s., ra St ,w t _ .• k.•.., � .. .,.; - � ' sad oa aai s -nuza {*ase � -�� ”. - - a s�r.� q��sg •`003. �o "�wxa U31101: swsa pp E /ati a� A $ QC10°3 x (tSS2�2 � A�pp�T uaw m ., s, i '��uautuak '`gEs3 �OQa 99T. y " �• •� ,{dr# a " u�aaiT ` op�a�uaz6 �'q, xasr ivat�2g ;� � a, ai,�� ua �uaunis jge�sS poo . a��:zado o� 'sM t2yzaua� a �- o � uot' a5 � I�� .za• d2u�. pug, FISOEuvou {FA9 ��4�P �C�rzoq�nle a a�,eb o suot�atn q• �ny aou2pzoo�aRRuz . SdtL3SIIH�'dSS 30 sHS'------ deK w fp.i � � 1 it +`i� ,k � v� �+j i�S*': 4 �•�}x�$ x��.l vv µ� 1 � ' � . „x'5t 3 r` R, r `-rx@3 '� _ ,#n � , a a -'� -•t.�., �G � of r ya,G•r 0081 1 t BG'�3,11 <�� t '� 6 s ii� � .'�' :.Y 21001 Hly.•yP33 1S� N0,10�Stl/1A.OZ l� +`� ; �y,-y'f.y' uz � � r r� :w�' ,�•'a ` 'a�n�. 'eK"�tkb "F?` ♦ Sir«.at ,,3.3a-^• 'v��" CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH ° - 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA O1970 � � ro,id(I �p TEL. 978-741-1800 l,"�JJ FAX 978-745-0343 J$}g STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO DEC +��R1 � MAYOR HEALTH AGENT '1 v CITY OF SALEM HEALTH CEPT. 2002 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT TEC# r1Sj " ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different) OWNER'S�NLLApME � .S/, TEL#�r✓ -le Ga ADDRESS - A4 FhIi4 .c-7 CITY STATE ZIP CERTIFIED FOOD MANAGER'S E(S) CERTIFICAT :#(s) (required in an establishment where potentially hazs food is prepared.) ardo EMERGENCY RESPONSE PERSON_ HOME TEL* 7a 020,53— DAYS/HOURS OF OPERATION: Mon._ y ue. c Ned. ✓Thu. --Fn. Sat.�Sun.= 7_%ohc or, �13a Aw) TYPE OF ESTABLISHMENT — FEE check only RESTAURANTS YES NO I �j -lJc $40 BED& BREAKFAST YES (WO-) $40 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT SOFT SERVE YES $5 TOBACCO VENDOR 69S) NO�,,3`4,� $10 NO CHARGE FOR NDN-PROF! (such as church kitchens)PLEASE INCLUDE COPY OF TAX EXEMPTFORM 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 6 C, Section 49A, I certify under the pains and penalties of perjury that 1, to my best knowledge and belief have filed all state tax returns and paid all state taxes required under the law. Signature ate Social Security or Federal Identification number Revisd 11 foods m Chack#&Date i�a3 /V9��5� COURT DOCKET NO. CITATION NO. CITY OF SALEM PD 165 VIOLATION NOTICE NAME(LAST,FIRST,INITIAL) MA,e%&r t ehvs7T;: r STREETADDRE &d S y SrSS C/rrY/TOWtN SATE ZIP 'off Z4,4 vpkn. LICENSE NO. LIC.EXP.DATE TE OF BI H OWNERS NAME(LAST,FIRST,INITIAL) STREETADD ESS /TOWN STATE ZIP fia r ti:,kf / „ REGISTRAT0 T EXP.DATE MAKEITYPE YEAR COLOR .: DATE OF VI TION IME DATE CITATION WRITTEN PERSON&. J / El Am iWURY ❑PM_. ��`-f�� ❑VES ❑NO LOCATION OF IOLATION ENFORCING DEPT. c'r1./vs (,Uric V 1 7d /0/1ael Sf- OFFENSE fi'1'/Eu�fc jty .yic CHAP. SECT. FINES A c o?m3cdt�P�trA P *," . Qs= 1 U B EFFICER LD.NO. 11 / TOTAL $FINE „1 N !A. SY''7XIS DUE /`✓ OFFICER CERTIFIES COPY jSIVEN TO VIOLATOR . ❑ IN HAND X G' // (.Lf'-.PFA��,Q alBY 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)705-9595 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 t $ CASE k SIGNATURE - SEE OTHER SIDE FOR FURTHER INFORMATION '- ENCLOSE PAYMENT IN THIS ENVELOPE;PEEL AND SEAL COURT DOCKET NO. Q CITATION NO. CITY SALEM PD 1162VIOLATION NOTICE r CiL ^`'AME(LAST,FIRST,INITIAL) ///A----?� ai t C'f/SYPH Y STREETADDRESS CITYITOOWN STATE ZIP LICENSE NO. LIC.EXP.DATE DATE OF BIRTH OWNER'S NAME(LAST,FIRST,INITIAL) .�Yr=°e/hc2ll9. f? F ,wS4-'c r /-/sa.. STREETADDRESS// CITY/TOWN STATE ZIP 7 S?FPin Vii« o/Y7t REGISTRATION NO. STATE EXP.DATE MAKERYPE YEAR COLOR DAT OF- IOLA77.ION TIME DATE CITATION WRITTEN RLIRIRYNB �!ej FqAM DA; ❑VES. 9 i2 S/ ❑PM 7 Q ,2 ONO LOCATION OF VIOLATION ' ENFORCING DEPT / rt7 Y raw ,/" 7c9 Sr- OFFENSE .f+ rq/ PP CHAP. Jt/6 FIPIES A d®ri • u ytri - rFG�"cr X sc/ ab C OFFICER I.D.NO. TOTAL $ eb FINEI DUE OFFICER CERTIFIES COPY GIVEN TO VIOLATOR 7^f �-- El IN HAND 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 (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 #' vCOURT DOCKET NO ...CITATION NO CITY OF SALOM p `JJ}} r_ &ti VIOLATION NOTICE;'PD 6L, NAM£{LAST,FIRST.INITIAL)...: Ches A-A 9 I JSe STREET ADDRESS CITY/TOWN STATE ZIPS { i ,Y`9 I �° ��,Y..: - faS LICENSE NO. -I Kf DATE t DATE OF BIRTH j �,OWNERS NAM `"YI=a �$, . '�«�;j' K `It''` " >!�'T i✓C+"'a?ae7�i?' PSfC x ADDRESS/ - CITY/TOWN/STATE ZIP , y iT hA �' `#yREGISTRATION NO. STATE EXP.DATE MAKET'PE YEAR COLOR -of '.' PEPSONN. DATEOFy1OL4TlO TIME DATE CRATIONW iRTEN mum Y y3eO 7.; FS 9b"a+Fyl`iY ❑PM j-G7�/-�� O , v. - LOCATION OF VIOLATION r'Y I�.S I. Q/tom ENPIJRCI¢GREPT. ,°d � i ' "'+ �..i� OFFENSE: f:d Cr e 'CHAP. S F#ES 3 1 , �� `a ,/dos; Ten�t[Jai�✓— c9w"cam t , N04 QY 7- 11 - ' { S� "b i �"� OFFICER I.D.NO-1TOT, "Gb. y} �O# a d' �. sap ry % i� r. �. ,w . n.I ... ,J,,� FINE. .. /�7LCSY DUE u"`" OFFICER CERTIFIES COPY GIVEN TO VIOLATOR ' `ted W ; IN NO BY.MAIL rG T, ' s �3 v, �` hf<a, '»�'� BT _' "` DO NOT MAIL CASH-PAY ONLY By POSTAL NOTE,MONEY'' ORDER OR BY CHECK MADE PAYABLE TO: '} CITY CLERK '- o� ' ym CITY HALL J ' '' v a m' r * i'7 u� ) oy.•• i 93 WASHINGTON STREET SALEM;MA 01979 y k s w f TEL (508)7459595 X 251 - '"' ' -.' "HEREBY ELECTTO EXERCISE THE FIRST OPTION AS STATED ON - CHARGED AND ENCLOSE a. -'REVERSE CONFESS 70 THE OFFENSE, - �AYMENT IN THE AMOUNT OF i$ CASE# <i IGNATURE s SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT.IN THIS ENVELOPE,PJ AND SEAL COURTDOCKETNO. CITATION NO, CITY OF SALEM PD 'VIOLATION NOTICE_ 1 U G NAME(LAST,FIRST,INITIAL) STREET ADDRESS CITY/TOWN STATE ZIP S « o e LICENSE NO. LIC.EXP.DATE DATE OF BIRTH OWNERS NAME(LAST,FIRST,INITIAL) STREET ADDRESSCITV/TOpWN STATE ZIP C V RE ISTRATION NO. STATE EXP.DATE I I MAK PE YEAR COLOR DATE OF VIOLATION TIME DATE CITATION WRITTEN PERSONN- �a/_0a ❑PM IMURY ❑VES LOCATION OF VIOLATION / ,2S pi R/F 7/ ENFOFiLINNGJ PT. 7 2 S-� _'7 Q'Nar OFFENSE (AI p O �— CHAP. SECT. FINES A �pcS�f7�i14'�d/f✓—t9GlJxL.4• X .oq �k- B �/rdL47�7p'>/ /w�7,2�WdvS C OFFICER I.D.NO. TOTAL 670/ FINE DUE OFFICER CERTIFIES COPY GIVEN TO VIOLATOR El IN NO �X Q[/rJ/ /� Y 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 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 N SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL 4 ew me TM fHG "`GOURT OOCKETNO, ORATION NO <: �T CITY°OF SALEMPD 1 VIOLATION zNOTI)CE, Y NAME(LAST,FIRST,INITIAL)' jV�jj� E ,(,// ,.y p !/� O 1'� '•f� '� ¢� i -tet �� l �I'/��W/r lJ.t//C15�/� � STREET ADDRESS CITY//TOWN `S�TATE ZIP .`{ n T LICENSE NO. .DATE E DATE OF BERTH J, OWNERS NAM x=9. 8 " `B.,F ? ,' '� a s, LF* 13q "Tt` �/YCa"171eZ�T' PSl'c•/Z'1r'�/SQ..` _ t o (' STREETADDRESS CITYITOWN STATE ZIP ` F REGISTRATION NO. STATE EXP.DATE MAKER PE YEAR COLOR- .� P d : $-{ � - ,4� i 0A'lE OF>/IOI.ATIa TIME - DATE ORATION W�tITTEN IWURO' i dd'' dd 11 �fffAM �. Ery�pRC{(� yk. . ' s-w: ��d�T1 •F '! LOCATION OF VIOLATION � /�,lJS(rf�'Rft Ty 1+3C7-C�PT 70 G^!lAa ec S gleatTy° x 1Y . n a as OFFENSE .�i✓.f7z�P.+f�i_ei�y,r1 `GHRF. s F7IEs y {'n 0 \1TYE 'fa A �cS7�^tJ'4�d/x s C!_.^x 4_ ,e1 X ` fal, /�`: -P"` iV $ r, tj. _$'{�iD�y7 J1>71 J ✓�Ti� dCS I 2 � S. .OFFICER . . +, I.D.NO TOTA Gb' vC1 6.ei.,,Lam:¢ FINE �1 L_ DUE *<3 a OFFICER CERTIFIES COPY GIVEN TO VIOLATOR � T?�-"' ❑ IN BAND .� sS� EKDv.Maa DO NOT MAIL GASH PAY ONLY BY POSTAI TE,MONEY tJl- ORDER OR BY CHECK MADE PAYABLE TO: ( t CITY,CLERK 93 WAS LL WAS 93 HINGTON STREET , r} >4�` t1r0" SALEKMA01970 i TEL.(508)745-9595X251 'HEREBY ELECT TO EXERCISE THE FIRST OPTIONLAS STATED ON r VERSE,CONFESS TO-THE OFFENSE CHARGED;AND'ENCLOSE AYMENT'IN THE AMOUNT'OF^$ CASE I - SIGNATURE - SEE OTHER SIDE FOR FURTHER INFORMATIONR ?;ENCLOSE-PAYMENT INTHIS ENVELOPE,PEEL AND SEAL-: 1< THE COMMONWEALTH OF MASSACHUSETTS -CITY • OF SALEM Address: 9 North Street Board of Health Salem, MA 01970-3928 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978)1740-9705 Name / Dae 5[ffFood enation s T e of Ins ection Service /Routine Address Risk IJRe-inspection 7a d f Level ntial Kitchen Previous Inspect,Telephone / 7yS� Date:Owner !5rary ❑ Pre-operation 1,v in HACCP Y/N + ❑ Suspect Illness Brea ❑ General Complaint Person in Charge(PIC) TimeV ❑ HACCP P t�P.0 iLGY✓I(/�✓1 Inspector In: ❑ Other Out: Permit No. Each violation checked requires an explanationhe tive page(s) and a citation of specific provision(s) violated. Non-compliance with: RED Violations 1-22 Related to Foodborne Illness 0. rv et ns and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health haz rd and quire immediate corrective 590.009(E)❑ s9o.00g(F)❑ action as determined by the Board of Health. . a Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities- EMPLOYEE acilitiesEMPLOYEE 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 SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source ❑ 16. Cooking Temperatures ❑ 5. Receiving/Condition ❑ 17. Reheating ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 18. Cooling ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20. Time As a Public Health Control ❑ 8. Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 21. Food and Food Preparation for HSP E110. Proper Adequate Handwashing CONSUMER ADVISORY 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories r` BLUE Violations(23-30) 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(RED Items 1-22):Official Order of Correction: Based on an inspection' ' / 7 o; ', of Health. Non-critical (N)violations must be corrected ad 9 ]- immediately or within 90 days as determined by the Board of Health. today,the items checked indicate violations'of 105 CMR C N 590.000/Federal Food Code.This report,when signed below 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-4)(590.005) cited in this report may result in suspensionor revocation of 26. Water, Plumbing and Waste (Fc-5)(59o.006) the food'establishment permit and cessation of food 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: S.59XMPp Fam 14 dX Inspector's Signature: !)/ Print: PIC's Signature: !/ Print: Page) , A�C,� g L of_Pages Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION AND MANAGEMENT IF_8% Cross-contamination ..1 590.003(A) 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 3-302.11(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 3-302.11(A) Food Protection* applicants* 3-302.15 Washing Fruits and Vegetables 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* Charm* Contamination from the Consumer 590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 131; 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003E 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 r. 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 Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness* 5-101.11 Drinking 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- Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 3-201.14 Fish and Recreationally Caught Molluscan 4-702.11 Frequency of Sanitization of Utensils and Shellfish* Food Contact Surfaces of Equipment* 3-201.15 Molluscan Shellfish From NSSP Listed 4-703.11 Methods of Sanitization-Hot Water and Sources* Chemical* Game and Wild Mushrooms Approved by 10 Proper,Adequate Handwashing Regulatory Authority 2-301.11 CleanCondition-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* 11 Good Hygienic Practices 115 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 Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* [ 6L 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* Ta s/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(J) Labeling of Ingredients* 5-204.11 Location and Placement* 7,1 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 Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-301.12 1 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: (,'Lii rs </,eiP-1v Date: 9- 3- d 9, Page: o2 of C ' tItem Code . C`.—Critical Item DESCRIPTION OF VIOLATION /PLAN OF CORRECTION Date No. Reference`' Fid—Red Iten( ke rLeasE rRiNtcreAiiw ,£ y •s''• Verified �]p vsrJ � ffi� /1�0 cE �u cr /?yJc �A,, k _ , � d Discussion With Person in Charge: Corrective Action Required: r ❑ No ❑Yes ,f 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 comply Exclusion with all mandates of the Mass/Federal Food Code. I understand that noncompliance may ❑ Re-inspection Scheduled ❑ Emergency Suspension result in daily fines of twenty-five dollars or susspensi•'n/re o ta/i//gqqqnn��o�'f your food permit. ❑ Embargo ❑ Emergency Closure (t—I/ Z �1I� ❑ Voluntary Disposal ❑ Other i 'p FORM 734B HOBBS &WARREN - BOSTON AP . `f Violations Related to Foodborne Illness Interventions and Risk 3-501.14(C) PHFs Received at Temperatures Factors(Red Items 1-22) (Cont.) According to Law Cooled to 41°F/45'F Within 4 Hours.* PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs I4'. Food or Color Additives 19' PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below 3-202.14 Protection from Unapproved Additives* 590.004(F) 41°F/45°F* 2L Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original 140°F.* Containers* 3-501.16(A) Roasts Held at or above 130°F.* 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-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS(HSP) 7-204.11 Sanitizers,Criteria-Chemicals* 21- 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* Beverages with Warning Labels* 7-204.14 D Agents,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.* 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.* 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of TIMEITEMPERATURE CONTROLS Animal Foods that are Raw,Undercooked or 16Proper Cooking Temperatures for not Otherwise Processed to Eliminate PHFs Pathogens.* Effective vv2001 3-401.1 IA(1)(2) Eggs- 155°F 15 Sec. 1 3-302.13-1 Pasteurized Eggs Substitute for Raw Shell Eggs* Eggs-Immediate Service 145"F 15 Sec.* 3-401.11(A)(2) Comminuted Fish,Meats&Game SPECIAL REQUIREMENTS Animals- 155*F Sec.* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.1l(B)(1)(2) Pork and Beef Roast- 130°F 121 Min.* catering, mobile food,temporary and 3-401.1I(A)(2) Ratites,Injected Meats-155°F 15 Sec.* residential kitchen operations should be 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, debited under the appropriate sections Stuffing Containing Fish,Meat, above if related to foodborne illness Poultry or Rattles- 165°F 15 Sec.* interventions and risk factors. Other 3-401.11(C(3) Whole-muscle, Intact Beef Steaks 590.009 violations relating to good retail 145°F* practices should be debited under#29- 3-401.12 Raw Animal Foods Cooked in a Special Requirements. Microwave 165°F* 3-401.11(A)(1)(b) All Other PHFs- 145°F 15 Sec.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 17.:. Reheating for Hot Holding (Blue Items 23-30) 3-403.11(A)&(D) PHFs 165°F 15 Sec.* Critical and non-critical violations, which do not relate to the 3-403.11(B) Microwave- 165°F 2 Minute Standing foodborne illness interventions and risk factors listed above, can be Time* found in the following sections of the Food Code and 105 CMR 3-403.11(C) Commercially Processed RTE Food- 590.00. 140°F* Item Good Retail Practices FC 590.00 3-403.11(E) Remaining Unsliced Portions of Beef 23. Management and Personnel FC-2 .003 Roasts* 24. Food and Food Protection FC-3 .004 X18= Proper Cooling of PHFs 25. Equipment and Utensils FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Water, Plumbing and Waste FC-5 .006 70°F Within 2 Hours and from 70°F 27. Physical Facility FC-6 .007 to 41017/45017 Within 4 Hours.* 28, poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Sp ecial Requirements .009 Temperature Ingredients to 41°F/45*F 30. Other Within 4 Hours* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. A' -tir'ri«i...v�,s•�::.-.M.-'amu.-m,�...h ']riw-�:w.-�.+`.nctiv N THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 120 Washingtork Street, 4th Floor BOARD OF HEALTH Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 745-0343 Name Date T Y f r i n T f In i n 43111,2 Q x'02/-(�2 Food Service Routine Address Risk l� Retail ❑ Re-inspection a .S Level ❑ Residential Kitchen Previous Inspection Telephone /b ❑ Mobile Date:10-61F--6rl Owner � HACCP Y/N ❑ Temporary El Pre-operation 1-/.5 o 9`-(9N/esy4 zi . ,vC ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed 8 Breakfast ❑ General Complaint ('f� NG7TIl�ryt In: ❑ HACCP Inspector X,/" vs ,YI. Out: Permit No. El Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) 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. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/ Knowledgeable/ Duties / LYJ 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 SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source El16. Cooking Temperatures ❑ 5. Receiving/Condition El6. Tags/Records/Accuracy of Ingredient Statements El 17. Reheating _ El 18. Cooling El7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 20. Time as a Public Health Control r ❑ 8. Separation/Segregation/ Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Wr9. Food Contact Surfaces Cleaning and Sanitizing ❑ 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related Items) Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1.22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/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)(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 V 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (Fc-5)(590.009) establishment operations. If aggrieved by this order, you * 27. Physical Facility (FC-9)(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: /1 Print: r/ PIC's Signature: , Print: /- -- + Page of-LPages FORM 734A HOBBS&WARREN -BOSTON C•' J Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 11 590.003(A) Assignment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients- 2-103.11 n redients2-103.11 Person in Charge-Duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2: 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) Food Protection* require reporting by Food Employees and VA 3-302.15 Washing Fruits and Vegetables mow. 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 Charge* Contamination from the Consumer 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 Restrictions 3-701.11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE 9' Food Contact Surfaces': Food and Water From Regulated Sources 4-501.11 I Manual Warewashing-Hot Water 590.004(A-B) Compliance with Food Law* Sanitization Temperatures* 3-201.12 Food in a Hermetically Sealed Container* 4-501.112 Mechanical Warewashing-Hot Water 3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures* 3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.14 Eggs and Milk Products,Pasteurized* Concentration and Hardness* 3-202.16 Ice Made from Potable Drinking Water* 4-601.11(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved System* Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Shellfish and Fish 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 Equipment* Shellfish* 4-703.11 Methods of Sanitization- Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* Y0 " Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 2.301.14 When to Wash* 590.004(C) Wild Mushrooms* 11- Good Hygienic Practices 3-201.17 Game Animals* 2-401.11 Eating,Drinking or Using Tobacco* 5 Receiving/Condition 2-401.12 Discharges From the Eyes,Nose and 3-202.11 PHFs Received at Proper Temperatures* Mouth* 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands r.6. Tags/Records:Shellstock 590.004(E) Preventing Contamination from 3-202.18 Shellstock Identification* Employees* 3-203.12 Shellstock Identification Maintained* 13- Handwash Facilities Tags/Records: Fish Products Conveniently Located and Accessible 3-402.11 Parasite Destruction* 5-203.11 Numbers and Capacities* 3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement* 590.004(7) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance 7 Conformance with Approved Procedures Supplied with Soap and Hand Drying HACCP Plans Devices 3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability 3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision 8-103.12 Conformance with Approved Procedures* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH - 2. r Establishment Name: s (� / r Date: - /-d 2 Page: of Item Code ' C-Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION �� Date No.y�; Reference R-Red Item I y`,tq x ' Y Verified • $ L¢` PLEASE PRINT CLEARLY -/--S'f- .CN PiN -L1.aS N a m✓ s v ZX oar/ a E Yzc 1 S_ n -t -/.vO'V"t vs_z 45'/ R o n �,,tc l �Fr v" ss.,� J. Yn / Polo a 7 n (-d w / O�¢i •lfru� ✓ Veiza N2L4-1,2j /Lf r4 - 62 n t52 rJ 1 le- #t{ f a/J G / Ale Re e A 1 „ e 7>XP,,0 /y2EZLI � !- - Y,f T I n / 1 i NC� A/d,a Y1i D/ W r c Pe ms, o /0461 -7 o S ey f �� IPV y' n O ti , /5 a 7A S P� p S ave S dY)'LC (o i7�7 • o P/tire G/llJ /.GCcP�LLac� C'DW %.�,o4c77d n } Discussion With Person in Charge: 6U/M/AJ 0-22'P wP t�'' Corrective'Action Required: ❑ No O Ye(s y 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 comply Exclusion with all mandates of the Mass/Federal Food Code. I understand that noncompliance may ❑ Re-inspection Scheduled ❑ Emergency Suspension s result in daily fines of twenty-five dollars or sus nsi n/revoc tion of your food permit. ❑ Embargo ❑ Emergency Closure r <— ° `�•�A�/i ❑ Voluntary Disposal ❑ Other ,v Y P FORM 734B HOBBS &WARREN - BOSTON ' Violations Related to Foodborne Illness Interventions and Risk 3-501.14(C) PHFs Recejved at Temperatures Factors(Red Items 1-22) (Cont.) According to Law Cooled to 4l°F/45°F Within 4 Hours.* PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 141? Food or Color Additives '"19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below 3-202.14 Protection from Unapproved Additives* 590.004(F) 41°F/450F* '1115 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original 140°F.* Containers* 3-501.16(A) Roasts Held at or above 130°F.* 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-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS(HSP) 7-204.11 Sanitizers,Criteria-Chemicals* 21 3-801.1 l(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* Beverages with Warning Labels* 7-204.14 Drying Agents,Criteria* 3-801.1 l(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact,Lubricants* - 3-801.1 l(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.* 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.* 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of TIMEITEMPERATURE CONTROLS Animal Foods that are Raw, Undercooked or 16° Proper Cooking Temperatures for not Otherwise Processed to Eliminate .,.,.fix PHFs Pathogens.* Enccvve 11112001 3-401.1IA(1)(2) Eggs- 155°F 15 Sec. 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* Eggs-Immediate Service 145"F 15 Sec.* 3-401.11(A)(2) Comminuted Fish,Meats&Game SPECIAL REQUIREMENTS Animals- 155°F Sec.* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.11(B)(1)(2) Pork and Beef Roast- 130*F 121 Min.* catering, mobile food,temporary and 3-401.11(A)(2) Ratites,Injected Meats- 155°F 15 Sec.* residential kitchen operations should be 3-401.11(A)(3) Poultry,Wild Game, Stuffed PHFs, debited under the appropriate sections Stuffing Containing Fish,Meat, above if related to foodbome illness Poultry or Ratites- 165*F 15 Sec.* interventions and risk factors. Other 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 590.009 violations relating to good retail 145°F* practices should be debited under#29- 3-401.12 Raw Animal Foods Cooked in a Special Requirements. Microwave 165°F* 3-401.11(A)(1)(b) All Other PHFs- 145°F 15 Sec.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 17= Reheating for Hot Holding (Blue Items 23.30) 3-403.11(A)&(D) PHFs 165*F 15 Sec.* Critical and non-critical violations, which do not relate to the 3-403.1 l(B) Microwave-165°F 2 Minute Standing foodborne illness interventions and risk factors listed above, can be Time* found in the following sections of the Food Code and 105 CMR 3-403.11(C) Commercially Processed RTE Food- 590.00. 140°F* Item Good Retail Practices FC 590.00 3-403.11(E) Remaining Unsliced Portions of Beef 23. Management and Personnel FC-2 .003 Roasts* 24. Food and Food Protection FC-3 .004 18'` Proper Cooling of PHFs 25. Equipment and Utensils FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 14TF to 26. Water, Plumbing and Waste 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(8) Cooling PHFs Made From Ambient 29. Special Requirements .009 Temperature Ingredients to 41°F/45°F 30. Other Within 4 Hours* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. e b CITY OF SALEM S BOARD OF HEALTH Establishment Name a Date: Page: of 3 item Code C Critical Item r DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION r Date ,D No. `Reference ' 'R. Red Item, '..p , Verified' 4 x '� '�' Z+' -PLEASE PRINT CLEARLY - - s• s•. [ - �7 of i 1 .O O //7` f e O ii y v IG' J.✓1 /� � ) i/il li'.,s c :c.� / 711/ .fo . n /, i -4 /) n / _ 7 .. - 7 k 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 comply Exclusion r = r with all mandates of the Mass/Federal Food Code. I understand that noncompliance may ❑ Re-inspection Scheduled ❑ Emergency Suspension result in daily fines of twenty-five dollars or suspension/revocation of your food permit. ❑ Embargo ❑ Emergency Closure � ��' ❑ Voluntary Disposal ❑ Other i L FORM 7348 HOBBS& WARREN - BOSTON JP Violations Related to Foodborne Illness Interventions and Risk 3-501.14(C) PHFs Recejved at Temperatures Factors(Red Items 1-22) (Cont.) According to Law Cooled to1°F/45°F Within 4 Hours.* PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs !L Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below t 3-202.14 Protection from Unapproved Additives* 590.004(F) 41*F/45°F* Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original 1400F.* Containers* 3-501.16(A) Roasts Held at or above 130°F.* 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-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS (HSP) 7-204.11 Sanitizers,Criteria-Chemicals* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* Beverages with Warning Labels* 7-204.14 Drying Agents,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.* 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.* 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of TIME/TEMPERATURE CONTROLS Animal Foods that are Raw,Undercooked or "16Proper Cooking Temperatures for not Otherwise Processed to Eliminate PHFs Pathogens.* Effective 11712001 3-401.11A(1)(2) Eggs- 155°F 15 Sec. 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell Eggs* Eggs-Immediate Service 145°F 15 Sec.* 3-401.11(A)(2) Comminuted Fish,Meats&Game SPECIAL REQUIREMENTS Animals- 155°F Sec.* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.1l(B)(1)(2) Pork and Beef Roast- 130°F 121 Min.* catering,mobile food,temporary and 3-401.1 l(A)(2) Ratites,Injected Meats-155°F 15 Sec.* residential kitchen operations should be 3-401.1l(A)(3) Poultry,Wild Game,Stuffed PHFs, debited under the appropriate sections Stuffing Containing Fish,Meat, above if related to foodborne illness Poultry or Ratites- 165°F 15 Sec.* interventions and risk factors. Other 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 590.009 violations relating to good retail 145°F* practices should be debited under#29- 3-401.12 Raw Animal Foods Cooked in a Special Requirements. Microwave 165°F* 3-401.11(A)(1)(b) All Other PHFs- 145°F 15 Sec.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES -17` Reheating for Hot Holding (Blue Items 23-30) 3-403.11(A)&(D) PHFs 165°F 15 Sec.* Critical and non-critical violations, which do not relate to the 3-403.11(B) Microwave- 165°F 2 Minute Standing foodborne illness interventions and risk factors listed above, can be Time* found in the following sections of the Food Code and 105 CMR 3-403.11(C) Commercially Processed RTE Food- 590.00. 140°F* Item Good Retail Practices FC 590.00 3-403.11(E) Remaining Unsliced Portions of Beef 23. Management and Personnel FC-2 .003 Roasts* 24. Food and Food Protection FC-3 .004 18<, Proper Cooling of PHFs 25. Equipment and Utensils FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Water, Plumbing and Waste 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. Other Within 4 Hours* "Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. �yeONDIT ' n b! CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH,RS,CHO 120 Washington Street 4"Floor HEALTH AGENT Tel: (978)741-1800 Fax: 978-745-0343 COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to : Owner' s Name : Chester & Lisa Hincman Name of Establishment : Chip' s Variety Address of Establishment : 72 Wharf Street Type of Establishment : RETAIL FOOD Application Date: 09/27/2001 Restrictions: Permit for Food Establishment 305-01 , Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 73-01 These Permits Expire December 31,2001 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH w� > n� C) � e a CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH, RS,CHO NINE NORTH STREET HEALTH AGENT Tel:(978)741-1800 Fax:(978)740-9705 2001 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT fy S TEL(9S S— ADDRESS OF ESTABLISHMENT 1 ap P, n' MAILING ADDRESS (if different) _ ' �1 a, n II__ II ,,,, ,,,, � I _ ll Ol�/Ca8 OWNER'S NAME CY ef)- Y, M S L� I n C M 14 t"V TEL# - �� r a ADDRESS p CITYf; STATE PA44 ZIP ©J4 nO CERTIFIED FOOD MANAGER'S N E(S) CERTIFICATE#(s) (required in an establishment where potentially Jhazardous food is prep red.) EMERGENCY RESPONSE PERSON /T I1lAl Pte, f-{1 V)r'{VI�L11 HOME TEL# TYPE OF ESTABLISHMENT �d 3 O/ heck only RETAIL STORE E ' 'NE) RESTAURANT ',YES NO #seats_ #nonsmoking_ $40 BED & BREAKFAST YES NO $40 ADDITIONAL PERMITS 0W ?1,1716/ MAKE ICE CREAM, YOGURT C OCG SOFT SERVE YES NO -7 �G 3 r; TOBACCO VENDOR NO 10 5-b NO CHARGE FOR NON-PROFIT(such as church kitchens) PLEASE INCLUDE COPY OF TAX EXEMPTFORM 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 52C-Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and b lief, have file II state tax returns and paid all state taxes required under the law. a re D to I Social Security or Federal Identification Number ----------------------------------------------------------------------—------------------—----—------------—-----------—--—- Revised - --- Revised 11/21/00 foodap2.adm Check#&Date dy..:y-.+,rid`«w.r#..l+r�y,.dr....c� ' . .../{r,N'l. -^::si,.uri+r•s:aweid.,rsc.+l,.�wr�.aT�ia*,�.'Y`�Yi:.1'u.ww.r•••w cw- THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 9 North Street Board of-Health Salem, MA 01970-3928 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 740-9705 Name Date T e of O eration s Type of Inspection /D-% -O Food Service 1-1Routine Address / Risk ❑ Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone8 y _ 11 11 Date: Owner � 11Temporary ElPre-operation qn HACCP Y/N El El Illness ' e#A Person in Charge(PIC) rl Time [1 Bed &Breakfast [I General Complaint ❑,HACCP I ` In: F1 Other Inspector Out: Permit No. Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: RED Violations (1-22) 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. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 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 SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source ❑ 16. Cooking Temperatures ❑ 5. Receiving/Condition ❑ 17. Reheating ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 18. Cooling ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20. Time As a Public Health Control ❑ 8. Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 21. Food and Food Preparation for HSP [110. Proper Adequate Handwashing CONSUMER ADVISORY [111. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories BLUE Violations (23-30) 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(RED Items 1-22): of Health. Non-critical (N)violations must be corrected immediately or within 90 days as determined by the Board Official Order of Correction: Based on an inspection of Health. today,the items checked indicate violations of 105 CMR C N 590.000/Federal Food Code.This report,when signed below 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-4)(590.005) cited in this report may result in suspension or revocation of 26. Water, Plumbing and Waste (FC-5)(590.006) the food establishment permit and cessation of food 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: 5:5901mpe[IForm6-Id.Eoc .Inspector's Signature: Print: PIC's Signature: Print: Page of oC Pages Violations Related to Foodborne Illness r Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION AND MANAGEMENT 8 Cross-contamination -I) 590.003(A) 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 l(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 3-302.11(A) Food Protection* Is applicants*PP 3-302.15 Washing Fruits and Vegetables 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(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* F_3 590.003D Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003 Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 's 4 Food and Water From Regulated Sources lr 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 Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness* 5-101.11 Drinking 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- Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 3-201.14 Fish and Recreationally Caught Molluscan 4-702.11 Frequency of Sanitization of Utensils and Shellfish* Food Contact Surfaces of Equipment* 3-201.15 Molluscan Shellfish From NSSP Listed 4-703.11 Methods of Sanitization-Hot Water and Sources* Chemical* Game and Wild Mushrooms Approved by `110 Proper,Adequate Handwashing 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* ;11'-- Good Hygienic Practices 5 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 Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 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 X13, 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(J) Labeling of Ingredients* 5-204.11 Location and Placement* 70 Conformance with Approved Procedures 5-205.11Accessibility,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 Handwashing 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. �,��... „- _. di.C..�.-n'. -j...'Rn.—:.�`.,,C:' :.sdrh'^n+w........_.a r...T'tt1T.�„^8`1'ra. %dr71..,y', a. r.� •"Rr�n �.,_.. r'K$d':� .I' - 4•i: s x.�s�f:" ri'C f IC THE COMMONWEALTH OF MASSACHUSETTS • City of Salem Establishment Name Date /O-Q-O/ Address 701 105c' e r- Sim Page A, of a Item No. In the space below describe all violations checked on front page. A(n). 4i,kpx✓rse inspection of this establishment was conducted in accordance with the State Sanitary Code for Food Establishments,Cha ter X, 105 CMR 590.000.The followingviolations were observed: NO O E' 9 iP o 4(4 l ? Discussion with Management I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection,to observe all conditions as described,and to comply with all mandates of Chapter X. I understand that noncompliance may result in daily fines of twenty-five dollars. il"�oo e 3 (a n R�V N G 1 cY L4nv TcN.� ^ sR{iMx ...�VA,lil^Y Y �A1.NMwrw`"�u"^'^,il•1M\s^'.°M"". ..a1J THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 9 North Street Board of Health Salem, MA 01970-3928 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978)741-1800 Fax: (978) 740-9705 Name Date Type of Operation(s) Type of Inspection i -,3-a/ 11 Food Service L1 Routine Address Risk Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: -a 7O/ 7 -- ❑ Temporary LlPre-operationOwner HACCP Y/N [I Caterer El Suspect Illness aS 11 Bed&Breakfast El General Complaint Person in Charge(PI ) Time ❑ HACCP �G Inspector In: ❑ Other Out: Permit No. Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: RED Violations (1-22) 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. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties LLT'/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 SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source ❑ 16. Cooking Temperatures ❑ 5. Receiving/Condition ❑ 17. Reheating ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 18. Cooling ❑ 7. Conformance with Approved Procedures/HACCP Plans 6% 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION 1:120. Time As a Public Health Control ❑ 8. Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 21. Food and Food Preparation for HSP 1110. Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories BLUE Violations(23-30) 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(RED Items 1-22): of Health. Non-critical (N)violations must be corrected immediately or within 90 days as determined by the Board Official Order of Correction: Based on an inspection of Health. today,the items checked indicate violations of 105 CMR C, N 590.000/Federal Food Code.This report,when signed below 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-4)(590.005) cited in this report may result in suspension or revocation of 26. Water, Plumbing and Waste (Fc-5)(550.005) the food establishment permit and cessation of food 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: S S901rspclFwmS-I d.Ox Inspector's Signature: ` / Print: PIC's Signature: Print: /C Page of Pages } Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION AND MANAGEMENT €".S'' Cross-contamination E 1. 590.003(A) 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 3-302.11(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 3-302.11(A) Food Protection* applicants* 3-302.15 Washing Fruits and Vegetables 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* Char e* Contamination from the Consumer _ 590.003 G Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* h3 590.003(DI Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003E 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* 4-501.111 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 Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness* 5-101.11 Drinking 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 Equipmentfood- Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 3-201.14 Fish and Recreationally Caught Molluscan 4-702.11 Frequency of Sanitization of Utensilsand Shellfish* Food Contact Surfaces of Equipment* 3-201.15 Molluscan Shellfish From NSSP Listed 4-703.11 Methods of Sanitization -Hot Water and Sources* Chemical* Game and Wild Mushrooms Approved by rW Proper,Adequate Handwashing 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* '11 Good Hygienic Practices g5 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 Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* It 6 Tags/Records:Shellstock 112_ 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- 3-402.12 Records Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(J) Labeling of Ingredients* 5-204.11 Location and Placement* i;7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance t` /HACCP Plans - Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices P3-502:12 Reduced oxygen packaging,criteria* 6-301.11 Handwashing 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. .,=.9r. ...�;':a.?'a'rr4r+.�.r'..sb.D,..+.*+.'LX''(L-r.G �T-r��'.r�*.^-+w '4•r.i.�� Y''Ad r-r+re.sn•rs".•rk"tr�# r' �r.r i. }+r. . ..f•' . .. 1� a,w'i-�-�.-z-�."".."�'r" ^ry'-J^ 3rdf`. rrrr+: ti THE COMMONWEALTH OF MASSACHUSETTS City of Salem Establishment Name e�,p� va ele 47 Date k-,3-O/ Address ,aC dU�x� Sy- Page— -of „Z Item No. In the space bellow describe all violations checked on front page. A"A//Y7/'e—yGjd, inspection of this establishment was conducted in accordance with the State Sanitary Code for Food Establishments, Chapter X, 105 CMR 590.000.The following violations were observed: ! O IW �& rdk4HV1,V9 d 3441d&jas ,� o.es e e o rd Nop 1,2 /-3 6 n a'va' k S -lig P e C . e- Fee r/ a /use /Ca-31 i . i /rd s 1'w A-_ �S. /d«7 n -i Fie .v i �0 oto/ . /6 a y j t _ E 7 g6l& ' V0 z�1LLL e, P N/ 0 4 Discussion with Mana§ement1i.✓ I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection,to observe all conditions as described,and to comply with all mandates of Chapter X. I understand that noncompliance may result in daily fines of twenty-five dollars. ma..�w..-..K'. `4y;.r,®,�y.[+w+slY"n '+.•r^.eFwr'r�r�...`'a•r+.....1'�..,r"'P..✓71'i�..isr4Fw+.wvws. ..}.;..-:,;ay,h,,....ey:. THE5-'CdM,MONWEALTH OF MASSACHUSETTS j CITY OF SALEM Address: 9 North Street r Board of Health Salem, MA 01970-3928 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 740-9705 Name / Date T e of Operation(s) T ofLeyns eo ction /d .PIF 7" 9-eZ - Food Service y Routine Address Risk ❑ Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephones 11Mobile Date: $IOi Owner El Temporary ® Pre-operation -� HACCP Y/N 11 Caterer L1 Suspect Illness Person in Charge(PIC) Time L1 Bed&Breakfast L1 General Complaint Nr El HACCP Inspectdr v In: ❑ Other (�• / Out: Permit No. Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: RED Violations (1-22) 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. / I Local Law ❑ FOOD PROTECTION MANAGEMENT LEI(i2. Prevention of Contamination from Hands El 1. PIC Assigned/Knowledgeable/Duties �4--/f 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS " ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14. Approved Food or Color Additives e[wi . E) 3. PersonnnnePwdh Infections Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED,SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Wafer from Approved Source p ❑ 16. CookingTemperatures 1 ❑ 5. Receiving/Condition ❑ 17. Reheating ❑ 6. Tags/Records/Accuracy of Ingredient Statements El 18. Cooling [17. Conformance with\pproved Procedures/HACCP Plans Y4,/19. Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20. Time As a Public Health Control ❑ 8. Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories 0 BLUE Violations(23-30)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(RED Items 1-22): F71 of Health. Non-critical (N)violations must be corrected immediately or within 90 days as determined by the Board Official Order of Correction: Based on an inspection of Health. today,the items checked indicate violations of 105 CMR C_N 590.000/Federal Food Code.This report,when signed below 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 V 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 26. Water, Plumbing and Waste (Fc-s)(sso.00s) the food establishment permit and cessation of food 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)(590.005) 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: 55901mWtFam 14.dx r y. Inspector's Signature: /�')y/ Print: �. ^0• PIC's Signature: /// Print: / Page t of�Pages i ^yam Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION AND MANAGEMENT I Cross-contamination 1' '.I 590.003(A) I Assignment of Responsibility* 3-302.11(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowled e* * g Cooked and RTE Foods 2-103.11 Person in charge-duties Contamination from Raw Ingredients 3-302.11(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 vl"I 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 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer L590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 3± 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003E Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* I`41', Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness* 5-101.11 Drinking 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- Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 3-201.14 Fish and Recreationally Caught Molluscan 4-702.11 Frequency of Sanitization of Utensils and Shellfish* Food Contact Surfaces of Equipment* 3-201.15 Molluscan Shellfish From NSSP Listed 4-703.11 Methods of Sanitization-Hot Water and Sources* Chemical* Game and Wild Mushrooms Approved by F'10- Proper,Adequate Handwashing 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* f 11' Good Hygienic Practices t 5 a,. 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 Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* ls:b 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* Ta s/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(7) Labeling of Ingredients' 5-204.11 Location and Placement* 9, 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 Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drying Provision *Denotes critical item in the fedeml 1999 Food Code or 105 CMR 590.000. THE COMMONWEALTH OF MASSACHUSETTS City of Salem Establishment Name Date y-a,'z0/ C AS �b 7� r Address 70, Page -.0—,of Item No. In the space below describe all violations checked on front page. A", 47Ne M ,�C°..Pi//r e- inspection of this establishment was conducted in accordance with the State eL /a�/ c a Sanitary Code for ood Es ablisM1menha ter X, 105 CMR 590.000.The followingviolations were observed: c c as e e IQ s u c cv Omoo r� Coa ,vo 7=- - ✓� � � .v /3 – /tb ..maple. ,c tm Saab a f A - d 3 — A E/e — 4e� a -Z La PGPS C�e� 4/ 4 w if' ✓e P 0 CIG�!/ P ..O . S /4/ /— /V9 iia B t 2 e ',ref _9 ' 13 771/4(• r r -ef I/P AjOr f-Ijo 4r YKAO m/>L® Os1 No,P e s v/ L o S A / Z/ti9 LeQcft r Y Ze 9, V ifl M /0itl 7.,nWP/P ., 0 6a / k' _ P 'iVIL - o i Discussion with Management I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection,to observe all conditions as described,and to comply with all mandates of Chapter X. I understand that noncompliance may result in daily fines of twenty-five dollars.