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CILANTRO - ESTABLISHMENTS Ctlr�, fu 282 O'`r6Y pfq< universal one. www.myuniversalop.com phone: 1-800-756-4676 UNV16162 MADE IN USA --- 1 vo ` -- 0282 Derby Street Cilantro & Taste of Cilantro City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 745-9436 Handwash Facilities FAIL ❑d RED Owner: Comment:Taste of Cilantro employee restroom missing paper towels. Provide towels. ESTHER MARIN Violations Related to Good Retail Practices (Blue Items) PIC: Food and Food Protection FAIL Critical BLUE Esther Marin Inspector: Comment:Various personal items stored throughout the kitchen. Personal items must be stored in designated areas. John Gehan Bowls being stored on top of foods. Utensils to be stored in designated areas to prevent cross contamination. Date Inspected:Correct By: Knife found with food debris on rack. Thoroughly clean and sanitize knife. 10/25/2006 Risk Level: Equipment and Utensils FAIL BLUE Comment: Cutting boards stained and scored. Resurface or replace boards. Permit Number: BHP-2006-0032 'I Some utensils stored incorrectly. Utensils to be stored in proper designated areas. Status: ! Walk in freezer requires general cleaning. SIGNED OFF #of Critical Violations: Same unit missing thermometer. Provide visible and accurate thermometer. 2 Time IN: Time OUT: GENERAL COMMENTS: All violations have been corrected. Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Oct 26,2006 ) Page I oft Item Status Violation Critical Urgency RED: Violations Related to Foodbome Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Oct 26,2006 ) Page 2 of 2 0282 Derby Street Cilantro & Taste of Cilantro City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: FOOD PROTECTION MANAGEMENT 745-9436 PIC Assigned/Knowledgeable/Duties PASS RED Owner Non-compliance with: ESTHER MARIN Anti-Choking PASS PIC: Esther Marina Tobacco PASS Inspector: a John Gehan ` EMPLOYEE HEALTH Date Correct By. v; Reporting of Diseases by Food Employee and PIC PASS ❑Q RED I Personnel with Infections Restricted/Excluded PASS ❑d RED Risk Level: FOOD FROM APPROVED SOURCE Permit Number: Food and Water from Approved Source PASS ❑Q RED BHP4006-0032 Receiving/Condition PASS RED Status: Open Tags/Records/Accuracy of Ingredient Statements PASS ❑J RED #Of Critical Violations`. Conformance with Approved Procedures/HACCP Plans PASS RED 3 A _ Time IN: Time OUT: s Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical' violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS&2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 31,2006 ) Page 1 of Item Status Violation Critical Urgency RED: _ PROTECTION FROM CONTAMINATION Violations Related to Separation/Segregation/Protection PASS ❑J RED Foodborne Illness Interventions and.Risk Factors (Require Food Contact Surfaces Cleaning and Sanitizing PASS RED immediate corrective action) Proper Adequate Handwashing PASS RED Good Hygienic Practices PASS ❑Q RED Prevention of Contamination from Hands PASS RED Handwash Facilities FAIL RED Comments: Handwash sink next to 3-bay sink missing sign. Provide"hand wash sink only"sign. Hand wash sink missing sign in Taste of Cilantro. Provide visible sign. PROTECTION FROM CHEMICALS Approved Food or Color Additives PASS 0 RED Toxic Chemicals PASSd❑ RED TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) Cooking Temperatures PASS ❑V RED Reheating PASS 0 RED Cooling PASS 0 RED Hot and Cold Holding PASS 0 RED Time As a Public Health Control PASS 0 RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food and Food Preparation for HSP PASS RED CONSUMER ADVISORY Posting of Consumer Advisories PASS ❑d RED City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 31,2006 ) Page 2 of Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and Food Protection FAIL Critical BLUE Comments: Personal items stored on shelves. All personal items must be stored in appropriate designated areas. Employees observed eating in the kitchen. Employees must eat in a designated area away from kitchen. Containers stored on top of others in deli unit in Taste of Cilantro. Containers must be stored separately to prevent contamination. Equipment and Utensils FAIL Critical BLUE Comments: Knives found being stored behind 3-bay sink. Knives to be stored in proper and appropriate areas. Cutting boards stained and scored. Resurface or replace cutting boards. Walk in freezer requires cleaning. Walk in freezer has uncovered hole. Provide cover for hole. Refrigerator upstairs in office area missing thermometer. Provide visible and accurate thermometer. Shelves in kitchen has accumulation of grime. Clean shelves thoroughly. Black refrigeration unit in kitchen has accumulation of ice. Remove ice. Ice scoop for bar found in handwash sink. Ice scoop to be stored in ice with handle up or in labeled container. Beneath coke machine in Taste of Cilantro requires cleaning. Water, Plumbing and Waste PASS BLUE Physical Facility FAIL BLUE Comments: Floor throughout kitchen and storage area has peeling and chipping paint. Repaint floor to make impervious and easily cleanable. Management and Personnel PASS BLUE Poisonous or Toxic Materials PASS BLUE Special Requirements PASS BLUE Other-See Notes PASS BLUE GENERAL COMMENTS: 630: City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 31,2006 ) Page 3 of Item Status Violation Critical Urgency City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 31,2006 ) Page 4 of %)282 Derby Street Cilantro & Taste of Cilantro City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone:,, 4 X k, PROTECTION FROM CONTAMINATION 745-9436 ;, Handwash Facilities PASS RED Owner = ` Violations Related to Good Retail Practices (Blue Items) ESTHER MARIN Food and Food Protection PASS BLUE PIC. Esther Marin ;;, '. Equipment and Utensils PASS BLUE Inspector John Gehan Physical Facility PASS BLUE Date" Correct By u- Comments: Floor in storage area has peeling and chipping paint. Repaint floor to make impervious and easily cleanable by next I �6 -_ routine inspection. Risk Level 4 == GENERAL COMMENTS: Permit Number 641:AII violations have been corrected from the inspection completed on 5124106. rBHP-2006-0032 M Status _ FULL COMPLY #of Critical Violations. Time IN t 7, UT m_ Urgency,Description(s) BLUE ; , Violations Relatetl to Good Retail Practices (Critical - violations must be corrected immediately or within 10 days)(Non-critical violations,;? must be corrected immediately i or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeOTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 01,2006 ) Page 7 of 2 Item Status Violation Critical Urgency RED: Violations Related to; Foodborne Illness Interventions and Risk Factors (Require,_ immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 01,2006 ) Page 2 oft SENDER.ICOMPLETE THIS SECTION COMPLETE THIS ON ON DELIVERY ■Complete Items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. 0 Agent ■ Print your name and address on the reverse X 0 Addressee so that we can return the card to you. a Printed Name) C. Date of Delivery ■ Attach this card to the back of the mailplece, or on the front if space permits. yy'[� 1. Article Addressed to: 11151 W 'rfferent from Item 1? Oyes v ad UI r dress below: ❑No Cilantro, Inc. C/o Esther Marin 282 Derby Street JAN 113 1986 Salem, MA 01970 CITY BOARD F all ❑Express Mall 0 Registered 0 Return Receipt for Merchandise 0 Insured Mail 0 C.O.D. HI4. Restricted Delivery?lie Fee) 0 yes 2. Article Number ! ' 11 7005:,1820;10000 `8814 '0510: (Ransferfrom service later _ , PS Form 3811,February 2004 Domestic Return Receipt - 102595-02-rt-1540 IUNITED STATES POSTAL SERVICE First-Class Mail Postage 8 Fees Paid Il USPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box I I BOARD OF HEALTH SALEM, MA 01970 U.S. Postal Servicer. CERTIFIED MAIL,. RECEIPT (Domestic Mail Only;No Insurance Coverage Provided) For delivery information visit our website at www.usps.coms.: C3 Restricted Dativery,Fee C3 R%MRZ'plFoe C3 Certified Fee C3 i Postage �.. C PS Form 3800,June2002 SFe Reverse lar Instructions Certified Mail Provides: (maret/)aooz ennr•ooee mo.4 ea ■ A mailing receipt ■ A unique Identifier for your mailpiece ■ A record of delivery kept by the Postel Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First-Class Malls or Priority Mail® ■ Certified Mail is rmtavailable for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Caroled Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return Race tmaYy he requested to mvide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3911)to the article and add applicable postage to cover the fee.Endorse mallpiace Realm Receipt Requested'.To receive a tee waiver for a duplicate return receipt,a USPSs postmark on your Certified Mail receiptis required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized a8gge8nt.Advise the deck or mark the mallplece with the endorsement WestfictedDefivetyt ■ If a postmark on the Certified Mall receipt Is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mall.! IMPORTANT:Save this receipt andDresent'It when making an9ngairy. Internet access to deliveryy information Is not available on mall addressed to APOs and FPOff. P CITY OF SALEM, MASSACHUSETTS o ; BOARD OF HEALTH a 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAx 978-745-0343 Kimberley Driscoll www.SALEM.COM Mayor JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT January 17, 2006 Cilantro, Inc. c/o Esther Marin 282 Derby Street Salem, MA 01970 Dear Ms Marin: Enclosed is your check#3887 dated December 9, 2005 for your 2006 Food Permit. You sent two checks for the same establishment. If you have any questions, please call my office. Very truly yours, toanne Scott Health Agent JS/mfp Enclosure CERTIFIED MAIL 7005 1820 0000 8814 0510 i 4 . ( 3887 CILANTRO, INC. 04-01 282 DERBY ST. SALEM, MA 01970 53-174/113 DATE I v C,.• �� t/i'll PAY ORDER OF V--i ! t f'--. /G.r=s+"=. .. ..-.� r $ 1 , DOLLARS 8 - i Eastern Bank 3t8 $fl(.EM,MA 01619 � � EA$TE )aeelan.bmk�{hn _, c.. FOR pn.!✓?/ / 717 Y _._ .—_. . 11'00388 ?u■ 1:011301 ?981: 06 0014026311' f _. '"-;! wc+rt x. w.; tr '' +4ri^4"'�`h £ryyx�+yC-"' .x. '.+�' s.ntrt•g.:. •4�..,�+?a*Mu �:�Pt��''R+n�1i�m+.:�h+.a,�� tsk ss}yRh�4aR CommonwealthofMassachuse tts x w - Y: Cltp of Salem to s Board of Health 120 Washington Street,4th Floor " SALEM,MA 01970 ITN Food/Retail Establishment Permit DATE PRINTED: 01/02/2006 WHO'S PLACE OF BUSINESS IS: Cilantro&Taste of Cilantro �. Fite Number:BHF-2004-0048 282 Derby Street Salem MA 01970 LOCATED AT: 0282 DERBY STREET SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions!Notes FOOD SERVICE BHP-2006-0032 Jan 2,2006 Dec 31,2006 $150.00 ESTABLISHMENT Total Fees: $150.00 PERMIT EXPIRES �ecember 31, 2006 �� Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 14 of 26 �U CITY OF SALEM, MASSACHUSETTS 3 BOARD OF HEALTH s 120 WASHINGTON STREET, 4TH FLOOR / )u SALEM, MA 01970 �MnYe TEL. 978-741-1800 STANLEY J. USOVICZ, JR. FAX 978-745-0343 MAYOR W W W.SALEM.COM JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2006 APPLICATION FOR PERMIT TO OPERATE A FOOW�E ST%qLISHMENT NAME OF ESTABLISHMENT d16.g1./r/Ld' /i�L�`ff r# `�9 ADDRESS OF ESTABLISHMENT 96 ?' MAILING ADDRESS (if different) OWNER'S NAME 647V- 12 MAA)d TEL# 5 777'✓ryZ3 ADDRESS �/a 1.7) O02AI tO/A X CITY MJVVLtTDN STATE M ZIP EDIT CERTIFIED FOOD MANAGER'S NAME(S) M /7 CERTIFICATE#(s) 3/ d6 (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME TEL# HOURS OF OPERATION: Mon. Tue. £t' Wed. 4 Thu. Fri. Sat. Sun. TYPE OF ESTABLISHMENT $ i/ �� R Fal FEE (check only) RETAIL STORE YES NO b "3D �� less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 ..------- ---- ----------------------------------------------.................----------......-------------------------- RESTAURANT YE NO less than 25 seats =$1Il0 1�D -de more seats =$150 more than 99 seats =$200 ....... ............ .................. $..............------------ .100.. ---------------- BED/BREAKFAST YES NO $ -- ----------------------------------------------------------------------------------------............-------..........------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem . This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. �d�72� is y/i9i� 0113 -515-- -6 3/ Sign jre,� Date Social Security or Federal Identification Number -------------------------------------------------------------------------- ----------- --- -------------------------------------- Revised 11/03/05 FOODAP2.adm Check#&Date we/7d 0282 Derby Street Cilantro City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Telephone: Item Status Violation Critical Urgency Nature of problem or correction 745-9436`" ' "'' '= Non-compliance with: Not Done Owner ,_ Anti-Choking PASS E:1 ESTHER MARIN Tobacco PASS ❑ PIC. e ,s - 'Esther Marlin FOOD PROTECTION MANAGEMENT Not Done Inspector: ., PIC Assigned/Knowledgeable/Duties PASS ❑J RED `David GreenbaumEMPLOYEE HEALTH Not Done Date Inspected: Correct By: Reporting of Diseases by Food Employee and PIC PASS ❑d RED 6/17/2005 Personnel with Infections Restricted/Excluded PASS ❑J RED Risk Level: FOOD FROM APPROVED SOURCE Not Done Permit Number _ a Food and Water from Approved Source PASS ❑d RED BHP-2005-0309 " Receiving/Condition PASS ❑d RED Status:` Tags/Records/Accuracy of Ingredient Statements PASS RED 'SIGNED OFF = Conformance with Approved Procedures/HACCP PASS RED #of Critical Violations. Plans 2 PROTECTION FROM CONTAMINATION Not Done Time IN: - Time OUT: Separation/Segregation/Protection PASS ❑d RED Notes: Food Contact Surfaces Cleaning and Sanitizing PASS RED 215: `° Proper Adequate Handwashing PASS ❑d RED Urgency Description(s): Good Hygienic Practices PASS ❑d RED BLUE: . Prevention of Contamination from Hands PASS ❑.� RED Violations Related to Good Retail Practices (Critical„ Handwash Facilities FAIL Critical RED The kitchen handwash sink obstructed at violations must be Corrected time of inspection. Handwash sink must Immediately Or within 10' be kept clear and accessible at all times. days)(Non-critical violations GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Jun 20,2005 ) Pate 1 of 3 0282 Derby Street Cilantro must be corrected Immediately PROTECTION FROM CHEMICALS Not Done or within 90 days) Approved Food or Color Additives PASS RED RED: Violations Related to - Toxic Chemicals _ PASS ❑d RED Foodborne Illness InterventionsTIMEITEMPERATURE CONTROLS(Potentially Haz Not Done and Risk Factors (Require Cooking Temperatures PASSd❑ RED immediate corrective action) ' , Reheating PASS ❑J RED Cooling PASS RED Hot and Cold Holding PASS 0 RED Time As a Public Health Control FAIL Critical RED Chicken out thawing at room temperature. Thaw potentially hazardous foods in a refrigerator or under cold running water. REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP PASS RED CONSUMER ADVISORY Not Done Posting of Consumer Advisories PASS 0 RED Violations Related to Good Retail Practices (Blue Not Done Management and Personnel PASS ❑ BLUE Food and Food Protection PASS ❑ BLUE Equipment and Utensils FAIL Non-Critical ❑ BLUE Left hand True cooling unit missing a thermometer. Provide a visible accurate thermometer in unit. Water, Plumbing and Waste PASS ❑ BLUE Physical Facility PASS ❑ BLUE Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other-See Notes PASS ❑ BLUE GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Jun 20,2005 ) Page 2 of 0282 Derby Street Cilantro 7� GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Jun 20,2005 ) Page 3 of �»�gcryf7f9Fv,Y�F+ a kr ♦ems WJMb .W P i3, '*er ''W` i 'Mn '+c�ip"�>W'+ nsU ,.knJ.c rt+±eOY'°�sss-vaiSK E .- '« .fie w. k.:c.,«.aC. ,.;rc a i. .t. S .. k �!remr x r.F*r- -�+,.zs" •hC n CITY OF SALEMv MASSACHUSETTS �, BOARD OF HEALTH - 120 WASHINGTON STREET,4TH FLOOR a SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICz, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: FOOD SERVICE Name of Establishment: Cilantro Address of Establishment: 282 Derby Street Owner's Name: Esther Marin Restrictions: Application Date: 12/7/2004 Permit for Food Establishment 196-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board Of Health. HEALTH AGENT CITY OF SALEM} MASSACHUSETTS BOARD OF HEALTH 99 120 WASHINGTON STREET, 4TH FLOOR q SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J: USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT �f NAME OF ESTABLISHMENT a/LAAvr20 TEL# ADDRESS OF ESTABLISHMENT 2dod- ad6,7 J 7- MAILING MAILING ADDRESS(if different) A� OWNER'S NAME 6_4. her � -f l!} TEL# � `�'� ? 2-(p ADDRESS _bea'r6,0 t C"-'& CITY STATE —ZIP J% CERTIFIED FOOD MANAGER'S NAMES) tcJ T "r 4ry� CERTIFICATE#(s) 3//a 'aSre (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON ZdttS r ��r`1 HOME TEL# 5 9)- ` �O 6 7 HOURS OF OPERATION: Mon._'�Tue./ Wed. Thu. Fri.—Sat.—Sun. TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES NO I t �" less than 25 seats =$100 ( t 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledg�e and belief, have filed all stat to returns and paid all state taxes required under the law. Signature , . --.^�ate Social Secu ity or Federal Identification Number ----------------------------------------------------------------- --- - - - ------- ----- ---- -------------------------------- - --------- Revised 11/03/03 FOODAP2.adrr7 Check#&Date 3JO03 0/ � l�o CITY OF SALEM, MASSACHUSETTS ,f ; s • BOARD OF HEALTH - _ 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: FOOD SERVICE Name of Establishment: Cilantro Address of Establishment: 282 Derby Street Owner's Name: Esther Marin Restrictions: Application Date: 12/11/2003 Permit for Food Establishment 179-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 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 BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR m SALEM, MA 01970 TEL, 978-741-1800 FAX 978-745-0343 STANLEY LISOVICZ, JR. .JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Q/G!lNr2o TEL# 9�� rSSz3(p ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different) OWNER'S NAME ��2N /P/ Alt?J+1/tJ TEL# TAP 3'T '22f°�'� ADDRESS �)69Y'6orn- CITY ��1 $ TE ZIP �� CERTIFIED FOOD MANAGER'S NAMES) �,t l0 t CERTIFICATE#(s) 2 :56 (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON IYL9"r 41`101 HOME TEL# C/1?g X72 HOURS OF OPERATION: Mon. Tue., 7 Wed.S�f Thu. S-f Fri.5 740 Sat. 6`-11 Sun. 5 9 TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 0 more than 10,000sq.ft. =$250 RESTAURANT NO ! " less than 25 seats =$i 00 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Secti 49 , 1 certify under the pains and penalties of perjury that 1, to my best,II-crtowied and belief, have file all S to tax returns and paid all state taxes required under the law. GslJf�" /a 0 of O 355 -631-02. Signature ate Social Sec rity or Faderal Identification Number - -- Revised A73---------z ------------------------------------------ 11/03/03 FOODAP2.adm Check#&Date 0 d Massachusetts Department of Public Health Salem Board SHealth M 120 Washington Street,4i' Floor Division of Food and Drugs ' Salem,MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978)741-1800 Fax(978)745-0343 Name Date T 4 of O stations T of Inspection C / yQ Food Service Routine AddressRisk ❑ Retail E] Re-inspection 2 r Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: ❑ Temporary ElPre-operation Owner HACCP YlN t ❑ Caterer [ISuspect Illness Person in Charge(PIC) Time 11In: Bed& Breakfast ❑General Complaint [I HACCP Inspector 1 Out: Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT .. ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties [] 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 - TIMEtrEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation[Segregation!Protection ❑20:Time As a Public Health Control [Pi9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 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 Number of Violated Provisions Related ( Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report,when signed below d t £ 23. Management and Personnel (FC-2)(996.003) 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 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 28. Water, Plumbing and Waste (Fc-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.o07) 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:590NspecfPo:mGi4.tla' Inspector's Signature ' Print: PIC's Signature: Print: Ed;r7�rJ4 A 4,q) /N Page_of_A�Pages .V Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination I 590.003(A) Assignment of Re, onsibiltty" _ 3-;02.11(A)(1) Raw Animal l oala Separated from a90.(H)3(B) Demonstration of Knowledge* Cooked and RTE Foods" 2103.11 Person in charge duties Contamination tram Raw Ingredients 3-30111(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other" 2 590.003(0) Responsibility of the person in charge to Contamination from the Fnvironment require reporting byfoal employees and 3-302.11(A) Food Pnatection" at locants* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contac'with Equipment and Applicant To Report To The Person In utensils* Char Le* Contamination from the Consumer 590.003(G) Re ortinIby Person in Charge* 3.306.14(A)(B) Returned Food and Reservice of Food" 3 590.003(D) Exclusions and Restrictions:': Disposition of Adulterated or Contaminated 590.003(1:) 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 Lag* 4-501.111 Manual Warowashmg-Hot Water 3-201.12 Food in a Hennetiwll Sealed Container* Sanitization re.nt.eratures* 3-201.13 Fluid Milkand Milk Products* 4-501_112 MechanicalWarewashina Hof Water 3-202.13 Shell E�wns* Sanitization To aeratures"` _ 3-202.14 Legs and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, concentration and hardness. " 3-202.16 Ice Made From Potable,Drinking Water* 4-601.U(.A) Equipment Food Contact Surfaces and 5-101,11 Drinking Water m from an Approved Svsts " 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 220T Contact Surfaces and Utensils* Sheiltfsh and Flsh From an Approved Soured 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Snrfaees at E ui anent* Shellfishs 4-703.11 Methods of Sanitization-Hot'Waterand 3-20,1.75 Molluscan Shellfish from NSSP Listed Chemical.* Sources* to Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Re uiatoAuthont 2.301-11 Clean Condition-Hands:cod Arms" 3-202.15 Shellstock Identification Presents' 2-301.12 Clean9n*Procedure* 590.004(0) Wild Mushrooms* 2-301.14 When to Wash" 3-201.17 Game Animals* It Good Hygienic Practices g Receiving/Condition 2-401.11 Eatin ,Drinkin or Urine Tobacco* 3-202.11. PIIFs Roomed at Proper Temperatures* 2-401.12 Discharges'From the Eyes,Nose and 3-20255 Package Integrity" Mouths` - 3-101.11 Food.Safe and Unadulterated 3-301.12 Preventing Contamination When Tastin 12 Prevention of Contamination from Hands 6 Tags/Records:Shelistock 3-202.13 Shellsfuck Identification* 590.004(E) Preventing Contamination from 3-203.12 Shelistock Identification Maintained" Lm Iotiees* Tags/Records: Fish Products I3 Handwash Facilities 3-402.11 Parasite Destruction's Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-203.'I1 Numbers and Ca acittes* 590.0040) Labeling of Ingredients' 5-204.11 Location and Placement" 7 mance with Approved Procedures 5-205.11 Accessibility, Operation mid Maintenance Conformance Supplied with Soap and Hand Drying 3-502.11 S ecialized Processim Methods" Devices 3-502.12 Reduced ox peen ackn"one,criteria'" 6'301.11 Handwashine Cleanser.AvaiiabilHv 8-103.12 Conformance with A rowed Procedures" 6-301.12 Hand Drvin,Provision "Denotes crawl item in the federal 1999 Food Code or 105 CMP,590,000. CITY OF SALEM BOARD OF HEALTH Establishment Name: r'1L4 /i g1> Date: /ePage: 2 Of Item Code C-Critical Item DESCRIPTION OF VIOLATION)PLAN OF CORRECTION Date No. Reference R—Red Item Verified ...PLEASE PRINT CLEARLY G C i t rr&_ r -4*f(2 K 0 v A SAr/r fT�'�t. a-aJR aIV rtld ,IyC . �fI Lrrt�- ,9 awR nN wt r� `L�'f C f u fM oe nd f1S tiJ d +✓ / rr N OO b tPt Yn (b iqr to Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. �� 0 Voluntary Disposal ❑ Other: P� 3-501-14(C) PRFs Received at Temperatures , Violations Related to Foodborne fitness Interventions and Risk According to Law Cooled to Factors(items 1-22) (Cont.) 41'F/45'F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for I'HFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-50'1.168) Cold PHFs Maintained at or below 3-202.12 Addiction 590.004(F) 41°/45°F* 3-302.14 Protection from Toxic Unapproved Additives* 3-501.16(A) Hot PHF,Maintained at or above 15 Poisonous or Toxic Substances 40°F. * Containers,7-101.11 Identifying neInformation-Qciginal 3-5011F.6(A) Roasts Field at or above 130° Cors 7-102-11 Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation Stora e* 3 101-19 Time as a Public Health Contra]* 7-202.11 Restriction-Presence and Use 590.004(H) Variance Requirement 7-202.12 Conditions of Use" 7-203.I I Toxic Containers-Prohibitions'` REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizens,Criteria-Chemicals* POPULATIONS HSP) 7-204.12 Chemicals for Washin fh-othtce,Criteria* 21 3-801.11(.0) unpasteurized Pre-packaged Juices and Beverages with Warning tsbels* 7-204.14 Dr ling a guts,Criteria. 3_801,11(B) Use of Pasteurized Eggs* 7-205.11 ]ncidental Food Contact Lubricants* 7-206.'I I Restricted Use Pesticides.Criteria* 3-801.11(D) Raw or Partially Cooked Animal Pout and Raw Seed S roots Not Served. '' 7-206.12 Rodent Bait Stations" 3-801.11(C) Uno erred Food Pucka°e Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw.Undercooked or 16 Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate -401.11.0(1)(2) F€0s- 155`F 15 Sec. 11 thogc;ns.* e''`°`"'°1,!/,'Ill E cs-Lmnedtatc Senate 145°F15sec* 3-302.13 Pasteurized Egg's'Substitute for flaw Shell 3-401.11(A)(2) Comminuted Fish,Meats&Game E gs* Animals- t55'F 15 sec. '" 3-401.11(13)(1)(2) Pork and Beef Roast- 130'F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites, lniected Meats-155°F'1.5 590,009(A)-(D) Violations of Section 590.009(A)-(D)in sec. * catering, mobile food,temporary and 3-401.1.1(.4)(3) Poultry, Wild Game,Stuffed PHF,, residential.kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultr,or Ratites-l65°F I5 sec. ' above if related to foodborne illness 3.401.1 1(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/129- Microwave 1650F* Special Requirements, 3401-I1(A)(1)(b) All Other PHFs- 145'F 15 sec. 77 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3403.t I(A)&(D) PHFs 165°F 15 sec. * (Items 23-30) 3-403.11(B) Microwave-165°P 2 Minute Standine Critical and non-critical violations. which do not relate to the Time' fiaodborne illness into ventions and risk fa<tors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in the followbtg sections of the Food Code and 105 0WR 140°F* 590-000. 3-403.11(E) Remaining Unsliced Portions of Beef item Good Retail Practices FC 580.000 Roasts* 23. Management and Personnel _ FO-2 .003 lg Proper Cooling of PHFs 24_ Food and Food Protection _ FC-3 .004 _ 25 Equipment and Utensils FC 4 045 3-501.L4(A26.) Cooling Cooked PRFs from 140°F to Water.Plumbinq and Waste FG-5 .608 70°F Within 2 flours and From 70'F 27--_ Ph slcal Factl FG-6 .007 to 41'F/45°F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14($) Cooling PRFs Made From Ambient 24- S ecial Re ulrements .009 Temperature Ingredients to 41°F/45`'F 30. ___ Other _.------,--_ Within 4 Hoursa s2,h, *Denotes critical item in the faaerul 1999 Food Code or 105 CMR 590.000. f Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4'h Floor Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name Date i:.0 Jr - o0Serations Tof Inspection ice tine oofd ej2rRou Address Risk ❑ Retail ElRe-inspection T_ Level El Residential Kitchen Previous Inspection Telephone , 04 ❑ Mobile Date: Owner HACCP Y/N El Temporary ElPre-operation Z k Malcl kJ ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint Inspector �� °fiY!/7a✓iitdl In: El HACCP AZ d Out: Permit No. ❑Oherr Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 1 Prevention of Contamination from Hands [1 1. PIC Assigned/Knowledgeable/Duties 13. Handwash Facilities EMPLOYEE HEALTH ' PROTECTION FROM CHEMICALS.: ` ❑ 2. Reporting of Diseases by Food Employee and PIC E] 3. 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 Hazardous Foods) ❑ 5. Receiving/Condition 1:11'6.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) F1 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP El11. 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 Immediately or within 10 days as determined b the Board v Y and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR ofHealth., 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 q p (FC-4)(590.005) cited in this report may result in suspension or revocation of // 25. E t , Plumbing and Utensils 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 ssaMsWfFom -14.coc Print: PIC's Si ature: Print: "6✓ - Pa ge-L of-Pages �r °r7 I Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) ` PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Gross-contam ination 1 590.003(A) Assi�ument afRespottslbillty*� 3-302.11(A)(1} Raw Animalated from 590.003(B) Demonstration of Knowledge' _ Cooked and 2-103 11 Person in charge--duties Contaminatiogredients 3-302A 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 repotting by food employees and 3302A I(A) Food Protection* a tlioantsv` 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility OP 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) 3-306.14(A)(B) Returned Food and Rescry ice of Foal* 3 590.003(D) Exclusions and Restrictions* - Dispositrota nofAdulteratedorConminated 590.003(2:) - 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) Cnmpli:mce with Food Law* 4-501.11 t Manual Warew�ashing-Hot Water 3-207.13 Food in a Hertnetically Sealed Container` SamtizatunTent eratures" _ 3-201.13 Fluid Milk and Milk Products* 4-501712 Mechanical War,wastung-Hot water 3-202.13 Shell E*as* Sanitization Tem eratures` 3-202.1rod .4 E =s and Milk Pucts.Pasteurized* 4-501.114 (:hemteal Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness.,t 5-104.11 Drhikiti Water from an A roved S stem* 4-(01.11(A) Equipment Food Contact Surfaces and Utensils Clean* 590.006(A) Bottled D inkin Watt 4-602.11 Cleaning Frequency of FquipmentFood- 590.006(B) Nater Meets Standards in 310 CMR 22.0* Contact Surfai;ea 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 Foal Contact Su faces of E of incur* Shellfish* 4-703.1.1 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* iq Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Reaularow Authorit 2-301.11 Clean Condition-Hands and Alms" 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 Gane Animals* 1.1 Good Hygienic Practices g ReceivingiCondition 2-401.11 atin ,Drinkin-or Usines Tobacco* 3-202.11 PHFs Received at Pro tar Tem erattnes' ?-401.12 Discharges From the Eyes, Nose and 3-202.15 Packeae Lite rte�* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When'I'astin "` 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Em to�ces* Tags/Records:Fish Products I1 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records.Creation and Retention" 5-203.11 Numbers and Ca acitiesa` 590,004(J) Labeling of Ingredients' 5-204.11 Location and Placement* q Conformance with Approved Procedures 5-205,1 IAceessibdit .0 ,ration and Maintenance /HACCP Plans - Supplied with Soap and Nand Drying Devices 3-502.11 Specialized Processm,Methods* 3-502.12 Reduced oxv en acka i n,,,criteria* - 6-301.11 Handwash9tg Cleanser, kvaiiabifr 5-10312 Conformance with Approved Procedures* 6-3117.12 Hand Drm�Provision *'Denote critical Item in the federal 1999 Food Cale or 105(7MR 596.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of 2 Item Code C-critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY 2S LG . �L i/�C Sin,/1 n Z� Xd Gg6r // E pr7/ v�toe O�il'i 4/ IW220 L Fooq' � alylsexaw 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/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. �d ?/T ❑ Voluntary Disposal ❑ Other: 3-501 i4(_C) Pl-1Fs Received at Temperatures Violations Related to Foodborne Illness interventions and Risk According to Law Cooled to Factors(items 1-22) (Cont.) 41`FI45-F Within 4 Hours. PROTECTION FROM CHEMICALS 770115 Coolin«Methods for PHFs Food or Color Additives 19 PHF Hot and Cold Holding 14 3-501,I6(11) Cold PHFs Maintained at or below 3-202.12 Additwes* 590-004(F) 311450 F- 3-102 14 Protection from Elna i roved Additives' 3-501,16(A) lot PHFs Maintained at or above 15 Poisonous or Toxic Substances 14WR * 7-101.11 Identifying Information-Qriginal 3-50116(A) Roasts Held at or above 130°F. Containers" 7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Stotave" 3-501.19 TimeasaPublicHealttiContt'oi* 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Ra uirement 7-202.12 Conditions of IIse* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.1.1 Toxic Containers-Prohibitions* pOPUi ATIONS(HSP) 7-204.11 Samttzer's,Criteria-Chemic ds` 7204A2 Chemicals for Washine Produce,Crile 21 3-S01,11(A) Unpasteurized Pre-packaged Juices and 7-204.14 D. °ing Agents.Criteria" Beverages with Warning,Labels* 3-801,ll(B) I,4�ofFaeteunzedE"a 7-205.11 Incidental Food Contact.Lubricants* 3-801.1 I(D) Raw,or Partially Ccokecl Aminal Food and 7-206.11 Restrictedi.ise Pesticides Criteria* 7-206.12 Rodent Bair Stations* Raw Seed Sprouts Not Served.'e Tracking Powders,Pest Control and 3-801.11(C) Unopened Foal Package Not Re-served. 7-206.13 Monitorial,* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods''hat are Raw, (Inderaniked or PHFs Not Otherwise Processed to Eliminate I'atho 3-401.11A(1)(2) E kgs- 155'F 15 See. Eggs-hnmediate Service 145°Fl5sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shelli 3-401..11(A)(2) Comminuted Fish,Meats&Game Eggs* Animals- 155'F 15 see. * 3-401.1 L(B)(I)(2) Pork and Beef Roast - 130'E 121 titin* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats 155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec.' catering, mobile food, temporary mid 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Smiting Containing Fish;Meat, debited under the appropriate sections Foultr V or Ratites-165`F 15 set. " above if related to foodborne illness 3-401.11(C)(3) Whole-muscle, Intact Beet Steaks interventions and risk factors. Other 145'F* 590.009 violations relating to good retail 3-40112 Raw Animal Foods Caked in practices should be debited under)129- Microwave 165'F* Special Requirements. 3-401AI(A)(1)(b) All Other PHFs-145'F15see. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165'F 15 sen. ,. (items 23-30) 3-403.11(B) Microwave- 165°F 2 Minute Standing Critical and non-critical violations, which do nor relate to the Time* foodborne illness interventions and risk faders listed above, can he; 3-403.11(C) Commercially Processed RTE Food- found in the f ollow4ng sections of the Food Code and 105 CMR '14WF* 590.000. _ 3-403.11(F.) Remaining Unsliced Portions of Beef Item Goad Retail Practices FC 590.000 Roasts* 23. Mang ement and Personnel FC-2 .003 IA Proper Cooling of PRFs 24. _ Food and Food Protection _ FC-3 .004 25. Equipment and Utensils FC-4 .005_ 3-501.14(A) Cooling Cooked Pll from 140`F to 26. Water, Plumbing and Waste FC-5 .006 70T Within 2 Hours and From 70'F ?7. -Physical Facigy____ FC-6 .007 to 4l'F/45'F Within 4 Hours. * 23. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements ` .009 Temperature'htyedients to 41'1-4/45`F 30. Other Within 4 I-Iours'i S WIN,n.as»s.,, Denotes critical item in the faleral 1999 Food Code or 105 CNIR 5901)00. �d co CITY OF SALEM, MASSACHUSETTS vg '� BOARD OF HEALTH a 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY USOVICZ. JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT e 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 : Esther Marin Name of Establishment : Cilantro Address of Establishment : 282 Derby Street Type of Establishment : FOOD SERVICE Application Date : 12/20/2002 Restrictions: Permit for Food Establishment 136-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 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. HEALTH AGENT -N ✓' /c��ln� CITY OF SALEM, MASSACHUSETTS /�y" 'Qi�y BOARD OF HEALTH 120 WASHINGTON STREET 4TH FLOOR �? - It SALEM, MA 01970 s�'�� TEI_. 978-741 - 1800 A0'O�MIrvE WN FAx 978-745-0343 STANLEY USOVICZ. JR. JOANNE_ SCOTT. MPH, RS, CHU MAYOR HEALTH AGEDIT 2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT J/ NAME OF ESTABLISHMENT CILIPI AL%20 /NC TEL# ADDRESS OF ESTABLISHMENT VZ MAILING ADDRESS (if different) OWNER'S NAME Ld wt-t MAy RIAI J TEL# %%d' 7 7- _)2 ADDRESS ��LIFCSD/L// OV �7 CITY N/ADGErZ1JL STATE M _ zip_ ! CERTIFIED FOOD MANAGER'S NAME(S) ES7/H',t-/_ MAR.la/ CERTIFICATE (s) 376_A__ 11 5_6' (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON ES;7-gclZ MA44W HOME TEL# '�20' '22.-5123 P.,30-z'd0 I00-24o /1,,o-2 o0 //>3o-z Jp5,-Z HOURS OF OPERATION: Mon. ,-' Tue.530-g Wed,�;'Jo-q Thu. •ss v.9 Fri.s3v/z'Sat.S3�-/o Sun, 550-9 TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 1 0,000sq.ft. =$250 RESTAURANT YES NO ' less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVE YES _ $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES (!�05 $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have fled all state tax returns and paid all state taxes required under the law. /- 7Hr 2-I U2, 1 /3—5 5 l0 3 O Sin Date Social Security or Federal Identification Number ------ ----------------------------------------------------------- - - --------------------------------------- Revised 11/25102 FOODAP2.adm Check#&Date ?a�?- r o •� owl l-ke*iv 1 _ 66+ 008 651 0"+ # �«' G�? � �� '� �.� �"�,� �� Massachusetts Department of Public Health Bureau of Communicable Disease Control Massachusetts Immunization Program SCREENING QUESTIONNAIRE FOR INFLUENZA, PNEUMOCOCCAL AND TETANUS/DIPHTHERIA 2000 A. General Screening Questions 1. What vaccines do you intend to get today? Influenza Pneumococcal Td 2. Are you ill today? Yes No 2. Have you ever had an anaphylactic or neurological reaction (eg. Seizure) to a previous dose of- - Flu vaccine? - Yes No - Pneumococcal vaccine? Yes No - Tetanus/diphtheria (Td) vaccine? Yes No 4. Have you ever had an anaphylactic reaction to: - Thimerosal (a preservative found in some vaccines and some contact lens solutions)? Yes No [Flu, pneumo, Td] - Eggs or egg products? Yes No [Flu] - Gelatin? Yes No [Flu] 5. Are you in your first trimester of pregnancy? Yes No [Flu, pneumo, Td] If these vaccines are indicated, some experts advise waiting until the second trimester of r'rr:;;�.q•. •rMy '�5P'�.ry.�•lS,+ly.1,.... rs. �e ....:..-.y...�..'.+y., , .I*y„h,+ r"rri.-*'r';..,-,a,•,^'alw�",xr rr.ee 'iRF;rfr vrc^w„.`A^1%�-,n:iP+Aa^,�y«�R':-ti. �.,.�y�..»�.;w.;:. Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4'h Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 t -- Name ( Date TVDa of Operation(s) T e of Ins ection 0 e `/ n� n Food Service 14Routine Address ` A n Risk LJ Retail El Re-inspection !1 Xn t Level ❑ Residential Kitchen Previous Inspection Telephone n t C� ❑ Mobile Date: Owner (� n `i \ HACCP YM El Temporary ❑ Pre-operation 1 CJA OA i ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) ( Time �,.❑ Bed& Breakfast ❑ General Complaint i t st In: ( `�� ' ❑ HACCP Inspector (/ )Permit No. ❑ Other P /' n Out: (� N�nA.�i-PI � Ar7� ./ Each violation checked requires A explanation on the narrative page(s) and a citation of specific provision(s)violated. �j 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),EK action as determined by the Board of Health. g �; o. 'FOOD PROTECTION MANAGEMENT,s„ ° , G?sp ❑ 12. Prevention of Contamination from Hands 1.j PIC Assigned/Knowledgeable/Duties 04, 1 EMPLOYEE HEALTH'=_ 3 El 13Handwash Facilities/ +PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC V t v �� -a�� ,�� „ a=�- "� �d�,A • . ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals F004 FROM APPROVED SOURCE„,,,,,";`,„,,,.,,,..__a„�,.,;� ®,®.®„W __ "TIMEITEMPERATURE CONTROLS Potential) Hazardous Foods ❑ 4. Food and Water from Approved Source 11 _ w LS(Potentially r ) , E1 ❑ 5. Receiving/Condition V [116.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements V ❑ 17. Reheating n G ❑ 7. Conformance with Approved Procedures/HACCP Plans [118.Cooling U14- x 1 ❑ 19. Hot and Cold Holdin PROTECTION FROM CONTAMINATION a 9 ❑ 8 Separation/Segregation/Protection /( J ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing (/�✓ a REOUIREMENTN FOR HIGHLY SUSCEPTIBLE P F}ULATIONS(HSP) (� El 21. Food and Food Preparation for HSP (� ❑ 10. Proper Adequate Handwashing El11. Good Hygienic Practices �"' `CONSUMER ADVISORY„ r„� ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C N by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.6 23. Management and Personnel (FC-2)(ss0.0 4) order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of 25. Equipment and Utensils (Fc-a)(ss0.o05)) 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)(590.067) 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 RRE-IINyS)1-PECTION: 5:5901nsPMFormEid me � V '�f,�VSNV� 9Gt.R . �,c�Or� p��n�l 1^ Inspector's Signature: \I l,i7--(A \P,rintj- L I - PIC's Signature: / \ Print: Page.. , of-2ftges �J Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Cross-contamination I 59Q003(A) Assignment of Responsibility* 3-302.11(A)(1) Raw Animal Foods Separated from 590.003(6)_ Demonstration of Knowledge* Cooked and RTE Faids* 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(0) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* applicants* _ 3-302.15 WashingFruits and Vegetables 590.003(F) Responsibility Of A Foal Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(6) Reporting by Person in Charge* 1-306.14(A)(B) Returned Food and Reservice of Food* 3 1 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Frx7d* 4 Food and Water From Regulated Sources F9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501..1.11 Manual Warewashing-Hot Water 3-201.12 Faxi in a Hermetically Sealed Container* Sam tizatiop Feureraerres* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashina Ilot Water 3-202.13 Shell Eggs* Sanitization Temper totes* tem 3-2(}2.L4 E==s and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization- P"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) Ejuipment'Food Contact Surfaces and 59(}.006(A) Bottled Drinl n Water* utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0' 4-602.11. Cleaning Frequency of Equipment Food- Contact Surfaces and Utensils* 5heltflsh 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-HotWaterand 3-201.15 Molluscan Shellfish from NSSP Listed ChemicaP° Sources* t0 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority2-301.11 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 g Receiving/Condition 2-401.11 Eavn ,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 bite it * Mouth* 3-101.11 Food Safe and Unadulterated* 3-30t.12 Preventing Contamination When Testing* Togs/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(F) Preventing Contamination from 3-203.12 Sbellstock Identification Maintained* Employees* Tags/Records:Fish Products 13 Handwash Facilities 3402.11 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* Conformance with Approved Procedures 5-205.11 Accessibility,Operation andMaintenance /HACCP Plans Supplied with Soap and Hand Drying Devices 3-502.11 Specialized o gen packaging, Methods*to 6-301.11 Handwashin Cleanser, Availability 3-502.1.2 Reduced oxygen ackaring, criteria* 8-103.12 Conformance with A roved Procedures' 6"301.12 Hand.Diving Provision "Denotes critical item in the Weral 1999 Food!Codeor 105 CkAlt 590.000. CITY OF SALEM t BOARD OF HEALTH Establishment Name: 01 Y A/) I ton Date: td �O � !'L age: of I =r 'DESCRIPTION OF„VIOLATION 1 PLAN OF,CORRECTION °Rem ' Code C Critical item e .. ,.� �, s' Date�,33- '. No, Reference, R-Redltem. , �' 'a” " ` yam` �*', �` y, �`;- _�'� :- Verified c.` .. .a ' . . �'�PLEASE PRINT CLEARLY I - 1�: _�/p,.f�. ./ (1 - y ._ alt. . n I 1 n 'x Ak L` -A Q,.� _o,,o -� A 0 (I Va I X),,�P_"!k , �'- ii .J?-1'�Xn..n 1/A-nLo Ao AA in , A -v j /1 �f_rven�=C [-'.A Y/" —llP 0All PA. �(a , osl Vaca, Fit —O I � PIC)t PmJC'�S �!7'yl I�7ii�l c'V� V��-�,,�. — �i4`,cY t/i � /1 C je �3 a-1 lJ _ t i i I I 1 r - Discussion on With Person in Charge: Corrective ActiRequired: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree'.to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 0 Voluntary Disposal 0 other: PHFe Reonved Aixordim,lo Lj�at 'C�xilttdtiiut-ea Violations Related to Foodberne fliness Interventions and Risk i I PHF""�'t'l o"e" Factors(Italian,I-W) (Cant) 4 1 L�14145'-iF Wi�lhiia 4 Houx� Violations ..Is Related label to F 0 FROM 3 5W 15 Coolia�,,Mafaxls"or PIMg PROTECTION FROM CHEMICALS LL9 PHF Hot and Gold Holding LL4 Food or Color Additives I6(IH FIHF�Maintained at or below -20'? elow -2072,12 ddlili�a�" d 3_ 2 1 �3ET4 Proleclion from —16(,k—) ,— His Pt-1f Maintained at(7-above Poisonous or Toxic Substances 140'F, Id I 1 1 5(11 t i 101.11 Identifying 1"llonw,tion--0a iced te -RAKiw,Held at ccabovc 130'T L20 Time as a Public Health Control -- no 7 102,11 — Ckuroll'Naroe, "Norkin.011gaincrO 7 20€.11Reach Control' -201 Re-cvicoon-Pre wc and Usc* Vaztanu rcloerr 7-2102.12 Condition,of Uso' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE I 72>03.11 Toxic POPULATIONS(HSPS_ Pre-paun}:agcd Juiccs aid k7-204-!_2 'L�airLe,("Inerl ' sg ill ------ fieverams with warm 7 204�14 cracria)� 1'pastel 7 205,11 Ineidemal Food Comiet.Lubricants* E20(_ E StdS iro I aliNot Served L, 7-206.12 Rodero Btion,� �iit S�a � ------n-1 9(il'i 1 0 U'rerenew taxi Paclia,v hat Rc-icrvuf 7 206 13 Tracking P iwd- Prst Control and CONSUMER ADVISORY TIM EITEMPERATURE CONTROLS i22 AnhoA f,,'k& I'h4t are Raw, i2ndercookcd a 16 Proper Cooking Temperatures for7 F Nor oflwr,�-ise Prece4scd to Eliminate 3-11 1 11 A(l)(-') 1gge- 155'F 15.4ee, 30" 13 P"�ix,oril-1xi Elflfe;Substitute foi -- I C, - imilimpted t ash. Meias&Gnne Ardhaus [55,17 l5liec. " SPECIAL REQUIREMENTS -401.11(13)0)(2) I 11man b d Beef kra,,si - 130�'F 121 zein" - ------ Viclhiljon,oi Section 590,00')(A)-(171 in Adj.I I(A)(2) Raines, fnwcd t4ems - 1557 15 s C cateri I;F. mobiktbod', teniporal v and rL,.meica f,:al Kitchen laperationa should he 3-46T.H(A)(�i) PonitrN,Wild Gainc�Stuffed PF.Fs,Fish; Ml, debiled under the ap,,oTmate ea ldxwe if ze1aled to foodborne illness 3-401ANC)(3) 'Nhde.nue, lc, Irract Beef Seclkn iniervem;ons and Hit: fiildors. Other 14ST590.009 violafion�rclininc to good retail I-- practices �;hould 1v debiter#29 - Cd und 1 3--OIA2 Raw Ainnial Foixh(,coked ul a Miclow ave 165'T Special 3-401,1 HA)kl)(b) All,(khei PH14i`F 15 sec, ' 8888 I Reheating for list Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES Pill-, 16,57 11 1 Iterns 23.30) 3-403.11(B) Nliciowave- IC5°F Z Minnie,Standing viviopwo, which do tore remn,in the Tante"' jklodhorne ifrners imerventiony and rizkjairors lfo4 ahol,e (an be 3-403,11 W) I Commn-i-ON,proi:csiied FTE 1-orld found in the fat elrugs ,tions of M6 Food Cade and P6 CAIR its m----f ,Practices fC-- -, 1-5-96.0 w-- 3-403,11 0�) Ronaiam", Unsllcfd poru�,-n�oflleeF- Poas!"* 23, NV193.9]anleni wxi Per,onnpl I FC -2 i '003 24, i RwAcnd Food Prolection FC- 3 W4 Ig Proper Cooling of PHFs —-------------------- FC-4 00� to 25 waml,Plumbing andlillasal 1 FC d_ iw00ii 7001;Within 2 lfourand from 10 T Facilltv 4 45'F Nkrinn" Houn;. ilsn c 7 '008 8 r - j FC 6 607 io l'F/ HZIF- _Eq�oijo 3-501.14(13) Coollvi-a P1 IR Made Form Ambient �,q 8 1 R mro ra its 'remperatine t04101745 6her leoiutp� ,nud tun ic ah:&,AelA 1499F0ojC,Ale,,r 105 CMR 59900o CITY OF SALEM BOARD OF HEALTH �� Establishment Name: CJOAA/ V o Date Page: of C Item Code,., C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF, CORRECTIONDate No. Reference R-`Red item "" - '^ " - t '_r �,� �.„ _.: Verified s PLEASE PRIlNT CLEARLY C2'4�G, GCCJ/N✓, Get` A Cl LI )ti{ lion J —le nom_ CA, 5kXAG,V, A,�_ rnc� � 1c11PnJ l�Q�{J �LPclCtr� V'ec r )P J or r Cq C_J/gc , ',i1s< — J` �n Z=t CJ r A(1 � rn �� SPr rn�• ��7 � � lr SP2 !! �� 0 ✓Jct t]I ^L? , it i Ili o { v/ r�yr' -lalI,a��Ci /�t.}J,MQ�L �C1 K1�1 Discussion With Person in Charge: Corrective Action Required: ❑ No f Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to >d5rRe-inspection Scheduled ❑ Emergency suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: i 375Tt 14(J) PHFs Received ext'Pnm}wraWrec Viclabons Related to Foodborne fitness Interventions and Risk Atxording to Lae, Cooled to Factors(items 1-22) 1Cont) 'I-FteStF Within 4 Houks� 01,15 Coolie,,Slethods for IIHFs PROTECTION FROM CHEMICALS i- -- Food or Colar Additives 9 PHF Hot and Cold Holding PHI s Mamoined at or i;�Klw 202 I2 4 1�145"F* Add ulvcO `;-30214 Protection from itives* Poisonous or Toxic Substances above501,WA) Hot PHFs Maintained at le 14(zIF. 3-501J6lA) Roisis Held at or shove 130cE Time as a Public Health Control 102,11 0omraon'Naiue- Workinlr'�llatailler" 7-201.I I Sr iabon 5miatxe 3-7()1,19 7-202.17 Resit inion-Pn,sence and Use' L7702.12 Clerdilion",of Use" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 1 7-2�03,11 Toxic Containcis-Rrohibitions* POPULATIONS(HS-D_ __ x-,- 204.11�11 -Sannizem Crmral--Chcmicds* 21 3-8t'.1 i(A) Uafal (CUT-Izcd Ne-packaged Ances and 7-21,W 12 'ti�zia* 7-2�04,14 Dr�ii _L �_.— with Crrteria� I 3-801JIHI) Ue is I'mtearized EQ %'* i,20TI�l adiorwl l7o, cut S' Raw or Pam:tIN Cooked Animal Fuad and 7-206AT Ro,iricled U,�e.fleucidelt, Critena' I I(D) L r Raw seed Sprontlt Nol serve 1 7-40612 Rodent Bell St3till1c," k---- 7 ^06 13 l'icking Powders,14esi C.orurd and T i (CONSUMER ADVISORY - -- ugoor Adisom T',%wd— '_7 for TIMEITEMPERATURE CONTROLS TAK,� �on —ongu-111puen of- 'I 22 3 Awnlol F�Nxls'that arc�Raw. Undercxxlked u; 1,6 Proper Cooking Temperatures for N(A Otter iso flocilglied to 1-Hinoreoe PHFS .1 �RtFi i A(l)(21) Eggs- 155'F 15 jjnzrrodiate 5er,,icc 1,45"Fl5sec, 1.363 11 Paste rand E&&;Substoule for IU% Shell r-laow Animals 15,5"F 15 sec. SPECIAL REQUIREMENTS 3 3 46 1(13)(1 if ) I 1 2 Poik ad Beet Rmw l'off, 121 rIsTO 3-401.11(A)Q) IWFi5 catering, mobill,,text,tednporru lr and 3401-WAif3) lsotfltrg,Wild Ciarre' Smiled PNFls, rctidential kitchen operations sbooki be Sluffuey('orgamim Fish, Meat, debited under the appropriate sections oultl, mr Rtnutls-l5'T 15 sec. i1xved'related to fi-K)dborne illness ;-401 I1(C)(3) llOrole-olusclo. heact Beef Steaks, noet ventrons, and risk factors, (Xiter 1451 * 590.009 violations relating to good retail I 3-41NJ2 Raw Annual Fottds Cooked ill a practices ehould fc d0ited under #29 - Microwave 165'F Special Requirements- 3-401 ll(A)(l)(b) All Other Pfil:s-- 145"F 15 sec 5746TI (A)T Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES fit� 'i 117- 1�5 T 15�sco, (Items 23-30) 3403.11(B) Nlicrowavc- 165-F 2 Minte,Stattlin, Criu-rel and roan-(rawal vlotaovtra, which do=tot reiare to lite Tells, ;`radborne illness boer ventiom and rust firl tors listed above con be -40111(C) Commercially Processed RTE Kxld 'fiould ill thejollou life, _eceOro of lh,!Food Code and 11s5 CW)? 3-403.3 I(E) Remaining Unsliced Portions of ivalfGood Retail Practices 000 FC 590, " nr - ------ R last.* 2,7- M ia rrlorand Per ersonnel 3 taL ge _ tFi - Proper Cooling of PHF9 24 FvAnnd Food P giecuon ......... 034 FC-4 066 3901.14(A) C(loling Cook,d PI-11-ts from l4lf'r-tT, P2 6, i Watel,Plurnisina and Waste FC-5 mi ---------- 41 Within 2 Hours and From 791' T" -- . FC-6 007 '008 3-50 4(8) C,gohvti PUN Made From Ambientt— R'Xalklarant's Temperature higredientr to 41-1,i45 F DO-- O6Pi-------ro ---------- Within 4 Hour,l* l—__________ -1— — use ill(tv foderal 1999 Foiltl("Xiror 105 CNIR 59001W, Massachusetts Department of PublicHealth Salem Board of Health 120 Washington Street,4"Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date Tvpe of Operations) Type of Inspection 7 �/� Food Service ❑ Routine Address ? Risk / [] Retail E],Re-inspection Level ❑ Residential Kitchen /Previous Inspection Telephone ❑ Mobile Date:)Z(�f�� Owner 5 J� HACCP YM ❑ Temporary ❑ Pre-operatwn to ❑ Caterer ❑Suspect Illness Person in Charge(PIC) ` U TimeElBed&Breakfast ❑General Complaint In'�'L�9 ❑ HACCP Inspector 0�01_ , Out: - Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.0'09(F) ❑ action as determined by the Board of Health. 'I'rin ;FOOD PROTEc7i0NMARAGEMENT '.„,"`""" "`;„';„ `��,„,..„ „ .. ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEEHEALTHm" • ': �'�M ` ,�,� }ry i.- km-� H , ..a» , , "' �, ... d.��-,„„w„•.« ,.,&.p PROTECTION FROM CHEMICALSs+ n. ❑ 2. Reporting of Diseases by Food Employee and PIC E E . Approved Food tiv ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded -1 ❑ 15 Toxic Chemicals 0:00DFROM APPROVED SOURCE" '-:i. ; �` „�,�s,�µ;�, M.„ei U`9 ❑ 4. Food and Water from Approved Source TIMErrEMPERATURE CONTROLS(PoteMfalty Ha ardous Foods)a y^ 3 .t v .=J-A+-m X. a. mM ii�.w.ilSu E®o mU �•�i.Eu do ,++„ate ..• :i: ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling i"PRQTECTION'FROMCONTAMINATION�'"� `� f�"' El19. Hot and Cold Holding ❑ 8 Separation/Segregation/Protection [120.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing TI EOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices riCONSUMERADIISORY'n " $�. .�`'=.L..��'��'� �..-b•.��-.��._- ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report, when signed below N ` by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-x)(550.003) 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: S:ssoiom�Fo 14,dm 1 \ w Inspector's Signature: \ / �� Print: PIC's Signature: . .L• Print: �c),%)� �y X11 by Page of $"Pages o Foodborne Illnessf F Violations Related Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT F S Cross-contamination 1 590.003(A) I Assignment of Responsibility* 3-302.11(A)(1) Raw Animal Foods Separated from ` 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* - 2-103.1 I 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 foal employees and 3-302.11(A) Fund Protection* applicants* 3302.15 Washan,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 Re; rvice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003{E) Removal of Exclusions and Re-strictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law*_ 4-501. I 1 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Tem ratures" 3-20113 Fluid Milk and Milk Products* 4-501.112 MechanicalWarewashino Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.14 E gs 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 DrinkinE Water from an Approved S•stem* 4-601.11(A) Equipment Foal Contact Surfaces and Utensils Clean* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in'310 CMR 22.0' 4-602.11 Cleaning Frequency of Equipment Food- Contact Surfaces and Utensils* Shellfish and Fish Froman Approved Source 4-702.11. Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 44--7103,11 Methods ofSanitization-Hot Water and 3-201-15 Molluscan Shellfish from NSSP ListedChemical* Sources* - Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Author" 2-301.11. Clean Condition-Hands and Aims" 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 g Receiving/Condition 2-401_11 Eating,Drinkina or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 21101.12 Discharges From the Eyes, Nose and 3-202.t5 Package Inteit * Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-20118 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Em to ees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible - 3-402.12 Records,Creation and Retention" 5-203.11 Numbers and Capacities* 590.004(7) Labeling of Ingredients* 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Nand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.1.2 Reduced ox• en )acka 'ng.criteria* 6-301.11 Handwashin Cleanser, Availability=] 8-10312 Conformance with A roved Procedures* 6-301.12 Hand Drying Provision .*Denotes critical item in the Wer l 1999 Food Cale or 105 CMR 590.000. - Salem B rd f Massachusetts Department of Public Health pa o Health 120 Washington Street,4"Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date Type of Operation(s) Tyne of Inspection C\ I G/4 r0 0 [N'Food Service 61 outine Address RisM El Retail �J Re-inspection r Level ❑ Residential Kitchen Previous Inspection Telephone ^ 5 ❑ Mobile Date:/y/m,X.)l 1 El Temporary El Pre-operation Owner 1 ." HACCP YM ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) S , / i Time ElBed&Breakfast E]General HACCP Complaint n � In: inspector nr Out: ;(� Permit No. El Other Each violation check d requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT„!„,m.w„��,,,E�,r „ " ; ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities ' EMPLOYEE HEALTH e u` �� wu3x 9 tM �'- aemwY--}r s k .: �a n!{a�,3� wrm :PROTECTION FROM CHEMICALS k cs: ia¢.xr q.pt, eH6 t ❑ 2. Reporting of Diseases by Food Employee and PIC d2a .8 .`$ m ,., r ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded j Eli FOOD FROM APPROVED SOURCE ';'"`,` 1"° " �� :""` "` 15 Toxic Chemicals t """`' ' "' - L" i i.,�TIME/TEMPERATURE cONTROLS(Potentlaity MataWous E] 4. Food and Water from Approved Source , ��di g r t ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling "PROTECTION FROMCONdTAIIINATION r� ❑ 19. Hot and Cold Holding p � � � B ❑20 Time As a Public Health Control ❑ Separation/Segregation/Protection r Food Contact Surfaces Cleaning and Sanitizing F REQUIREMENTS FOR" HLY SUSCEPTIBLE POPULATIONS(HSP)w? .. ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing p.❑ 11. Good Hygienic Practices - [CONSUMER AbyiSORYtiW„„ F, ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices ` Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(990.009) 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-s)(sso.00s> 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.� M 30. Other DATE OF RE-INSPECTION: L o�Ct a 00 4- Keu7� i Inspector's Signature: Print: PIC's Signature: (/ Print �F/h&,6r A/c�� Page-Lof Pages Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 590.003(A) Assignment of Responsibility* 3-302.1!(A)(]) Raw Animal Foots 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 Aminal Fools Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require repotting by fool employees and 3-30111(A) Foal Protection* a rlicants* _ 3-302.15 WashinE Fruits and Veigetables 590.003(F) Responsibility 01'A Food Employee Or An 7304.11. 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) Returned Food and Reservice of Food- 3 , 590.003(D) Exclusions and Restrictions* Disposition ofAdulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions _Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590A04(A-B) Compliance with Food Law* 4-501.111. Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanifization Tent eratrnes* - - 3-20113 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashino Hot Water 3-2.02.13 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 DrinkingWater from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* - 59Q 006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source4_702 11 Frequency of Sanitization of Utensils and 3-201.1,4 Fish and Reereational'ly Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-I-Iot Water and 3-201.15 Molluscan Shellfish from NSSP lasted Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory 2_ Author" 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* ll Good Hygienic Practices $ Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes, Nose and 3-202.15 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting" 6 Tags/Records:Shellstock L12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.0(k4(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employees* Tags/Records:Fish Products 13 Handwash Facilities 3-40271 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(1) Labeling of ingredients` 5-204.11 Location and Placement* ry Conformance with Approved Procedures 5-205.11 --Accessibility.Operation and Maintenance IHACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.1.2 Reduced ox en acka 'na.criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with A. roved I?rocedures* 6-301..12 HandD. Provision Denotes critical item in the Wend 1999 Ford Code or I05 CMR 590.010. p m CITY OF SALEM,MASSACHUSETTS BOARD OF HEALTH - 120 WASHINGTON STREET,4"�FLOOR )?Ub�1CHCR11)'1 Ymvrne.Pmmom.Prolec. TEL. (978) 741-1800 FAX(978) 745-0343 Ixamdin e salem.com ICIMBF.RLEY DRISCOLL LARRY RAbIDIN,RS/Ri.,,HS,CHO,CP-FS MAYOR H7.3Aurm AGENT This Form will be collected during your next Board of Health inspection. QUESTIONAIRE —GREASE TRAPS 2012 1. NAME OF ESTABLISHMENT: (!1Z,&1740, /AIL 2. ADDRESS OF ESTABLISHMENT: 200L �616y 3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP? yES 4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT HAVE? CAPACITY IN GALLONS go 5. HOW IS THE GREASE TRAP MAINTAINED? ON A DAILY BASIS? BY AN IN-HOUSE PERSON OR BY AN OUTSIDE CLEANING SERVICE? 0uj-s, de ele_-<n),jj ��NiCe 6. WHAT IS THE FREQUENCY THAT THE GREASE IS REMOVED FROM THE TRAP? On� �i �on fti 7. WHAT IS THE NAME OF THE FIRM WHO REMOVES AND/OR PICKS UP THE GRE E FROM Z YOUR ESTABLISHMENT? ( /7J Vaca 6 ," A E ware JI)c 8. WHAT IS THE DATE OF YOUR LAST INVOICE FROM THE REMOVAL FIRM? i/�4 /aI4072,