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CIRCLE K 7502-SUBWAY - ESTABLISHMENTS 5o2/Ivbwhy 323 h•�� i� a Vt universal one,m www.myuniversalop.com phone: 1-800-756-4676 UNV16162 MADE IN USA . i it OD V Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2011 ESTABLISHMENT NAME: Circle K 7502 / Subway File Number.BHF-2008-000021 323 Highalnd Avenue SALEM MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2011-0103 Jan 1,2011 Dec 31,2011 $140.00 ESTABLISHMENT RETAIL FOOD BHP-2011-0102 Jan 1,2011 Dec 31,2011 $280.00 TOBACCO VENDOR BHP-2011-0104 Jan 1,2011 Dec 31,2011 $135.00 Total Fees: $555.00 PERMIT EXPIRES ecember 31, 2011 Board of Health 1 This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4"'FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 MAYOR DGI2EENBAUb1@SAI:EM.COM DAVID GREENBAUM,RS ACTING HEALTH AGENT 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT G i rc t f k -15 Kg\ TELA 1 D •1 JS 1 6 g'( ADDRESS OF ESTABLISHMENT 3�Q (aA FAX#Zi3,'3 1 ' 0 L 0 MAILING ADDRESS(if different) T 0 OX b u5, Z: N Lil-M'k EMAIL- Business': `' A Website: p p OWNER'S NAME C t rc'c C� JA n LLC- 1 TEL -I�Al x 1341 ADDRESS ? 0 T30 3`�1r �eIN ^1bi4s N L�Iyl STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) �,,/ .( � EMERGENCY RESPONSE PERSON A;J SGC J r', 1 6C Af e r HOME TEL# O 6 0 'V l� ( 15 -(+i ^DAYSOFOPE,RATION ; =Monday ; r=" 'Tuesda v'Wedne day °Thursday : � rFndayt�, i<' SatuMa HOURS OF OPERATION 1 Please write in time of day. 1 For example Ilam-11 m 1 TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. 1000-10,000sq.ft. more than 10,000sq.ft. =$420 - --------------------------------------------------------------------------------------------------------------ie-s"s--------------------------------- - RESTAURANT YES NO less than 25 seats =$14 (Outdoor Stationary Food Cart$210) 25-99 seats = 60 more than 99 seats =$420 BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES/NURSING HOME------------------------ -------------------------------------------------------------------------.....---------------------- ADDITIONAL PERMITS MAKE(not just serve) ICE CREAM, YOGURT/SOFT SERVE YES,, NO $2 TOBACCO VENDOR YE 1 5 ALL NON-PROFIT(such as church kitchens) S 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 fled all state tax returns and paid all state taxes required under the law. / � DFC - 3 2010 aC 1f8 Signature Date Social Security or Federal Identification Number ----------- — ---- - -------------------------------- Revised 10/7/11 FOODAP201 Ladm Check#&Date $�� '...k•1.r.-..T".n._,,;{,s..•y , f �t _ ...!e-..: N' .'.. ``1"' ° "'; �'i 'Ta•; F � -eh' ..'h ' ! 7(ea !' 7 +,. Massachusetts' Department,of,P;ulilic-Health salem Board of Health , ' • • + l 120 Washington Street,0 Floor Division of Food and Drugsr f Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT t ; Tel. (978)141 1800 Fax (978) 745-0343.1- t, a' Name /� Date Type of Operations) Type of Inspection C(rca 7<d ❑ Food Service ❑ Routine Address ) / / i Risk Ej Retail �Re-inspection t1 ti Level 'M Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: I 1 OwnerHACCP YM El HACCP [IPre-fper i n � ❑ Caterer { ,..._❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed 8 Breakfast, ❑ General Complaint In: ❑ HACCP Inspector 1 Out. w 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 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 ",�,;�„"",„ .. '`_�, " at" F ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties ❑ 13 Handwash Facilities €EMPLOYEE HEALTH "W9 xl `PROTECTIbN FROM CHEMICALS�[Vu°�'"' m'"" EF ) -; 1€ ❑ 2. Reporting of Diseases by Food Employee and PIC S, gym _ »A-� i w �� •� =�3��u� j ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals §n,FOODFROMAPPROVEDSOURCE„.; ,d Y„' �`,grrk" P:ur+„4. . ; . ....e_. ❑ 4. Food and Water from Approved Source TIMETEMPERATURE OONTROLS(PoteMlalty Hazardous Foods) - ❑ 5. Receiving/Condition ❑ 16,Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling f"PRgTECTION FROM CONTAMINATION` ' 'L,f 1= r -, n ❑ 19. Hot and Cold Holding s uI>&s aan..nmrav w=ws di ,a --a nni El8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and SanitizingIREOUIREMENTS FOR HIGHLY SUSCEPTIBL6,P0PULATIONS(tiSR), ❑21. Food and Food Preparation for HSP [3.1 0. Proper Adequate Handwashing .. ❑ 11. Good Hygienic Practices i�CDNSUMEfiADYI50RY;is wtdiZ �„' nF��.,......!��...:. ,€�'•sk ,i k ❑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.7 7 590.000/federal Food Code. This report, when signed below C` " by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.0 04) Management and Personnel (FC-2)(590.0 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)(sso.o0s) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(59o.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: /A 5:5901nspeclForm6-14.d. A Inspector's Signature: l Print: PIC's Signature: ( I,�!�. � ) Print: d t � >C�t Page of Pages v --:F ,I Violations Related to Foodborne Illness interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT F S Gross-contamination . 1 I 596.003(A) Assignment of Responsibility* 3-302.11(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Coked and RTE Foods* 2-103.11 Pelson in charge-duties Contamination from Raw Ingredients 3-302.11(A)(2) Raw Aniuul 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 3-302.1l(A) Food Protection* applicants* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.1 1, Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) Re orcin b Person in Charge* 3-306.14(A)(B) Returned Food and Reservice ofFood* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.1.1 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Focd* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Com tliance,with Food Law'k 4-501..1.11 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures,, 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 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 A roved System- 4-601..1[(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- Contact Surfaces and Utensils* SheiNish 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 3-201A5 Molluscan Shellfish from NSSPlisted Chemical* Sources* 14 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Reoulatory Aufhord Arms* 2-301.11 Clean Condition-Hands and As* 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* L1 Good Hygienic Practices g Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures 2-401.12 Discharges From the Eyes, Nose and 3-202.15 Package integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 TagsfRecords:Shelistock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained" - Employees* Tags/Records:Fish Products 13 Handwash Facilities 3402.11 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 Conformance with Approved Procedures 5-205.11 Accessibilit ,D oration and Maintenance fHACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods's IDevices 3-502.12 Reduced oxygen packaging.criteria* 6-301.11 Handwashin Cleanser, Availability 8_J(Ci 12 Conformance with Approved Procedures* 6-301.12 Hand Drying Provision Denotes critical(tem in the federal 1999 Ford Code or 105 CMR 590.000_ r ' Massachusetts Department of Public Health 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 R I Name Dao TVDe of 0 eration(s) Type of Inspection I ❑ Food Service Routine Address Rik E4--Retail Re-inspection ^ Level C] Residential Kitchen Previous nsp ction Telephone El Mobile Date. 1� Owner I �� HACCP YIN ❑ Temporary ❑ Pre�� petition ❑ Caterer ❑Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑General Complaint Inspector in: 5 J Permit No. ElHACCP Out: :Do ❑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 El i.- PIC Assigned/Knowledgeable/Duties EMPLOYEE HEALTH ❑ 13. Handwash Facilities ----_- PROTECTIONFROMCHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC E] 3. Personnel with Infections Restricted/Excluded El 14.Approved Food or Color Additives _P _-___ ._ ®15.Toxic Chemicals FOOD FROM APPROVED SOl1RCE_ _ ❑ 4. Food and Water from Approved Source TIMELTEMPERATURE CONTROLS(Potentially Hazardous Foods_) ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing - REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP), ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11.Good Hygienic Practices [CONSUMER ADYI$DRY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations.must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C x by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(5590.090.0 044))) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (Fc-a)(5so.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: ssBOrnspeclFormb1a eoo ^ Inspector's Signature: \I 'nb PIC's Signature:�Gl Lc Print: pL Ctn0.Q C O S Page.,of Pages I Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.1.1(A)(!) Raw Animal Foods Separated from 1 590.003(A) Assignment ofResponsihility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-}03.11 Person in charge--duties 3-302.1.1(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.11(A) - Food Protection* require reporting by food employees and 3-302.15 Washing Fruits and Vegetables applicants* 3-304.11. Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An Utensils* Applicant To Repots To The Person In Contamination from the Consumer Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 590.()03(G) Reporting b Person in Char e* Disposition ofAdulterated orContaminated 3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Fwd* 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 MilkProducts* 4-501.1 t2 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.1.4 Eggs and Milk Products,Pasteurized'* 4-501.114 Chemical.Sanitization-temp.,pH, 3-202.1.6 Ice Made From Potable Drinking Water" concentration and hardness. * 5-101.1.1 Drinking Rater 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- 590.006(B) and Fish From an.Approved Source Contact Surfaces and Utensils* 4-702.11. Frequenc-v 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* to Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301,11 -Clean Condition-Hands and As* 3-202.18 Shellshxk Identification Present"` 2-301..12 Cleaning Procedure* 590.004(0) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices 3 Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.1.t PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and 3-202.1.5 Package Integrity* mouth* 3-101.11. Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 TagstRecords:Shelistock 12 Prevention of Contamination from Hands 3-202.18 Shellstook Identification * 590.004(E) Preventing Contamination from 3-203.12 Shellstoek Identification Maintained* Etn to ees* Tags/Records; Fish Products 13 Handwash Facilities 3-402.11 Parasite Dcstruccon* Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(J) Labeling of Ingredients' =6-301.11 Location and Placement* 7 Conformance with Approved Procedures Accessibility,Operation and Maintenance IHACCP Plans Supplied with Soap and Hand Drying 3-502.11. Specialized ProcessingMethods* Devices 3-502.12 Reduced oxygen packaging,criteria* Handwshin Cleanser,,Availabilit8-103.12 Conformance with A. roved Procedures" Hand Dr 'n Provision 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. y CITY OF SALEM (('�� 7� BOARUOF HEALTH Establishment Name: G rcQ Date: IF4141 Page: - of Item 4 Akerode R-CritRed item Item DESCRIPTION OF VIOLATION/PLA OF CORRECTION Date. No. Reference R-Red Item PLEASE PRINT CLEARLY Verified C� I I G- �L YJv1f JKrn i ly reti,-edQ-%,- ij vc)lw G9'1 Akwer C11R,4 J iL- U ut 3P'7 JW✓JAI I u / O/t l30 C G �— V, f r C;XZGf�(112�% (UVU/ rr✓ r7 r� 4lpc. t C �� ry y.. S U aJ a we I O G S J S L, q i Ghe--"- f' 54N-ry AIA-V'- l� D c W ne ��.� a.lf-- (leo / 6Ar �./K e, 7, Discussion With Person in Charge: Corrective Action Required: ❑ No I Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ce ❑ Employee Restriction violations before the next inspection, to observe all conditions as described, and to Exclusion comply with all mandates of the Mass/Federal Food Code. I understand that .aC Re-inspection Scheduled 11 Emergency Suspension noncompliance may result in daily fi 'of ts E3caw@nty-five d esdollars or suspension/revocation on/revocation of Embargo Emergency Closure your food permit. -- lel G G� '-�.. ❑ 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(hems 1-22) (Cont.) 41'F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Additives* 590.004(F) 410145'F* 3-302.14 Protection from Unapproved Additives* 15 Poisonous or Toxic Substances 3-501.16(X) Hot PHFs Maintained eros above 140`F.* 7-101,11 Identifying Information-Original 3501.16(A) Roasm Held at or above 130°F. Containers* 7-102.11, Common Name-Working Containers* 20 Time as a Public Health Control 7-201.1.1 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* 7-203.11 Toxic Co utiners-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS HSP 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-80111(X) Unpasteurized Pre-packaged Juices and 7-204.14 Drying Agents.Criteria* Beverages with Warning labels* 7-205.11 incidental Food Contact,Lubricants* 3-801.11(B) Use of Pasteurized Eags* 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served.* 7-206.12 Rodent Bait Stadons* 3-801.11(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEMEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods-That are Raw.Undercooked or PRFs Na Otherwise Processed to Eliminate 3-401.ItA(1)(2) Eggs- 155°FISSee, Pathogens.*E'rnnoot Eggs-Immediate Service 145'F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game E Animals-155'F 15 sec.* 3-401.1I(B)(1)(2) Pork and Beef Roast- 130'F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in see.* catering,mobile food,temporary and 3401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sec.* above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,intact Beef Steaks interventions and risk factors. Other 145'F* 590.009 violations relating to good retail 3401.12 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 PHPs-145'F 15 sec. 17 Reheating for Hot Holding VIOLAT/OMS RELATED TO GOOD RETAIL PRACTICES 3-403.1 i(A)&(D) PHFs 165'F 15 sec. * (Items 23-30) 3403.11(B) Microwave 1650 F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Time* - foodborne illness interventions and riskfactors listed above, can be 3-403.11(0 Commercially Processed RTE Food- found in the following sectionsof the Food Code and 105 CMR 1400F* 590.000. 3403.11(B) Remaining(Insliced Portions of Beef Item Good Retail Practices FC 540X00 Roasts" - 23. Management and Personnel FC-2 .003 18 - Proper Cooling of PHFs i 24. Food and Food Protection I FC-3 .004it_ 25. Equipment and Utensils _ FC-4 .005 i 3-501.14(A) Cooling Cooked PHFs from 14TF to + 26. Water.Plumbing and Waste I FC-5 .006 70'.F Within 2 Hoots and From 70'F 27. Physical Faclfi FC-6 007 to 4 t'F/45'F Within 4 Hours." 28. Poisonous or Toxic Materials FC-7 .008 3-50114(B) Cooling PHFs Made From Ambient 29. Special Requirements .009 Temperature Ingredients to 41'F/45'F 30• I Other Within 4 Hours* s.wnM,xrx-aa *Denotrs critical item in the federal 1999 Food Cole or 105 CMR 590.000. L •e: T 'CITY OF SALEM nBCARD OF HEALTH Establishment Name:�j /dC✓ (/ Sya * Date: r Page: .? of ROM code c-critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date NO. Rate %nce R-Red nem Verified PRINT CLEARLY �G. (il0 / l r✓ UVJ? I - I fS /1 ✓I J (4 ! r1 CG r nQ /K C. /! Ci C c ltc AI v J leSfW< 90b 0J1WJ -f'WJc Sho 41 t - U (a ra -'x5<'/y� Id . I \fr r. t AzK — csr✓ ve i Grs, /(R/licv a /ti t. - ,� GJLc L.t� ri (1 w G"/ 4A ,M FfCC& F3r3 ) t CL4 LZ QTV `o rwoycj ';Z4 I✓ IS��7Yr�vle W, a ( u,4 h -- n.J✓ � t ,,,, u- 4 S K a rete z 3�d -t,>_ I6 axo O`, c 1N / O �r✓ t-. nKl r 7pe� 3 ��U� c)t � P.N.�rer i i � J� •IJ �I r 01. w ,I Discussion With Person in Charge: Corrective Action Required: ❑ No Yes have read this report, have had the opportunity to ask questions and agree to correct all ❑ voluntary Compliance ❑ Employee Restriction/ fr 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 I noncompliance may result in daily finewenty-five dollars or suspension/revocation of L3Embargo C3Emergency Closure your food permit. 13 Voluntary Disposal ❑ Other: 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne illness Interventions and Risk According to law Cooled to Factors(Mems 1.22) (Cont.) 41°F/45"FWithin 4 Hours. PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below 3-302.14 Protection from Una 3-50 Unapproved Additives* 104(F) 410/450 F* 15 Poisonous or Toxic Substances -SOL16(A) Hot PHFs Maintained at above 7-10111 Identifying Information-Original 140°F. 3-501.16(A) Roasts Heid at or above 130°F. Containers* Time as a Public Health Control 7-102.11. Common Name-Working Containers* 20 7-201.I 1 Separation-Storn e* 3-501.19 Time as a Public Health Control" 7-20111 .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 Sanitizers.Criteria-Chemicals* POPULATIONS HSP 7-204.12 Chemicals for Wishing Produce,Criteria* 2I 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drying Agents.Criteria* Beverages with Wanting labels* 7-205.11 Incidental Food Contact,Imbricants* 3-801.11(B) Use of Pasteurized Eggs* 7-206.11 -Restricted Use Pesticides,Criteria* 3-801.1.1(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders,Pest Control and 3-801.11(C) Unopened Food Package Not Re-served. Monitoring* CONSUMER ADVISORY TIMEMEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.11A(1)(2) Eggs- 155°F 15 See. pathogens.,E1j 1.lnxat Eggs-immediate Service 145°Fl5sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game Eggs* Animals-155°F 15 sec. *' 3.401.11(8)(1)(2) Pork and Beef Roast- 130°F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec * catering,mobile foot!,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec. * above if related to foodborne illness 3-401.11(0)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to goal retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3-401a11(A)(1)(b) All Other PHFs- 145°F 15 sec. 17 Retreating for Hot Holding 11101 ATIONS RELATED TO GOOD RETAIL PRACTICES 3403AI(A)&(D) PHFs 165°F 15 sec. * (Items 23-30) 3403.11(B) Microwave-965°F 2 Minute Standing Critical..and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140°F* 590.000. _ 3-403.11(E) Remaining Unsliced Portions of Beef Hem I Good Retail Practices FC 590,000 Roasts": 23. Manimement and Personnel _ �FC-2 .003 11; Proper Cooling of PHFs 24._ Food and Food Protection FC-3 .004 i 25. Equipment and Utensils FC-4 .005 7 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 FacilityFC-6 .007 to 416F/45'12 Within 4 Hours. * 28. Poisonous or Toxic Materiats FC 7 .008 3-501.14(B) Cooling PHFs Made From Ambiens 29. 'Special Requirements .009 Temperature Ingredients to 41°F/45°F 30. 1 Other Within 4 Hours* +svcf«m ,2e: *Denotes critical item in the federal 1999 Fwd Code ur 105 CMR 590.000. L U.S. Postal Servicer. CERTIFIED MAIL,. RECEIPT (Domes$c Mail Ohly;No Insurance Coverage Provided)_ For delivery information visit our website at www.usps.conna EFICIAL VS - E3 Postage $ Gerlifled Fee C3 Return Receipt Fee M (Endorsement Required) Here C3 Restricted Delivery (Endomment Required) 0 Er Total Postage&Fees L .O : PS Form 3800:August 2006 See Reverse for Instructions Cerlifled Mail Provides: ■ Amailing receipt r , ■ A unique Identifier for your mallplece ■ A record of delivery kept by the Postal Service for two years Important Reminders. ■ Certified Mall may ONLY be combined with First-Class Mails or Priority Mails is Certified Mail is not available for any class of international mall. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return RecNpt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 38111 to the article and add applicable postage to cover the fee.Endorse mailpieoe Rehm Receipt Requested'.To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized aent.Advise the clerk or mark the mailpiece with the endorsement'Restriciedsefivery'. ■ If a postmark on the Certified Mail receipt Is desired,please present the arti- cle at the post off lee for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present It when making an Inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-0009047 + CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4".FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAx(978) 745-0343 MAYOR DCR1iI,,NBAUM@SAG3.M COM DAVID GRI::I NBAUM June 18, 2008 Ac,PING HF.At..11-I AGENT Circle K 319 Highland Avenue Salem, MA 01970 Dear Owner: On Tuesday, June 1, 2010 personnel from the Tobacco Control Program conducted a compliance check to determine if your permitted establishment would sell a tobacco product to a minor. A 16 year-old Female purchased cigarettes from a clerk in your store. Documentation is now on file at the Board of Health regarding that sale. Circle K is in violation of Section III (A)of the Salem Board of Health Regulation Affecting the Purchasing of Tobacco Products. According to this section,the sale of cigarettes, chewing tobacco, snuff, or any tobacco in any of its forms to any person under the age of eighteen shall be punished by a fine of($100.00 Hundred Dollar fine)for the first offense. FOLLOWING THE THIRD(3RD) OFFENSE, THE BOARD MAY CONSIDER POSSIBLE REVOCATION OR SUSPENSION OF THE PERMIT. The North Shore Tobacco Control Program and the Salem Board of Health have worked with you and your employees to demonstrate methods to ensure compliance with this regulation. Therefore, you are ordered to pay a fine of$100.00 for the violation stated above. A check or money order payable to the City of Salem must be at the Board of Health office, 120 Washington Street,4�h floor,within ten days of receipt of this notice. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven(7) days of receipt of this Order. At said hearing, you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports, orders, and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. If you have any questions regarding this notification please call me at 978-741-1800. Winrel�yura Acting Health Agent DG/htl CERTIFIED MAIL: 7007 1490 0002 3077 4243 cc: North Shore Tobacco Control Program Barbara Poremba, Board of Health Chairperson and Members F- City of Salem - Board of Health Tobacco Control Regulation - Violation Notice a Smoke F,ee Go ` This notice is to inform you that your establishment violated the Salem Board of Health Youth Access(YA) Regulation and/or Environmental Tobacco Smoke (ETS)Regulation. P Name of establishment i Address Date of viblation Time of violation Minor's age/gender Minor's ID# Inspector (Ordinance,Section,Regulation) (Act Constituting Violation) Narrative information 7T 61 � it o v �, � Ct�� Uv `� 7—Tc e v L C styap � c Iaffirmi,}rider the pain and Pena ties of perjury,that the a6 b v report is true to the best of my knowledge ai d belief. (1C` 1 iInspector, (Signature) �� (Print name) � 1 - VENDOR STATEMENT: I acknowledge I received this Violation Notice on 20 at'- AM/PM and I ari being given a carbon copy of this notice.I also acknowledge that I have been informed that the Salem Board of Health will provide additional,follow-up information to this violation notice. te Owner/Managgrr/Cl, erk(Sygnature) (Print name) If vendor refuses this Notice or if the inspector feels unsafe in delivering it,an explanation must be \ written on a note attached hereto.Mailing of this Notice is thus required. �° , �\ \vu For further information,contact the North Shore Tobacco Control Program at 781-477-0432 Establishment-white NSTCP-yellow Board of Health-pink COMPLETE THIS SENDER: COMPLETE THIS SECTION SECTION . ■ Complete items 1,2,and 3.Also complete A. Sign ture Rem 4 If Restricted Delivery is desired. 0 Agent ■ Print your name and address on the reverse ❑Addarssee so that we can return the card to you. B. Received by(Printed Name) C. lel of Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. D. R delivery address different from Kem 1? 1. Article Addressed to: If YES,enter delivery address below: 0 No Vcc. e, I, 319 I���UIa AUtnut 50-k¢t4n t1A 0 11 7 6 3. Service Type 0 Certmed Mail 0 Express Mail 0 Registered 0 Return Receipt for Merchandise 0 Insured Mail 0 C.O.D. 4. Restricted Delivery?(Extra free) 0 Yes 2. Article Number -1 - (transfer from service laW 1rir1 17007 1490f0002 3077-"42431j 1 r PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 UNITED SW !(i!1:4"J.1 it �P kt'q ,Ce 'aid L IWS:; .",, : ga Hlill "• ; Sender: Please print your name, address, and ZIP+4 in this box BOARD OF HEALTH SALEM, MA 01 970 'A. . .: ;� i-N.aa_n i«. ;, ,n r.9ews,rM'ff ) f'P.t.Y f# - n."'Myjr n..:.;:�. ..,�f..;»:p^p",.Lr:,..,..i� p'V.�a„�...�J �'•yu. . . f YN_�M'�n.�'Y Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4'"Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name �J Date Tvpe of Operations) Tvoe of Inspection ( ,r 7 ❑ Food Service ❑ Routine Address 1 / / n,I 0� � Rik [-Retail -2 Re-inspection 1 Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: Owner HACCP WN ❑ Temporary ❑ Pre-operation _DRV r- OIL r7 ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint _ In:�- El HACCP Inspector ) n Out: _i Permit No. ❑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„'„ „ -_,A7 ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties ❑ 13 Handwash Facilities .'EMPLOYEE HEALTH',-,jrM PROTECTION FROM CktMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals 2 •M , . Foo.FROM and Water SOURCE„„„„_,W o rce €:TIMErtEMPERATURE CONTROLS Poteidiall_ �' .._a. 6 � 7j ❑ 4. Food and Water from Approved Source � _ (, y Hazardous Footlsj'"`° ,) ❑ 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 E] 9. Food Contact Surfaces Cleaning and Sanitizing - I REQUIREMENTS FOR HIGHLY SUSCEPTIBLEPOPULATI01N(HSP) ❑ 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing F-111. Good Hygienic Practices 7CONSUMER.ADVISORYn:;,, ❑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 01 N 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 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)(19o.o0s) 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:5901ns tFOm 1444 - ( 1 ✓ Inspector's Signature:t � �, Print: --'`;jj= ^ qv/ages PIC's Signature: �'/'" Print: Pagel of a 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) Asstgnment"'Responsibihty* 3-302.11(A)(]) 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(0) Responsibility of the person in charge to Contamination from the Environment require repotting by food employees and 3-302.,11(A) Food Protection* applicants* 3-302.15 Washin 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(6) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated - 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Urnsafe FOOD FROM APPROVED SOURCE Food" 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food taw* 4-501.111 Manual Warewashing-Hot Water 3-201.1.2 Fond in a Hermetical) Sealed Container* Sanitization Temperatures* - 3-201.13 Fluid Milk and Milk Products* 4-501.7'12 Mechanical Warewashing-Hot Water 3-20213 Shell Eggs* Sanitization Temperatures* 3-202.14 Fgi,,s and Milk Products.Pasteurized* 4-501.11.4 Chenueal Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinkin-Water* concentration and hardness. 'w 5-1.01..1.1 Drinkin Water from an A roved S stem` 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.(x)6(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* 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-IIot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* Lg Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Reculatory Authorii 2-301.11 Clean Condition-Hands and Arms* 3-202.18 Shollsto:k Identification Present* 2-301.1.2 Cleanim Procedure* 590.004(0) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Came Animals* F,-I Good Hygienic Practices Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11 P1I1s Received at Proper Temperatures* 2-401.12 Discharges From the Eyes, Nose and 3-202-15 Package Lite it * Mouth* 3-101.11 Food Safe and Unadulterated* 3-30112 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004Q Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Em to gees* Tags/Records: Fish Products 13 Handwash Facilities 3-40111 Parasite Destruction- Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Ca atones* 590.004(J) Labeling of Ingredients` 5-21)4.11 Location and Placement* 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 ox en acka ha,criteria* 6-301.11. Handwashin Cleanser,Availability 8-103.12 Conformance with Approved Procedures" 6-301..1.2 Hand Drying Provision Denotes critical iter in the federal 1999 Fond Cale or 105 Cf,-IR 590.000. - CITY OF SALEM /� BOARD OF HEALTH Establishment Name: l/—t r( (G Date: BIZ-i)/, Page: of J_ Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified ,/J / ry I jPLEASE PRINT CLEARLY I / /-�.IIr �]JIQ / i, (,-4T r IV-In t ,i A�l�nri/J l/cn. l r t i 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 LlEmployee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion p comply with all mandates of the Mass/Federal Food Code. I understand that Ll Re-inspection Scheduled ❑ Emergency Suspension noncompliance may result in daily fines of twenty-five dollars suspension/revocation of ❑ Embargo ❑ Emergency Closure our food permit. �l�y) ❑ Voluntary Disposal ❑ Other: p 3-54)1.14(C) PHFs Received at Temperatures.$ Violations Related to Foodborne fitness lnterventlons and Risk According to Law Cooled to Factors(Items I-Z2) (Cont) 41'F/45'F Within 4 Homs. z _ PROTECTION FROM CHEMICALS 3-501-15 Cooliog Methods for PHFs 14 Food or Color Additives 19 PHP Hot and Gold Holding 3-202.[2 Add tivesx — 3-501.16(B) Cold PHFs Mainmined at or below 590.004(F) 410/45F* " 3-302.14 Protection front Lnapprored Adddivesw_� "tJ0l 16(A) Hot PFII-s Alain[ained ai or above 15 poisonous or Toxic Substances (01.11 ldent,t m>intionmat!on-On mar I 140'F. " i c.ont,uu rp _ -- C ? 5!1 l6r A) Ko.rsts Held at or above 1309-, a - -"-�- Time as s at PPuubbiEticU Health f2 Control + 101 11 Comnun,Name Worhim,Container,* 5 i 720L11 JSrprarn SFnar 9 ')2.11 l " —�et on Pr �cn a and t t `00,t{}uJi} ( V_rraz,te R raimttrent — N)ZJ} C ondroon of Ilse REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 03 1111 To; is Contarmo nrob l unS POPULATIONS(HSP) ^Oi 4.11 s npi-IeLs Criteria Chemic in r '64.1° C.h..to r' or WaCh� Fr�'u ncv tilt- -ia' 01.11tAr Unprreunzr.d Pre-packaged Juices and m C rnv i a�� - a _ SevPr e.with-Wa m l ? '04.14 Orerb.Isa' .,--� lventc= _- - - St)i 11(B) ..�-I— o' Va wort ed t ' P �_l5 t hand ni tl ! >'xl C r nrxt ia!b t o s : SJl r 3 r O) ` R?,w or P"tti:ttl t C t d Animal Fa>v and '16.11 R:a,ur tltic P ude� Crru a- - --f--- S dtip-out Not Scrtvo ' 1,206.12 12ixlct 6 `s Jnnn� Pac!_ae , Aof R Served. 306."1 e 1, F, r r 3 raider 1 s C'ontnd and _?���— CONSUMER ADV;SORY TIMEIYEMPERATURE CONTROLS 2 3 40 11 if 1r{ sor s z t><uJI for C o umptiun of aper Cooking Temper atureb for _ fti>a la OmNzi xdt 111a uae k u-Cnd rix -Sx;is PHFs t _ esvr t' rmre e 101 1 t(r 9g 5"�F 1 S , 1 rr 30- i i 1 fear <t t -sohsl rat fol Kala Still 1 Hirt.di tt[ 4c ie t 7 l r Siler' 1 I l.t'(1)f_ r r t ! nate'1 h ti4ea, tkumr1 - t dOt t rf 1t I J r, t ,i 1; it K< nt ri* ' t SPECIAL REOWREMEN t S _ t .� _ _ _._ i c,,} ,;)vii-J>' + iiala 7 ui Se iatta ){,).CdJ1(41 i�>i;n n r t bgGvi a 4t, t5 J J, C. ro'rt le notate ,)Oot t rap rat v and 13 4(,1.1 i(A) }_ ._j P ojin Wild G im vtu'te PITF�, l ! 1 rt.ti�u' a al kitchen ott."raiC3rt hnuld ba coni u n .list Mt"11' rwehat t" ra=dar flic a,rani lioc sec Boras 1 1 r .. -_,,. I. i,%u'r8Ct nks „w ,J.. 0"' .-0..00.0_..' 9ehcaf+J for teat!-;aiding VIOLATION ?ELd7 } 'V Gc?(7 RETAIL f RAGTSC�S -- t03.1It1)t'eUr (it ros24 31)) 103.1 LrS, 1 Mi ou,1e- if 1 2 Nlmu. swiloing j :t ,. �- ,r�: tc,z u:-:cwt, , ,t--+rs. x atch.clo uu? r ar, ;;v I a e r It r r e:'k t -rt Cr to t m'a r= t arta rc Pt ed abovc, can t>r -.03.11 C) C ante ria.lt f'.rn. acd,?[) }i,iti i rr< r t!tc,r ,air y c. ?r,hc rnutlf�„e ct 19K ut1 Rei J .rt.g l r rir,"d Por.x nv of lime; , Item Good ileei t Practices .__ FC b4i9.BOfr 1 lanag ne i c d Pei urn 1 FC 2 002 LC 18 -Proper Cooling of PHFs i L21 E xi 3 d t oxi P ore. t,tn c t CtC f y 25 e_`1u rr enJ and Ute +n 6 e 45 I -501,14A) -- exrl".a..Cat), d1'M trm l414Flo - c ys J�tCr Ptt r_,rPtlmt v1_;1;_.. FC 9_ '. _ i r,`E A iifim 2 tfra rc.:nd From 1`)'k F(; b i �007 ` i t ” € J. F l%i Idn: fiorw, 2e r vis J r ox a ,,,r ti x=G 7 364 - 1 _.. ,- - ._ ... >-501.(diB) t ,ria ,Pi IT- 11,de From #mhieot �5 F"UeYr`'ir� OL63 Timl :rnturt Tn rcda.nts tc 7. t =1.,`t r _30 Omar � 1 r 'g r,tc.L of rJri;le, i 1,'v34aM: 41e. , a4r rpyft. { .!'Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4'"Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name (( / D Tvoe of 0 eration(s) Type of Inspection C( C& �\ /& d ❑ Food Service ❑ Routine Address ' h / IL^ll �K i Risk [Retail O Re-inspection p�7 t� Level ❑ Residential Kitchen Previous ns action Telephone /: ' -1,�� ❑ Mobile Date:31<71(0 Owner / Vn HACCP YM ❑ Temporary ❑ Pre-operation t 7 n nr i C) ❑ Caterer ❑ Suspect Illness Person in Charge(P C I Time ❑ Bed& Breakfast ❑ General Complaint In: � r [I HACCP Inspector Out: Permit No. [I Other Each violation checked filiquires 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 MA4AGEMENT'7-7 3"-'� i"'i'I m ., ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties ❑ 13 Handwash Facilities l EMPLOYEE PROTECTION FROM CHEMICALS'°"'"® q i-ng,u-;r ❑ 2. 'Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals L FOOD FROM APPROVEDSQURCEr. ;'a ._,"�; s urz? aiw,mp ❑ 4. Food and Water from Approved Source (TIMENEMPERATURE CONTROLS(potsntlally Hazardous Foods)" k a ywt x-a,tam�,_„.Ji ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements . ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans [118. Cooling -PROTECTION FROM CONTAMINATION "`I "�' °' ❑ 19. Hot and Cold Holding Twal Tk'n ❑ 8. Separation/Segregation/Protection [120.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing I_REQUIREMENTSFOR HIGHLY Stl$CEPTiBLE POPULATION$(HSP), ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADvISORY;';`'T�,® [122. 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)(590.003) by of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 7. Physical Facility (FC-9)(990.007)' 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: A�Uj' 2 3 dam!Q S:5901na cfFom 14.dw Inspector's Signature: Print � n PIC's Signature: U1()I •W (f ���_ Prmt. 1 �!�I ` 1 Q Paged of�Pages Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT g Cross-contaminaton n 590.003(A) Assignment of Responsibility* 3-30211(A)(]) Raw Animal Foods Separated from �590.003(_B).. Demonstration of Know ledge* _ Cooked and RTE Foods* t 2-103A 1 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..1.1(A) Food Protection* a }Bigots* 3-302.15 Washin Fruits and Ve etables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Foots Contact with Equipment and Applicant To Report To The Person In Utensils* Charge' Contamination from the Consumer 590.003(G) Reporting by Person in Chuge* 3-306.14(A)(B) Returned Food and Reserviee of Moat* 3 590.003(D) Exclusions and Restrictions* - Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Pestricttions Food 3-701.1.1 Discarding or Reconditioning Unsafe. FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources IF9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 _Food in a Hermetically Sealed Container* Sanitization Tem ratures* - 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashina Hot Water Sanitization Tem eratures* 3-202.13 Shell Eggs* � 3-202.14 Eggs and Milk Products,Pasteurized* 4501.114 Chemical Sanitization-temp.,pH, 3-202.16 lee Made From Potable Drinking Water" concentration and hardness. * 5-101.1.1 Drinking Water from an Approved System, 4-60111(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Faul- 590006(B) Water Meets Standards in Approved CMR 2urc ` Contact Surfaces and Utensils* Sish a h 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* 1p Proper,Adequate Handwashing Regulatory Au Game and uthord Mushrooms Approved by 2-301.11 Clean Condition-Hands and Artns* 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* it Good Hygienic Practices Receiving/Condition 240111 -Eating,Drinking or Usinp Tobacco* 3-202.11 PIFs Received at Pro er Tem eratures* 2401.1.2 Discharges From the Eyes, Nose and 3-202.1.5 Package hitegrityMouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock ]2 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(F) Preventing Contamination from 3-20312 Shellstock Identification Maintained- Employees* Tags/Records:Fish Products 13 Handwash Facilities 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* 5-204.1.1 Location and Placetnent* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11. S ecialized Processin Methods* Devices 3-502.1 •.2 Reduced oxygen Packagina,criteria* 6-301.11. Handwashin Cleanser,Availability 8-103.12 Conformance with Approved Procedures' 6-301.12 Hand Drying Provision Denotes catical item in the federal 1999 Foai Cale or 105 CMR 59Q000. CITY OF SALEM BOARD OF HEALTH Establishment Name: T SZ) Date: / i Page:___ of Item code C-Critic al Rem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item ,ti VerRled. - PLEASE PRINT CLEARLY i _ - n C?-n- v- ^ ) r10 nOc n lin _/ kCs { 1 i i 1 / - Discussion With Person in Charge: Corrective Action Required: ❑ No -EYes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ vo untary 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 that noncompliance may result in daily fines of'1ltwenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure urfoodpermit. ,yo �rt!r.1� y L ❑ Voluntary Disposal ❑ Other: r � 9-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to ` Factors(Itenis 1.22) (Cont.) 4I`F/45`F Within 4 Haws. PROTECTION F130M CHEMICALS 3-501.15 Cooling,Methods for PHFs ---- 19 PHF Hot and Cold Holding 14 Food v Color Additives— _ 3-501,16(B) Cold PHFs Maintained at or below 3-262.12 _ Additive,* 590 004(1) 110145°F" 3-302.14 Protection from Umppro=-ed Additives* 3-501,16(:1) Hot Ptil v Maintained at or above 15 Poisonous or Toxic Substances _ 340'F 7-(()1.11 identifying info;mnion -Oriinal z5[N,'16A _ �- Cantaui n" - {)— Roasts Held at or above i30 1•. --- i- — -- 20 ( -�Time as a Public Health Control 7 102,1 (:o nronn time Poo ki i (.om un r+ I .— ----� im,as e Public,Health Contual' —�- ' '02 Re t ict on Pr uneo u d L.o 5 aianet t.eyuirement 202.12 } Conduwns of UW -/-?03 /?0311 1 Toxic C c et comer Prollibl6wro REOUIREMENTS FOR HIGHLY SUSCEPTIBLE 204.1 I Santureu Criren i ( nuimie inti _ POPULATIO_NS HSP) 21 3-F01,14AiUnp,.(cu IndPre ptclaged lakes suit ?204-!2C.hcnusti,f,rxNishni1 �dncOo'da"' { � 7-204,14 Urtm 4,ente (nn i u - — L ��— 1 l;e 4s'i a ea �ttli 4+a ni filar __. --�—� -{' - I1(3) Us�of Pu-teui7rcd 1 c. ';" 205,11 head ntal F >+xi(.ntat I ean,c con 1 - -g- -- ��{{ 1 1(D) Ka v or 1 ioa3 (_ ok d Animal F td ami 7 206 !1 1 R.n 1 t ' a 1R, ticide,. Cxife ( 1 $ tr--- - - � 2 S err n x Serra ed. 7 n r.12 Palt n i(Tua+ r ac4 t,i. Not,F .. _.__ . _w._._. r :crrr ' c: t_ CONSE:3IER ADMORY _ i 1MFJ':"E:a?FE'RATURM CONTROLS (,� •v r r Ac; so:v P(ra 31'tr ton ounpceon of � �r. � r xt; fha is fi� Cr zc,�_ai.a o: _ r SRC REQUIRE T I"S)i i - i i ,rb a 9 13 c h, .t- t t I main ._ A cN S —. SPECIAL i i rl. (�},. i ,i<r !..'.�:u.a ti(:,t>. • k ' j k• �d !in)- i}, lrttei l,l )tt <,:Sit if.i . it t�iH i(,+ {e)) it7 -I rtt Vixll i Hxi. tcznpt riu iand 1 4!, WA) li I rti,r ��.�'Id r .V tU. °tU fx� t l .� i •.,i:i..3. a .rii 13,.. ..}�ii.,.Ch � i °d 1?8 ctiote: i a , try} l 137 � I Rehezhrg tar rlat FI king j t/FtJt ��1�FtiS r{t r AF>�fJ TO 30:JOI3 RETRtf_ €-FtrX{`7 �"x .{s.Li4)�i i) ill 67-I ! c _ _ � {lEeeus 2111)1 ilicl(waw- 10, F_" Minn S1.zdng l �1 t '. /is r.�i me rlr s x r •rt � m - .d n c r tot ur r;. rc f r .'r aza br _ AWF, igr 00111, oi 40411 13 Item ' Good Retail Practices, _ ~ $ . Pat i .. � FC_ 003 Proper Cooling o4 PHFs �Fai,rEjon F{ 3 _004 oh c FID4 ,n s561-k4(A) � C<n,luCxkdPHFs frrm i+ iic w nei1.FerP rogvu J *e ' FG S OUti W, Within 21Iou and From l' L2 tr4 a F_c l - -- FC 6 rf7 r\k tl m f H,t _ d i 'xs moi r Tnx Pl e, ; -- Fc 608 s :A01.HfBi ( 00111 PHF M lc Cnm 1inh,ent j �. 9 SpK ttft-co L..n{ rawre 30 nthrr _ I tbithin d Hauc:. a *;.k)a,+';4; 4 0 9*M rfJ .i``4LtA. a - t�' +A..'7� Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,a Floor' 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name rf n 22 TVDe of Ooerationfs) Tvoe of Inspection X? T, I� ❑ Food Service E-Routine Address I / 'Ung (�� Rik ®-Retail ❑ Re-inspection 7 Level ❑ Residential Kitchen Previous Inspection Telephone /?� _ ❑ Mobile Date: 7064v, HACCP Y/N Owner I I �� El Temporary ElPro-operation vrnF O( I ❑ Caterer ❑Suspect Illness Person in Charge(PIC) Time ElBed&Breakfast E3General Complaint In: [I HACCP Inspector ( Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. � m�-� "FOOD PROTECTION MANA6EMEN7,p ,,�„„„-„,® t �:_,,._, El 12. Prevention of Contamination from Hands r_11 PIC Assigned/Knowledgeable/Duties a ❑ 13 Handwash Facilities EMPLOYEE HEALTH �rc �s€F ..,.Jm.-.H a.Si.H,=.`�u'� �=av r� �''3-i :PROTECTIQN FROM CHEMICALS;{i"nnr-v I x;,� I �a a' T t! ❑ 2. Reporting of Diseases by Food Employee and PIC L a1. ) : ❑ 14.Approved Food or Color Additives ❑ 3. Personhel with Infections Restricted/Excluded ❑ 15 Toxic Chemicals I;.FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approvveil 51 -"'"�'- iffiT "" m ® r:TIMEITQNTROLS(Rotentially H;azaMous Foods) Q Approved Source EMPERATUREC ❑ 5. Receiving/Condition [116. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling 'PROTECTION PROM CONTAMINATION= ❑ 19. Hot and Cold Holding - .._x �o-yevu.»....iw.wm..mmw.w'p$w<a.m.wmmvunw+m mven,I62�bItL]bromta.$ ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing OOUiR21. Food and FoodlPreLY paSUongo HSP POPAt4ATION6("SO) A ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices !,CONSUMER ADVISORYa '`",, ❑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 2 , 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 6. Water, Plumbing and Waste (FC-5)(590.005) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007)' have a right to a hearing. Your request must be in writing PH28. 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. n 30. Other DATE OF RE-INSPECTION: ! S:5 01ru FV, 14.dw Inspector's Signature: Print: J PIC's Signature: _ Print: P P� O 7 ' / Page ofages 1 Violations Related to Foodborne Illness Interventions and Risk Factors(Items 8-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Cross-contamination 1 596,003(A) I Assignment of Responsibility* 3-302.11(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* 2-103.11 Person in charge-duties Contamination from Raw Ingredients 3-302.1.1(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.1I(A) Food Protection* applicants* 3-302.15 Washing Fruits 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(03) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and 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 ma Hermetically Saeed Container* Sanitization Temperatures* -- 3-20'1.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell E- s* Sanitization Temperatures* - 3-202.14 Eggs and Milk Products.Pasteurized* 4501.11.4 Chemical Sanitization-temp.,pH,- 3-202.16 Ice Made From Potable Drinking Water' concentration and hardness.* 5-101..1.1 Drinking Water from an Approved System*tem* 4-601 11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(33) Water Meets Standards in 310 CMR 22T 4-602.11 Cleaning Frequency of Equipment Food- Shellfish and Fish From an Approved Souroe Contact Surfaces and Utensils* 4-702.11 Frequency of Sanidzanon 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 2-301.1 t Clean Condition-Hands and Arms* 3-20118 Shellstock Identification Present* 2-301.12 Clea ttino Procedure* 590.004(C) Wild Mushrooms* r 2-301.14 When to Wash* 3-201.17 Game Animals* 3.1 Good Hygienic Practices ReceivingtCondition 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 Packa e Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3301.12 Preventin Contamination When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Em to ees* Handwash Facilities Tags/Records:Fish Products 13 Conveniently Located and Accessible 3-402.11 Parasite Destruction* 5-204.1( Location and Plla 3-402.1.2 Records,Creation and Retentions` 5-203.11 Numbers and a amts* 590.004(J) Labeling of ingredients' cement* 7 Conformance with Approved Procedures 5-205.11 -Accessibility,Operation and Maintenance 1HACCP Plans Supplied with Soap and Nand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12Reduced oxygen packaging,criteria* 6-301.11 Handwashin Cleanser,Availability 8-10312 Conformance with Approved Procedures* 6-301.12 Hand Drvin Provision °Denotes critical item in the federal 1999 rood Code or 105 CMR 590.000. - - CITY OF SALEM BOARD OF HEALTH Establishment Name: rr f- <! Date: Pager Of 3 t Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION "# No. Reference R—Red Item f _ PLEASE PRINT CLEARLY s-aas. 4 ,r ,/- lc�o k _— , C cy4pnm r r, r gi S 4- Rel l f7 lWo _ /. C7� 9�9. ( i n n i �2 J 'J O f ) L 754-( �! o�� , wt aw �- f— Mwt )S— J t Nor, RJ 'r t dJ A- CEV NJ K_J1W AlaJ t-� �le SI IL 0 I I v I �C l/rf— "J Jc­� m L C17TV Ci �.�d / C oZ �(M /1✓L U. 3 l r f lej Ca e"` I L 3 n .3& v G rt m-3, 'zb f ( j J,4 I ) r9rt �9-a r� t'c orn,.xc aJ oz- orv. om')U- -z / 4t'j I , o G1lI( 1 �� yt, �ro.n l�2C 1 `.3 O lxl( rU�'fA'F4 \3ZA(e_ Ian O, Q P-eA-V7W770777-57'0, Discussion With Person in Charge: Corrective Action Required: ❑ No lzl_�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 that noncompliance may result in daily fines of twenty-fit v dollars o !suspensio cation of ❑ Embargo �i` ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: i" _ _t-SO I J 4(t.} P}1Fs Received a[Temperatures Violations Related to Foodborne illness Interventions and Risk Aminlinb to Law Cooled to Factors(Itettt 1.22) (Cont.) 4I'W45`F Within 4 Hows- 1k PROTECTION FROM CHEMICALS 3-501.15 CooliaL Methods for PHFs 14 Food or Cola 79 Additives PHF Hot and Gold Holding 3-507.16(B) Cold PHFs Maintained atm below 3-202.12 Additivc,I _ ._ 590.41)4(F) 41V,15`F" __. 3-302.14 Protection from Unapproved Additives* — i — 1.5 ,-- Poisonous or Toxic Substances 351;176:Aj l Lx[HR bt ttntained tt or above_ 101.11 t Identifying O on - n.mal 1 �4{7v" Identifif - Y E Rr t, ,F4cEd a,or above 1301-, Container 20 ' Time as a Public Heatth Control ,-142.1 I Ctinmon\imc N i 1< . . C c:a rm rn — - itm --r-- 720t 11 � t ancn SP,naTc , a.aPublic liealthtontiri' `_- ,fH \ r iF.,fflt r � � pirLn?Pti 2f72 l t � 12 t let on Yr xn i. m-t 1-11", - --- --_ -s ---`�- - -_- 7-202-12 COrldjuon,of 7 '09.t 1 Flo-tr f ont tinea Prob Seo T REQUIREMENTS FOR HIGHLY SUSCEPTIBLE i "h1.1 Sannuur cfnenn citemc 1c _ POPULATIONS{HS�� --�-'- - 3 31� Silt +1: �t-nP: teariccd Pt Irai4: ed lvicec:uui I 7 11 r 704 1_4 It vntn tisctontr.._cnte t t )rid, f u' [i,—t"• Betiera es vithRn ahLi4.. bit; i t t3) t z of Pt wu z d} e -fi511 lini&wdi NA Cvw is luhr <ai —j--'— I I DI titac r Pao mik,C, d Aarmil t(x,d and 7 �Qfa i R nu a l c- Pe r idc; Cnsc i t — --4-- S d �ti.'au,1vt Sent ii LL 06.12 RCXI+.tt t3 t St.0 nn, _ - - -� ___ — _. ___ St31 :i _ lir t ed F'ixd [:ets a Not R t n'e '0�I-r I I t,nrd P. Ov . k ,;,f_cntt_3 and -- _. ltca o :nom r ___ CONSUMER ADVISORY rtMFfy EFhPERTURE CONTROLS ` 2 3 4,w 11 1 ':usn etc sotw 'ostl 4br C rnt cured<,e of 1.iELTAI 1 n'tt c fz,w, CRdPfC tt>1:,Cci :`r 7 }g PraW, Cooking Tenspetantres tot i ✓-tOdlvz isToifm.ina�tr b01.1 1 ° : t -- —`x —... ! r , 157 to, R z .shcli _ tate c iinmi di m Su-nz t r5 S l 5 ec ' t :Ah_, lr n-.5.nowd 1-;,h, Mei , t ami 1ct is- j5. ' 1 v-.:. _w _. SPECAL REQUIREMENTS f . Rr121til =ttA)t . _._ LS tr ti . _ 1 i-JO L!ifAi 7) i ' i tti 'Wild C a c Sro h !f HFa, ttc.ncn o; t a.Gvn4 hctid ,�c. duh l d t ndei t1w tt prt,ltna! it._i ionR t �. i s s;l'hat ... s `F v ; i .i7st%'c � rC.l;i.�81 J(`C.0 • ;;-t. .'): .'x ,,. a,tai ( ':alio., t, i�,i •..!' ..._ .meta t. �t.- y,•,i:_ _ ._ _ � .. ._ k. - , _ . ' PM .... _ ...._..._..._.._ 17 ' Reheating for Hot H,nAj ng VIOLATIONS FZELAT"EI: TO GOOD RETAU. PRACTICE S> r 4i}�1 r'k3� ct:cun�v�-7r 1 3�i:nr. Stsdiu , a -1 , r c nt rt 1r ic+rrr f_w; ar is Il t r tU, , ;ir ,is , t -°rr : rr_i Af t,n 1_r { u (::n oa 403. 1(t.) t m r,.r-_iaily .2 tt 1-+�.ttl- k n >r,,.,l+ <:.f. rr , ?ood c-ourn . x _;C'11R L.. ___... .� .._. _..._. ---- ------- Item .._ttsm ` Good t; to 4Trar6,ees _ �FE 590.06"0 2 Eh atit x i-- 3 7'lnayt re i c d FAt. _ PC_ c ; Proper Cooling of PHFs 3 !24 F_ooa d oxiP.ott toi _- -a-cC c fi0 -_ ——� : t: — f . o>5 a E=u- n+� d i-e s:s _ - 1 Fr' A 5(ir14(A) C<XikdlHF� ro l4)'Fto -- LNatu Pi t! t� aC FC 910 0o I1 2 00�74nnouuncrcn t _ _ ": t17;..F W N.m . ficni . .....d 2r as r of 501.lAiBi CiaJ,ui;PHF_khOt From Anlhiuu 21 ; b ,�.r k - t fttaipafaurzc 6i:rec;er.;'S.c 1;"F!-#5't ` rto {?ihrr Within'Hcutrc I i s ' t n`.'::1iIU -: f-•..!. ,. V .�i-.L93C ._ _�.;t. t( I) :Jv__ CITY OF SALEM s BOARD OF HEALTH Establishment Name: C((-dire V Date: 3191lo _ Pager of JS Item Code C-critical item DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date 4 No. Reference R—Red Item Verified 1 ^-�) / �( �/ / _ �y PLEASE PRINT CLEARLY IBJ d 7- l i !`_d_ �-r U C�. `1 S G- p/L.� 1 Tl I t' .3-1,i.2 dwr, r04 W (3ti A l M I n CAz� QRS G 17r (�P� S{1p 11 ate , l>' S � L Qk 1 �� ,Ll. � � �/ � . ,ter cxe . � � I 1_16 UP42,1,14ni�,A f Gt l S�I�oYI. Lf1r/� z l 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/ Exclusion violations before the next inspection, to observe all conditions as described, and to ©�_Re-inspection Scheduled ❑ Emergency Suspension 'i comply with all mandates of the Mass/Federal Food Code. I understand that U noncompliance may result in daily fines of twenty- Ge dollars or susp nsi revocation of Zi Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: ^k 3SU 1.14(C) P}FFs Received at Temper-- atures —, Violations Related to Foodborne fitness Interventions and Risk Aarording to LawGoofed to Factors(llems 1-22) (Cont.) 41"F/45`F Within 4 How's * PROTECTION FROM CHEMICALS 3-501.7 5 Coolim•Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additive,* __ 3-501.1'6(B) Cold PHF.Maintained at or balow 590,004(Ff 41`/45°F* 3-302.14 Protection front L napproved Additives" i-501.16!A) Fiot PHF Maintained aintaed ai or above Lis Poisonous or Toxic Substances _ a011 _ IOL/l identil}Ing Jni2ntnation-On tical C ?-:w 11tv k) I Roasts Held at or above 130°h_ i �. 7,102 11 Common Vance- Workiro-,C waia-rs* LAI - Time as a Public Health Control t --- -- ---�� 4� t tPubhv11ea1thControl' '0117 mm<t Sana -�- } O't011 j7 � ' t +ner 'se tnremet,t ---{{ F•at ut on Pfe, .nu vd C e:�� --- -t- -. - _�- 7 n02.i� f2ltdm<,n.oft.fsO Toxic l o tamct Prol}ihitiot, REQUIREMENTS FOR HIGHLY SUSCEPTIBLE F �-- -- �—j POPULATIONS(HSP} _ 2Ud.i1 Sannvus C,nten+ Chuntci�s-: I -- _ ��0-1.1? Citutu ais for�S t hu g f xt ped Cl it t,ri,t"A Bc r 2t ( .-Srt1 P(A) Uapa,acsti/ed 1 rc packaged Juices aid ra es with l� utnn Lal.,is' °04,14 U �m At ate. at ,t _ � 1-80',17i B, fc of Pu'td-un cd F . -015.11 6u to n ai t xd f in to 1 tib tats' t qC; i,(I)t Kau r Pvtialt ( ol.„ -d Antmai Fdxai and � 72061' it-..,,,ttt Pn+dlcto cri[c..imtrrl'aud F __Xi_i i (C , i tr, S cd .F:xxirtacf sgSCtijrtR..sc-�er 06 7n i )2oc' a Beit S .rlloa _ .05 ft I r.^,cn o" tgrnr uta' i -_.._ __...o- CONSUMER ADVISORY - -r-r--..� -- -- 22 3 bU_ If ov'looel k soR posrel F,r( ata=untOGon zif TWEJTEMPERATURE CONTROLS r Ric- liars '£lc-u< I 16 Proper CoaWng Temgaralures for isc Pro rs<s o)r:Eirnn t o 1 101,, 7-- ;5'T I 5:ec -,5ni5:ec- } is=r fir. Suns ti Fur Raw 51 wrc-� : .,..'iI.Ih VI j ! i ttU?3'F �h M'n" l C,dlte ------ SPECIAL L _.SPECIA REQUIREMENTS ('t , 1 f- �1 Rt, s' ; )')"F (a otin' _ ) _. _._. r - - t"- - i " 'iQ9{R)- t7 ° 2C=1 4 4E lid t l(i.IKUl�h r-30 2 V _ ,L.7 tAl - ( 1 c i,,wn g Til hfi,t hit,.-tenip.rat and i a,)F. s id7 a,:at kitcnca dt.el'thcos;bectid he Fi At „ S r r thil�i 1,tri Stu etc iT:s,- � � j C , P C mt+ss,t list h t- t chit d midor the ,, 13rt p .rK ,jots .,iia c t.v Xi is': rc.:J, 0.11 -- n. ? �, - tng for rtl ot t h flika4 Hotdt7LATIONS PELATED TC GOOD RETAIL PRACTZ S ...._ry 7 ...-. ...._.F F fftms2330) 903.11(8; - Sit ,uuava.�Irs ( 2 '43,nu- Stands; r+ fr }, nr_?rr r ur-rz c rt rr.:. u,rrh 'n ria: ca ±hr ;r7 reit n v r 10A ,rr7 f(i- td r ao"b" C rt r„triaih !',c>~, cci is l3 hsxxl- r ne' n•t.,r f r ^,; >e:., t-hc'Ioo l t->a .. -'10• '3o .R 41;1.1 1"r), ) R t ani ,Lrsl,red Pa'i tt( g ofBe"), � item 1 Goo Rvfs t P acbces _ FC 5.40.000 I 1 tna9r r i fl J P r i� r• -t r C` pt o �__.__.-.._..-..�._ ...._._., I- .._. r M.'n n (W "c t o FC Propers Coaling of PHFS }� --+ - d P - -- a - - I_ ,. _ o t -F r ert and Ve-- ,s r ; z ins ' S(=L WA) t tn,t h�C rwk it PH( from 144,11710 2r' Viater,P ,bwq u c 1},,terxg- F i t� F Wuh:-t2tou, iold F,rmt * 7 +I�k au,tr«3+ tt"'as > tX ' . r-y I t A' F'4 �F tAttlti t }r>tit _ I nc •r , 6S`ia -701.:4(6, ��into�PifF hl.:dc Ft:jm Ambient j fctnperau,re i,;r,.ccx., r ' P tl i❑4 Fkxi,r s I '" r^"" i, ;_.iii I 7rk;."!-i AIC" )01. 1 Eifi,i ...r`(: �iF 1r'a^Yr'-'-s�'" Tp `L.'Y..a. A P':^,6`i.FWY >"fyj. 1 r::n.:..i,.+'p-.h "gin. % •r).'-'.:. e:... t' ^� , il( Massachusetts Department-of Public Health Salem Board of Health Division Of Food and Drugs 120 Washington Street,4th Floor Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT . 4. < t Tel (978) 741-1800 Fax(978) 745-0343 Name . C 1722 f S Date' Type of Operation(s) Type of Insvection ��b(-- _Mvt -, C .MVt . Food Service outine Address F / u Risk LeRetail 'El Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone ! r _ G ElMobile Date: Owner HACCP YM Temporary ❑ Pra-operation r X- ❑ Caterer ❑ Suspect Illness Person in Charge( .IC) Time ❑ Bed&Breakfast ❑ General Complaint In:3;¢f ❑ HACCP Inspector Out: Permit No. El Other Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors 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 "°„; .'('"`"„� [:112. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13 Handwash Facilities j�EMPLOYEE HEALTH . = '•" i !`PROTECTION FROM CHEMICALS «Y ❑ 2. Reporting of Diseases by Food Employee and PIC fr - .0 " • •• � 'yak . .. " ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded • 15 Toxic Chemicals FOOD FROM APPROVED o . . u � t +E] . Food and Water from Approved Source TIME/TEMPERATURECONTROLS(Potent adi-F6 .4) ❑ 5. Receiving/Condition. ❑ 16. Cooking Temperatures ' ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ :7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling O El 19. Hot and Cold Holding 1 PROiTECTION FROM CONTAMINATION a , .'s ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control 9.Food Contact Surfaces Cleaning and Sanitizing tREOUIREMENTS FOR HIGHLYSI)$CEPTIBLE POPUtAjIONS(HSP} X�� ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices r CONSUMER ADVISORY o ❑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. •'-P,� Na 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 cited in this report may result in suspension or revocation of / 25. Equipment and Utensils (Fc-a)(5so.00s) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007 ) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(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 501ns E-INSPECTION:S'5901ns tFom514,0 Inspector's Signature: - Print: /- PIC'sSignature•. IIA h _ Print: \/-.;1,1•x,. I V�I D Page(I of -Pages r Violations Related to Foodborne Illness Interventions and Risk Factors(Hems 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT $ Cross-contamination 1 596.003(A) Assignment of Responsibility* 3-302.11(A)0) Raw Animal Foods Separated from 590.003(B) 1 Demonstration of Knowledge* Cooked and RTE Foods* 2-103.11. Person in charge -dutiessI Contamination from Raw ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Uch EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* applicants* _ 3-302.15 Washing Fruits and Vegetables 590.003(F) ,Responsibility Of A Food Employee Or An 3-304.1 t 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 Char e* 3-306.14(A)(B) Returned Food and Resetvice of Food- 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources FT Food Contact Surfaces 590.004(A B) Compliance with Food Law' 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a HermeticallySealed Coma ger* Sanitization Teneratmes* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-IlotWater 3-202.13Shell E- s* Sanitization Temperatures* 3-202.14 Eggs and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, concentration and hardness.' 3-202.16 Ice Made From Potable a Approved Water* 4-601.11(A) Equipment Food Contact Surfaces and 5-10111 Drinking Water from an A roved S stem* 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- Shelltlsh and Fish From an Approved Source Contact Surfaces and Utensils* - 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods•ofSanitization-HotWaterand 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* 590.004(C) Wild Mushrooms` F2-301 14 When to Wash* 3-201.1.7 Game Animals* 11 Good Hygienic Practices �j Receiving/Condition 2-401.11 Eatin ,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 Togs/Records:Shelistock 1.2 Prevention of Contamination from Hands 3-202.18 Shellsto k Identification* 590.0(4(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employees* Tags/Records: Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* ConvenienV Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* Labeling of Ingredients* 5-204.1.1 Location and Placement* 590.004(J) 9 g 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 3-502.12 Reduced oxygen packazing,criteria* 6-301.11 Handwashin Cleanser,Availabilit 8-103.12 Conformance with A. roved Procedures* 6-30112 Hand Drying Provision °Deno critical aem in the @decal 1999 Pail Cate or 105 CMR 590.000. C CITY OF SALEM BOARD.OF HEALTH 5 Establishment Name:--- 1 Date: (- I C) G Page:_ of _ Item Code C-Criticantem " f DESCRIPTION OF VIOLATION I PLAN OF CORRECTION 0 Date , • y ,u,`'� %� i'sv ;. , ,.z . rrci�c 1 w =Verified No. • Reference!* R-Red Item ti. , ^� x . 1. ;; „a;�c. �; %' ', r �n ,� . `F. . �`r ,.:r�. •' r " PLEASE PRINT CLEAR LY `'�' -• _ t-1 �.�/ r.�Xlti WON)< NSLPr-L ! Oc Irn C(Of-, -=)d •S�' VPS QJ (v4OU 11tj- ,jr— �1 �IC /IIGJR vCr- C�/P/� R.tc� /7^ _n t C1oGr✓ n.J �aA.n. �'7v G. � 4 1/ � / �.,n � (1 . N,t dr1'n- 'h 2. ^ �s�21);�/,� `-3'P'r'-'� /'.t'"�i'- (!i lY U � ���r L �- 6 Jcc� S�/r d c/I Wi tC ht, f-ti a `S�'1 S� S- f 54,GIoba�' (/.)rm� G�J••+, 1--,��� AXn. C r- A SJ ti /Ii r r o r I e e f's 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 VFe=inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand thatnoncompliance may result in daily ffiines-of twenty-fivedollars-or suspension/revocation of mbargo ❑ Emergency Closure your food permit. �� �� ❑ Voluntary Disposal ❑ Other: „Fi 71 i ilflFs ReCTIV at reiriperaLUT, Violations Related to Foodborne fitness Interventions and Risk According,to Law Cooled to Factors(Ileors,1-22) (Cont) Within 4 Hours. 5Qt 7i G2Ki1ia,,,kleLhoffo PHFs PROTECTION FROM CHEMICALS � 1 T fllr'� PFF Hot and Ock!Holding 1=4 Footl r Color Additives 3-SUt 1G(I3) Cold PHFs lvi,int,ined at or ll­elvw - 72(f!12 1 Addini,7,” 190,004F) 410/45"P� 3-302.14 Protect 7n firola Una 3-501.16(A) }int VHF� klaphitiandat or above --!-P�o�isonous or Toxic Substances 14()'F, kllasl,Held at or above. I;OcT Time as a Public Health Control ota 7- I I Coinnion Narne Al 17- -201.11 Tine, flub v Tiea th�C,)nt,ol �90JXWH) Variance R�� i-20111 R�qrictioe pri'scnce aild Ls' /-202.12 Conditions of tlso' Toxi(;Containorl, - Probate on. REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(H$ Ht 1?03 1'1 Sarl Criteria- C' 7-2c,4.12 Cheoiicalc for L Rc,��iaae,with Gs ai nnl�Labok* I L—i--. -- 404,14 Dr ileria' 3-801 ll(B) Us�!of Pasteurized E -- - -----) Au�—Ailertt-2— i-i&�,I I Inculcrnal FolA Contact-lAiln icanis' - 7-206,11 ko,ericled Use Peqicides,Cr tet F5--bOITf7i)i 1�iworf`inlalt,,0,Al.,dAVinud Food and kav, St. Not Stryed. 7206.12 Rode Bait SUJUOM' �E bix 0�il ,T�—I — served. �_�_1-_n,T�ened Fix Ki Packata� Not Re 7 106 13 Backing Ponders, Pesi Control and CONSUMER ADVISORY l—2 —7—cort....... . 2 1 soy TIMSTEMPERATURE CONTROLS Posted [or Collsomption of Proper Cooking femp�,ntuesfo,�--� Aniin,il F,�sds"'hat art: Raw. Under"Acd in 16 V4)t Ot1wTV he Prkx!essed to Eliminate PHFs 3-404.13 A(l)(2) Cgg�,- 155'F 15 011 w='Subsioule fla Raw Shell 11111� L :�&ate Set Ac 145'FI.5sec, 3- n 401,11(A)(2) Connui ill,J Fish.-view,et.Gaza: A-nim-ils J�5'17 15 sec SPECIAL REQUIREMENTS 3-461.t I(B)(1)f2 oro Beet Roast - 1301- 121 RLnL Virlkiiif%ln,�of�ection 590�009(A)-(D)�in 3-40 1.11(A)Q) Ra1jwAnice tod %Av, 1 s-F15 3 AITII(A)131 lloiotrk,Wild Giune, Stuff ed 111-[Ps, rcmdcul'al kitchen operations should be I Sniffing,Cowaining, Fish, Meat, debited under the appropriate sections LouhrS�or karitesh65"F'15ice. above if related to fia)dhorrje illness IntLo Beg Steaks in(ef venljonand risk faclors, Ohlier 590.009 violations relating to ood retail 340i,12 Nrlirml RxlCooked J�4-" i _ 7 11 a practicesMiould be debited under#29— , Mictowave 165'F i Special Requirements, 3-401 11(A)(1)(b) _AliOthel PlIF", 145,F Issec, 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-103,11(A)&(D) PHF, 165`l 15 (Items 23-30) 3-403.11 CBj Microwavc- 065 F 2 Minute Stactfin,, coitira;aild non-'riwal vii)"aimm' which do trot i-ehac to 111C Time" 'foodhorni,rills ss rW,,,rvcnfi,)nv?md rokfinerors tared above. can be 1763-7170 Fos ld 'found o, the Food Code and 10-5 CUR 140'F 3-403.1 i(F) Runainfng.I,ns6ced Portions of linef Diii- Tdo y Roasl'K* _22 3 J—, Personnel FC -2 1 W3Ig � Proper Cooling of PHFs 24' Foodand good Prolectiorl FC 3 .004 — 5 �'N ent and Utensils -T 4-5_01.i41Jk) (axzfin-C(loked PFIF's froo) 140�F to -- I � 23 l Water, -5 1 0L9- 70 "l, Within 2 1 four,wid From 70'i _LaLFaFlRy_-- FC-6 '007 4- - -I w4 `F!45�F Within 4 fiowl,. 28 1 Polsonous or Tinc Maieriais 1 FC-- �008 1 h75 0 1,14(T) Cooling PFfFs Mldc Hook Ambient ----- -069 - Tempecaazre ffi ,dicute took --aa- qther gre ...... "'Denotes exlder8 gon in she feto .I N')9 F o'%! 165 CN-TR 590 not), - fi--. CITY OF SALEM ' 7 BOARD OF HEALTH t Establishment Name: �Ou 'YZCl-C JC �a—QC_ - w-r r- a Date• Page: of J Item Code, C-critical nems �a DESCRIPTION OF VIOLATION 1 PLAN OF CORRECTION Date , •No. Reference 4 R Red Item a M� � e sir rr� � � �..�. � „� ,� y-c, � ,..-a ,. - . � z f , Verified ., '-3 �,.r`�.r ' 4 ;`,%.� .Lm H'ss,• ' I `PLEASE PRINT CLEARLY .°' '�hR .•,.ah.Jr`"a` � "a�s� ^". �"' i 1 k0A 0c,"'D a a(i _11c) 41%/N. ( Pin VpS-/ roc 4�,YG 5,Kr rv�o d -1� /1 o cXJoSu� bs — f\ d J c Q_o�A rG rnr G Y✓� Q rr. V 1 f Discussion With Person in Charge: Corrective Action Required: ❑ No f`!es 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 PErn e-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty--five dollars-or-suspension/revocation of bargo ❑ Emergency Closure .'[you r food permit /� J �/7< f �-_ t ',v F l �� 0 Voluntary Disposal Cl Other: Violations Related to Randbran&Ifirease Interventions and His)( according to 1r Cocied to Factors(item 1-22) (Conti -,I'JV45"F Witbin 4 Hours, — PROTECTION FROM CHEMICALS 1-5 Coolinl, M 19 PHF Hot and Cold Holding F14 L — Food or Color Additives, -7- 3-501.16(B) Cold PHFs Miurit,tined at or below 3-2()2 i2 AdltNoO 590 fY)4(F) 4 1°145"F 3-302,14 Protection frol 3-501.16(A) Hot PHFstLuruained at or above 35 Poisonous or Toxic Substances 140'F 101.1E LRllasts Held at or�,uiovc 1300F, Colaaiuersi� � 7-10ease Public Health Control 2,11 CorwoonNartle- Workin 'oauaner�* L�0— un 3-5f)1,19 as public Health cora roP 1-202.11 Rclitrictioii -prestill:v and U �90�904(1-1) �e* wiance R 7-202.12 —1 Lo-n 1111 u 11 of Use" 7-203,11 -Prolahaiomll REOUfREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP 7-204.11 SjnjtjatN,Criteria _ClIe'll"rals- T—so 17iTi­,,�j 7-204. to,--I --Witcc,Cirteda, 21 UnpRa=iziA flre-paclagcd Arices wid Wash ng 11r, e\,ral!es lyitfi Warning 7-)04 14 Use of Pa,teurizsd E'et's 7, & A bruidental F(Y,>d 1,uhl aauns= �-w,!.I I(D) Rao,orpoatiall"Cooked'- A;�tipa j)d and P7 ,ji Tend �:�206�11 Rosirided Ise Pc�aicide,�,crqcral� L�,a--, Sprouts Not Served 7-20R12 Rockall 13mu SW1a11P,' r-1 19 1 er 1 7-206,13 Tnicking Pinodem lest Coritrof arld 1� L CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 1 22 -o()311 Cmnfs orywAnlisory w,d lot Consumption of 16 i 1 Ainwu Fxxl 'Ilnv nm Raw Undercooked v.toper Cooking Temperatures for PHFs Not(Moet ease poe,easesl to E'lintinate 3 401,11 A(l l(21 Egg. I 55,F 15 S"C. 3,3ij2.13 TlgivaunfA Eps:Subsuatie foe Raw Shelf Intruediate,serviat 145115sn, co"Ilrultand F;cle axis tti.(aunv Animals- LiS�F q ser: SPECIAL REQUIREMENTS 3-401.I!(B)(1i(2) Poiltand 13k,ef Roast - ifff` 121 win* —5q�-(AVIA) Violations of Section 590AC, 1�9 'A�4 1-4-01,11 FA)i74 e"Injecle'd Wxl, 15a F 15 in s,,c. :,�atcring, mohik food, ternportary, acrd 3 40711(A),3j r Poo try.Wild Garne-StaFT, W,,, residential kitchen operations Alould tic Surlbug Cortaming Fish,Meal, Uolaielunder Phe apin,priate seclions Poultry or kataes165'T', 15 scc. ak-we if related to fsxsdborne i llncs5 3-401.INC)(3) j Wh(IC-Mu'scic, Inlact BeJ Steaks interventious and -isk firctorq, Other 1459- 590.009 violations relattn� to rood retail 34)LI2 Ra% Ijoraal FolA,Cooked in i p Idiclowavc lu�,F practices should he debited under#29._ sptscial Requirements, 1-401 P(Af(lyb) All Othei PilB-- 14517 15 sec. Reheating for Hot Holding TIONS RELATED To GOOD RETAIL PRA mcks - - — 3 637iT A-F&(D) P HF, 165'IF 15 sen. - (items 23-30) 3-403.11(B) Microwavr- 165'r 2 Mkinuie Standing Clairal and non-(runail otos afiwo, which do nor,eiate to!ire Fullei, foodborne illness mro ventionvand riakfactors livtedals've corn be 3-403.1 J(C) commercially Prix essca R io of the Food Code and 105 CkIR 140'FT T ------ 3-493.7 (u) Renewun,, ("Adwed Portions of Beef Good Retail Practices FC 46.01)6 Roasl,* kilanalif�rLnIn and Per sonno -------------- '003 - - --- .1 Proper Cooling of PHFs 24, Food and FoW Prolicaillp FC -3 CKF adv engia; fC--4 006 I �01 14(A) CooHI-',s hj)�Coolo,,d Pfoaa 140`F to - --------- ,6 Water PUnbiri tiand Waste 00- ------- ...! 6 pk 7,01'17 Within 2 flours and Froat 70'1' 27'1' nysical Factity_ r0,6 1 �007 j FC---7 7008 u)Temp Within 4 Room 1 28 sonl)lr5l Or 0XIC Matepa!3 alo. 14(li) Cooliva PHFs Made Front Ambient 1 20 S 009 qZ l- -7-0tirel' Temp'rature hasrediena;1(,41*1145 L- -t-1- -.------- III Within 4 lfoqr,* S��X, Ia:Z.v, is lr,r f"'Lval 1099 0,112 5900(e), CITY OF SALEM C �Q3 kS Ijt T BOARD OF HEALTH Establishment Name: 5144or �F� -n 6 ry /1�L� n sF� i Date: Page:_ of I Item [Codee C-Critical item '° ^�` DESCRIPTION OF VIOLATION/PLAN OF CORRECTION " ' Date�No. ' efernce. ;R-Red Item:; •` -'�„ ° , �-� , Veri£ed ' � ' F �/ � spa: 'off" ' f a PLEASE5PRINT CLEARLY } J l _ ne n I 4, /trnc 0 r1(r n eIn,ne 11 r (or.. _ n � 1 + I� �U a c' T � n 1�� CCcJ .�[.ivn J ( .,�ift/1�ZK un it �r ,_.�/�1 .coo 1v6,�a n c V t QVC r - i A)e-0 t 4--LAD- 1U(7rr f ! /�o/ Fynnn n �� r�(Ct$ (1 GuJu r•n� G((n� F �n _ 1 C<< W u/ cY�r o a tP 4 j -r- r Discussion With Person in Charge: Corrective Action Required: ❑ No ,0--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 ept 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 suspensioJn/revocation of L) Embargo ❑ Emergency Closure • your food permit. j ,�- V (� � ❑ Voluntary Disposal ❑ other: ,j{T I i(C) p}1f4,s Recl'ived at'femperatures Violations Related to Foodborne fitness Infemontlens,and Risk According to Lau Cooled to Factors(helms 1-22) (Cont) 11"F/45'F Within j Hows, -c"(4ine Meflrods for PHFs PROTECTION FROM CHEMICALS PHF Hot and Gold Holding 1=4 Food or Color Additives Li9---- 1-5ro'jb—(Bj mmnoxjrrcd—at or below -727(2TE 3-501 16(A) f lot VHFs Maintained at or above Poisonous or TOXIC SubstancesI 14(f F Orwinat. 3-501,16,(A) fa�xlsts Held at or Above 130'F, Contat ers� 20 1 Time as a Public Health Control 7 102,11 1 (ommon Name - Worlon,�Cootains�rO 7-201 11 o7 as a Public ilealthiC it 004i'll) 'at iaLnirrnteat 7-2011 Rest,iction-Prestnoo,and Use* ce Pt� 7-202.12 coaditions of VsoREOUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203,17---Fox-ic Conlin a , -rola it om. POPULATIONSHSP 72 4.11 Sarrhilers,criteri,-chenricals* � 3 21 -801,1 i l A) UnixmcurizvA Pre-pacraged Juices and�7-2(412 � Chant c'Ms for beM 104 114 _ Use oc pastialli 2 11 IL 05 11 Incidental Food Conlact�1-uhrwanti' 11 2 L7-206.11 Ro,aricied Use Pe�litideq,Critcaul' 1 3-$01.1 I(D) Rawor Nutially Coakcd Animal Fillad and 7-206.12 — Rodent Boa Station" N ot Sc i s cd. Chad P'Llixi Pack LTE T�ll�C) -U- t T��O6�111 Ilacking pi)Nl.der""P,'sl Control arld 'M( or i a L=-]2'�,(—z I t CONSUMER ADVISORY TIMFJTEMPERATURE CONTROLS 22 3-60- 1 Cormizaar Aoyisoi v Posted Prr Constatuption of 16 Proper Cooking Temperatures for Plaiiiol F<sa&That art, Raw, LarderouiAcd ot PHFsNot Othei-wise Poicessed to Fliminate F gg,- 1551F 15 5,1 3 401.1,1 A(I J(2) E11iileediatc Service I 45'F15sec, 3-1012.n llaslcuriztd Fgg:.S'"Iishlule fol Raw,Shell 4-401,11(A){2) Commintood Fivb,Moats&Gama L Ald tnals .1»"F 15 sec. -- SPECIAL REQUIREMENTS -�, 40 1.11(B)i 1)(2) polk and 1;evl Roam - IT11 121 rahi� - 3-401.11(A)(2) RdtifO, liliedeil klcllu, 155 F 15 o�atAt TIVirlailansof liection 59WXff9(A)-(D) in c. 4;iiF clacring, mobik food, ternpurary and 37Z1. - 1 I(A)(� ilouhr),Wild('jlnne, ShirFed �s' residential kitchen opal afionv should lye 'Zitiffille Contairlm',Fish, Meat, debited raider the Faultry oilitatitts-16511 15 sec. 11 above if rehlied to foodborne illness 73401.11(C)Q) Whale-nus la, lnti heof Steaks inter ventions a3)d risk factors. Orther 45 I 590.009 violatioic;relating to good retail 3-401.1 Raw arras(Fclsls(ookcd in a 11 C practices .should he debil.W under#29 slictowave 16.5'F TZ51 (Ar(l)(b) All Offita PHF - 1.45`415 15 sec Eji:. Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTWES 3 TF3,1 1TA)&(6) PIIF165tT 13 sec. (fiedisl 23-30) 3-d(13.11[$) -Micisawavc- 165°F 2 Minute Standing Cl We al and rwn-cf*wal violations,which or)no; l elate to the Tirre" foodborne Hine"interventions ona rist-jactors licicd above. orn be Conlurerr,i ally Pi messcYR -'Kxul R 140'F 3-401 1 I(E) Reinamilt" UnFivred Ptartirar�of Beef or Fr 590,000 �2 Mallag-er!'cid and Personnel FC -2 .003 Proper C;i;llng -FoA and otPHFs I and Prolection 1 FG--3 004 F�7-- E 1, t its FC-4 005 Civiing Cookcil PHFs from 14W17 it-1 , M -Water. Mbiq 'MCLV�as G-5 FG-5 006 7011- Within 2 ffour�end From'70", I - ��2 , _ _.fhpL�latl F FC-6 t .007 to 41'F/45�F Within 4 Hows. 28, Poisonous or Toler?Aate-6a-!s-- �IFC'77­1-008 :ooling,PHI'alMadc From h-5-01'l'T'KF— r Ambicilt ...22 WsL,,tlenanta '009 Trmperawre Ingrediculs lo 41'1145`F ------ Within 4 HouF' 11)enoosald:d new in 1he CITY OF SALEM G �� �S'"L7c /J: �cl BOARD OF HEALTH ? Establishment Name: Dafe: Page: of 4 'Item• Code C Critical Item �•... —T--- fVo ' Reference R Red ftem % DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION " Date .. ,.r, .. � PLEA &PRINT CLEARLY '_ � :rc.. sta .J _ Verified zP� . r �� �� nlzoc to �sIzl ad n+ -h�t�<�4 t SVC I jo ne- K t E' Q vice. fGt/ a `T, G_ u2 9n. ' zsh /tcc nc 5?P -Z Ce tir L I c j � - A 1 — ?> GJ j2. � ti.1 �'CPf? CI ,It J rt i , . �1C �t �n $�GI; 1 vt b ti1J/� 0;) aoe� {Xti.r .n { t3r3c? V Prr ? f>i o� � soa d ) C>!(�Te/TL/« }1 c ,r Cx-, C4W /IG- nnc` '�� �"e� ,�Y -t✓5 o t orclm UK G ( O'f' QTS / . ,0 . 'M•"_CjL 7s c7 14 ? ��s—�—H-441_f t4c, 1 QTyZ L=:ton T3 L/ M"x--3r1Da L41 Jt 4cc, 1 o otzia z art7. ' AAA �3�5 off- (or-, G ( tr,r Q .lel r U9 t-t 1, J---f a I ci `�rOz t�Avt ttf c5� Ike 4r7 Discussion With person in Charge:f�t r_iC AA L p</\o(,yVt�e Lyftriryr (� 3 , -"I" "2J,7 'Corrective Action Required: No C]% Yes 1 have read,this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction violations before the next inspection, to observe all conditions as described, and to Exclusion comply with all mandates of the Mass/Federal-Food Code. I understand that Re-inspection Scheduled ❑ Emergency Suspension noncompliance may result in daily fines of tWenttyy-4five dollars o sr uspe(nsion/revocation of ❑ Embargo ❑ Emergency Closure your food permit. \ f �__ ❑ Voluntary pisposal ❑ Other: Tl 14 PI-IFs Recewed at i;rmenatuir,3 Violations Related to Foodborne fitness Interventions and Risk A'vordin,In Law Cooled to Factors(ftelfts 1-22tf (Coot) 4 1'F/45'F Within s Hours. . olia,, Me�i. RFs PROTECTION FROM CHEMICALS 1_50 111 coho&for"RFs 1=4 _Taad_OrFoicrAdd ffllfa PHF Hot and Cold Holding TL__ 3-50!.16(B) Cold PRFs Maintained at or below —;-27(_f2 ,2 Additives 390 0it4F) 41�/450 F, 3-302 T4 Protection front Una ML—Addhives"--I I 3-50T 1 N7) 1 lot PFIFt %lainlained at(It above IS _Pu�inmls or Toxic Substances lRj'F. IOLII Tlcmnvuqz Infiamotion-. 0,,&T 6 1 Containers* (A) t Rt at or Above Y'0°F. L-2TfinW as a Public Health Control 7-10111 C,uourlon'Name--VorkinItainer'* b 3-4i I'li; Tint,,,aLsji public Tieallittlarinoil 7-201.1! C90,00110i) variance R --l'amiativat-Slot 7.202.IT Resiriction -Pres oiccand 7-202.12 Ctexhij(,n,uFlise- REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 201 11 )xic Containex.,-Probibillons, POPULATIONS(HS�j 9243.11 10-1 7, T SLr�u�Iers, ttrill—ChtnaicitW �2044.[if 21 1-801�I FC A) Prt-pa0mlzed Tu ccs will 7-204.12 Chenticak for kva<hia, Ci hot i;%4� ? M414 L '�-Sli 1.11(B) Ustt,of Paste"I 1-205,11 Incidental FlN)d Cune a'K L,a�dt C3-ts0l.1 l(D) Raw or Paitialiv Calked Ammal Raid and 11. Real ictell Use Pericidet,.CIlterial Raw set'll is- roms Nlktt Srrvvd, TA7_206 I� Roden, B )706 13 lksa Control 'u', "onhorin., CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 (10oqumarAutt i sot v Post M 1,)r C(nisumption rat Annual F xd<Thin art Raw.Under"loied o: 16 Proper Cooking Temperatures for PHFS Not Otherwise firocersed to Flinturve L_ 3 401A I A(1)(_-*) Fgr;,:- 155'F I55 c.ZLL�krjim.diiate Service 145F]5,,ec _43­;0' !3 F'aa::SuNtitulv to! Raw Shell �' 401.11(A)(") Comminuted Fish, Meats& Caine Aiduads l5s"F I ycc_ I SPECIAL REQUIREMENTS ;-401A I(R)0)(2)Pull, and Ilvef Roast - 130-1-121 nhn" r-- 101A (1)I I lutes.InJecf,,d Meatsts- 155T 15. 1 590'l; 3- 9 'Vl-TJ1'7 "1C,1,jt7il;7 or Section t90 W0(A)-(D)in Sec. cateringniobit„.food, tenpaaa v and T401-1 I(A)(3) Foulfry,Wild Game, Stuffed PIT'i, rel ddcutial kitchen oplailtionsAiould be }tisk Meat, debited under the appaoprle to sec anh Poultry or Ratnes-165115 sec, .bove it related to forldhorne Alnoss 3-401.I rI C}(3) huals Be Steaks truci vraltions and -ask filidorq, Other 590.009 v,tolations rtrlatin,Q to good ret” Raw Amucil FlNids C(m�cd in a 401.12 be debited under#29 - Nlictowave 1651" Special ' 3401,0(At(!)ib) tilt OThin l"Iffs-- 145`F 15 sec. UL- Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES NII,165'F I fl W( '* (Iteral 23-30) 3-403A I(6) 4ttetosysvc 165'F 2 Mulaue Situ din); Cii&al and non-,rnwal i4okilums, which III:)not relate to ine I Tittle, foodhorle ufrze s s ime)velvioioand riskfiettars tined above. (on be ----------- 3- ft, Kxt- foand ul of the Food Code alld It15 C"WR I 140'Ft '90,000, 1 FC 4 0�11 I(E Zcinamiko,tnh,,TF�ortioils orlieef � 5.90,000 23M 1 FC 2 003 lg 4, and Food Prollr;u rl _P,ope,—Cooling of PHFs ._.._. Ft,­i .004 Equ,p TI its fC-4 )5 5'0 1 14(A) Cooliog Clok,xi PIFs from 1401-to _a -- —te- I FC-5 (I)l3 X20J_yViter 7001-'Withut 2 lour ouLaid From 7101' to 6 Priatonous at Total:Meisel 7 008 a 1�3 301 14f B) Cooling PHFs Made Floor Ambien - ----- Terapermurc Ingredieuts to 411,/45 F Within 4 Hklurs Defillles Lritaal Real ill Ir,'k3et (,! 1999 i'l)(In Conor 105 Calk 590 000 Commonwealth of Massachusetts city Of SAI m Board of Health 19m�Y D �I f20'Washingtw Street;4th Floor.. S*ErW,h4A---41M_. Et)od/Wetaii,-E-stablishmmt:Perimit DATE PRINTED:. 01/12/2010 ESTABLISHMENT NAME: ClrcWK 7502 /%bway- FS1e Number.BHF-21)1)s=000 N _..323 Highalnd.Avenue. SALEM MA._01470. LOCATED AT: SALEM, MA 01970 Permit Type Permit No: Permit issued-- Permlt Fig im - Fee-Restrictions t Notes FOOD SERVICE BHP-2010-0315 Jan 4,2010 Dec 31,2010 $f40.w ESTABLISHMENT RETAIL FOOD BHP-2010-0313 Jun 4,-2010 Dec 31,2010 $280.00 TOBACCO VENDOR BHP-2010.0314 Jan 4,.2010 Dec 31,2010 $135.00 Tota1'Feesr... &5,,55,00._ _ PERMIT EXPIRES December-31,20I8 Soardof It¢s[riir This Permit isnot transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,3mprovemeuts,or equipment changes are made,all plans for such.must be submitted to and approved by the Salem Board-ofHealtir page,1 CITY 4F SALEA. MASSA.CH'USETrS BOARD OF HEALTH 120 WASHINGTON STRI3ET,4'`FLOOR TEL.(978)741-1800 I0v1BERLEY DRISCOLL FAX(978)745-0343 MAYOR ttt usn nmQ a}mitt COM DAVID GREENBAUM, ACTING HEALTH AGENT 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT G 1 �t k p o� TEL#, �$ �' Mgt Zr 2R ..FAX#, S L2r" t. O({7 ADDRESS OF ESTABLISHMENT 3 K h to V iLiNG ADDRESS(if.different) ° I jo�� �' kj ( ► IV ;EMNL-Business: Website: OWNER'S NAME J1 Circf G k LLC- TEL# i( . �`�� X` 0.1 ADDRESS, 0 4o x �{l1 het« 6�ts Al �('l�o STREET ) CITYSTATE a ZIP CERTIFIED FOOD MANAGER'S NAME(S)_ iL 0 4' LLP 04— CERTIFICATE#(S) G5 0 O 350 (Required in an establishment where patentia0y,hazardous food Is prepared) , !4C 3 EMERGENCY RESPONSEPE2SON iJ. Set:ur: CAIr HOMETEL#90 -64`' IA5 I 1a HOURS OF OPERATION 1 j Neave wise n time of day. FatBxaa Ilan-St S tt7 TYPE OF ESTABLISH NT FEE (check only) RETAIL STORE ES NO less than 1000sgA. =$70 1 -10.000sq.ft. A& more than 1 0,000sq.fL 4420 ............:...:..... .................... -` -..--.............................. ...........:... RESTAURAN YES NO less than 25 seats (OtRdoosr stationary Food Cart$210) - 25-99,seats 280 more than 99 seats =$420 ,... - BED/BREAKFAST/ YES O GHtC:OGARE SERVit�SSlNURSIPtG NgME-•------ ---- 10D ------------- - ------ --------------------------- .......$ ................------••----• ADDITIONAL PERMITS MAKE(not.just serve)ICE CREAM,YOGURT/SOFT SERVE YESc7 / 1� TOBACCO VENDOR YES NO 13 ALL NON-PROFIr(such as church kitchens) YES NO $25 1 'Please pay,total with one check payable to the City of Salem, iJ c� J"l This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted In a prominent location in the Estabtishmertt 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 HoalNr. Pursuant to MOL Chapter 62C,Section 49A,1 cerfify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns and pale as st a taxes required under the taw. -�—� �� . 1�,-W- Oq a6. 2��( 76�8 iga - Y - Date --Sa--elat;5�e-em�tYea Federal Identification Number, Rodeo!4/24/07 FOODAP2008.adm Cbxk4 Date. ..... W02� Ld kU2F:TT 6 7'1 '�aa 'ON XU1I I.•i•,,.:..Jl.'tY'.r4d+.s'.;i(y���;--rG:1.....,M.,».1/:{.. '.. .m x u.. ... -,. J. ".• ., 'J.�, y :i .. � J4:.N1?...r.w .. J a - yt. K: F adv t �, I Y lftssachusetts Department of ,Public(Health Salem Board of Health Division of Food and Drugs 120 Washington Street;4 Floor Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT R , I',`� Tel.,(978) 741 1800 Fax j978) 745-0343 Name Date' I T of 0 eration(s) Type of Inspection S- 06AIJ U jai d Food Service ❑ Routine Address 3 ` (� Risk Retail 2 Re-inspection 13 8W"ZICILevel ❑ Residential Kitchen Pr vious Inspection Telephone _ El Mobile Date:tobi(� Owner J HACCP YM ❑ Temporary . ❑ Pre-operation /ov (`2 ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast El General Complaint _ In:6:0S [__1HACCP Inspector ( OU Permit No. ❑ Other 22s- Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. S+ 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 MANAOEMENT„'l,`m " dy o1k , a r + „l"``�` ❑ 12. Prevention of Contamination from Hands El 1. PIC Assigned/Knowledgeable/Duties ❑ 13 Handwash Facilities r EMPLOYEE HEALTH h ,.. - .�._.m..,._. .. , ,.,,,., „ ,«„.a,a[ PROTECTION FROM CHEMICALS „r�` ask-4'"�r, R ❑ 2. Reporting of Diseases by Food Employee and PIC �. E �,r �n.=...n� ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded P _. El 15.Toxic Chemicals (;FOOD FROM APPROVED ® ., - El 4. Food and Water from Approved Source )'TIMEITEMPERATURE CONTROLS(Pai6tially Hazardous Fooda)"�, ❑ 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 re x + e `�" 1"`�' '"f "`�' ❑ 19. Hot and Cold Holding °' ratio'" "Segregation/P ote do " 420.Time As a Public Health Control ,• ❑ 8. Separation/Segregation/Protection ❑ El 9. Food Contact Surfaces Cleaning and Sanitizing ;,.REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATK)NS(HOP), ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing El11.Good Hygienic Practices 'i 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 by the Board and Risk Factors(Items 142): 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: S,ssaMVs fFo�+a.dw n Inspector's Signature: Print:< 7. PIC's Signature: ' f / Print: v �S} �Qt7. Page of C. gages It Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Cross-contamination 1 I 590.003(A) Assignment of Responsibility* 3-30111(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 Annual Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* a plicauts* 3-302.15 Washin Fruits and Vegetables 590A03(F) Responsibility Of A Foci 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.(H}3(G) Re orring b Person in Char Vie* 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) 'Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 1 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 Tem eratures* . 3-20't.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Ea s* Sanitization Temperatures* - 3-202.14 Eggs and Milk Products,Pasteurized 4-501.114 Chetnical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. * 5-101.1.1 Drinking Water from an Approved System- 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinkin Water* Utensils Clean* 590.006(B) 1 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* 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* GameSources* 10 Proper,Adequate Handwashing Regulatory e Mato Authorityand Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms* R 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* 2-101.12 Discharges From the Eyes, Nose and 3-202.15 Package hiteit * Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventin Contanvnation When Tastin 6 Togs/Records:Shelistock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(F,) Preventing Contamination from 3-203.12 Sheilstock Identification Maintained* Employees Handwash Tags/Records:Fish Products 13 Facilities Conveniently Located and Accessible 3-40111 Parasite Destruction* 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* ry Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance IHACCP Plans Suppled with Soap and Hand Drying 3-502.11 S ecialized Processing M_ ethods* Devices 3-502.12 Reduced ox en acka 'ng.criteria* fi________FHanrhvashing Cleanser,Availabila 8-103.12 Conformance wi h A roved Procedures* 6-301.1.2 Hand Drying Provision *Dentes critical item in the federal 1999 Fwid Code or 105 CMR 590.(100. CITY OF SALEM c f+ BOARD OF HEALTH I Establishment Name: CJh.y>= t� / . ;fir Date: / -)9 Page: ',;;t of Item Code C-Critical Item ( DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item (� . .Verified PLE114S-E PRINT CLEARLY J/�f / I7I(�7YI��l//1i�� `�I71 Qi^✓ /! iyl (, / /r� �e ./' /f/ /.yG �A4/" /1 r'nG/1/✓!S' tall rc'S,cl � �� /1 nI7A✓ nn r,,,,�. Vp�r L"b� e/ /✓Hri+ `JC IV _ ,/-d- } /fir t) Pn�L• YG�4 rr/k4o' f t T L x i t i Discussion With Person in Charge: Corrective Action Required: ❑ No l Yes'' ' I have read this report, have had the opportunity to ask questions and agree to correct all '�° V.oluntary 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�-fiv(e dollar r suspension/revocation of C3Embargo El Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: I ?-A11.IAlC7 PHFs Reu ived at Temperatures Violations Related to Foodborne fitness interventions and Risk Accordi ng to taw Cooled U) Factors(lfetrfs 1.22) {Cont} _ 41=P/45`F Wilbin 4 How's. _ PROTECTION FROM CHEMICALS 3-5(11.15 Cooling A4cthods for PHFs F, PHF Hol and Gold Holding 14 Food or Color Additives350' 16(13) Cold PHFs Maintained at or below 3 202.12 A( huties'r _ 590,W W) 11°145`f -� ?-302.14 Protectior)from L`nappnn°ed Additives" 1.5 Poisonous or Toxic Substances '-50 i 16(A) I Lx PH1 s Marra at or above 101.11 h( otitif m' tnfoitnation-Onoinal -- i4I I ( . - Y g i "; �tiL151,A) Rix-ws Heid at or above 1300F a - - t !02,11 Gomm�1 orlon*( rutin<r+" Time as a Public Health Cartrol �C'r t r ac a Public 1Icaidi Control' [7-1 Ret icttn�E'runeeanul 2 Co uL t on.of t s�'..03 t1 ToxtU(oxainex Pmhrbiclnn ` REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSPL I 204.11 Strte , ( iCheics- - -- 121 i- S9' I(At -294,1 ihrp r to me d Ptn r e ta-cd Jui—ces"nU -- Chun tic trn x; r hr� 1 x ( rt xuv"_ with A nr� all ts' r °0114 �Ut vr� Arot,.Cnt rt _ - -` SGI ll(Ht l a+ Puttuvid} c _ ti.511 Lot' n t) t xxf r.rrict t iht r11Nt�kaw it n4mHr (rvt�Animal Fixed and [2-2J6.1 I 12.:, n 1 i c Pe 4 3e C t kr m i ' I Istx r w P ri station" . rt;: Ur d T"W pae ay Not R "Qlvcr3. -i e e- Monoou i ' CONSUMER r`aC7`J;SCeFs"'i TlN9[ 3 EMPERATURE CONTROLS 2u 3+tit-' 1 r tl ns tmo Ac e:so.x t' sie 3 Cor C ousa}npu(in of t--r---_-- --, a.iint 1I ,<vi lin a (. t Lnnc,rc cx.fic'i1 cr '' to 16 , Proper Cooking'Tempnrares for r a :Ji `'t< ' trr -' t 4,tl.lt ,ret:; inirSt H I e,� utdr we e5 I ret 1 ' r 1 r 401 1(,A 1 C, n i intrtr d i, h. tilc.a , 1 tr lig r r 1 i H r. Poet terld Mcf Ro s' r r I iiia'-I SPECIAL F;�C,t9.foFitjd ra S 1 Il.i rt Sir r �r rt Lij aA1 .t_ t r 3� - - 1 i � i ahti`C Ifi D,�Cr11;`1 ><.' tcnnp rr3 &ad. i .1 i W r 1 } tigi Cr :i ti 1 r 'D'iS 1tt ciE i`Cl +0! r nr:3i ntrrrY d rrt ru c i tit t'. t�U;)(1.,F ac` t elle( C '..Lrr13 t r - €ri I;,, r i .h,j r 7 4ch< img fir riot liolomq VIOLA FiONS RELATFD TO u9000 Ai-,T& PRAf.7T E.5 I .Ft3.iLU ter,_ cHl (5"=r r s .-� (Itetes23-30) 43.11(11) � t1t es�aVr it'+'F2 tijmu 8tandeg j err -r1 riON, -r.` n 1 -rt> _ rr hr'r. nt ea ' ."ypc i t ( i7i +r. zgedkowut ea>rbe, { 03.11 ) 1 mnel ixis t9ar '.-:a 211 1 i<i- <c it rir a:, ni r _cr i hrF xxrto're ut tIr, b CGU -4(9.11{L) RcoiamutgLnhevuPuttit sat liar; item rG"ooYReraslPractices -_ C o9o.OD-- __� kz iasis" i s Aaaanenc t a-td P r r r rC l 1 043 r---�- ( 2 t r�xi d Few P etc t c PC f 00 -- — L Proper Cooiing of PHFS - I ------ ---- 2> ,.„rr�nt anti tater +s F"; 4 )n.: 501.1.3(A) i f rx lin Conk d PHI-'s f� to 14117 in � 1_ r `t- -. ._ _. - 1h ger P tbnc; tic i ;'e _ 1 EC_° 0€,3 f hitt in ' t10u .ro Fre r-t o F .a al'F elity __ - GC E 607 # FIJx F 4L ti m 111 to _ t or .ixr r,f r t, _ FC 7 008 I �aUl,t�#(iiif r to PRF '41 dv Front 1tr hr ut _ - 7 m,.rawle im rtcacros to ad"1-1 iS'1 " r}(tic 1 .I Wahin.11'Sw , i ' .rJr...b ' - ...w•^"'.t`n..rk......r„s++'r!-+r^�f3°�tr'4�,n..' *+�.e�'+1, _ .l.:a..1..rA-.: �`^.'k Y -'¢�. ti. -^A i Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4 Floor 9 Salem, MA 01970-3523 FOOD ESTABLISIHMENT INSPECTION REPORTI _ 4 Tel. (978) 741-1800 Fax (978) 745-0343 Name C Dat �/ Type of Oneration(s) Tvoe of Inspection J Food Service rZF[outine Address 17C Risk 'LJ Retail '❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile- Date:4(0�10t Owner HACCP Y/N ❑ Temporary ❑ Pre-operation _1120/1 O i L ,`T",)- ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed& Breakfast ❑ General Complaint In: S7 0J ❑ HACCP Inspector Ou Permit No. ❑ Other Each violation checked iniquires an explanation on the narrative page(s) and a citation of specific provisions)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 PROTEOTIOjJ ,r„�,,,,, s.,;a_ , l [1'12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties ❑ 13 Handwash Facilities EMPLOYEE HEALTH & ❑�2. Reporting of Diseases by Food Employee and PIC U Ell , 1 W ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded El 15 Toxic Chemicals �FOODFRO MAPP ROVEDSOU RCE "®ss, �"`�" ;m,'s"3'a''I=;g ,TIM&EMPERATURECQNTRbLS Potemlall HaYar pus Foods �e°w1 ❑ 4. Food and Water from Approved Source �, Ae , , i � ( � y d ) � ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 118.Cooling g PROTECTION FROM CONTAMINATION ""'� 1} 4 '� ," n! 19. Hot and Cold Holding ❑�8. Separation/Segregation/Protectwn [120.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing EREQUIREMENTS FOgH(ONLp SU -'EATIa4E PQPULAftONS(FISP),;;„ El 21. Food and Food Preparation for HSP F1 10. Proper Adequate Handwashing , �°1e9kj El 11. Good Hygienic Practices1 ❑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 ,aN P 9 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.005) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(59o.ou) 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:seaInapectFwmb-ia.aoc IVC�yQ'u� 3 Inspector's Signature: I Print: I �q PIC'sSignature: Print / Y! I Page f of�Pages Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT g Cross-contamination 1 590.003(A) Assignment of Responsibility* 3-302.11,A)0) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge°` - Cooked and RTE Foods* 2-103.11. Person in charge-duties Contamination from Raw Ingredients 3-302]I(A)(2) Raw Anitrial 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* a flicants* 3-302,15 Washin Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-3tk1.11 Food Contact with Equipment and - Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.(H)3(G) Re of ling by Person in Charge* 3-306.14(A)(B) Returned Fad and Reservice of Foods 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.11I Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* SanitiyatiorfTeu eratures' 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 Utensils Clean* 590.006(A) Bottled Drinking Water* 4602.11 Cleaning Frequency of Equipment Fa�d- 590.0M(B) Water Meets Standards in 310 CMR 22.0* SheHtlsh and Fish From an Approved Source Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught MolluscanFood Contact Surfaces of E ui gent* Shellfish* 4-703.11 Methods of Sanitization-¢Tot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301.1 I Clean Condition-Hands and Arens"` Regulatory Authority _ 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 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 lnte i[ * Mouth* 3-IOLll. Food Safe and Unadulterated* 3-301.12 Preventing Contamination When'fastin " 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employees* Tags/Records: Fish Products 13 Handwash Facilities 3402.11 Parasite Destruction* Conveniently Located and Accessible - 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Ca acities* 590.004(J) Labeling of Ingredients' 5-20411 Location and Placement* g Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502,12 Reduced ox en packaging,criteria* 6-301.11 Handwashin Cleanser,Availability 8-103.12 Conformance with A. roved Procedures'" 6-301.I2 Hand D in L Provision Denotes critical item in the federal 1999 Food Code or 105 CMR 590.(100. C ` CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Item Code C-Critical Item / DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Reference R-Red Item verified No y PLEASE PRINT CLEARLY/ f! _ I �'� /1' , _ r vl-{_n Loi n_ . f n-.� n r ,f- s- _ _ n - 'S V 1 lr �1\—r I .l n/ 14 1�L 44Ir✓ - /1 .�..--/ d: i v t, tf ,r ti I �rIAt)o — rnr l . _�- o- •� off, n_ ,_ ,f � •_. 1 iArr! - , ,` i - n /1 /� - G ,) e - h Discussion With Person in Charge: Corrective Action Required: ❑ No Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins P Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of fw?nty-f�ll fls or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. /�/� Voluntary Disposal ❑ Other: r I •r " ,501.14(0 �- PHFe Received arTemperatures Violations Related to Foodborne Illness Interventions and Risk According to Las+Cooled to Factors(Itettts 1-22) (Cont) _ 41iiF/45"F Within 4 Hours ' PROTECTION FROM CHEMICALS 1-3-5011, 3-50115 Coolitr�Methods fix F-PH --- 19 PHF Hot and Cold Holding 14 Food or Color Additives 3 ,501,16(B)' ColdPHFs Maintained at---or bdjw ----1 0-202,12 Add noes 590-00-4(F) -71`/451 3-302.14 Protection from Unapproved Additives` -- 15 Poisonous or Toxic Substances 350116(A) Ilot PFIF,;Maintainedat(rabove 40+F_ '-tUl_ll ldentifGwg infa.ntalien--0o"isa, field at 1 � � F-35N,t611) R(e.?+ts Hcid at or above 130°F.t { Comau er." �_ -_- -- ;- 10111 ` Common\'ane tt >rkiae L uoi n r-• X20 � _ 1 Time as a Public Hsattb Conirol 7 SOU 1 �S�jm (nun St',n t � � 1 t ioL ! 1 rim.. ac t 7 uhhc Heatdt<'unU'ol*_ , 2172 I t });;,trlct on 7-202.12 Coudeo>n of Us,,, t}3.11 Toxic f u u rinec P ohibi: of s' -� REOUIREMENTS FOR HIGHLY SUSCEPTIBLE ? �- POPULATIONS(HSP) i 1-2(•l.II : S, nu ucis crile is Uicnric. is -�- _ ?-'_(}4.i? _ Chemicals fbt_Wash u,. t;_Y_rd c C.rrisi;C-i �I =k?i (•k)T`yf un iz¢d Pr ) n aged Jtncec std I7-904.14 D;yiiw 1t ence.tnt !i! SW M13, k-c ofPawim dtc -205.11 lacidc nt al t xxl Contact, � 7 rsi;h [I r2o u, I d -sc P tattle... C. t t � l '~vl i.ci)t FawolnartmL CK �d Abrmal F(xdand .._ ) 1<ai 5 d ti 1 7-206J2� rho' r 13 r 4.si c. u a 1 i -... _oon S�t'�s ) uc+ r<x+a l ;e ta_ 'N' R. .crvcdl ' %Ci6.I? lira n rsg rctu9„ # s:C°ontre` .tuei -- - ! ^4...i,`v'M01 AI}sTFSOFY _ 3 4)i-' I i i,U till 1e s! i O't ii)eleil io; im n3-rtion OI TIMET EMPERATURE CONTROLS _.—----- Anowl ief ilk t Ra U tduui..'ked Itq Proper Cooking Ten,Patxitrc, rar 'rs : nt _ , 155 F I -------- SPACIAL REOWREC14 ° i t is I ) l2c rr_ Il eJlic. e ). .fit' 1? D) in - 11c i g, mobil- i<xx_tcrnp„rat t and. t S. _.. I740 -.-R'SF!1_E}}<5= e; 1 > u ;. 4rri(!'f ai.e. tv 4 1"I'll, - ! "sx4 Ilfi s11.3tet- t, E;,z3u6.!r;, l_a c.i,71 ire j .iclitfild u1106'! the u,'I(?ii ie } .�}.<c`Ut I •c'-t1,x(ir1 i aC<°� ")( 00 rl :v{tF( �t) 1,,,A t ........ .............. _... _ - rI �.� a 'l; ... •i.is t.� Reheating iiiHot ealcin9 _ _ VIOLATIONS RELATED TO GOOD RETAA LrtPRACDCES._..... r __. � .> N'-- l)c ;1� (hems 23-30) -. 10°.11(b, hheiu :asr E+ 12 Yluuu< Si�lrldmll r I i z ! :a nu rfta r S ii i c-a i na ri r f<l i s?s e l c u -r ears 1:-r 1 40A,II(C) �'ti<.t1 {CeL"e11..t ) ..11%{ 3 4c...s I(1's 1 t2 !t !nxig L s�.c ed hczvx zs c;! hicr! ! 1 (tem ' Gaod Retail Practices __ FC 596.e70fi rlo ,,P+fjmd IG 2 X13 1 eod rrd F(xl P otert or cG t : Y"4 1 Ig Proper Cooling of PHFs ; k- I - - a - c-._j.� — - — l 25 cr ci;n ?rn and Utes !a5 i f-,- n e�" 5-Sill.WA) 1 (a l ntrCtwk d Plli c fern 110 ` to 1 �; e 4” _ - -i r, �UtG' vl _ i G 3Cr3 1 Within 2 Ilan : :d From ':N1= j Fa-, r; FC-6 �7 ; a rUn -' M 15"1 R tI n ? Hnnr r zF asp a s r rsz F res v6C' Fr - -- - - _.. — ling lHF 11 d From gni ion( Other � I ern ruuirc fii rec`..e-taz, �I4S1 _ C - �,rtl. n 4 HcR3n { CITY OF SALEM / / BOARD OF HEALTH Establishment Name: SSIJ 3l f7! h144-1A- Date: /6I07/0--7 Page:-3 of :_ Item Code c-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION mei No. Reference R-Red Item -- ".'` ;. ;Verified PLEASE PRINT RLYfLL)� A ( nlnCbe(l)A2E/ - �'4 S �G (// Si I(^ y G 6 . I�J4 .to� YYV�( I nr n (L Co -r .t 110< � s [cv PEE] 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 ❑ Volu tary 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 that noncompliance may result in daily fines of twenty-five doll rs or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. // /L �� 2�— 0 Voluntary Disposal 0 Other: F7, 501,14((') PKFs Received at TefuperaWres Violations Related to Foodborne Illness interventions and Risk Atax)rdiri,In Lam Cooled to Factors(Itehil;1-22) (Cont) 41`F/45'FWithin 4 Hoijxi;,. 3- (CL15 Cooliln,Mellhods for PffFi; PROTECTION FROM CHEMICALS Q F14 Food or Color Additives 19 PHIF Hot and Gold Holding 3-202,12 AfkfitiN,_<* 501.16(B) Cold PHk Maintained at or b,�Iow 3-302.14 Protection frout Urrappru,-,cd Adtlitivcsi90,004(F) 41 /45"F' 3-501 INA) Iltit PHI's klainlaineCl at or above Poisonous or Toxic Substances 14(j'F, Roaeb Hc1d at Or above 130"F, 1 70 Time as a Public HeafiW�Controli 10, 11 Common N,. ;Ial, workm"Cowam"I", li 7Eati'I lluhlit,Health Contrujn i V_�__,nanm rt ntrentei,t L7_--')iLf Re.�triii loll -Yr uncc and I'sc, 'II Condition,of Us�, REQUIREMENTS FOR HIGHLY SUSCEPTIBLE _Toxic_Cuwtamcl� POPULATIONS(NSP _L 17-204.11 samtirex,.crileria -chemic,,,W 21 Stii 114 A) Unp�mctn jz.d Pre-pacroged Juices and _7-204,12 Iji evez%a,,le�,with warninil 7 204A4 Di iing Agcial,.Crnciia B lW­.__,,__ w 1.i',11, I of pawlwi�­d -1 105.11 Luau nt ti 1(wxI Corlinct Luh!wautv j C J-jljjjdj",C,KF i�i-Aritrial Fad an, ---------- d P»rdor;, ----------- CONSUNIER ADVISORY TIU.EJTFli!PERATU1iIE CONTROLS io O P ----- --------- 'A 1'a ftzv, S!01 Fl,-(;i A L 71 1 RIF20,a 14 r3 F", i I wid v,,A !J1C Cow lm.nMemr, ,3s 3t 10 A 0, tFt i06 1, fichcatitil for Hot Ho'uIng 00LA710tu-S REJ-A'f ED TO G000 AY Tu PPACTfCkS ---------- f ireni�23-30i lo:lj I(b) 'Smu"Im, i I- I eafc:,;I;:, lg(Cor, dwo,", cwl br :,j R'l F F ""and in eht a seiofc", he food Code_,wd JfLCz"R I 41u F, ------------ Remamiw, fl,muon,,)! B,, j I firm Good Retail Practices FC 0 23 0,a, laao m ar—d perso nn,;1 f-(xV,;od�(X)d prc+c�13(,r, 3 ()(C4 -proper Cooling of PHFS - --- -- ---- 2�5 tjoomr��l"4nd tjrells,s 17--' ,p5 501 1 ICA) I Cwiiw_,C��)ks,d PHI-'F ifoul to 2G, ,Va ,p!:.,7C,,iqq;U­aNto cl(_ 1 ! 7`J4 Within ' Iron it�A From 1')'I' CK`/ j k, I! 'i/!S'F Withm I How- 'a o r mc fvC 100S [ %-Lidlv F,om AmNent 10 ------ Within-11 ',;! "11 1,13v I"o. %;Je"t I "IR i G rt 1.45"F' "4y4v r- Massachusetts Department of Public Health Salem Board or wealth t -a i-1120 Washington Sheet,4th Floor Division of Food and Drugs Salem, MA 01970-3523 4 i V FOOD ESTABLISHMENT I SPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name 1 rC �� Date Tvoe of Operations) Tvoe of Inspection ❑ Food Service ❑ Routine Address 2 f A 7 Risk R-Retail RRe-inspection 0 1 C Level ❑ Residential Kitchen Previous Inspection Telephone _ ❑ Mobile Date: Owner HACCP Y/N ❑ Temporary ❑ Pre-operation4- V ( �r 7 El Caterer El Suspect Illness Person in Charge PIC) Time ❑ Bed&Breakfast ❑General Complaint Inspector I pO OEl ut:ut Permit No. ElOher 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„= '�x ' "" "' „6. ", ,„» ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties R ❑ 13 Handwash Facilities EMPLOYEE HEALTH ` j �a�.,.,wa...2 r PROTECTION FROM ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives , ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals � I FOOD FROM APPROVED SOURCE�� � M; '®: , 1MV TIME/TEMPERA7URE CONTROLS otemiell Hazardous Foods " ❑ 4. Food and Water from Approved Source » E RE �_ , j?. 4Yµ_ ®gamci .) ❑ 5. Receiving/Condition [116. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling i PROTECTION FROM CONTAMINATION" P�" -a . .�,�. m ❑ 19. Hot and Cold Holding :_44 El 8. Separation/Segregation/�.. Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing [REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)µ ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices I`.CONSUMER ADVISORY;= _' 't;, �' �`�,",' n ,.,�1!"I ❑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)(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: s:sso,�we,Fo.,s-,a.aa C)o Inspector's Signature: n A Printi ! PIC's Signature*'---� ,.W,,,- Print:')asp_X ' )q..�� �,.�,� ,.`n- Paget of-7-Pages U Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8I 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 FoWs* - 2-103.11 Person in charge-dot e Contamination from Raw Ingredients 3-302.1.1(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 foal employees and 3-302.11(A) Food Protection* applicants* - 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility OFA 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 Chive,* 3-306-14(A)(B) Returned Foal and Rescnice ofFood- 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food' 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Com9iance with Food_Law* 4-501.II1 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Ter eratures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashina Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.14 Eggs and Milk Products.Pasteurized* 4-501.11.4 Chemical.Sanitization-temp., pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. 5-101.1.1 Drinkin&Water from an Approved System* 4-601.1[(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(B) *later Meets Standards in 310 CMR 22.0" 4-602.11 Cleaning Frequency of Equipment Food- Shellfish and Fish From an Approved Source 0ontact Surfaces and Utensils* 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 Regulatory Autharit Came and Mushrooms Approved by 2-301.11 Clean Condition-Hands and Anns* Authority 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 Inte it * Mouth* 3-101.11. Food Safe and Unadulterated* 3-301.12 PreventingContamination When Tasting* 6 Togs/Records:Shellstock 1.2 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* ELnkr gees* Handwash Facilities Tags/Records:Fish Products 13 i h Conveniently Located and Accessible 3-402.11 Parasite rds: 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(J) Labeling of Ingredients' 5-204.1.1 Location and Placement* ry 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 os gen ttcka 'ng.criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with A. roved Procedures* 6-301.12 Hand Drying Provision Denotes critical Item in the federal 1999 Pool(.We or 105 CAIR 590.000. _ t CITY OF SALEM F BOARD OF HEALTH / _Establishment Name: Date: / Page of � Rem Code C–Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R–Red Item ,Verified PLEASE PRINTCLEARLY elr I r � l2J— GI tr= (iC f r2� 54 .a 7 Discussion-,With Person in Charge: Corrective Action Required: ❑ No 7 Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Res riction violations before the nb3(t ins ection, to observe all c ditios as described, and to Exclusion p nLl Re-inspection Scheduled Li Emergency Suspension comply with all mandates of the Mass/Federal Food C,de. I understand that noncompliance may result in daily finesenty-fiv dollars or suspe sion/revocation of C3 Embargo Ll Emergency Closure +lyour ffermit. ^ ❑ Voluntary Disposal ❑ Other: 4r -4-501,W(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Litu Cooled to Factors(/tents 1-22) (Cont) 4 1°F/45'F Within 4 Haws. PROTECTION ows- PROTEC71ON FROM CHEMICALS 3-501,15 Coolin-,,Methods for PHFs7-----7-- r- 19 PHF Hat and Cold Holding 14 Food or Color Additives I 501.16(B) Cold PIIFMaintained at or below 3-202,12 ArUtivc.,'* 590 004F1 41°145`F* 3-302.14 Protection from IjIna -,j Additives, — 3-50,1 1-5 Poisonous or Toxic Substances ,INA) li(It PJJF'� \faintnined at(it-above 140'F - . 101.11 ldeniit�mg Infomation - OnIginal 11-a01—15(A) koarts H Idal ornbove 0014, i 20 Time as a Public Health Control 10111 (onnutai N;int, -- N 1 7-201.11 Sia tout- Stena * J) q-I'Cz 1 on -Ill t'ak nce'uld U Ji"_ —i Fi —V�!-;.arse R eq a I f�—�l 11 C I I t 7-202J2 Condilion,of Us�' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE LJ Toxic Conlainciz - POPULATIONS(HSP 1 7-204.11 salli67ef�'criwrill -Chir tic tiv _I t-- 7-'04.12 Uhotit icas f)l `A'acct nv'V:ttd;;�C'Ciitcji Rr:sCtaS tvill) 7 )0-t_14 Di�inLAiltaw.Crwrla�� ----------- 205 fnti&wal Frxxl("untict LoN icams� S0'A'tB,1 U�,,ol Pa,teu6zcd E 11� lla!N Rxd triid ... R�tv tt4 S�l evd. L ... SIMIOTt�- P1t11`,dvrz'f"'S'Control itt'd Moitkoli"' CONSUMV ADViSiDni TIMEfTEMPERATURE CONTROLS 1"r("anImPT11"fl 0 Proper Cooking Terapeialoros Fn�-7 PHFS 3 1 ;i PAO Egg, 155 F i 55�x. ----- ----------- ------- c- ---------- SPE CiA' ttltn ":'Ibil t 3 " )I-IhAoi) P.rt. n ViidCut,., siiPlccl N - ------ ---- v Rphatirtj trtr Hai I ictki;vqt D 4 JE" �3000 RETAiL S WOL A 3--�66J 1,10". i: (ite'lls 21-3lii 401.11 ti) Miootkv"' lf 3 il';MU 1�t:M IT f 0'jd C'J'e'aV;;4 j-V13.1 1(C) �'!F Fl",d 1401- r ooeF� t'h Rcmaima, Unslwed c ""3. Managemt-i and Per,,,o, ni�, T 24. �Irmr?,�vor, -ofPwi— I Eqoprn!neina ulenqiis 4 up5 ---------- -- 2(5' V+ater P; mz)ml'vid Oj "Lf FC- 00" 701 Within 2 Fron /:�"A* 1_.2t Fawca,Fac:ii!v FC-G �W7 7�x�, IV polso�nkls or i, I i 1 7 0013 -- ---------- ------ -rom Airlllicnt 6mt 1�- 'fi C,the Pi IR, M�tdv I Y•wr•.i{4+f..::,��.5`fi-• kr'.r:�h+• sM4v,�.��R•-p"rs"ire"�i..wr'i�'lre.(+'A+•.M`^'.r'�y-tti. ....,i' , �r,r Jib�•r'i'y�Ffw's'6M�'..,/'� } �jr, �a�� J� dF+t'r'^I^4Y1�'!�Y�,ay{�4K fs^rI iR-yq,,�1T'•~'•• Mal sachusetts Department of Public Health Salem Board of Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT, Tel (978) 741-1800 Fax(978) 745-0343 Name (( Date Tvoe of Operations) Tvoe of Inspection Cl f cU (� 5 S✓�i )�����h ❑ Food Service ❑ Routine Address 3/3 �� h�G^r f V e Risk EJ-Retail 0 Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone 1� , ❑ Mobile Date: Owner HACCP YM El Temporary ElPre-operation -�-FV r, G f Or Cc n ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In:4 ❑ HACCP Inspector J (� 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 Ami-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 MANA¢EMENT=�,�"�., s,_ .,.�'"_�;,, El 12. Prevention of Contamination from Hands E] 1 PIC Assigned/Knowledgeable/Duties ❑ 13 Handwash Facilities EMPLOYEE HEALTH - "•G ' . :am..„,,, .s.,.,�ias,�,m.,a .". .,i,,. e'�PRQTECTION FROM CHEMICALS r, El2. Reporting of Diseases by Food Employee and PIC _' �a-a �s =s � _ =fy U _ .- "�.. » ❑ 14 Approved Food or Color Additives E] 3. Personnel with Infections Restricted/Excluded ❑ 15 Toxic Chemicals FOOD FROM APPROVED SOURCE�;„"�`'` "°s`ft"s" "�_�""" `tel' '_��„ � �-" �'" � °' I TIME/TEMPERATURf CQNTROLS PoteMlal 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 m - 19. Hot and Cold Holding (,PROTECTION FROM CONTAMINATION"��" ,4, � : " `� 9 xi im .»a ,-:-,».11 ,.. �.'x� .,m. »m' .,.m,,,.,x.w,d,dm,m,�• >.as«..�.,. .,' ❑Y8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing :REOUIREMEN'1'$FOR HGHLV SUSGEPTIBI PFil1l.ATtDNS(NSP) El21. Food and Food Preparation for HSP El 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices ej i,t:ONSUMEFADVISORY k,„ „s" � w.w. e¢� ,�ri ❑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. 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)(990.009) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: ff ff sssomsoecrFu,msia ew /� UG�t�, 7/, 11 ' n Inspector's Signature: % Print: PIC's Signature: Print: - �--^-I Page of�Pages V Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Grass-contamination 1 590.003(A) I Assignment of Responsibility* 3-302.11(A)(]) 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* Charge* Contamination from the Consumer 590.003(G) Re orcin b Person in Char 3-306.14(A)(B) Returned Food and Reservice of Food* 31 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 1Food 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 Tent eratures* 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 E �s and Milk Products.Pasteurized * 4-501.114 Chemical Sanitization-temp.,PH,- 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. 5-101.11 Drinking Water front an Approved System" 4-601_I I(A) Equipment Food Contact Surfaces and Utensils Clean* 590.006(A) Bottled Drinking Water'" 4602 590 006(B) Water Meets Standards in 310 CMR 220" .11 Cleaning Frequency of Equipment Food- Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.1 t Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contac Surfaces of ui ment* Shellfish* 4-70311 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 Authadt 2-301.11 Clean Condition-Hands and Arens* 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 Receiving/Condition 2401.11 Eatin ,Drinking ox Usin Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and 3-202.t5 Package Integrity* Mouth* 3-101.11. Food Safe and Unadulterated* 3-301.12 preventingContamination When Tasting" 6 Tags/Records:Shellstock 72 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 3402.11 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* 9 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 S ecialized Pxocessin Methods* Devices 3-50112 Reduced oxygen packagim,-criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-30112 Hand Drying Provision *Denotes critical item in the Cedes] 1999 Food Code or 105 CM R 590.000. CITY OF SALEM " /1 BOARD OF HEALTH Establishment Name: I ICG .S v Date: 1 V�.�T Iy 9 Page:�o of Item Code C-Critical Item D SCRIPTION OF VIOLATION/PLAN OF CORRECTION Date, " .NoReference R-Red Item ,Verified a /PLEASE PRINT CLEARLY .•.. .. -r 1 J'4 ( I �J r.S (' �1 Y1 ! � r .[w..'n c� I I f' 7� I ..'I fl3 Cris - t � J/�an s C! 1 ✓1Pi, 4^ I?VjL✓ � �U GcYA,� ( /. l Dc rye I�i`1 Gi/Clt , JC.)A CjYI I W1 G4 f Cx IS AJ90 Irc-1v0"-\ ruf�I/J 4 Discussion With Person in Charge: Corrective Action Required: ❑ No es I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction inspection, to observe all conditions as described, and to Exclusion violations before the next ins p Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that ,noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure `your food permit. 0 Voluntary Disposal ❑ Other: 3-Sil l.l4(C} PLiF's Rett�ived at Tem(ieratures Violations Related to Foodborne illness interventions and Risk According to lain Cooled to Factors(Ifef»s 1.22) (Cont) - _ 4F.F/45'F Within 4 Hours. * _ 3-501.15 Cooling Methods for PHFs PROTECTION FROM CHEMICALS _ ( 14- 3-501.16(B) PRF Hot and Cold Holding 14 Food or Color Adtlitives 3-50i 16(B) Cold PHF.Mainuiined at or below 21)2.12 d Ln�es,R 590-O.k(F) fl /4�'F- --ll 3-302.14 Protection Prom Unapprvaed Additives' 3a0! 16(R) tir t PH1 v't4 Maintained at or above 15 Poisonous or Toxic Substances 14()'f-. " 7-[01.77 Identifying lnform2tion—Qdgioal 3.50#.16{A) gats[,Held at or above 130'F. + —� LN-- Time as a Public Health Control ai j 7 102,11 + Gwnnxm dame N 3i6i i C root i l r�- � -- --t—� — —' 6. 1r1 Timc-as a Pubh- ii ;iia(i Conftol= 7-202k 1 l i R cAk i<t rni Yr s,nce and L 7-202.112 (�,Ondoiorkk,of Lts� �— — REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 9 iWa t 1 ' Paxu C ont nnei P ob bi..on POPULATIONS i 7-2(A.I I Sam+Veiti criteria Chcnuv is _ I � UnF teunred Juices Lnd itA.l; 61 I f t —j — Bow t, e.with Nal-o"i -It` r 204,14 D vu 1t cntc (ra +t - -r- S01+1Pe teu.a rd 205 ('(l3 t_ t t l __ 1 1 mi Licid lt xxf l r c' fait iia :s _ a ----�-— i r fi:i i liJ)�t<:. r>r P�.f {tKiE` a Atnnlat Flxrd attd7 L7-206 1 I�. i t a t u Pr retie. C.nt u l _ _.�.a 12rrc S d St cn n N<i`rune I 1..xi Ptc' t� �, r2 cd. _. 1,0NS1k,WER Ar,'<?ISORY T IME TEPAS EItA r 1}J r CONTROLS3 =r t r orgun t r o scxa P �r ,� k t aio l l coat -hat c 1. R',", Primer Cooking Tempe.atures totI, Nr F _ _ 3 t )3 rt tr,.cti t i s �.._._ �. ➢ __ i 1 01A, ., Cl YG+ Y: +�'+.{ "SEM ES't i J lSl i1 l..V) 1i it f l gU { 17s G31i ._ .. ...., i_ I rlatkMng. tnobih,l.xoc i,.a€o ra mid <h.e.I. bt-ild .L.:., S10., 1'11(,:. 1 { ,.l_c( r. i �.tu3 - i E E :LCii . {-.,.j he t ` -i Crat+ it rr nisi klca: i ' cizE-sltt t~ un(kr th a �,it'(Sriaii r it?;ls lo rS 9tf 0 ,lt3 stti:i —z" L!, 17 ; s c stst y irir{ 04 otdueg F>L.r*s i It.1rYS tlEt.t,.i'�r7 i tJ .`suF?CY F37,nkL r'F>nk s,af:G'S ._.. 3:13.ti� 1) +6i { 1 'tt (� c _. _.. ilfarns 23-30) __. _._ ._.--_._. _ -_-. i . JJ3.1!(kr 'thy eru 3ie <_' t'2 tituic S indEa , C' e u rr = rxil >rr r, ,t rrrn t.'o na t a 1 r r t4Sf jws,s 3r fro ret rn ;, it l,}rtc iIkff tr ,rteztrlbr eft 34t?3.fl!(..) tni :'riictlyi'na:c>td,tl! 1 .=k< rui , .u .3-, 1 Ger. o :ar orelcn,;_: wd11it 'L"R Rr i3al;L til. ,A M IS_r. i tPs+n t,noi Rot Practices _ FC 53f7060 tt,l n 3 t4an-agrmi to idFer oil _ I rC 19, L .----_ -- 24 f o tt end`o xi P Jick tiU cc r 00 w LProper Cooling of PHFs _ _ — ��_ r. — i UtPa t i 501.110\) t+,1 u.C,:ah d PRFs It om t i0k F to j �r a,�r n�. -b� a,c r ,y �C_ pGh , 4'e t + il... . .1+'.thrt 4Ii-.t,a. r t -c �d :lrfi a Facailr) _ FC'_r 007 �1 Oki 'Ait'td-n Huura ad Door;7 Y. l i n C�, ` .�- , Soi)i r ,x, P Ert9 FC UP 501-i4iB1 N-IF h' do Front rt bicnt i S-,r , aft vc:rec�t _ a d : I mp inose lu rz.L.,rts to t4itlin 4 floti.,, '1 L*.ri]cai i• a t s -'i=�x's11 ��e�.` 1N C _- Ia....d/rwAlv' .. ,...�t..'-a.....+,j,�L+,r^w•l�+F'•'e'r3'f1:i+Fp*f•'n,�at�:Y.:.S�.,iC:�,iR x .'.v..Y«, _y.,.�,:��^.°`'kS.rfa�.�;�'E�°17�i��'�'',�'?�.^�,ii. .M'�f"��ik -'{xt;.[� �i Massachusetts Department of; Public Health 120 W Board S r et,4hi 120 Washington Street,4 Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT,INSPECTION REPORT kTel. (978) 741-1800 Fax,(978),74'5-0343 Name Dat" Tvoe of Ooeration(s) T e f Inspection t J[(� K ro a S �I kv0 l�CI ❑ Food Service Routine Address /I // 11 Risk ® Retail ElRe-inspection / ��rh1,hid Av& Level t] Residential Kitchen Previous lnspecti n Telephone 'id --- J6 lh9 El Mobile Date: 403/a� Owner HACCP Y/N El Temporary ElPre-operation ( ,it G v,L 7' ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In; 5 . n_ ❑ HACCP Inspector (p Out: .)t 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 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: ` � " mw .mf ❑ ,atiw �. 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties El��� m 13 Handwash Facilities EMPLOYEE HEALTH r r = r t, ,�, ,,,,.,._ - ,g`.6,,,�. „ �.a�:„ ':PROTECTION FROM CHEMICALS , , 6F "'""' ,.. """ ❑ 2. Reporting of Diseases by Food Employee and PIC tt�Y A .,,,.,„.�' .f na..„_-E :.S.w. k.,ld.vup„.-�� is ,����' 4,5 a.amwv r z� „a.Lkk ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excludad ❑ 15.Toxic Chemicals ;FOOD FROM APPROVED SOURCE ' ;t„�„ „„�.,„„�;;,„, ., "TIME/rEMPERATURECONTROL8 Potentlall'Hazardous Foods nt ❑ 4. Food and Water from Approved Source _ y ❑ 5. Receiving/Condition El 16,Cooking it ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling .FPROTECTION FROM CONTAMINATION4° "r�p -- y ;Y :amu Eb El 19. Hot and Cold Holding 'ffl❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing 'REQUIREMENTS GOR H1 .. .SUSCEPTIBLE PQPULATIONS(HSP)" E]21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected r To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C ` by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations A Food and Food Protection (FC-3)(590.0044))) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-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)(510,,o,) 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: �(�� /It S.50inW IFOr 14,E ,� W �a / .ao 0 Y Inspector's Signature: Prin� v 1:2 1 PIC'sSignature: (- � Print:�'/1� ? - rS Page-/of CC JPages V v i Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION _ FOOD PROTECTION MANAGEMENT F 8 Cross-contamination 1 I 596.003(A) I Assignment of Responsibility* 3-30211(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 3-3021.1(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590,003(,C) Responsibility of the person in charge to Contamination from the Environment require reporthte by foot employees and 3-302.11(4) Food Protection* applicants* 3-302.15 Washing Fruits and Ve etables 590.003(F) Responsibility 01'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 Chau 0 3-306.14(A)(B) .Returned Food and Resecvice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated - 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-2011.2 Fax]in a Hermetical] Sealed Container* Sanitization Tem eratures* 3-201,13 FluidMilk and MilkProducts* 4-501.112 Mechanical Warewashing-HotWater 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 Ir:e Made From Potable Drinking Water* concentration and hardness. * 5-101.1.1 Drinkin Water from an Approved System* 4-601.1'[(A) Equipment Food Contact Surfaces and ss"90.006(A) Bottled Drinking Watery Utensils Clean* 4602.11 Cleaning Frequency of F,quipmem Eood- 590.006(B) Water Meets Standards in 310 CMR 22.0* Shellfish Surfaces and Utensils* and Fish Froman Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-70311 Methods of Satlitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Reme and Wild Mushrooms Approved by Re utato Authorit 2-301.11 Clean Condition-Hands and Arens" 3-202.18 Shelktock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 1.1 Good Hygienic Practices 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-202.11. PHFs Received at Proper Temperatures* 2-`101.12 Discharges From the Eyes, Nose and 3-20215 Package Integrity* Mouth* 3-101.11. Food Safe and Unadulterated3-30112 Preventing Contamination When Tasting* 6 Tags/Records:Sheilstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590k04(E) Preventing Contamination from 3-203,12 Sheilstock Identification Maintained* Employees* Tags/Records:Fish Products 13 Handwash Facilities 3-402,11 Parasite Destruction* Conveniently Located and Accessible . 3-402. 5-203.11 Numbers and Ca acuies* Records;Creation and Retention* 5-204.11 Location and Placement* 590.U04(4(J) Labeling of Ingredients* 7 Conformance with Approved Procedures 5-205.11 Accessibility, Operation and Maintenance lHACCP Plans Supplied with Soap and Hand Drying 3-502.11. S ecialized Processin Medrods* Devices 3-502.12 Reduced ox' en acka nom,criteria* 6-301.11 Handwashing Cleanser,Availabilit 8-103.12 Conformance with Approved Procedures* 6-301..12 Hand 2n ,Provision *Denotes critical]tem in the federal 1999 Foal Cade or 105 CMR 59(1.000, CITY OF SALEM (1 7� BOARD OF HEALTH ,; / `Establishment Name: C,r 5`b� ✓�� l� Date: D Page:_ of Item Cone C-Critical Item DESCRIPTION OF VIOLATION!PLAN OFCORRECTION Date No. Reference R—Red Item _ _ PLEASE PRINT CLEARLY 1 .Verified a 1 d tx ac u cr I{ u/Is c:-f�r A , ke c t (o LA J.ae ` C nC �r Y1cc1 /V c )) v i C n mot / " (e - CSA, �- M,reoi+ (L) 6ryn, t-A/(ar t1c ne 0 IF /r14_ to �Ucf N (_PrCC�L CSI n NJr u q4e^ X rM S(10 I I' Go F 6K 33r4� PtckLOA 3-5-a-7- D /Xc0ve 1 r _ . Q AdAd 0l r 4- -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 O 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 that -r;oncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: 501.14((:) PHFs Received at'rempetatures Violations Related to Foodborne illness Interventions and Risk According to Law Cowled ter Factors(Items 1-22) (Cont) 41'.F/45'F Within 4 Hours. _ 3-501.15 Ccolimt Methods for PHFs PROTECTION FROM CHEMICALS —_= 14 — PHF Hot and Coid Holding 14 Food or Color Additives 3-501.16(6) Cold PHFs Maintained at or below 3 202.12 Add nve.," 540 004(F) 3-302.14 Protection front Unapproved AddtRves - 15Poisonous or Toxic Substances 3 ;01,W A) Ilot PHF.tvfaininined at or above -}— � ` 7-101.11 k� lenttf5mglnfcn�tnaolln-CJtiginal i 146 F _ ( Container.'` _ 3-�W1,1b(A) -I-Reasts Field aiorabove 13001= '" / IJZIl Common Sem• Workir scat un-r. -� _ t Time as a Public Heatth Control �----. — °-- .-- -- 1 vJ i i Tm as a Put'In Health Contt�al- i ( r.AJI �S� inn Snla),c- — — __1_T ---' �I):�11 tH} 1 ?rwllk uirement 7-202.11 I Pe Lric on-Yr-sutra uld 1 e - - ------- 7-202.1 - .--..— `----�--- _ '02.12 (b uc col of Loc REOUIREMENTS FOR HIGHLY SUSCEPTIBLE ' _ -I J (t;>,tc C r liana' E'roii bi lot _ POPULATIONS t 1 2J4.11 Samurer, C'nttrt+ Cttu rx lc _- - - — _ 21 ( 31-N0 i (A) tel;tp icu v d Piz, liar >~eh)traces:dtd 1} � L._ 41 ( Cf1um alt roc�l tvhu t k- w i <iittuu z' ,.— Ue t c.ici11 1+ M"aI-a I } s F710114 Diinw,Aecum Critciiat50; 1 tdi t=c o' Pu.<ci1 dic : _ DS 1 iJllt-rd n al t xttl t eni� t L+b alt - i —} r — --1 ( t vn -1 An m 1 Field acid 1 Lr. '06.11 ko,oi,feJ Vre Pe. 4 ito C i i t Si,d a.i it SE tier < 1 1 .06.1 ' lulu 1 f S:n oT _ — t-- — _. .__... et;i l" 0i ce t x11' i,x . .t n i1Ri alit r13" GONSUR"ERADVJSORY _ TWE/TEMPERATURE CONTROLS Z r„ , i 1...< it ntif'ion or 16 ; pscrpar CooXing Tontpa afore Err_ _.. I v t==' i >E i :Ii.!f jr, t'HF6i t;ltf n i.e i 73 l t - i t t IIIASl.l3l ltA est C I S A s.._i � t t _ _...». ... ._ .y .P1t CI CCN S .S ~2UtF't rt__ STs . i"' v . _bii!oo"3l I .:-bOLi tA'31 Jiut t, ti c ( ai e-; c 1 r.,, i ! tiiE' t ,1 ti.tciZ 7 nJ r'. ;em 'u 1n iz;: tu?Jer 211t dprnro.ar1 1lV, _, 10?13 ol t _.... . J l; �.'tt.lJt1' t.. + JKttt nig.`#o Hqt Joydlrr.._..—. tdt2jZy R_.L€;- ---- �___ F ED TO.,cOODFrF_AA. r .ghCirC,S ents L ._.._._... S r a.cc i I S WJi iH Stln(,.t 5� t f ,r=d r r 1 al e t zi ann ct 1 nn: eta r`i<F mie, _.— _ _ __.....{ riot h(rile !Mt r i, I r: C Ale,t rs?i. < 1 m c. e<xn fir �403A1 C} C wioci,,iatv ,-r, ttn"x borncou�a.rr. 21 ii.i (t[ ° 12c ii n;nng Z 14t :«Portic s,.fpl,L' itram baa i Retail liraatmos — FG 548.000 - 123 t,41 3`tA� n\ u.10 P f iii f ... C; 2 ,y _.i .. tgProper Cooling of PHFs 1-ee F" ') cxxa P otf 1 cn FC vii_ �..�._______ _.�_._.._ .. , of gut r 1 a id Uie*i A,� _ F.; t 0 I ..�( 1 J.-tfA) CEn lir.c,Cal}, dPFt1sit u J ,C - ti, r e „'iter P! nibmq,mcj J t;; ' FG ^G3 Wolin'2 Houry sal Flom .r'i ! ox F y'vz Fr ark. _ FC C Cti' 'I 14.5'F Within tJ i ! i3 r> 3 i �x s tit v r o0e _ _ -- i �CA,l 'Bt �te i no,PHF Mdr From Amliiellt ! " SIP 3t21 ,r ;rel pt1 i Tnmi�atnrt Inti ocr,,t,, 1 J CITY OF SALEM BOARD OF HEALTH / Establishment Name: -75-62 / Date: (nla.4 Page:_ of Item Code C-Critical Item DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date- ' d No. "°-Reference R—Red Item ' Verified _ PLEASE PRINT CLEARLY f.� a ' . tr. G 1 M ... 1 C)C e7J�9 x alt 1 !/ �I S /, v a6 0 z VAri, ItA t Ajvs-,W r -.cZC c/oc, lar( "j✓nc/ C(rcw _A94- i ??4-2_; d G- JG- U l d retia✓tel '3, u, st CJJA:$e oZ- on, II /-cM,1A9j �(te71-T?Kk f ar cL torr I qQM�.cc� 12r+.1 Ir�G JJ����-S inti t 5,4rra sf r'✓ ll4t�i a a� O (vAi��a t �/rsC , Vto� oy Terra LN - xie a to t m.) tf 0`7 mvG-ir CrJS1 0 Df 4 ('kAIR Ve ( ,,��G ,�o4 JJNag u5 0C,7 0 bOi Discussion With Person in Charge: r Correc ive Action Required: ❑ No y Yes t I have read this report, have had the opportunity to ask questions and a ree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ p PP Y 4 9 '`' 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 1 noncompliance may result in daily fines of wenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. Ud ❑ Voluntary Disposal ❑ Other: 1 -501.14({') ^� PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk Aa ordiug to Law Cooled to Factors(IleMs 1-22) (Cont.) 11'F/45`F Within 4 Hours. # PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs ----- 19 PHF Hot and Cold Holding 3-202,12 . 1 14 Foodi%es'°Color Additives_ 1 .501.16(B) Cold PHF.,Maintained at or below pj rotec, 3-302.14 rotcUitrollfioltnappro'aed ekdditives° 590,004(F) 4I`W"I 15 Poisonous or Toxic Substances 3-501.16(A) Hos PHI-s Maintained at or above ?-(01.11 ( Identifying Infounation--Chi„ina4 1401'.' I Roasts Held at or above I30`I:. COltldtllc[, Time as a Public Health Control �7 i Commo 1012.11 n Work same �g 7-20L]— - i--. — _----j tit t rrrr� a,.t PubYtr Health Control' t � SQpr rtun .---- PO,trP?(}}, I Y ranacR 'nir �rreat 2f}11( { Req:lu cn Prk,xDoc.tuld.l. c 7-202-12 C on<' t on of Use -) ro — i REOUIRFMENTS FOR HIGHLY SUSCEPTIBLE taxrcfuxtm�r Probbr.; r, POPULATIONS(HSPS 1 0111 11 Samtuer, Cnurr, - It7I(Wlr Chrr,tca,frrUthui Modik,c,Ciiwii,- iLt S?111 A� : lSrl vrcarir�d l'r �>ar i;>, ISuicas:uu3 1 ! tic 1 �e, +�iih li rinink' 'th h' 7 ?01.14 Ornvry !t r < r rlr r:r -_ — - - P r Se urs� c r i r a,,- .--.._._.�.1 0)t Parlmilk,f !, a 1nun:lFfxx}ao A _ i 1 Pc rclde. t r r r>> ��512 1� r � t' dl It ..� tu. C�t`V�i 1J 6 n : 5:�rt 1 __ c t 1 ricd CONS 1 3 -.. i 2 $U' TE94-Et`T'Ftsrtk%ERA 17URF. _ .-_._ t_� i I Prr s3t+r f,'or4iag,TaurP��ta:an fiov i N➢�F5 ti -. L.t .. ' Pol r ri tRu _r 12 3 'roll . SP tat r„ $hrtFiltEtd nx _- _. t: i!11; s r.es 1 1 , t`li I t yi ..S .il 1"+ 1f,,.. •��nt1 a 1,v n1 ti. 't,�.dL 1 � __.. �. ..., i,: 1 t psi .`:Utlt+ � : r 1 Rr heaang for H>t r f�itrg N. .. .?,a t.. <.,•t:'i.,_ z.. sd1i=V f,i�,"d1L H, PI[i 1651x _ 1 1lt�ans'�3_3(P; 7i'3.14 F51 �.1 \Sr gut.'.vt it'+ t Iml ��.;rldtc:; 11 t t rrR<.'t i 't-1 t Jkt tett la( ! st'i° <r r1 twtt�r l )n)11:vrztu0r l' lkI axj - q 1m: h, .. .: qe zv"?"' f1 tttf:l.. R riamiu,1. O eciPo..vr of, ltaw Coo< 4eolI Prrrtmes FC .SJQ006 { .ton a C t w-. P : ... _. __. .oxto f c xf P otc tac r-C s W4 ( proper Cooling of PHFS 3 - _- --_ a _. .. : ..-s(ii.14(A) !`<x hn,: C:�krdlHF= fmk I4rFo, 1 � . ._ _ n`r ant±JYe. 3 ._._ I trn r ,_ c a` ( r I tltrhin 7 tiaura,.d From I:rF I 'z 3c Ity_ ("C C Xi r MS'S 13ttlmin 4 lroo ,-�. 7 QGi -50l.t4(3'1 Cl t icn:,Pi(F.,Nflidc Floor.arl6ieut a t u�osre - 4 30 Crte t Within 4 li,ras'' aa.41 r , CITY OF SALEM nn BOARD OF HEALTH Establishment Name: Ctrl S OOa/f��u/�~y Date: 1o6ti/a Page: 4 of nein Code c-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date l No. Reference R-Red Item 'Verified PLEASE PRINT CLEARLY h -r�r Ct-J -<A & aO We W10 Nf,)I.- i /0 0 4 <7i�z:' oN 71 ,)o v, o r- oa oe a� AJ%1J 00q 6j_K-4. �f-vel �b aq- a fowukl, 0 -7 14111 M71.) +�I - C. 600 a., /'PMale�[ f r slr 04 0 Al J� {�1 �/ i�'iw� VJ (ir-CrI� aJ o--;-L 011,, r (�M��ad T TA4Z , uJ Je7vl p1 /haGt J 6o-, t'( 0} LL, Jd tic JT Jy / - 5 /a )r-wN T« 8J O /D l� NJye� /y a S�Jri 4i 5 -r+KK Clay 93p'f- u 6 rOmxel it­)A. C3100-1 r"AL_- lSt t��s'1 r�/J )J 9 -j- h OkY'1l , 12tSY 7r IL )a-,, d(l, 1 3 ua 4(1l<e/ 13a . 2u {r (J C i C aXt l- e S ctwi ZJ i x ✓C�? �`4 -.�cri on J CJ e ' 1) S-d 0 7 ICL 1/ l '•� r r o s�t "� e c► 4 y OC/` i N1G�c r A/1AvIG r� a ow st0 ;Ll . USC AvC p ✓n 'c ' H✓ve U c ( a S ce_0 v 1/ D JO 0 tZ Discussion With Person in Charge: Corrective Action Required: ❑ No Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to . Exclusion violations before the next ins p �Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that VV noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ���� 0 Voluntary Disposal ❑ Other: 5071.)4(C) PIIFs Received at Temperatures Violations Related to r'oodborne Illness Intervenobns and Risk According to Law Cooled to factors(Items 1-22) (Cont) _ 41'F/45`F Within 4 Hours. * _ PROTECTION FROM CHEMICALS 3-5(11.15 Coolio�Methods for P}iFs 14 Food or Color Additives J 19 PHP Hot and fold Holding 3 2(2.12 Ad Lave,* 3-501.16(6) Cold PHF s Maintained at or below 590.0114(F) 41 !45°F _ 3-302.14 Pn.tection from Uuapprmed Additives, i 4_jg�,I6(A} I lot' PHF v Maintained at or above 15 Poisonous or Toxic Substances t -(OL11 ldenurym,lntumatcm- On .oal �� 4— -- �fll tri-\�v--- Rwsta_Hold a[nr above i30'F.7 i tot ttza r _ 02.11 Ccaar'aoe to+- 41 > 6i �!.,�u tt r� X20 Time as t Public HaaHh Control '0t 11. _-� .. ._ €trr .is a Publw health C ontt�plz_ t u S tin Stuff r c .___.i I rU 1)04,11) t i -t Pequircoiciv ------------- r7 02.12 b idmon o1 the REQUIREMENTS FOR HIGHLY SUSCEPTIBLE '03 [I T(Xi, ruitun..l Pnahj!.on } — - POPULATIONS(HSPS_ 1 "�0-1.11 4aat errs Cri±e i+ Chcmtc is _ -- — -- i 21� :R-h@F ;alA� 2 l;n teatimd75 ,u'.-n>edluiasa3nd 7.'(4.I (.hint ,1s I'm R t,hiq t ,rd c (,:I iRr l _ '3c ra es v€ria 1� n un�.'xh Is - i 204,14 lF14 n D_.. r. ltv n OofAiit,cc}-.u. .e_c_r-,-ttr,murer ti o td_irit -_--- 106 1 x ( R ,i2j_� S< t Ft'uo tSprout, d-\« cY�rtint_t 061 ( ttlI•.cntt C',,, ratd -- R tai_ CONSUMER ADVISORY ++r`,T' 1 -ouIv rcr Ac isoz v Po-tcd ior( xvmip,nuiisn o3 TIME TEMPERATURE CONTROLS_ ��_.._ flat ,x c P , . l noel x kvd i 16 1 Proper_Cooking Temperatures Tor f Pa'F t j x t ()t(1 r IlrCx<r1 t;i a IT l3 "t Sxa s u_ to_ REe-Shc£1 3 SPECIAL �s2 it sccl it t ,c�.!lCt2 t ,D) II (l ?ii,3) i txt is3 t _ w C„r,c..Stu`te a 1x�;F�s. � I �.aa u,:ai E;itcilcl o;_'rattors htaild zt: i Umhn 't i'c tt pSC+iZr Bill Siff;W11`: j Iota, s^ I O st, ,t t +ot It rtrira dtt"iLAbONS RV-'A Et-D 70 GOGO Rkw"IWL „_, 17.'x::..-_. 'S.tt a}. 311E ( IlleTn�23.36) (d'3 F'r' w:;?.ii(!.j t .,n t•r:i:z Lc.. ..i if,.la } d , «:rt CMN l 2-40 3,!,(( , R 1 t, t,;r : �, t�t P,rt.,t r4 Bre., ! - tem FC S.ga:_o ! f e (ro+(� fo:Xt P oe^tL .... cC < tn',: Fg proper Coo+iny of PHFs .{ - - - - t._._ 5 4Lt (n+3^CI UCP ia9 f” . �O_. -SCi tdG'1} 1 xd,nt.uw4 dPFltSfi un i 4 t'tu '.. ._ . 1 : .. ,T' t 201E 4Yuhnr 7 Hoot;wid I m l r P va Ft Ry 1 FC C _007 i._ ` .. rFur.. x a c Lg: it fit r,Ceti f't t _ _. l{Ek r .; Fi.-_ -._�501.t413PHFti4:dc Font t :.=t _.. .' Ft. ah.:,at�:ac ,t rsic uta tt .l r;.igaU :Alf i ,< i-.int : 1,wI;,, ., .. CITY--SOF SALEM t. . OJ BOARD OF HEALTH < -.Establishment Name: OJI V 5�� Date: /c-t42_34)9 Page:_ of �. Item Code„w C-Critical Item f,DESCRIPTION OF VIOLATION/PLAN OF CORRECTION ' e • Date--'.«,-,.syr” *a r� - r ,z _ Verified No. Xy'. iReference� �R-Red Item . 2 '�s,-�? :'y ar�,�x 'dk ' "s ,<... ,,- A f z PLEASE PRINT CLEARLY ° - •"�' �/ ""� ' `` •� ' C� ��u ��rJ r Allo;` L-L J V w NJ�cr!41 i �J _or . 1-k fit- 1/1 ., � G "'a ✓P Aiif d I Rk t - r GfLZ. . / r5 r - wci`� Y "r•JYe .S (VCf C-14 17 V Q trY../ / 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 R striction/ Exclusion violations before the next inspection, to observe all conditions as described, and to P Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that .- ,noncompliance may result in daily fines of�twenty-five dollars or suspensionhevocation of ❑ Embargo ❑ Emergency Closure your food.permit. . ������� ✓,���,� ❑ Voluntary Disposal ❑ Other: . F,`�071,—14fc—, ra Tern— peralure's Violations Related to Foodbanno fitness Intenientions and Risk Arcordin.,to Law Cooled to Factors(Iforris 1-22) (Coot) 4 1�F45"F Within 4 ffour�, 11.15 Cooluu, 1%4�!nuxls for PHF, PROTECTION FROM CHEMICALS PHF Hot and Cold Holding F14 Food or Color Additives --- �1-202AT— 3 501 16(B) Cold PHFs MrinitAncd at or below 590 0141- 41"745"F� 3-302.1� front�Una —U— L2��� 7-367 1(it A) Hot PHF�Maintained�q or above Poisonous or Toxic Substances 140"F. 0 bi uhinon - 01 it'i rn I ---- Rtsists,Hold ro,or abo,.e 130'F, L2!L Time as a Public Health Control 7 IQ 11 Common Name-'Workiflu,Containers- I 3-5WA9 Tini,��as a Public fleafth Cori 7-2()J.F=,M� f------ I pd1juon�:jolia st" r1illent 1-202-11 Reoric6csi-Prescawand I 7-202,12 Conditions oft T e 1 REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-103 t I Toxic Container Pro]ii in:ions,: POPUL IONS HSP sann,lers,Tntie-la-C�Ccicllv -T , Merle —Unp-u�tcurizod INe-pacTeged Airces anT - 75—cnucai�Tl�`W 1-11 uo� 2()4�12 --ilu lieveraee�whh-��� 7-224,14 Dying — 3-801,11(11) Ulw of Pasteuvi�ced Epg�%,� 1 '; 2F,11 Incidental Fooil Correct,Lubricants' [17:Aid Resnwf�d Use Peqitades,Criteart* ......... tjf—�,o, si�"d S rouii Not S(:rvcd� 7-406.12 Rod= Bart Station, , -,!C) k 7 106 l3t Tracking Powders.lutst Court ol and CONSUMER ADVISORY ,r 22 1 Con�uniet All,iso�v Postod!or 0,insomption7f TIME)TEMPERATURE CONTROLS Animal Foo<ls'llcuarc Raw, Undercooked ul Pr W-1 16 oper Cooking Temperatwes in p HFs Not(-)it wi v,i so Process iol i it,I"I nin true P h 3-40L[T-10,),I�—.T Fggs- 155iTi5,5irc. Enrs-hinnediare Service 145`1`1 fiw� -1-302.13 Patitconzed Fp z�S�ibsntwe for fla,w Shelf comantured Fr�lh Nfeats,&(itanc ArnhraL� - 1 55�F I SPECIAL REQUIREMENTS 3-401.11(8)(1 Q) put k Aral Beef ponst - 13W F 12 1 min (Do T NTjhlti�Tjx�,, in 3-40131(02' R t' 's Infcoed imeav-- 155�F 15 calerinit. mobil d 'set- v 7an �VViid(iarneTtu rcmdeut4 ai ki tc hould be 4 1 debited n,rchu-the appropriate �ecliouh TI(A I Of on Id be Stuffint,,Containing Fish�Blear, poultr�'kh Rainier-165�F 15 scc. above if rclafed to totorlborne fflness 3-401.1107fli) bitacT beef Shen I ka' interventions and risk factors, Other [45'+ � 1 590,009 violations relating to good retai! 3-40 1.12 Rawkninial Foo(k Ccxikad in a prawficesshould tv debited under#29 - — M io kyx ave 165'f* Special 3-401,11(A)00) All()oau Plffi-- J4S`F 15�ec 17 Reheating for Not Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES T403.1 I(,A)&k I)) Pilf� 16511- 15 sio�- - (Iterais 23-30) 3-403.11(B) Miciowavc- 165'F 2 Munc�,Standing Criurr�'evir?nvn-,,riio;a1 vio,alwns. which do not relare p�ohc Time" ftioirlborne iiiness ouerverrhons and ri�kjwntnq 1;�lcd abovo f in?be all Processed RT17,.Food- found in the jollfrti ing orriions of the finsd Code accl 105 Calti ,403.11(C) c ornmersi v 140"F I 3403A I(E) Rernahinr�Uw liced Portions,of Beel -T 7-190 I how Good Retail Practices PC 3 Rotra,� ntanq_Parzw��pl FC -2 �003 1 24--TH and Fund Prinecilao FC--,i Proper Cooling of PHFS -------— ------1. -- wltne and Wensini FC- 4 t 5 125�- _PcEttin-2ccloard PHFs from 140017 14) 26, Water,PiLrobtrijand Waste I FC-5 00d 7WF Within 2 flours,and From 701, -,T I Pjriy�jcai Facilij FC 6 W7 i p ...... — - - ---- ___ --J Poisonous or Tora;klamnals i FC -7 DOB (rioldo,PHFs Made Front Ainbi 2�1, uph; i -1 eut� ___ —1 r3 i_0 I I 'Femporature Inf;reduaho;to 41*F/45 F 30, Other Within 4 Kruis' Den"Ie,�rfical nein m the 1�,1�,rrd I M)Foon 0*��r 105 CMR 5 tif t 000 Massachusetts Department of Public Health Salem Board of Health 120 Washington Sreet, Division of Food and Drugs Salem, MA 01970-t35234 1h 190-35234'" Floor FOOD'ESTABLISHMENT INSPECTION REPORT Tel.v(978) 741-1800 Fax(978) 745-0343 w 4�aT �5 Name Date I T of Operations) Tvoe of Inspection _ r (o �SUo! A It /� ❑ Food Service C1Routine Address Risk EJ'-Retail A Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone -1 _ G_ ElMobile Date:q/, ( 5 Owner Y O `' HACCP YM ❑ Temporary ❑ Pre-operatior) C ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint El HACCIP Inspector j�,nk t Ou? 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_=g,�,.H` „,. .„, „,„.��; �„,;, ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties EMPLOYEE HEALTH ""' °' El 13. Handwash Facilities _ m L PROTECTION FROM CHEMICALS t ❑ 2. Reporting of Diseases by Food Employee and PIC �el� ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15 Toxic Chemicals x FOOD FROM APPROVED SOURCE . " �"tTIMEIrEMPERATURE CONTROLS{Potentially Haxzardous Faods) ❑ 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 r PROTECTION FROM CONTAMINATION 1 'Y"" a ❑ 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 HIdMLY SUSCEPTIBLE POPULATIONS(HSP) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices - -CONSUMERADVISORY_ „µ! ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C�, .N ' by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(sso.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(990.0044))) cited in this report may result in suspension or revocation of -25. Equipment and Utensils (Fc-a)(sso.00s) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.00s) 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'501nspe Wo 14.Goc _ n Inspector's Signature: Print: i PIC's Signature: 1 i Print: % ,� Paged ofZ,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 Responsthility* 3-30211(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* - Cooked and RTE Fonts* 2-103.11 Person in charge--duties Contamination from Raw ingredients 3-302.1.1(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other' 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require reporting by foot employees and 3-302.11(A) Food Protection" applicants* 3-302.15 Washing Fruits and Ve etables 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* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.1.1 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 1Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111. Manual Warewashing-Hot Water 3-201.1.2 Food in a Hermetically Sealed Container* Sanitization Tem eratures` * 4-501.112 Mechanical Warewashin;--Hot Water 3-20113 Fluid Milk and Milk Products Sanitization Tcm eratures' 3-202.13 Shell Enos* 3-20214 P, s and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. 5-101.11 DrinkingWater from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled DrinkingWater* 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* Shettlish and Fish Froman Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.1,4 Fish and Recreationally Caught Molluscan Food Contact Surfaces of E t i ment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 1g Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Reutato Author! 2-301.11. Clean Condition-Hands and Aims* 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(0) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices g Receiving/Condition 2-401.11 Ta-fin ,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures" 2401.12 Discharges From the Eyes,Nose and 3-20215 Package Integrity* Mouth* 3-101.11. Food Safe and Unadulterated* 3-301.12 Preventing,Contamination When Tasting* 6 Tags/Records:Shelistock 12 Prevention of Contamination from Hands 3-202.18 Shellstcek Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained" Em to ees* Tags/Records:Fish Products 13 Handwash Facilities 3-40211 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(.1) 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 3-50111. Specialized Processing Methods* Devices 3-502.12 Reduced ox• en acka 'ng.criteria" 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures" 6-301.12 Hand Drying Provision - '"Denoles critical item in the Weral 1999 Food Code or 105 CMR 590.000. I CITY OF SALEM /rn/� BOARD OF HEALTH Establishment Name: C r,X , JsOa �s,l,, k,� Date: .4b,,A'i Page: a of � Item Code w C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION ' *. Date No.��.; Reference =R-Red hem= K .` 5 ,,,, f` '`="u {' " 'PL/EASE PRINT CLEARLY"` I /"\ �" •"{ yy d' •,S{ Wiz: r?, n Venfled - C— 4'_ � . �L T 7 r�, o ^� �_ c ^ Q V 1 '/tom �M 7Y" �l9 r� �/J�� a- Ia _ .4 IP-:t) oc ' I VC r�_� /.�,�v/x?il l /Yl I.�YY�� nn`fl,n 1 �I rj ` -4 <r R. A, AG. � ,n c _MI(� r lel Vlr' Do A—i (�I. Ali i ?DC TYl/1 l r � i — io Ct 1-k") /P/t� )J✓. i f Discussion With Person in Charge: Corrective Action Required: ❑ Nodes r Y 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 P � 1 C) 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-fivefdollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. �� ❑ Voluntary Disposal ❑ Other: i '0lA4(C,, PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Lain Cooled to Factors(items 1-22) (Cont') I[�,R45-17WAhin4 Hours. PROTECTION FROM CHEMICALS for PHFs L Food or Color Additives j�- — L19 PHF Hot and Cold Holding 1202 12 3-501-16B) Cold PHFS Maintained at or helow �90 004(F) 4 1 14��'F, 3-30114 ProuctionlooTI.Jaa roved ------ 3- 431 1 WAI Hot NIB Kuraidned at or above Pei7sonous at Toxic Substances Idontifying Imbity-tation- orj,'inw Containers, Rww'Held at or above 130'F, -co—ntrol - -(12.11 Time as a Public,Health in 7.201A 1 �-5w.lq Time as a Public Health Control En -20117 Ratriction -Po,scricc and Use* `o)0 0040-1) Variance 4e4ttirement _' 7-202.12 Conditions of Use, 7-20111 Toxic Conlainw REQUIREMENTS FOR HIGHLY SUSCEPTIBLE - _ POPULATIONS(HSP -204.11 Sanitizer�,Criteria-Chums is �=--— -- 21 3-80 1.11(A) Unpiistinlrized Pre-pacPagcd Juices and 7-204�12 (".1ionicals not W�,�h!L _� E! odhtce.cluel'a, Reveoi?ss with Wit SIS* 1-204,11�4 1 ;-got.11t$) IJs"of Pastel ranl—a_j�b---- ----- 20G.1 = I It, Jdarnal Find C", I , al lo�r J 2l5� 11 Tricitiz )ralci, )riclmts� 11 llae,trik"A 1 s Regicidea Critel cl r..... Raw or Painalk CuokcdAnitnal Food and aw seal 7-206.12 Rodew 1z set slauoTa,' T7! C 2�6 I racking Plo,%&Ci,P,",�[COMT01 and A,= Li Mouilotin" CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS34)0,'-1 lltnaerdr ;.sory P;AtM rorC wilon of lb raper Cooking Temperatures Animal F,,irils That era Rau-. Undercookedin PHFs Not Caliere ise Pros sled to ENinucire -Ti7-16i—1 IS(1 Rgg,-, l55'F 15 Sec. :A 11'51�15secl F.L F. Lsio Substitute foi Rax shelf (A)"'2) Comminuted Fkh' Mews&Ginne Animals I ts'Y 15 S'ec. SPECIAL REQUIREMENTS Po{!, and ft et Rtmst- 130'F 121 ritm ------------- 3-40 1.11(A)(2, ltalitts, In 590()()9(A)-(D)7 Vjoliujons oi Section in jee1cd1%,Ivdt�- 155-F I Sat:. calerinV. nioluIc.fix-icil temporary -i'ZTI i(A)t3) Poultry,Wild Ganatut ,(11" "' lcsidtaI al kitchenoperationsshould be Fish, "Vleat, dcbitedenvier the appropriati:- sQcltons Poultry or katnes 165`F 15,iiec. 11 above it'related to 1%riodbw ne Juno, �101 INC)13) Intact Bect'steaks inllerVtalflooand tiSk filetorS, ()tller 590 009 violations relating to good retalil 3-401 12 Raw AinTrul Fo,y&Cooked in a pradices Should tv debited under#29 - _ titierowsve 16c'l, Special RcqLjjlCnjclI%. 3-401FNA lll)(Ifi Al,Other l45'T 15 sec. L17 -plebes-ling for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3--103,11(A)&(D)(D) PFIF, 165'F 15 sec. -1 -- (Iterns23-30) Miclowavc- 165°P"Minnie Standing Ciiw-,?j',SS;d noo-crmf al viol doelj, which do nor re;atc io lite Time, - -- Tfoodborne il lneTv inevrVentiorei and riJjurors listed above, an be 1:403.1I(C) Conarercla5vPio �,ed� �Tool- finand in the. following mrtioris of Me Faud Code and 105 CMR 140 IF N -T-46—111(F j Rellulunrel, 11'rlslwed Portions of Desi item Good Retail practices I FC 596.000 -i --17-6 7? 23, lA ment and Personnel tg Proper Cooling of PHF 24, Food and Food Protection C--3 004 a 7 E (�njarqjutensils FC -4 005 !L m . ....... ........... 75�11,14(,A) Coolint,Cook--d PHFg to4Jatermein nd Ste PG 5O b an 14(ff to 26---, 70'F Within 2 llour�and From 701 '2 I'IyLcail ty I '00i to 41`,F/45�F Willim 4 Hour!�. 2� Poisonous or lvlatprial'a FC -7 1 ad, Frout Anibinit I a!1pu� ;ni� 3-501.14(5) Conhug,PHFs Mt -s� 009 Tertiperantre Ingredients lo 41 iF`45 L3 Other Within 4 How s' Dfi"Ieseritwal Item n5 the 12'lencl 1999 PoW C,xle w 105 Coln 59;,000 F rr l;,,.��v�' • - .. c%trf a'�'i eY+�Er �f. rr� .,� •r:.k_,..-x:'..r.'y4•..+m"'"h"Am."R-"d'.`S^�r`�61�..,iA.-,•,I+r,oi.: yam'_ ..'� .-... •r•.. i Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,0 Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name (� DateT e of Operation(s) Tvpe of Inspection 0/U -Food Service ❑ Routine Address Risk ❑ Retail EeHe-inspection Level El Residential Kitchen previous Inspection Telephone J of ❑ Mobile Date: !!ii h`�1 Owner - HACCP Y/N El Temporary Elp Preerat61 -12p,Xoir, C) ,L, ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Ti m� ❑ Bed&Breakfast El General Complaint In7' r� ElHACCP Inspector Out: Permit No. ❑Other Each violatiorf 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. FOQDPROTECTIONMANAGEMENT�,: "'"`"'�""= ''� : " " ;� s,®,,�„-�r�„ h „ ,„;,:„ :, ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties ❑ 13 Handwash Facilities '� - �§�9 xmawp ,L ii��, EMPLOYEE HEALTH-`''` � a , . I3ig � ,...xe , PROTECTION FROM CNEMICALS� .' i#�A A_� ❑ 2.Reporting of Diseases by Food Employee and PIC ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ElromApproved a� 15 Toxic Chemicals „FOOD FROM APPROVED E] 4. Food and Water from ApAppp 'eroved Sourcme "TIME, EMRE CPERATUONTR©LS(Potemia16,Hazardous 064ds)� k=�alal-al�;d,": ❑ 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 dq I "i l ❑ 19. Hot and Cold Holding � ❑ y8. Separation/Segregation/Protection [120.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing r REQIiiREMEN '$FOR HIGHLY SUSGEPT)61.1 POPULRTIONS ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices - i°CONSIJMEE A VISORY, r M",94a ,' ,771 M 72° EMM-5_ ❑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 ofoHealth. 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 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 RE-INSPECTION: S.S Ine IFDm 14.Ex Y f Inspector's Signature: /l Print: I L y , PIC's Signattir`e: (((X , �, / Print: ; ,7, l � Page" t ofZ.. Pages i Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination � 596.003(A) Assignment of Responsibility* 3-302.1 I(A)(I) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* --� Cooked and RTE Fcxtds* 2-103.11. Person to 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* a plicarus* 3-302.15 Washin Fruits and Va etables 590.003(F) Responsibility Of A Food Employee Or An 3-30471, Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) Re porting b Person inCharge* 3-306.14(A)(B) Returned Foal and Resetvice of Food* 3 590,003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(H) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Ford* 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 Henneticail Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Tem eratures* 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical.Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. * 5=101.1.1 DrinkingWater from an Approved System 4-601.11(A) Equipment Food Contact Surfaces and 590A06(A) Bottled DrinkingWater* Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B} Water Meets Standards nt 3pr CMR 22ce Contact Surfaces and Utensils* Shellfish and regFish o all an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreational'iy(aught Molluscan - Food Contact Surfaces of E ui ment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP tasted Chemical* Sources* Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Re ulato Autho 2-301.11 Clean Condition-Hands and Arms* 3-20218 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(0) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* I1 Good Hygienic Practices 5 Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11, PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes, Nose and 3-202.15 Parka a Irate it * Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventin Contamination When Tasting* 6 Tags/Records:Shelistock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained" Employees Tags/Records: Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 3-402.12 Records,Creation and Retention* 5-204.1.1 Location and Placement* 590.004(7) Labeling of Ingredients' ? Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methals* Devices 3-502.12 Reduced oxygen packaging.criteria* 6-301.11 . Handwashin Cleanser,.Availabilit 8-1 2 Conformance with App roved Procedures'" 6-301.1.2 Hand Drvin,Provision Denotes critical Acm in the federal 1999 Foaf Code or 105 CbiR 590-000- CITY OF SALEM /� BOARD OF.HEALTH 1 Establishment Name: ��ja f Date: 4 f®fn4 Page: 7 ' of RemCode 'C-Critical Item'- 7<DESCRIPTION OF VIOLATION!PLAN OF CORRECTION r 3" ^,, Date Reference :R-Red Item "� d .w .. • - ?% Verified -:.>., x�u'•. „�. ;W, „: ,ms td,: ,.d%vn. :kC 3b. ,Y'a :/i{a Pax5.-. ,PLEASE PRINT CLEARLY ^° xr 11 1 *, - � x �T �"��i.I I -t C✓1 C'. (4 1) 4- G ,/� " - ,o ' �1"ta✓1P1 .�•�Y). .ov ,.,-M1a�1 r �lY I�n n Si{,n �zv_ , �..—�t•• !I 1 f r S� EA �O .Y Gnl i S.gYI ,'72.c 1Csr /nC_ - V (U � . 1fS Gn/ a �it .r✓1 C �l.o \ a.SS./n, t-rG�,•...e �r !�o ' 1-- t' nC( ;�.: i c-/ 3 j 1 l t • ' � 7 Discussion With Person in Charge: Corrective Action Required: ❑ Non Yes I have read this report, have had the opportunity to ask questions-and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins P � Re-inspectioh Scheduled ❑ Emergency Suspension comply'with all mandates of the Mass/Federal Food Code. I understand that r / noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure' your food permit. ( nX P A M/� %_>1 ❑ Voluntary Disposal ❑ Other: i Violations Related to foodborne illness Interventions and Risk ccordial;to,Lzv, Coolad to Factors(items 1-22) (Cont) 11 F/45'[- Within al How 2 3 5011.15 ccx4m"Mcffiods for PHFs PROTECTION FROM CHEMICALS L!4 Food or Color Additives Li-9 P14F Hot and Cold Holding 3-501.10(B) Cold PI-IFsMainalmed at or below I— Addijiivc"� 2 590 N)4(F) 41`745°F- Protochou firceoll=wed Addiioees* r 1-1 Poisonous of Toxic Substances 1-501�16(A) Hot PHF� Maintained at or above Li2— AWE j 101.11 Jdatitifyin"frilto neltion -ovq""', 3-�01.16(A) Roastt,Held at or above 130"F, I 2t) Time as a Public Health Control 102,11 Coulaxat Name - W-orkki,,Cowainem* Time as a Pubtic Health Control' 3-50, ?-203.3.i �90.004(11) VariLp 7-202,11 Restriction -Pr and Use* —7�2(02,12 Conditions iow of I!'�3e REOUIREMENTS FOR HIGHLY SUSCEPTIBLE 7?y3 t1 To'Xi(Xvinlaireaploldbizion�" POPULA IONS(HSP Saaki7cM C'Tit(Tiii-ChtalliOlS* 7._04.1T I it I-X0 1,11('1? unpt:oeul m'd pre-11, cd Aco:s arid 7:54 12 Choill"'vk for Wash �Lodece,CAictia" I — 7204,14 Vi ��e 'ria�ritC Rever xt"�j-' Lre of Pwqevuize 7-205,11 hwidental Foi)d Contact,Ltmijeavits' (11 A l(D) i Rawor PaiiiAtiv Cook-d Ariunal F(xyJ and kosinuld Uw Pefiudes.Critero)* 1,,,112 Rodeta Bait Sea ons Served.' i�o' Tracking Powderi.P,-si Control and em CONSUMER ADVISORY TIMEfTEMPERATURE CONTROLS _T2 3-60-� 11 011,;ual"r Aek�so v�'y Postal 14 �,,ifxo;TIP7�on 147 r—16 --7 roper Cooking Tempeoturps for Alum".4 f�axis Iia! Raw, Ltndecux>kcd c. PHFr iNot Pus aced to lljiva.'a Pgewar cd F&g��Subv�wul�' rov Riiw She Irfuped;aw iiervicc I'6'F 1 51ec G'amr F01 I I(A)i 2 v comininwed Fi'lv, %fea(st- 'lIhnais- 15''F i 771TI, flock and&'et Roast - 1""' 1 SPECIAL REQUIREMENTS T�9,At-7j)) 7 ViOall')Sls of secti(ot -590.(X)9(A)- D) i 340 1�I I(A)� llititc, lniw�d Mz:,�tb 155 F 15 cal�-ring. mobAcz foo d, feinp(gw'e i.14 40F Tif W3) i PoWtry,Wild resldenl;ai kitchcn opefaticfnshouldbe j Sofffing comninina Fish'Meat, i debited under file approprivive,sections lioultry or katnes-165T', i'vs,�c. above.if rclatW to tKxlborvic ilhiosg 401.1h(7)(3i Whoie-mm'de, iteact Btvt Steaks intervemiow"and Jsk 1'acivxsOtber 145r"F* 590,009 violatoikvr rchtuvl.�' to pcid lv-.to r pra,�lices aliculd Ix-,debited imder#29 - 401.12 Raw Avenial rokb;Cooked in a Nlictowvoe 10,5Fpeel 1Reguiasrnetrt All OThei Pffs.- 145°F!ec, 17_ Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES T 3_T X 1— T __ .(i';T I'l-IF, 165'�F 15 W� (Ifenis 23-30) V 4 0 1.1,11(B) 'Nfivvvwavv- bis'F klinvo!Standing 1i CrWralziel vvv,n-c nwat viv);"coan, which do atc relate to lite tum .foodborne illness iWerventiow and r kfiwiors bvied anove. can be 3-403,11(C) conertn:jalby piwesscj R1 'Kwxi- alnd iii zhefiuP0iv bfgsertioris of the Food Code tokI 105 CMR 140'F* Jaft"')tio Renlailuyq"Unsficed porncns of Ikef Item Good Retail Practices I fC 590 poo i Roasts* 3 1 FC -2 003 i 24, FccA and Food Prowvion, eviv and utevisli; FC—4 005 PqO -- — —--i 3 5OL14(A) Cooling Cookt�xt PRF's from 14Wl'to 6 Water. ul e I FC-5 1 OCK3 101;Within 2 Hours and From 70�1' 12 Ail- ...... FC-7 008 ------------- -� S(7114(b) Co(-,jite,PHF�� Made Front Atribical S FcPuIngredients t(,41 1F/45`F 11_3o. Other ........... Within 4 IlkwO penults critical nem to the fedeoll 1909 Foml it A'e w)5 CM 590 000 t, l Commonwealth of Massachusetts sa City of Salem Board of Health Kimbefley Driscoll 120 Washington Street,4th Floor Mfiey SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/23/2008 ESTABLISHMENT NAME: Circle K 7502 /Subway File Number:BHF-2008-000021 323 Highalnd Avenue SALEM MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2009-0190 Dec 23,2008 Dec 31,2009 $280.00 TOBACCO VENDOR BHP-200970191 Dec 23,2008 Dec 31,2009 $135.00 Total Fees: $415.00 PERMIT EXPIRES December 31, 2009 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 1 F4.OM ` FAX NO. _ Nov. 18 2008 11:24AM P2 BOARD OF HzALTH 120 WASHINGTON STREET,4'FLOOR "CEL.(978)741-1800 KTMBERZEY DRISCOLL FAX(978)745-0343 IbLWOR QIONNL&ALL CO-M JANET DIONNE, ACTING HEALTH AGENT 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT. NAME OF ESTABLISHMENT C oL)c V, ¢ 1 S O TEL#_ 1 15` $� ADDRESS.Of E.$T9BL),5.)�AE,�dT�3 U a ^ MltILiNG:ADDREss=(ifdittt):� 0 h 3 yl C o u us N EMAIL-Business': Website: OWNER'SNAMEa °s Goy\ VQ � «ncL ott6 L1 C TEL ADDRESS T O 'bo x 3y1 E a 4 r us : N STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) I -Art,\ d 0 w t CERTIFICATE#(S) (Required In an establishment where potentially hazallouS food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# &(Foyrexarnlile S.QFOPERAsSu. S&rd '`:SRS t OPERA—I1 �/t` Iewmteintanedday. 5 1 \' ` I lllam-11pm 1 TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE ES NO less than 1000sq.tt $]L 1000.10,000sq.ft. C-$280 more than I0,000sci tt X420 ---------------------------------------- ------- .................................................--------------'------ RESTAURANT YES NO less than 25 seats =$140 ..(Outdoor Stationary Food Cart$210) ._ ....... 25-98 seats ... . . _._.. =$280 more than 99 seats - . - .............................. . ...... ........................... BED/BREAKFAST/ YES NO $100.:. CHILDCARE SERVICES ADDITIONAL PERMRS ------------------- MAKE(riot just serve)ICE CREAM,YOGURT/SOFT SERVE JSNO $25 TOBACCO VENDOR ALL NON-PROW(such as church kitchens) S$ O $zY "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 Statefflafore any renovations improvements,or equipment changes are made,all plans for such must be submitted to ahe Salem Board of Health. Pursuant to MGL Chapter 82 af under the pains and penalties of perjury that 1,to my beat knowledge and belief.have filed all state tax returns and paid all state taxes w- SignatureDate Social Security or Federal Identification Number go Revised 4/74/07 FOODAP2008.adm� Check#&Dave IS 2008-111810:37 Page 2 Commonwealth of Massachusetts s e City of Salem Board of Health Nmberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 07/15/2008 ESTABLISHMENT NAME: Circle K 7502 /Subway File Number:BHF-2008-000021 323 Highalnd Avenue SALEM MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2008-0514 Jul 15,2008 Dec 31,2008 $280.00 TOBACCO VENDOR BHP-2008-0515 Jul 15,2008 Dec 31,2008 $135.00 Total Fees: $415.00 PERMIT EXPIRES December 31, 2008 Board,of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 ':, JllL-15-2pOB 11 :10 BAKER&DANIELS 317 237 8321 P.002 CITY OF SALEM, MASSACHUSETTS ., BoARi>Or I-IEArrm 120 WASHINGTON SfRFFT,4"'FLOOR TFI..(978)741-1800 IOMBERLEY DRISCOLL FAX(978)745.0343 MAYOR ISUWII&SALEU, 0012 ,JOANNE SCOTT, FIEALrtt AGENT 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT r f t if-K -IC50o2 TEL#�7 7� 7�e25 ADDRESS OF ESTABLISHMENTT9-11-f FAX# MAILING ADDRESS(if different) P'. �- !J �711(f.IG- -31-/7 •-f-.14-,Ieh /A.) d4 e�.. i EMAIL•Business': t�-C �wwa�-5gyc.�-cc.�ek.M Qsi , f-- c, OWNER'S NAME ed e- LE M4-5-aCtIISE= 44C- EL ADDRESS �. i� F G1� 3 y7 Ct t kk,-n htf -S ln/ STREET CITY STATE t� ZIP CERTIFIED FOOD MANAGER'S NAMES) 4 8c,n! _�DY ' CERTIFICATE#($) (Required in an establishment what&pannicany hazaNagai hed is prepared} EMERGENCY RESPONSE PERSONW4 0 _,HOME TEL _{/�&-q5 Vj DAYS OF PERATION � Monday �._T gsda,�.T WaMsSdav � hursday Rely z Saturday Sunda I v HOURS OF OPERATION Please write N time glday, ` I I t :!(F-/o1O /"�/r✓ :q-10 , '—w 9-w 19-w 9 ) TYPE OF ESTABLISHMENT fEE !check onN1 RETAIL STORE YE NO less than 1000sq.ft. =slo. 1000-10,000sq.ft. d9E) more than 10,0005ci . =$420 RESTAURANT YES O lass than 25 seats =$t40 (Outdoor StationaryFood Cart$210) 25-99 seats =$280 more than 99 seats =$420 .................................................. ........ .. . .............. BEDIBREAKFASTt YES N ........ ...........» .. $100 CHI-ID.G.Aft�$.ERVICES............................................ ADD4TIDUAL PERMITS MAKE(not just serve)ICE CREAM,YOGURTISOFT SERVEY $25 TOBACCO A CCO VENDOR NO <1D> ALL NON-PROW(such as church kkchens) YES I� $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,of equipment changes are made,all plans for such must be subtnlited to and approved by the Salem Board of Health. Pursuant t L Chapter 62C.Secdon 49A,I Pantry under the pains and penalties of ps"that I,to my bast knowledge and belief,have 1110 all state tax ret au ate texas requkad wxkr the law. Signaler: Date Social Security or Fcdeml,derdfGcatioa Number tfev4red4t24t07FOODAP7db8adm Cbccka a;Dole 5„_ _J_••__—_—» EXAM FORM NO. 4308 o 0 Mm o CERTIFICATE NO. 5146655 a Se�rvSaf�e ,r m L— � � m co .t co � as sr m w . uricationServSafe® Cer y n-. r a � Ye F it c 1 .. 1 ,' , �.�ca ✓ .:t.o rs. i .3 1.o�.�.'w'.. .v._--ssl .. i 1 for sucogWmAy oM"ting the standards set fort!b/the National Restaurant Association EAL%=60 tat Fau!Aetion i for the SerrSate•Food thotection Manager celtiGcetion Examination.vWcb is*=edited by the American Naliotw Standards Institute(ANSI/-Conference tot Food Protection KEPI. Pit"ritedby the fttloml RastauneotAseod0W"Educabonaf Formdoon 1/18/2007 � DAt"f OF EXAMINATION m 1/18/2012 9ATE OF ExPIRAT'ON Lurl Owe gif/y.UKa1 witl t�Hml reaulelory a9eetl`1a teronifce6n reprteleeNs. . 0 - National Restaumm mswattonA ra+nAE Ami EDUCATIO _NAL FOUNDATION C pme nteme GNet Opsntt4O" w N J 01MI2�.0Tg Ny p Optrl11,294=0%lWooNiOn Eduee'iaYI FYxN[een ..� .. Otmetae Appi�aueurt AeNanenERnJood!Dello mom It j .JUL-15-2008 11:10 BAKER&DANIELS 317 237 8321 P.001 FACSIMILE COVER LETTER; BAKERODANtELS` "M 6 DMICIS W 300 NOM Maldlan Street Suite 1T00 Indlanapona.Indiana 462041762 Te1317.237.0300 Fae 317.237.1000 vwW.taaefdanlNidDln CONFIDENTIALITY NOTICE: THE MATERIALS IN THIS FACSIMILE TRANSMISSION ARE PRIVATE AND CONFIDENTIAL AND ARE THE PROPERTY OF THE SENDER. THE INFORMATION CONTAINED IN THE MATERIAL IS PRIVILEGED AND IS INTENDED ONLY FOR THE USE OF THE INDIVIDUAL(S)NAMED BELOW. IF YOU ARE NOT THE INTENDED RECIPIENT,BE ADVISED THAT ANY UNAUTHORIZED DISCLOSURE,COPYING,DISTRIBUTION OR THE TAKING OF ANY ACTION IN RELIANCE ON THE CONTENTS OF THIS MATERIAL I$STRICTLY PROHIBITED. IF YOU HAVE RECEIVED THIS FACSIMILE TRANSMISSION IN ERROR,PLEASE IMMEDIATELY NOTIFY US BY TELEPHONE TO ARRANGE FOR RETURMOFT�E FORWARDED DOCUMENTS TO US. PLEASE DELIVER THE FOLLOWING PAGE(S)TO: N= C.omnenv FLX No. Phone No. 1. Joanne Scott Salem Board of Health (978)745-0343 (978)741-1800 From: Kimberly D. Henry Date: July 15, 2008 Joanne: attached please find the application for a Permit to Operate a Food Establishment we had overnighted and that was delivered to your office on June 11th. Comments: Once I find out how much their bank charges for a stop payment fee, I will have our accounting department issue a new check and get it out to you. Thanks for all your help with this! Return To: Total number of pages,including cover letter: 3 A hard copy of this transmission will be sent by regular mail will be sent by overnight mail will not be sent under separate cover IF YOU DO NOT RECEIVE ALL PAGES, PLEASE CALL THE FAX DEPARTMENT AT 317.237.1467 AS SOON AS POSSIBLE. 1 ? CITY OF SALEM BOARD OF HEALTH r (� ) �t✓�� K S v S Gl ) Date: 7 I S o k Pa l Establishment Name: e: of 9 Item Coder` aC Crit lcal Item ;� z DESCRIPTION OF.VIOLATION l PLAN OF CORRECTION 1 x ` � ; `Date Verified I NoReference R-Retl Item ' + :" 11 -""'_ ��"'° S - ( � PLEASE PRINT CLEARLY r, -- IZcSib(L% I�v� Wo�i Q ti r 1�� �wf'SI� S�a� K )vim l - 1 2� c�t,1 SIhC io rr ` � I • r c�� �M�'. a+ I ) o° � . l v , a o?cn a—� 1lwc I AVN) f > Noi�-' CoP OF- h V) 1-z' a_j :-N) GT a, fl- j '7T'Pior-j Q-oPjT /7r �UiL- Y�-oaJ i H psi, S �`�.-v �V\,S k.-•,�� ,��� \o2y�n��JVO PJ 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 o 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 do Ilars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: PHFReceived at Temperatures Violations Related to Foodborne Illness interventions end Risk Accordin.,to t. Cour d to Factors(items 1-22) (Cont) 41 F1451', Wiffint,11 Hours. 2-501 1,5 cooljn�,Metho&for VHFs PROTECTION FROM CHEMICALS — LL -- 1 19 PHF Hot and Cold Halt 4 Food or Color Addffi�Les It .........i_ _.._ --i Plil—1 -VT-9 3-202,12 6(B) 0�c Memnon I at(,n t,'I"'c" 590 O(k4(F) 4P�'457'F- 1-50LWA) Hot 1111FsMamtained atorabode Poisonous or Toxic Substances 140'F ing Intoi nait on-Orj,,na lo, ——------------------------------ 3-501Po I Conorzlfl(A) �iM�Hold at or above 130"T 20 Time as a Public Health Control 7-102.1( Common Name- Workim,Coiaain(�rs* a --c -- -3-507! t9 Firm a Putific Ileald)Conool, SLe11u To(j54(H) vanftllu R niecnieset R-micnt-;or -Prescricomd U*cA 7-20112 condoions of ljsc, --------- REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-303.1 f -Toxic,Confairicu, -ProljifnliomlPOPULA I -- - -E _L 7-204. Sai�,077trs,Criteria...Chevnic�ls' (t�P 121 3-8'1)1-1]'�—A) Ujipaqteurii.orl lre-pacl,,agcd Juices wi�-- 7-204.]T— ChLalilcak for Washine,Ilmduce-Ctiteria'r 7-?04,114 Dr,in &,evts.Criteria" L Be wra�,,c,,wnh—Wal 1111 rlz� ET2 PaNtell 7-205,11 lnci&,mal I-�xxl Confart.Luinicants' Lj-20�5-I RcstricW U�e Pe.,tladle-Criteria* 3-b0l,I I(D) Raw or Pattiall',Cook,,d.Amimal Rxid and Raw sled qsrrsit Nt Served 7-206.12 Rwewi 13pit 41u6l�lln ------, 7 j-_riuLttjed�*,xxi Pad,ale 4ot Re-served. i�,a7kniig P,)A&,rq,Pere Control:aid 06.'I3 1 1 rionit CONSUMER ADVISORY inion of Anion it LaW, Undercooked or Proper Cooking Tempef 16 states for 22 3-003 1! CouloaqerAid�ispi v Poo�d Stir Consoin TIMEITEMPERATURE CONTROLS I Not Othei wise Pr(lceswd to E'litionate PHFs 3-401.1.J A(l)(2) F&ga- I 55'P 15 Soc. miut�d Fi,�h, Win,,&Gaint ,sahmoccliate Svfvic�� Fff5sec� telilt/cd 174"sob,�titult for Raw Site,, 7470 �71(Ali Comn ---- Armin is - 157'T' 15 gec. SPECIAL REQUIREMENTS 3-401.11(13)(1)(2) Pork and Beef Rtxof - 1301` 121 aiLDL -770 1�II(1)t2) Route�, hvjecicd Ntivkas - 155 3F 15 590.6­079-(—A-)-�-157 Viohtmo,�(if Section 5, sec ( catering. mobil- fotycl,temporai v and 7401 liA)(3) GiioStuTleTPRFs, rcsidenlial kitcheir operation,Altadd 13C Sluff ll Com mink Fist, fent, L!clnted under the appropriate sections I Pouitry oi llatitcq-10°F 15 sic.xi aWve if related to AxAborne illness (CT;)-- ti4hcic cons 11--hil"It B1-1t—Slla:� iorervention<;and risk factcir5. Otber 1451; 590.009 violations relating to good retail jnatfice,,Aioold be debited under#29 - ,-Il)1, 12 Raw AnnZI Co,&Ldul a Microwave W,Focial Requirements. Si, i c'"hel lliff,� -- 14517 15 sec, 1 —2 L17Reheating for Hot Holding —VI—OLATIORS RELATED TO GOOD RETAX PRACTWES 3-40TI I D) PRI-s 16,'F 15 sec. (Items 23.30) Tinle, foodborne Wne-Ti inferventiumv and riskjiwzort listed above, cat be 3-403.1 I(C) Counnercially Paxzssed RTF Food- found in the ft4hlwnig sections ofthc Food Code and 1(35 CVIR 140'1' v0 X0 3-463.11 )3 1 1(E) Remainimg Lns�ic�d PornensoFliccf IL&21 1, Good aod� 004, ldProleca Ft8 Proper C;;lIng bt PHF; 2ELuip!j;er PC -,4 005�i ittI WA) Cix-1i tipCookt,,dPKP's lrom 14WF ti i Utensils -——----------- Waste 70'F Within 2 Hours and From 701' �27 i Physical Facility_ 6 �007 to 41 71,1 Y F Withi n 4 Hours. 2 sonous or Toxic Matenals 008 1.14(B) Cooling Pl-!]F�Made From Ambient 2 30 4sow7,2";R- ulremant Q09 Tcalperacure Ing".dients to 41'F/4i'F Within 4 1-1clujs* lkil"les',nocal licin ill aha 1�Iera1 1999 Forxi f.4xie or 165 CaAB 5901)00, CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Item Code C-Critical item DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY Discussion With Person in Charge: Corrective Action Required: F❑,-- No ❑ F,Yes d have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: )4(c) PHFs Received at'femperatures Violations Related to Foodborne fitness Interventions and Risk Ac cx)rding to Law Cooled to Factors(Items 1-22) (Cont) I 4 1'FiztVF Within4 Hows, E15 Coofia�Wtho&for PHFs t4 t PROTECTION FROM CHEMICALS Food or Color Additives L29_ CHF Hot and Cold Holding 3 501.1 6fB) Cold PHFs Maintained at or below Adlui, 3-202 12 590'tig(F) 4I t45°F* 3TOT14 proteenon fro 150 1,1 6�'A) Hot Pl-ffi�Maintainedator above is -Poisonous or Toxic Substances 140'R i 101.11 Winufying Infol matron - oviginal 3-501 16(A) H.cEd at or abase 13Q"F. Time as a Public Health Control--1 7 102.11 1 Common Name _F_ ork i rL 2-11 3_50 1,1 f� Time as a Ntifie Ifeahl)Control, 7-201.1 SrJ�ara�L(aa — —]IM - __�90 owai) Variance Requiremeat 7-201 IT Restriction --Presencc and Ise* 7-202.12 Conditions irins(if 1'1s0* REOUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-103 11 Toxic Prohibitions"-Prohibrna` POPULATIONS(HSP) 1-204.IT '1117, 111,"critrria—chemicNis* 7-204.12 Chemicals for WashIll I'loduce,Ctitotia" F2 CTT�_ol 1-1�A) 7Fn�_z�steunycd Pic-paclagcd Juices and Beveraoe�With ik—larn"I 7 204,14 D A c t� Critetia L111", kc L_= i 3-801.11(H) Uc of Pwtemized LL­�� _TKS-1 I to I w Ed CnMact.[Atbi irants' 3-Wl,11(D) Raw or Paatjafl,,C(y,)k­dAtjomd F("acrd -206�11 7 ReerrtcSed 1'te eq,��,Touts Not Served 7-'06 12 'd Rotlern Bait Stang a,�* .206.13 , Iazting Powders.P-si Control and Monitor CONSUMER ADVISORY 22 3.60-A CODsWnor Aovisory P(Awd 14 Congumption of TIME/TEMPERATURE CONTROLS Tviinwl FKWIlial are Raw. Under000ked ot Proper Cooking Temperatures for HFs PHFs Not Onhcr,,i i.w Processed to Filinmaze L T__ _ _ - Patfimons lot I I A(l 'F 15 Sec. Eggs- 15i �,�s �.W I I I`,,qezm d Fe,;Subsiftine for Raw Shelf imajediato rierl�I[C _3-40131(A)(2) Comminuted Fish, aleats& Gamt —------ Annnak- 15,5"F 15 soc. -7-401—11(13)(l7)'2) Portand Roast - 130"t-,121 min* SPECIAL REOUIREMENTS 40 1 11(_k) �Vielation,�of Section 590.W)(A)4D) in catering. mohiic.fixxt,temporary and remdential kitchen cipemfioris should tic �1 4071 I'iA ['nahry,T§"rid C"Ime Stu Stuffing Containing Fish,Mega, dcfaied under the appropriate wc110fls above if related io foodborne illness ---------- 3-40EUiCn3i Whole-masci, tntact i3ectStow intcrvennons and risk In(tors. Other 590.009 violations relating to good retail 01.12 Row lninwl Foi Kk—C(K)kcd in it I practice,,should he debited under 1129 - Nficiowave 165'F* Speeiad Requircrnonts. 3401,11(At(i)(b) Afl Othei PHF,-- 145"1 IS sec. L17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.1](Ate4t)) pfllFs 1659_� 1 sec. (Items 23-30) - i-4©3.11(B) Microwave- 165',F 2 Minnie Standing Critical and non-critical violatwni, which do not relate to the TIA10 I inodhorne illness and rc�kjn(fors fim�dabw'c C�m be 1:40_31'T(-C) complercialiv pioces�ieTRi"i,_11-1T_ found of 1he Food Code and 105 CWR _Jnr -Good -------­­IFC C -,F590-.M-W (I Regialnin,Uw�hced Finrdrana of BclefPiac wes, _23- 1 �_A a-r-a- I and-Per_so n-n-e-i poaS0 FZ 2' .003 Igrene, 24� Food ond Ford Protection FC 004 1=8 proper Cooling of PHF& ------ 2S_ _E_qM...rn, 105 - 3-S01,14(A? Ox,ting C(X)kcd PHFS from 1401,to - ------------ ---mi 26, _PWahir,Pftimbina-Lnd Waste FC-5 —----------- 7W Witbin 2 ffour�wal Fron)70' 27, Phy cd F@EiH FC 6E 007 T w 4!'F/45�F Within 4 IlouN. 26 roisonouc or Toxic Keenaf 008 --j:-4- ---­- -- �3�501 14(B) Cooliag PHR�Made From Ambient R,N� u 2i ern ants 009 Tcmperatore fngredicnts to 41°1,/45 F Within 4 ffixus Denlltecriucal 41C111,11 lhe c,iera! 1499 FoM OA,or 165 CMR 5W 000 i I CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Item Code C—Critical Itemz DESCRIPTION OF VIOLATION/PLAN OF CORRECTION � A Date . - No. Reference R—Red Item gy - {.t +" - _ & �• �. t � � Verified PLEASE PRINT CLEARLY - i l t ' rc J t 3 i ( ? Discussion With Person in Charge: Corrective Action Required: E2No LlYes 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 + r noncompliance may result in daily fines of twenty-five,dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure t•+ ti your food permit �' p ❑ Voluntary Disposal ❑ Other: F75",TT4(C) P141 s Rec,6wd at TmZratures Violations Related to Foodborne fitness Interventions and Risk Alxordinl;to Law Cwled ill Factors(items 1-22) (Coot) 4l'Pi45'FW4hin,1 Hours T-5('�T 15 —C&Cn,,lvlothod-Tf-br—PRFs PROTECTION FROM CHEMICALS 1=4ves L!-9- PHF Hot and Cold Holding 2fi2-I2 2 it�ov,, I-SW,16( Y'Cold PHs maintained at I-ir belvw j9().l)d4(f 41,'745-F, --T ii2,14 Protectfronl 3-501JNA) Hot PflFrNiainfamedat or above r15 Poisonous or Toxic Substances Ill I1 Identifying lim nfol ailon- Original 140'F. i 3-5ml.16(A) Roasts Held at or above 130"F 7-W11 I t C�mrqoo'Name-- Work LLD- Time as a Public Health Control - �� 1 19 rimcasallublil;1lealrbC not, 7-201. S�j)ta'atkal--Stia� I .0 on 7-202JI Reqliction -Presence and uao* 79U I1-202.12 Condflowof kso� REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-iO3 H Toxic Conlanoa�,-Prohilitfiom* 1 264.11 ani,"ell,Troma- 0,1111CIlls POPULATIONS(HSPS 2t-TS"-01.115, Unpteuliicd Pre-packaged Juices and 20 .12 nilsforyq40 &Vml-'els with 2'04 14 teul��Cvw� Ir, II(Bl t —70_4.14 , 226'T Incidental [oNxl(Amtom Lubricants 4��t Served, 7-206.(i �. 12cai ic.�ed U' c}'e: turdes�Cnneria*� � 3 561.E 1 ti)} t R�x car Putiall Ctakal Aaunat Farad and 7-206.12 Follow E'lit stacwns°----- r7— I EiLl�-CT i-flop-e—ned 206,13 Tracking Powder,. Control and CONSUMER ADVISORY 22 340 1 Conlaorwr Advisor~ Printed for('amumpurn;or TIMErrEMPERATURE CONTROLS Animal lxl&That tic Rawo, Undemx)kcd 16 Proper Cooking Temperatures for FNot Odiem ise Proa ogsed to Fliarinlar PRFs j ' 3-401,11A(l)(2F' l ,,g,,- I55 c 15 5,,c. latfii�- dtate ser'qcv 145,F15,ec a I e R 'teurtzcd Tqs Sabstivne for Ram,Shell -40 1,11 t A)(2 1 Coirnmnut�d t ieh Meats h (7lilrrle Anhuals1 Is cto- SPECIAL REOUIREMENTS 40 1.11 k'B)(I s2) Put k and Bt of kunst I W'F 121 non 0—0 1 A)—(T)7) Viol—cll z i I i 11,,of Section 5—90,W 9—(A) (D) in 3-401.110400) Ra"de'S'lorevi,Xi MrAts - 155°F 15 -atering, mobik t"l,temporray and 3-40 1.11 Wt 3) Pouhry, 1 Od C,sine, Stuftel PRFs recidctd'al kitchen operations should be sluffunz Coulaimilb Fish. Meal, jebited under the appropriate sm-tions Fouft-v or Rahn,,-i(l5"'F 1,5 si c. above if rk-Jated to foodborne illness 3-401AHC)QWilde-muscle, Intact BtCf Steaks intelventlon>and tisk Iaclors Other 3-40ITT— I-451, 4, 590.009 violatwns relating to good retail Raw Arland Fw(k Cooloxil in a pi ac 'itiould be debited under #29 - exquiremonts. Mictowave 16"'T'* Special R I tA(1)(b) All()the,P11171-- 145"1 15 sec- VIOLA TI&KS RKI GOOD RETAIL PRACTICES F-17 for Hot Holding 3-403.11(A)k D) Plll-s 165tT 15 sec, (Items 23-30) 3-40375—B�)— M crowave-165°F 2 Minute Standhrg Cfiuva"and non-critical vwbdwns' alach("(I not reiare'w yhe jime, �feodhilmc illness nuervemomv rand riskjamIrs Evert above,(an Lr 3-403.11 IQ Commercially Processed RTE Raid- found in the, ser wins of;he Food Code rued 105 0141? 140'F" 5 90,000. 1,E) �e1nalains 3403,1 Unslwed Pord�ns oflicer I FC 590'aw RoastO 2 1 003 rd "erzonnA -arli -L ---------.---I.---,--�----------- Proper Cooling of PHFs 4, F(xA�iral Food Protection i FC 3 004 Egl�iil d tens;!s FC--4 005 I', A, _7 colla Cook front 140'F it :;-901.WA) 26,-- i ------ Was, Plc d Wasto 70"T Within 2 flour`laol From 701' 27, _I QFC 5 007�ng_arld ------- to 41`F/45�F Within 4 fiows_ 2�1 slonous or Trim Matenq!u FC -7 1 008 --�50 TI4�1�i Coolhn� PHR,Made FioniAminjew Tcolj.,,�,ranktre Ingnofients to 41'F/4.5'F L8q, other Ill,"ithin 4 llon;-O P-filltes Intical 4eln in me 1e.kilqI! F)491' NI("Ac or 105 C'Mit 590 WO lMPGRTANT MESSAGE FOR 3=> W Y DATE 1 ' Ib -ay TIME P.M. M ?--el)- OF ��Ulq�ll OlL PHONE AREA CODE NUMBER EXTENSION O FAX ❑ MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED ,; PLEASE CALL CAME TO SEE YOU WILL.CALL AGAIN WANTS TO SEE.YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU. MESSAGE 12v�Q'�a �1�--• SIGNED FORM 4009 MARE IN U.S.A. NOTES ---- - -- ,. ' �IMPORTAMT MESSAGE FOR DATE . v8 TIM M OF PHONE AREA ODE NUMBER EXTENSIRN ❑ FAX ❑ MOBILE AREA CODE UMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU : WILL CALL AGAIN WANTS TO SUE YOU RUSH RETURNED YOUR CALL WILL E'AX TO YOU MESSAGE c a SIGNED FORM 4009 V� MARE IN U.S.A. I-� NOTES - _ _. -- - _ r PORTANT MESSAGE FOR TTIIIME t -==P.M. MJ"'„-"rices OF PHONE �� ^(.>Do7 - 79V AREA CODE NUMBER EXTENSION U FAX U MOBILE AREA CODE UMBER TIME TO CALL TELEPHONED....... PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN' WANTS TO SEE YOU RUSH RETURNED YOUR CALLWILL FAX TO YOU MESSAGE SIGNED FORM 40 MADE IN U.S.A. NOTES I I IMPORTANT MESSAGE' FOR DATE VV TIME 32 P.M. M L I DFS PHONE AREA CODE NUMBER EXTENSION - U FAX U MOBILE AREA CODE UMBER 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 I MESSAGE, v SIGNED FORM 09 MARE .S.A. 1� C`cxi s�c+���a F JIMc Qalz: 7,�4 1,0;,Aa CITY OF SALEM BOARD OF HEALTH Name of Establishment: Irving Gas/Ciro k K Address: Highland Avenue Owner(s): Daring-Gas-Peter- tr-reil HS-Feed-GW s--Speeialist;John Tardiff, Arliance (;-5`n9tUCtl1M L ieCl t K �. �d ➢�a .*� �' Phone: 603-559-8750 Vic' 1.ii c co -rV Kato i3ctote Mr. Burrell and Mr-Ter-diff discLsM plans for this establishment. A review was conducted in accordance with the State Food Code. This establishment w be a gas station with an associated Subway Take-out, a Bfae-eam)e Bakery, and a retail food area. CI✓tur Y_ FOOD All food items displayed and offered to the public must be from an approved permitted source. There will be a Subway Take-out area where sandwiches, subs and salads will be offered. • Refrigeration units must have easily visible internal thermometers. • There must be a Certified Food Manager responsible for the operation of this area and for compliance with these conditions. • Foods placed in the cold holding section must be at a temperature of 41°F or lower prior to placement. Food in this section must be maintained at 41°F or lower. • Temperatures of the food in this unit must be checked each hour with a sanitized stem type thermometer for compliance with the above requirements. • Food may not be added to containers in the cold holding area. Instead, the container must be replaced by a fresh sanitized container. Product from the original container may be placed on top of the product in the fresh container. • There may be no bare hand contact of ready-to eat foods. Serving utensils, tissues or gloves must be used. A bakery food prep area will be used. Breakfast sandwiches will be made here, wrapped and placed in a hot holding area for purchase. These hot sandwiches must be maintained at a temperature of at least 140 OF or higher. Sandwiches will also be purchased from a wholesale food operation, "On a Roll." All items wrapped and placed for sale must be labeled with the name of the manufacturer, with the address, contact information, sell by date, ingredients in descending order, and specific listings of food allergens that may be present. nJ 1 All refrigeration units must have easily visible thermometers. TRASH um�>fe. rwi /I 6p— FINISHES All areas where food is displayed, stored or prepared must have finished floors, walls and ceilings. SINKS A hand sink will be located in the Subway area., in the bakery area, and in the rear prep/dishwashing area. There must be wall hung soap and paper towel dispensers at these sinks. Hand sinks may be used for handwashing only. A three bay sink will be used to wash, rinse and sanitize all utensils, pans, etc. RESTROOM Employee bathroom must have a hand sink with hot and cold running water and wall hung soap and paper towel dispensers in the room and a sign that states that employees must wash hands before returning to work. SANITIZER a// Sanitizing Solution must be accessible at the-dpj area.3 Quaternary ammonium compound will be used as the sanitizer. Test strips corresponding to the kind of sanitizer, must be on hand to check concentration of solution. Solution must be made daily, tested, and the results recorded on a log sheet for examination by Board of Health inspectors. Solution may be prepared in the 3'd bay of the 3-bay sink and spray bottles and/or wiping pails may be filled there. Spray bottles with clean paper towels may be used, as well as wiping pails with wiping clothes always held in the solution in the pail. Spray bottles and wiping pails must be clearly marked "sanitizes." EXTERMINATION Monthly services of a Licensed Pest Control Operator are required. Please keep receipts for inspections. LABELLING Labels may not block "sell by" dates or other information on retail products such as baby foods. Outside area of premises must be kept clean and sanitary. Y 1 J nhee Scott ' Date Health Agent \(/ 7 r Burrell Date �, � IAU