CUSTOM HOUSE ROTISSERIE - ESTABLISHMENTS ,f
a
i
I
1S R4$1;�L1. Z�Z
'57
Aj=W
g;
Tg'qp� --A
'uounnonwonith-of] V f4w,% _-Z
V' W'W
Ny
..AW
_45
R
—,A cit gm I
yOSalem
'd 6--T'.g
,Board 01,11CMER1w, x "; � Kimbl3fltiy DSII
o
Tap T
V,
m
• g
SALEM,
T,
- �F
&kehflfitib
Iffent-PiFrWmitC
ATkPk]NTEb 01/06/2014'
, tw
_h
I kz� N
ji
M
Mt
W
- V
_ESTAB CUA6h,Hods6.f
othiffle
",
A,
vm-
bei 2
... ........
�4,1
&
T',
_U
=4
LOCATED AT
v vww"l
A
Tl
J-
AC
M iTI� ------
I XpjreS_ . Fee
Permit Type, 14�iwft No." Issued Permit E4,��
-,FOOD SERVICE�
- BHP-201402V7Q',- j
0
W-A_N7JT, V5
T-t�gjan161� ii ! 10
4ESTABLISIMENl A 9JQO
NOA,
74,
m-
sit Fees- Q *g f,
$1400
gr,i
0 gw
K AP
mgZ,WW-�
mw
-C` -I- -
In—
'A &V 3-M
T T_
IT
TT
k4,
4T�
x�
6A
2-
'M IM ss"0WO R lv
11%
IT
A,
* A-, - Al
WTV
0,W
A 2
3-
'mow
PERMIT EXPIRES,
nuer,J I ZQ14 p
w
xa7-E
i'V A
"TV
V-Bodird-of Health ?�
io� T_
TT
-N- V
M gq
Zn
g
&
vi
�Zk
99This Permit is
not itnj&ej,lbk"and must be reissued upon change of ownership Jorloc a tion T:heiieA@
11,1114,
v
iu_a prominent the Eitiblisfiin&A.;�tk
In accordance with thiSfate 9anftirCodq;'�be_ofre4n_ U ,
h
improvements,,orequipmence anLgy
y revona ons,
'7
all plans,6 such must be'sobirdtted-toandby.,lheSalem,Board*'of,Health
TA,
WE
TV
Y
%
TT
CITY OF SALEM, 1P
MASSACHUSETTS rbtn
BOARD OP HILAI.II-I `••�.,.o.,....� .
120 WASHINGTON SIReIrT,411^F1 OOR
KIMBERLEY DRISCOLL Tel..(978)741-1800 FwY(978)745-0343 LARRY R,, vW IN,RS/REI-IS,C1 10,C13-1�S
MAYOR Ir=djniQsakm.com HEAL:rH A(iF.N'r
Food Establishment Permit Application
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name: ` C.�S�o N O s ` k O F : S
2) Establishment Address: '-431 R - tr kN S�
3) Establishment Mailing Address(if different):
4) Establishment Telephone No: C'j 1 - 1 y \ , y y
5) Applicant Name&Title: r
8) Applicant Address:
7) Applicant Telephone No: g1$ lit S- x9 0, 24 Hour Emergency No: Email: h36 Ua,,Lao- Co • Cc
8) Owner Name&Title(if different from applicant):
9) Owner Address(if different from applicant):
10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of
officers or partner.
An association Name Title Home Address
A corporation
An individual
A partnership
Other legal entity
12 Person Directly Res onsible For Daily Operations Owner, Person in Charge,Su ervisor,Manager,etc
Name&Title: �'-3 , 1 1 , V � \- o p„
Address: 3 S )-'--s , , ` ct S�- S a` e �
Telephone No: ci-1 8,y a7S- 2) Fax: �i 78'�4 S &&9 y Email: WG U a,,Lo a 0-0 - ^^
Emergency Telephone No:
13) District or Regional Supervisor(if applicable)
Name&Title: - \ \\
Address:
Telephone No: q1£s —I 1�� ' a-9 0'7 Fax: X115 14 5 ly Email: a o ^C G-o 1 .C_o
Check#: Date:-- / Z7� Amount: "
-i Food Establishment Information
l 14) Water Source: 15) Sewage Disposal:
DEP Public Water Supply No: ( if applicable)
16) Days and Hours of Operation.-T - Ste' N 1'.30-'T.30 17) No. of Food Employees:
18) Name of Person in Charge Certified in Food Protection Management:
Required as of 101112001 In accordance with 105 CMR 590.003(A)
19) Person Trained in Anti-Choking Procedures(if 25 seats or more): ❑ Yes No
20) Location: 22) Establishment Type(check all that apply)
(check one) ❑ Retail( Sq. Ft) ❑Caterer
Permanent Structure✓ ❑ ood Service-( Seats) ❑ Frozen Dessert Manufacturer
Mobile fJ Food Service-Takeout ❑ Residential Kitchen for Retail Sale
❑ Food Service-Institution ❑ Residential Kitchen for Bed and
Meals/Day) Breakfast Home
Food Delivery ❑ Residential Kitchen for Bed and
21) Length Of Permit: -Breakfast Establishments,„ ,,,,„ ,,,,,,,,,,,„
.............................................................................
(c cit one) RETAIL STORE R TAURANT
Annual ✓ ❑Less than 1000sq.ft. $70 Less than 25 seats $140
Seasonal/Dates: ❑1000-10,OOOsq.fL $280 ❑ Residential Kitchens $140
❑More than 10,OOOsq.ft. $420 ❑25-99 seats $280
❑More than 99 seats $420
Temporary/DatesMme: ------ ....................................... .......... 0
............................................. .....6--------
❑Bed&Breakfast/Childcare Services(Nursing Home $10
ADDITIONAL PERMITS
❑MAKE ICE CREAM,YOGURT/SOFT SERVE $25
❑ PASTURIZATION $25
❑ALL NON-PROFIT” $25
*Including, church kitchens,state funded childcare&private club
23) Food Operations: Definitions: PHF-potentially hazardous food(timdtemperature controls required)
Non-PRFs-non-potendally hazardous food(no time temperature controls required)
(check all that apply): RTE-ready-to-eat foods Ex.sandwiches,salad;muffins which need no further processing
Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held
Pre-packaged Non-PHFs for More Than a Single Meal Service
Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly
Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility
Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill
Prepared by Consumer
Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance
Processed Foods for and/or HACCP Plan(including bare hand
Service Within 4 hours contact alternative,time as public health
control.
Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of
Non-PHF and Non- Retail Sale Animal Origin
Perishable Foods Only
Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered
Retail Sale Events or Institutional Food Service
Offers RTE PHF in Bulk Quantities
To be completed by the Board of Health
Retail Sale of Salvage,Out of Date
or Reconditioned Food Total Permit Fee:
Payment is due with application
1,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will
comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR
590.000 and the Federal Food Code.
24) Signature of Applicant:
Pursuant to MGL Ch.62C,sec.49A,I certify under the penalties of perjury that I,to my best knowledge and belief,
Have filed all state tax returns and paid state taxes required under law.
25) Social Security Number or Federal ID:
26) Signature of Individual or Corporate Name:
Inspection of � _4 Date Time
Name_ Cw2�'rot1. I �c ..✓� v� Address a'�' �� 10 S'_L
Owner LL f i k-.A y`/QA^ �eo 1.D Tel. No.
Type of Inspection Inspector Ul±�
( '�) QRemarks aand�Violations are listed below: V4,1
,. CA^
u�
3
Report Received by:
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,0 Floor
Division of Food and Drugs Salem, MA 01970-3523
Tel. (978) 741-1800 Fax(978) 745-0343
City/Town of Address:
FOOD ESTABLISHMENT 114SPECTION REPORT Tel.
Name / Dat Type ofOperation(s) Type of Inspection
y1daisri Food Service ❑Routine
Address r ✓ R' k E Retail N Re-inspection
Telephone Level ❑ Residential Kitchen Previous In pe ion
❑ Mobile Date: �/6/17
Owner HACCP YIN ❑ Temporary ❑ Pre-operation
s0 ❑ Caterer ❑Suspect Illness
Person-in-Charge(PIC) It �t Time ❑ Bed&Breakfast ❑ General Complaint
insjZt� ❑ HACCP
Inspector Ou ,-t!-D 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-(Red
Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑
Allergen Awareness 590.009(G) ❑
corrective action as determined by the Board of Health.
_FOOq;PROTECTION MANAGEMENT._ _ - ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
.._--_ ,_� �..��-. ❑ 13. Handwash Facilities
EMPLOYEE HEALTH -
IONI
❑ 2. Reporting of Diseases by Food Employee and PIC PROTECT..... OM'CHEMICACS"
El 14.Approved Food or Color Additives
El3. Personnel with Infections Restricted/Excluded
--_- _ -._ _ ❑ 15 Toxic Chemicals
-FOODFROM APPROVED SOURCE_
F14. Food and Water from Approved Source ;TIME-ItEMPERATURE:CONTROLStP,otentlalty MaxerdousFocds)'
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy.of Ingredient Statements ❑ 17.Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑18.Cooling
-PROTECTION FROM CONTAMINATION___ _ -= El 19.Hot and Cold Holding
❑ 8.Separation/Segregation/Protection ❑20.Time as a Public Health Control
❑ 9. Food Contact.Surfaces Cleaning and Sanitizing )REQUIREMENTFORHIGLY. USCEPTIBLE-POPULATIONS[HHSSP);
El 10. Proper Adequate Handwashing E]21. Food and Food Preparation for HSP
❑ 11.Good Hygienic Practices fCONSfCONS ADVISORY_
❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices-(Blue Number of Violated Provisions Related
Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22):
of Health. Noncritical (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)(590.0 order of the Board of Health. Failure to correct violations
24. Food and Food Protection (FC-0x590.0044))) cited in this report may result in suspension or revocation of
Equipment and Utensils (Fc•axsso.00s) the food establishment permit and cessation of food
26. Water Plumbing and Waste (Fcsxsso.00s) establishment operations. If aggrieved by this order,you
27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing
9 9 q 9
28. Poisonous or Toxic Materials (FC-7x590.00&) 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 bfJ dac
KQIC ✓V .
Inspector's Signature: Print _
PLCs Signature: Print: Page of ZPages
Violations Related to Foodborne Illness
Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT 8 1Crass-contamination
3-302.1.1(A)(1,) Raw Animal Foods Separated from
1 590.W3(A) Assi tratent ofRes Knowledge*
- Cooked and RTE Foods*
590.W3(B) Demonstration of Rnowled e* Contamination from Raw Ingredients
2-103.11 Persan in charge-duties 3-302.1.1(A)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Other*
Contamination from the Environment
2 590.W3(C) Responsibility of the person in charge to 3-302.1.1(A) Food Protection*
require reporting by food employees and 3-30215 Washing Fruits and Vegetables
applicants,* 3-304.11 Food Contact with Equipment and
590.003(F) Responsibility Of A Focal Employee Or An
Utensils*
Applicant To Report To The Person In Contamination from the Consumer
Charge* 3-306.14(A)(B Retuned Food and Reservice of Food*
590.003 G Reporting b Person in ions*Charge* Disposition of Adulterated or Contaminated
e' Restrictions*3 590.W3 D Ezelu.tonsandR str ons
( ) Fuad
590.003(E) Removal of Exclusions and Restrictions 3-101.1 t Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Food* _
q Food and Water From Regulated Sources F9 Food Contact Surfaces
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water
3-201.12 Ftxxl in a Hermetically Scaled Container* Sanitization Ternperatureo,
3-201.13 Fluid Milk and Milk Products* 4-501.1 L2 Mechanical Ware-washing-Hot Water
3-202.13 Shell Eggs* - Sanitization Te eratures*
Eggs E =s and Milk Products.Pastentized* 4-501.114 Chemical Sanitization-temp.,pH,
3-202.16 lee Made From Potable Drinking Water* concentration and hardness.
5-101.11 Drinkinte Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and
Utensils Clean*
590.006(A) Bottled Drinking d Water' 4-60211 Cleaning Frequency of Equipment Food
-
Shellfish
Water Meats Standards in 31 D CMR 22.0* . Contact Surfaces and Utensils*
SheJtfrsh and Frsh From an Approved Souroe -
3-201.14 Fish and Rec eatioaa!ly Caual t Molluscan4-702.11 Frequency of Sanitization of Utensils and' Foal Contact Surfaces of Equipment*
ShelLish` 4-703.11 Methods of Sanitization-Ha Water and
3-201.15 Molluscan Shellfish from NS5^r Likted Chemical*
Sources* to Proper,Adequate ffandwashing
Regulatory Authority
Game and Wad ooms Approved by 2-301..1.1 Clean Condition-Hands and Arms*
3-202.18 Shellstock Identification Rresem* 2-301..12 -Cleaning Procedure*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201.17 Game Animals" 11 Good Hygienic Practices
5 Receiving/Condition 2401.11 Eatin ,Dri ng or Using Tobacco*
3-202.1.1 PHFs Received at Proper Temperatures* 2401,12 . Discharges.From the Eyes,Nose and
3-202.15 Package Inte it * - Mouth*
3.11)i .11 _ Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting*
6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* 590.0(9(F) Preventing Contamination from
3-203.12 Shellstock Identification Maintained" Employees*
Tags/Records:Fish Products 13 Handwash Facilities - -
3-402.11Parasite Destruction*
Conveniently Located and Accessible
3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities*
590.004 .� Labeling of Ingredients" - 5-204.11 Location and Placement*
7 Conformance with Approved Procedures 5-205.11Aceessibili ,0 ration and Maintenance
/HACCP Plans Suppfred with Soap and Hand Drying
3-502.11 Specialized Processing Methods* Devices
3-502.12 Reduced oxygen packagm&criteria* 6-301.11 Handwashing Cleanser,Availability
8-103.!2 Conformance with Approved Procedures* - 6-301..1.2 HaudDrying Provision
"Denotes critical item inthe federal:1999 Forxl Code or 105 CMR 590.0(N),
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: 10ey— Date: Pager_ o&=�
Item Code C-Crnleal Item DESCRIPTION OF VIOLATI N/PLAN OF CORRECTION Date-
No. Reference R-Red Item Verified
PLEASE INT CLEAR Y
6 hJ C
6
Discussion With Person in Charge: Cor rec a Action Required: ❑ No s
I have read this report, have had the opportunity to ask questions and agree to correct ailVoluntary Compliance ❑ Employee 816striction/
Exclusion
violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled Cl Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of tw ty-five dollars ors pension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
�t ❑ Voluntary Disposal 0 Other:
t
Y Iw
3-501.14(C) PHFs Received at Temperatures
Violations Related to Foodborne illness Interventions and Risk According to Law Cooled to
Factors(Reins 1-22) (Cont) 41'F/45`F Within 4 Hours.
PROTECTION FROM CHEMICALS 3-501.15 Cooline Methods for PHFs
14 Food or Color Additives 19 PHF Not and Cold Holding
3-202.12 Additives* 3-50116($) Cold Plirss Maintained at or below
3-302.14 Protection.from Unapproved Additives* 590.004(F) 410/450 F
t 3-50L16(A) Hot PHFs Maintained at or above
1 gg Poisonous or Toxic Substances _ *
7-101.11 Idemitying Information-Original 140 .
[ - 3-501.16(A) Roasts Held at or above 130'F.
Contaiaers*
# Time as a Public Health Control
7-102.11. Common Name-Working Containers*
*
3-50L19 Time as a Public Health ComroP
7-201.11 Separation-Stora
7-202.11 .Restriction-Presence and Use* - 590.004(H} Variance Req
uiremem
7-20212 Conditions of Use*
7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POP
7-204.11 Sanitizers,Criteria-Chemicals* 21 ;-$41.1.7(A) U(A) Unpapasteurized Pre-packaged Juices and
DNS HSP
7-204.12 Chemicals for Washing Produce,Criteria* Ig
7-204.14 'n encs,Criteria° :Bevzra*es with Warn
3-$01. Labels*
11($) Use of Pasteurized B
7-205.11 Incidental Food Contact,Lubricants* 3-80L 1 I(D) Raw or Partially Cooked Anin-W Food and
r
7-205.11 Restricted Use Pesticides;Criteria' Raw Seed Sprouts Not Served-
2-206.12 Rodent Bait Stat ons* 3-801.11(C) Unopened Food Package Not Re-served.
? 7-206.13 Tracking Powders,Pest Control and _
Moritcuin * CONSUMER ADVISORY
f TIMEIfEMPERATURE CONTROLS 22 3-603.I1 Consumer Advisor Posted for Consumption of
16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or
Not Otherwise,Processed to Eliminate
4
PHFs Paiho*ens.*t7rx�re varix,
!, 3-401.IIA(1)(2) Egos- 155`'F 15 See.
Eegs-.immediate Service 145°Fl5sec* 3-302.13 1 PasteurizedEggs Substitute for Raw Shell
6 3.401.11(A)(2) Comminuted Fish.Meats&Game E
Animals-155'F 15 sec_*_
SPECIAL REQUIREMENTS
( 3401.11( )(1)t2) Pork:and Be - 130°F 121 min*
3-461.11(AA)(2) Ratites,Injected 590-009(A)-(D) Violations of Section 590.009(A)-(D):m
i injected Meats
ats-155°F 15
i sec.
* catering,mobile food,temporary and
t 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
W
Poultry or Ratites-165°F 15 sec, * above if related to foodborne illness
3401.11(C)(3) Whole-musde,Intact Beef Steaks interventions and risk factors. Other
145°F" 590.009 violations relating to gaol retail
3-401.12 Raw Animal Fntxts Cooked in a practices should be debited under#29-
Microwave 165°F* Special Requirements.
3-40111(A)(1)(b) All Other PHFs-145 F 15 sec.
I7 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
340111044(D) PHFs 165'F 15 see. * (Items 23-30)
3-40.11 Microwave- 165`F 2 Minute Standing -Critical,and non-critical violations,which do not relate to the
Time* foodborne illness interventions and risk factors listed above, can-be
3-403,11(C) Commercially Processed RTE Food- found in the following sectionsofthe Food Code and 105 CMR
1400F* 590.U00.
3-403.11(E) Remaining Unsliced Portions of Beef i #ern l Good Retail Practices FC 590.400 i
Roasts* 23. + Management and Personnel 1 FC-2 .003
24. i Food and Food Protection I FC-3 .004 j
1$ Proper Cooling of PHFs t 25. 1 Equipment and Utensils i FC-4 .005 l
3-501.14(A) Cooling Cooked PHFs from 140`F to 126, Water.Plumbing and Waste }FC-5 .006 1
r 70-"F Within 2 Hours and From 70°F 27. I Physical Facility FC-6 - R07
to 4I'Fl45'F Within 4 Hours. * i 28. 1 Poisonous or Toxic Materials i FC-7 008
y 3-501.14($) Cooling PHFs Made From Ambient r29. -Special Requirements - - .609
Temperature Ingredients to 41'Fi45'F 30 1 Otho`
Within 4 Hours* sy°cr m�.o.ad
I
'Dews%critical moa in the federal 1999 FomI Cale a 105 QJR 590.000.
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,40' Floor
Division of Food and Drugs Salem, MA 01970-3523
Tel. (978)741-1800 Fax (978) 745-0343
City/Town of Address:
FOOD ESTABLISHMENT INSPECTION REPORT Tel.
Name ^ C` Date Type ofOperation(s) Type of inspection
(,✓ V Food ServiceRoutine
Address r t0 Ris Retail n Re-inspection
Telephone Level ❑ Residential Kitchen Previous Inspey�ion
_ ❑ Mobile Date: /3�.�--/,}
Owner HACCP YIN ❑ Temporary ❑Pre-opera ion
U. (I O N V ❑ Caterer ❑Suspect Illness
Person-in-Charge(PIC) r� Time ❑ Bed&Breakfast ❑General Complaint
In:l f co ElHACCP
Inspector41� Out: Permit No. E3-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 Factorstems) _(Red Anti-Choking 590.009(e) ❑
IViolations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑
Allergen Awareness 590.009(G) ❑
corrective action as determined by the Board of Health.
} FOOD:PROTECTION MANAGEMENT _ ❑ 12. Prevention of Contamination from Hands
El 1. PIC Assigned/Knowledgeable/ Duties
❑ 13. Handwash Facilities
EMPLOYEE HEALTH . - .. _ _ - -i . . _
,PROTECTIM'CON FROHEMICACS__
❑ 2. Reporting of Diseases by Food Employee and PIC
El3. Personnel with Infections Restricted/Excluded El 14.Approved Food or Color Additives
_ ._. 4_. _ _-. --.__ - _. . . _ . -1 ❑ 15.Toxic Chemicals
.FOOD_:FROM APPROVED SOURCE._ , __ _ .
E] 4 Food and Water from Approved Source
TIMEREMPERATURE.CONTROLS(l?otentiallyHazardousF..00d9) y,
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy.of Ingredient Statements ❑ 17.Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling
.PROTECTION FROM CONTAMINATION _ _. _ - 519. Hot and Cold Holding
❑ 8. Separation/Segregation/Protection ❑20.Time as a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing <iREQUIREMENTS FOR;HIOHLYSUSCEPTIBLE4POPULATIONS`(H812)_J
❑ 10. Proper Adequate Handwashing
E]21. Food and Food Preparation for HSP
_ _ _
❑ 11. Good Hygienic Practices C__ONSUMER`ADVISORY� + _
❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related
Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22):
of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590-000/federal Food Code.This report,when signed below
C N by a Board of Health member or its agent constitutes an
23. Management and Personnel (Fc-zxs90.0 order of the Board of Health. Failure to correct violations
24. Food and Food d Utensils Protection (FC-3x590.0044)) cited in this report may result in suspension or revocation of
25. Equipment an (Fc-4x590.005) the food establishment permit and cessation of food
6. Water, Plumbing and Waste (FC-5x590.006) establishment operations. If aggrieved by this order,you
Physical Facility (FC-6x590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (Fc-7x590.008) 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. OtherDATE OF
RE-INSPECTION: dL� V`_0S b,aeac
Inspector's Signature: Print:
PICS Signature: - .,� Priv[: t J Pa 07-11/pages
• � ..� ,Y Y .. �. �' � �. �1-.'Y.Y �.s'�'._�1�� v��'Y. e�w�FnY.��r.�Fa• e r .. .. -dln-
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT F-8 - Cross-contamination
1 590.003(A) Assignment of Responsibility*
3-302.11(A)0) Raw Animal Foals Separated from
Cooked and RTE Foals*
590.003(B) Demonstration of Knowledge` - Contamination from Raw Ingredients2-103.11 Person in charge-duties 3-302.1.1(A)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Other*
Contamination from the Environment
2 590.003(C) Responsibility of the person in charge to 3-302.11(A) - Food Protection*
require reporting by foot employees and 3302.15 Washing Fruits and Ve etables
applicants* 3304.11 Food Contact with Equipment and
590A03(P) Responsibility Of A Food Employee Or An
Applicant To ReportTo 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*
Disposition of Adulterated or Contaminated
-
3 . 590.003(D) Exclusions and Restrictions* Food
590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding-
or Reconditioning ung Unsafe
FOOD FROM APPROVED SOURCE Food-
4 Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) C'.om liance with:Food Law* 4-5(11.111 Manual Warewashing-Hot Water
3-201.12 Food in a.Hermetically,Scaled 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*
3-20114
em eratures*3-202.14 Eggs and Milk Products.Pasteurized* 4-501.114 Chemical Samlization-temp.,pH,
3-202.1.6 ice Made From Potable Drinking Water* concentration and hardness. *
5-101.1.t Dunkin Water from an A roved S tem* 4-601.11(Ai Equipment Food Contact Surfaces and
590.006(A) Boided Drinkine Water" Utensils Clean*
4-602.11 Cleaning Frequency of Equipment Food
590,006(B) Water Meets Stand rds is 31.0 CMR 22.0*
Shel%ish and Fish From an Approved Source Contact Surfaces and Utensils'"-
4-702.1 i. Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationaliy Caught Molluscan Food Contact Surfaces of E ui men(*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and
3-201.15 Molluscan Shellfish from NSSPLasted C
Soares* hemical*10 Proper,Adequate Handwashing
Regulatory Authority Game and WildMushroomsApproved by 2-301..11 -
- Clean Condition , Hands and Arms*
3-202.18 ShellstockidentificationIrescm* 2301._12Cleanin Procedure*
590,004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201.17 Game Animals* - 1.1 Good Hygienic Practices
S Re.ceivingrCondition 2401.11 Eating,Drinking or Usina Tobacco*
3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges.From the Eyes,Nose and
3-202.15 Package Lie,it * - Mouth*
3401.1 i Food Safe and Unadulterated* 3-30(.12 Preventing Contamination When Tasting*
6 1 TagstRecords:Shelistock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* 590.004(F.) Preventing Contamination from
3-203.12 Shellsto:k Identification Maintained* Employees*
Tags/Records;Fish Products 13 Handwash Facilities
3402.11 Parasite Desttuedon* Conveniently Located and Accessible -
3-402.12 Records.Creation and RCetention" 5-203.11 Numbers and Capacities*
590.004(1) Labeling o1 Ingredients* 5-204.11 Location and Placement*
7 Conformance with Approved Procedures 5-205.11 1-Accessibility,Operation and Maintenance
IHACCP Plans Supplied with Soap and Hand Drying
3-502.11. Specialized Processing MethWs* Devices
3-502:12 "ng.criteria* `6-301.11 Handwashin Cleanser,Availability
8-103.12 Conformance with An roved Procedures* 6-301.1.2 Hand Drying Provision
DenoW cruad item inthe federal 1999 Paxi Code or 105 CMR 590.000.
CITY OF SALEM
✓��// BOARD OF HEALTH
Establishment Name:T-11-d.�f U—�iss �2+ P Date: Pager_ of
44
Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date-
No. Reference R-Red Item Verified
PLEASE RANT CLEARLY
.VA r - o tiJ c t
L 45 i.J
e74t
(iJ r-v a-
Jirlb,
Lz A A
r ,
L'7-)r`I /U S1
'41'b3 , 1, �.
Discussion With Persoh in Charge: Corrective Action Required: ❑ No Y
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Rels1riction/
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 dollars or uspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. C/� , /
✓CIL ,� ❑ Voluntary Disposal ❑ Other:
3-501.14(0) PHFs Received at Temperatures .
Violations Related to Foodborne fitness Interventions and Risk According to law Cooled to
Factors(Hems 1-22) (Cont.) 41'Ff4_5°F Within 4 Hollis.
PROTECTION FROM CHEMICALS 3-501.15 Coolie Methods for PHFs
r 14 - - - 29 PHF Hot and Cold Holding
Food or Calor Additives
" 3202.12 Additives*' 3-501.16(B) ColdPl3FaMantainedatorbelow
1 590.004(F) 41'145°F*
3-302.14 Protection from Unapproved Additives" 3-501.16(A) Hot PHFs Maintained at or above
15 Poisonous or Toxic Substances 1400F. *
7-101,11 Identifying Information-Original 3501.16(A) Roasts Held at or above l30'F.
Containers* r 20 Time as a Public Health Control
7-102.11. Common Name-Working Containers* - -
' 7-201.I I S oration-Stora e* 3-501:14 Time as a Public Health Cootrat*
7-202.11 ,Restriction-Presenceand Use*
590.004 PI) VarianceRe Requirement
7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP
7-204.11 Saradzers.Criteria-Chemicals*
7-204.12 Chemicals for Washin Produce,Criteria° 21 3-801.I I(A) Unpasteurized Pre-packaged Juices and
l;evetanes with Sl"
7-204.14 a Agents,Criteria* Eggs Labels*
7-205-11 Incidental Food Contact,Lubricants* =3-801.11(13) -Use of Pasteurized Eggs*
'r
7-206.11 Restricted Use Pesticides;Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food and
1 - - Raw Seed S uts Not Served,
7-206.12 Rodent Bait Stations* 3-801.11 C) Un ned Food Pac Not Re-served.
! 7-206.13 Tracking Powders,Pest Contra]and
Moniturin * - CONSUMER ADVISORY
' TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or
PHFs Not Otherwise Processed to Eliminate i
.Pathogens.*FMxers,naMr
3-40i.11A(1)(2) Eggs- 155F 15 Sec.
A-Immediate Sernicc 145_F15sec+ 3-302-13 1 Pasteruri.zed Eggs Substitute for Raw Shell
+ 3-401.11(A)(2) Comminuted Fish.Meats&Game E
Animals-155°F 15 see.* SPECIAL REOUIREMENTS
' 3401.21(13)(1)(2) Port:and Beef Roast- 130°F 121 miu*
t 3-401.]I(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D') Violations of Section 590.009(A)-(D)in
jsec.* catering, mobile food,temporary and.
3-401.1.I(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 facturs. Other
145°F" 590.009 violations relating to good retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 1657* Special Requirements.
3401a1(A)(1)(b) All Other PHFs- 145°F 15 sec.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRAC77CES
3403A I(A)&(D) P1.7s 16ST 15 sec.* (Items 23-30)
3-403.11(13) Microwave--165`F 2 Minute Standing Critical,and non-critical violations,which do not relate to the
Time* foodborne illness interventions and riskfactors listed above, can 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.
i 3403.11(E) Remaining Unsliced Pordow of Beef Item 1 Good Retail Practices FC 590,wo
` Roasts` 23. 1 Management and Personnel :, FC-2 .003
1-
18 Proper Cooling of PRFs 24, Food and Food Protection FC-3 OOd
25. Equipment and Utensils 1 FC-4 .005
3-501.14(A) Cooling Cooked PHFs from 140°F to 26, 1 Water.Plumbinq and waste FC-5 .006
70°F Within 2 Hours and From 70°F 27. Physical Facility FC-6
to 41°Fl45°F Within 4 Hours. * 128. Poisonous or Toxic Materials i FC-7008
3-501.14(8) Cooling PRFs lblade From.Ambient Special R uiremenis i .009
I Temperature Ingredients to 41IF1456F 30, 1 Other - !
I Within 4 Hours"
'Dentis critical mai in the f dara1 1999 Fowl Code w10�CMR X90.000.
CITY OF SALEM
OARD OF HEALTH
Establishment Name: C s Date: Page.-,> of
Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date,
No. Reference R-Red Item Verified
PLEASE PAIVT gLEARY
l ��s14 ! '
Mud-
V) -
Wo ,C J
i'
\ _ Tcq
Discussion With Person in Charge: Corrective Action Required: ❑ No as
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ vol Cary compliance ❑ Employee R friction/
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 tw my-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. /"/'o�w- L— 1
0 Voluntary Disposal ❑ Other:
3-i01.14(C) PRFs Received at Temperatures
Violations Related to Foodborne Illness interventions and Risk According to Law Cooled to
Factors ffrerns 1-22) (Cant.) 41'F/45F Within 4 Hours,
PROTECTION FROMCHEMICALS 3-501.15 Coolie Methods for PRFs
14 Food or Color Additives 19 Mile Hot and Cold Hptding
._-._......_._._ 3-501,16(13) ColdPIlFsMaintained atorbelow
3,202.52 , Additives* _ 590.004(17) 45°/4S'F*
3-302.14 Protection from Unapproved Additives" 3-501.16(A) - Hot PRFs Maintained at or above
15 Poisonous or Toxic Substances 1400P. * .
7-101,11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130'F.
Containers* 2® Time as a Public Health Control
7-102.11. Common Name-WorkingContainers* 3-501:i9 Time as a Public Health Control
7-201.11 Separation-Stora * - 590.004 H) Variance Requirement
7-202.11 .Restriction-Presence and Use* - - -
7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPT16LE
7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP
7-204.11 Sanidzers.Criteria-Chemicals* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
7-204.12 Chemicals for Waa'
shut Produce,Criteri
Bevera es with Warning Labels*
7-204.14 Drying Agents.Criteria* 3-80IA I(B) Use of Pasteurized E *s*
7-205.11 Incidental Food Contac,Lubricants*
7-206.71 -Restricted Use Pesticides;Criteria* - 3-$01..11(D) Raw or Partially Cooked Animal Food and
Raw Seed Sprouts Not Served
7-306.12 Rodent Bait Stations* 3-801.11 C Unopened Food Package Not Re-served. `
7-206.13 Tracking Powders, Pest Control and
Monitoring* CONSUMER ADVISORY
TiME1TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
Animal Foods That are Raw.Undercooked or
16 Proper Cooking Temperatures for Not Otherwise.Processed to Eliminate
PHFs - Pathogens.*eRvC�"'P"'
3-40i,11A(l)(2) Egs- 155`1715 Sec.
E as-Immediate Service 145'F15see• 3302.13. Pasteurized Eggs Substitute for Raw Shell
E
3-401.11(A)(2) Comminuted Fish.Meats$Game
Animals-155'F 15 sec.
SPECIAL REQUIREMENTS
3.401.11(11)(1)(2) Pork and Beef Roast-130'17 121 min*
j 3-401.71(A)(2) Ratites,Injected Meats-155'F 15 590.009(A)-(D) Violations of Section .590.009(A)-(D)in
sec.* catering, mobile food,temporary and
3-401.1 t(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
! 3401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
t 145°F* 590.009 violations relating to good retail
I 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165'F* Special Requirements.
3401.11(A)(1)(b) All Other PRFs- 145'F 15 sec.
17 Roheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3 113.11{A)&{D} PHFs 16ST 15 sec.* (Items 23-30)
3-403.11(B) _ Microwave--165'F 2-Minute Standing Critical,and non-critical violations, which do not relate to the
Time" - - foodborne illness inten'entionr and rix&factors listed above, can be
3-403.t 1(C) Commercially Processed RTE Food- found in the following sectionsof the Food Code and 105 CMR
140T* 590.000.
3403.1l(E) Remaining Unsliced Portions of Beef Hem ( Gard Retail Practices 1 FC I 540Dw i
Roasts" 23. i Management and Personnel {-FC-2 .003 l
24 1 Foci and Food Protection FC-3 .004
18 Proper Cooling of PHFs
125. lEquipment and Utensils 1 FC-4 .005
3-501.14(A) Cooling Coked PRFs from WF to r26, 1 Water.Plumbing and Waste FC-5 .006
'( 70'F Within 2 Hours and From 70°17 27. I Physical Facili
to 41`F/45'F Within 4 Hours.* -28__ Poisonous or Toric Materials FC-7 .008
3-501.74(8) Cooling PHR Made From Ambient 29. 1 Special Requirements .009
1 Temperature Ingredients to 4I'Fl45°F 30. Other
t _I Within 4 Hours* sssar��a�;ca.e -
*Denores critical item in the f&=1 1999 FwA Cate a 105 CMR 590.000. -
J
Commonwealth of Massachusetts- ; :.
10-
= ��
• b City of Salem ;s = '
y 4 iF .
Board of Health 3. Kimbefley Driscoll ;,v,
a � 120 Washington Street,4th Floor x &MByOr '
v i� iM
SALEM,MA 01970
n <
FotidlRetail Establishment PermM .
lt
s
DATE PRINTED. ` 12/18/2012
k
t
1
ESTABLISHMENT NAME: ,- Custom House Rotisserie
File Number 6HF-2010-000056 " 282 Derby Street Unit 2104,
n
d s
£ SALEM � MA,_01970 ;' r
LOCATED AT:
SALEM, MA 01970
r7
Permit Type Permit No. Permit Issued Permit Expires - Fee Restrictions/Notes' N c
FOOD SERVICE BHP-2013-0232 '.-Jan 1,2013- Dec 31 2013 '$140.00
ESTABLISHMENT
' . Total Fees $146.66'
s� V.
n v e' °a `
=z
K
�#ae
PERMIT EXPIRES .December' 31-,2013 Elk
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted ^
in a prominent location in the Establishment: '
In accordance with the State Sanitary Code,beofre any.revonatlons,improvements,or equipment changes are made,
all plans for such must be submitted to and'approved by the Salem Board of Health. Paget. '
Zr
4,0
3 _ k
fe
CITY OF S.ALF.M.
' MASSACHUSETTS ;�exe Ith
p�.�rp7,wp BOARD of HPn1
: .TFi
� 1� ����l�G�d l41 \SIi1NGCON$ 'I
nz[.n ',4P1FLOOIL F-1.1 PP�1[
KIMBERLEY DRISCOLL CC 201�r1-(978)741-1800 FAx(978)745-0343 LARRY RANIDIN,R,S/RI.I-IS,CHp,(P-FS
MAYOR QCC 1 1tamdinQsalcm.com I- FAL n—i AGENI'
CII f 4& HF1A-IK
B °
�`Food Establishment Permit Application
(Application must be submitted at least30days before the planned opening date)
1) Establishment Name:
2) Establishment Address:
3) Establishment Mailing Address(if different):
4) Establishment Telephone No: a)4
5) Applicant Name&Title: ��" 1;
6) Applicant Address: 'lam 1 Q
7) Applicant Telephone No: 9G7 24HourEmergency No:97&-y;23 �"i Email: So1e,..0kde-001•co
8) Owner Name&Title(if different from applicant):
9) Owner Address(if different from applicant):
10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of
officers or partner.
An association Name Title Home Address
A corporation
An individual ✓
A partnership
Other legal entity
12 Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor,Manager,etc.
Name&Title: I
Address: 35 v ,' ff //
Telephone No: G-1"a- H- L"� Fax: G? ES p,--7Y9-REmail: 5o4lct- 646 s 6 �' co-\
Emergency Telephone No:
13) District or Regional Supervisor(if applicable)
Name&Title:
Address: 3rj v r\
Telephone No: Fax: /JEmail:
Check#/ Y60— Date:�� Amount: �/
Food Establishment Information
14) Water Source: 15) Sewage Disposal:
DEP Public Water Supply No: ( if applicable) =7
16) Days and Hours of Operation: 17) No.of Food Employees:
18) Name of Person in Charge Certified in Food Protection Management:
Required as of 101112001 in accordance with 105 CMR 590.003(A)
19) Person Trained in Anti-Choking Procedures(if 25 seats or more): ❑ Yes No
20) Location: 22) Establishment Type(check all that apply)
(check one) ❑ Retail( Sq. Ft) ❑ Caterer
Permanent Structure ❑ Food Service-( Seats) ❑ Frozen Dessert Manufacturer
Mobile XFood Service-Takeout ❑ Residential Kitchen for Retail Sale
❑ Food Service-Institution ❑ Residential Kitchen for Bed and
( Meals/Day) Breakfast Home
❑ Food Delivery ❑ Residential Kitchen for Bed and
21) Length Of Permit: ------------------------------------------------------------Breakfast-Establishments
....------ -
(check one) RETAIL STORE Vg
TAURANT
Annual ❑ Less than I000sq.ft. $70 Less than 25 seats $140
Seasonal/Dates: 0 1000-10,000sq.ft. $280 ❑ Residential Kitchens $140
❑ More than 10,000sq.ft. $420 ❑25-99 seats $280
❑-More than 99 seats $420
- - --- -- ------ ----- --- -- ---- -- -- -- -------- --- --- ---
Temporary/Dates/Time: - - --
❑ Bed&Breakfast/Childcare Seryices/Nursing Home $100
-------------------------------------I-------------------------------
ADDITIONAL PERMITS
❑ MAKE ICE CREAM, YOGURT/SOFT SERVE $25
❑ PASTURIZATION $25
❑TOBACCO VENDOR $135
❑ALL NON-PROFIT $25
(Including, church kitchens, state funded childcare 6 private clubs)
23) Food Operations: Definitions: PHF—potentially hazardous food(timeltemperature controls required)
Non-PHFs—non-potentially hazardous food(no time(temperature controls required)
check all that apply): RTE—ready-to-eat foods(Ex.sandwiches,4alads,muffins which need no further processing
Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held
Pre-packaged Non-PHFs for More Than a Single Meal Service
Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly
Pre-packaged PHFs Cold Holding for Single Meal Service ° Susceptible Population Facility
Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill
Prepared by Consumer
Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance
Processed Foods for and/or HACCP Plan(including bare hand
Service Within 4 hours contact alternative,time as public health
control.
Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of
Non-PHF and Non- Retail Sale Animal Origin
Perishable Foods Only
Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered
Retail Sale Events or Institutional Food Service
Offers RTE PHF in Bulk Quantities
To be completed by the Board of Health
Retail Sale of Salvage,Out of Date
or Reconditioned Food Total Permit Fee:
Payment is due with application
I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will
comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR
590.000 and the Federal Food Code. / yn
24) Signature of Applicant: // (N/
Pursuant to MGL Ch. 62C, sec.49A, I certify under the penalties of perjury that I,to my best knowledge and belief,
Have filed all state tax returns and paid state taxes required under law.
25) Social Security Number or Federal ID: 0Z,7- S O d 7S
26) Signature of Individual or Corporate Name:
Commonwealth of Massachusetts
i City of Salem
Board of Health Kimberley Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 12/28/2011
ESTABLISHMENT NAME: Custom House Rotisserie
File Number:BHF-2010-000056 282 Derby Street Unit 2
SALEM MA 01970
LOCATED AT:
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
FOOD SERVICE BHP-2012-0122, Jan 1,2012 Dec 31,2012 $140.00
ESTABLISHMENT
Total Fees: $140.00
PERMIT EXPIRES Oecember 31, 2012
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted
in,a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any revonations, improvements,or equipment changes are made,
all plans forsuch must be submitted to and approved.by the Salem Board of Health. page 1
CITY OF SALEM, MASSACHUSETTS
BOARD OF HE..ACi'H
120 WASI-11NGTON SrR>vcT,4„.FLOOR
TEL. ()78) 741-1800
IQNiBEdtI1 1'DRISCOLL F_�x(978) 745-0343
NL \YOR Iramdi,1a sglem.com
LARRY RA NIDIN,RS/RHI IS,CI-IO,CI'-FS
Hh:V:!'}tAGk�aV'f
I
201 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME Ji= ESTABLSSHtvicNT S�a r. h10 ,ag� K of e_v t.TEL# �� -7 .A +- 14�q
ADDRESS OF ESTABLISHMENT oa&-4. TJ e-r V4v S"'(' FAX#
MAILING ADDRESS(if different)
EMAIL-Business': Website:
OWNER'S NAME ^^ y ^ Lo r. TEL# 1 4 a3 a8 a I
ADDRESS 35 v .} c.- O 1`}'l C5
STREET CITY - STATE ZIP
CERTIFIED'FOOD MANAGER'S NAME(S) E� ^ U d r\ a ” ' CERTIFICATE#(S) r3
(Required in an establishment where potentially hazardous food is prepared)
EMERGENCY RESPONSE PERSON l J ', '^M0.^�� HOME TEL#
DAYS OFOPERATION ' ,. MondayTuesday Wed nesd Thursda -` Friday Saturday ; Sunday
HOURS OF OPE WiTION
"?-36 I It.30 1.30 � tt-3b `7'30 11.80-~7 3a It'-3o^:36 tI S0 -'7!3a
Please r&rAe in time day,
P^
(Far example 11 am-11 pm
TYPE OF ESTABLISHMENT _FEE (check onlv)_
RETAIL STORE YES NO less than 1000sq.ft. =$70
1000-10,000selA. =$280
more than 10,000sq.ft. =$420
- - - - - - ---------- --------------- -------.--------- -
RESTAURANT YE. NO le::;than 2e sweat_ -$140
(Outdoor Stationary Food Cart$210) 25-99 seats =$280
more than 99 seats =$420
------- - - ------------ --------------------------- ---------- - . --------- ------------
BED/BREAKFAST/................. - -
YES NO $100
GHIIDCARE SERVICEStNtlf2SiNG HOME ------------- --------------- - ...... ------------- ----- -------
ADDITIONAL PERMITS
MAKE (not just serve)ICE CREAM, YOGURTiSOFT SERVE YES NO $25
TOBACCO VENDOR YES NO $135
ALL NON-PROFIT(such as church kitchens) YES NO $25
'Please pay total with one check payable to the City of Satem.
This Permit Is not transferable and must be reissued upon change of ownership.The Permit must be posted In a prominent location
in the Establishment..
In accordance with the State Sanitary Code,before any renovations,improvements,or equipment changes are made,all plans for
such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that 1,to my best knowledge and belief,have filed all state tax
returns and paid all state taxes required under the law. -
Signator - Date /Z 1 Social Security or Federal Identification Number
G „3,15 77 2 4
Updated 5/2 /11 FOODAP201 .adm Check#&Date_1
Massachusetts Department of Public Health Salem Board of Health
Division of Food and Drugs 120 Washington Street,0 Floor
Salem, MA 01970-3523
Tel. (978)741-1800 Fax (978) 745-0343
City/Town of Address:
FOOD ESTABLISHMEN' IN PEC ION REPORT Tel.
Name Dat Tyypeyf Operations) Type of Inspection
Epp'ood Service ❑Roug�'IIne
Address Risk ❑ Retail M R91nspection
Telephone Level El Residential Kitchen Previous Inspection
❑ Mobile Date:
Owner HACCP YIN
F1 Temporary [IPre-operation
❑ Caterer ❑Suspect Illness
Person-in-Charge(PIC) Time ❑ Bea 6,tbreakfast ❑ General Complaint
Inspector In Permit I ❑Other
CP
Out: ❑
Each violation ftecked requirbs arrex0lartation on the narrative pages)and a citation c f specific provision(s)violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors_(Red
Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑.
corrective action as determined by the Board of Health. Allergen Awareness 590.009(G) 1P/
FOOD;PROTECTION MANAGEMENT __ ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties +
EMPCOYEEHEALTH - ❑ 13, Handwash Facilities
- .._._ _. -- PROTECfIOMFROM`CHEMICALS' a -- _ ---
❑ [114.2. Reporting of Diseases by Food Employee and PIC
Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded
FOOD,
OO:FROM APPROVED S_OURC_E _ - [115.Toxic Chemicals
_ _
4. Food and Water from Approved_Sour�...ce_ TIMEfrEMP.EMT.URE.CONTROLSoi,otetifillykizaidoaF.6od ;
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17.Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans [118. Cooling
PROTECTION FROM CONTAMINATION _ _ - - 19. Hot and Cold Holding
❑ 8. Separation/Segregation/Protection ❑ 20. Time as a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR.HIGHLY-USCEPi18LEEPOPULATIONS(HSP)'
❑ 10. Proper Adequate Handwashing
El 21. Food and Food Preparation for HSP
' _ _
El 11. Good Hygienic Practices .CONSUMERADVISORY _ _ _
❑22. Posting of Consumer Advisories '^_ ,►-
Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related LJ
Items) Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors(Red Items 1-22)r
of Health. Noncritical(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. 590.0001federal Food Code.This report,when signed below
C N
23. Management and Personnel (Fc-2X590.003) by a Board of Health member or its agent constitutes an
24. Food and Food Protection (FC-3X590.004) order of the Board of Health. Failure to correct violations
25. Equipment and Utensils (Fc-aXss0.005) 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-6X590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7X590.008) 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. therDATE OF RE-INSPECTION:
S 614 r,�, I
r 1 r VC, W kl
Inspector's Sign Print: h
PICS Signature: Print: Page-Lof�Pages
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)(L) Raw Animal Foals Separated from
1 590.003(A) Asia ment of Res osibilit * Cooked and RTE Foods*
590.003(B) Demonstration of Knowledge Contamination from Raw ingredients
2-1.03.11 Person in charge-duties 3-302.11(A)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Other*
Contamination from the Environment
2 590.003(C) Responsibility of the person in charge to 3_302,11(A Foal Protection*
require repotting by foci employees and 3-302.15 WashingFruits and Vegetables
applicants* 3-304.11 - Food Contact twith Equipment and
590.003(F) Responsibility Of A Fuod Employee Or An
Utensils*
Applicant To Report To The Person In Contamination from the Consumer
Char e* 3-306.14(A)(.B) Returned Food and Reservice of Food*
G .
590.003 Reporting by Person in Charge* Disposition of Adulterated or Contaminated
31 590.003(D) Exclusions and Restrictions* Food
590.003j ) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Gnsafe
FOOD FROM APPROVED SOURCE Ford*
4 1 Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Cum pliance with Food Law* 4-501.111 Manual Wazewashing-Hot Water
3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures*
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water
3-202.13 Shell Eggs* - - Sanitization Tem atures*
3-202.14 Eggs and Milk Products.Pasteurizzd* 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 S-.tent* 4-601.11(A) Equipment Food Contact Surfaces and
590.006(A) Bottled Drinking Water=' Utensils Clean*
r 3 ,r� rr 4-602.11 Cleaning Frequency of Equipment Foal
5.,>0.006(B) Water Meets Standards in.1.0 CMR 2_.t,` Utensils*
U
Surfaces antensils
ShetNish and Fish From, an Approved Source Contact Sur -
4-702.11 Fr of Sanitization of Utensils and
3-201..14 Fish and Recreationally Caught?vloliuscan Frequency
Shellfish* - Foal Contact Surfaces of Equipment*
3-201.15 Molluscan Shellfish from`1SSP Izsted 4-703.11 Methods of Sanitization-Hot Water and
-
Sources* Chemical*
Game and Wild hfushrooms Approved by 10 Proper,Adequate Handwashing
Regulatory Authority 2-301.11 - Clean Condition-Hands and Arms*
3-202.13 Sheilstock Identification Presena* 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
S Receiving!Condition 2401.11 Eating,Drinking or Usina Tobacco*
3-202.11 PHFs Received at Proper Tem eratnres* 2401,12 Discharges:From the Eyes,Nose and
3-202.15 Package line_it.* Mouth*
3-i0i.11 Food Safe and Unadulterated* 3-30L12 Preventirt ContatunationWhen Tasting*
6 Tags/Records:Shel!stock 12 Prevention of Contamination from Hands
3-202.18 Shellstock identification* 590.004(E) Preventing Contamination from
3-203.12 Shelistock Identification Maintained* Employees*
Tags/Records:Fish Products 13 Handwash Facilities
3-402.II Parasite Desnve(ian*
Conveniently Located and Accessible
3-402.12 Reands.Creation and Retention* 5-203.11 Numbers and Capacities*
590.004(n labeling of Ingredients' 5-204.11 Location and Placement*
7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance
IHACCP Plans Supplied wk.h Soap and Hand Drying
3-502.11 Specialized Pra:essin :Meth(x)s* Devices
3-502.1.2 Reduced oxygen packaging,criteria* 6-301.11 - Handwashing Cleanser,Availability
8-103.!2 Conformance with App,ovedProcedures* 6-301.1.2 Hand Drying Provision
lleno[es critical item inthe federal 1999 Pox!Code or 105 CMR 590Mil.
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,0 Floor
Division of Food and Drugs Salem, MA 01970-3523
Tel. (978)741-1800 Fax (978) 745-0343
C.ity/ToINn of Address:
FOOD ESTABLISHMENIP ION REPORT Tel.
Name a Dat TType�f Operation(s) Type of Inspection
IniLl-'Food Service RRoutine
Addreh�h ' Rlsl I ❑ Retail ❑Re4nspection
TelephonLevel ElResidential Kitchen Previous Inspection
❑ Mobile Date:
Owner HACCP YIN [ITemporary ElPre-operation
❑ Caterer ❑Suspect Illness
Person-in-Charge(PIC) :In!:.
e ❑ Bed 6,Breakfast Ll General Complaint
�/ HACCP
Inspector ut: ermitNo. GTI( I ❑.Other
Each violaticierchickid req re n explanation on the narrative p&ge(s)ji3nd a citation of specific provision(s)violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors_(Red
Items) Anti-Choking $90.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑
q Allergen Awareness 590.009(G)
V
a action as determined by the Board of Health.OTECTION MANAGEMENT ? ❑ 12. Prevention of Contamination from Hands
C Assigned/Knowledgeable/Duties
t✓�-I Handwash Facilities
,,,,
EMPLOYEE HEALTH - - - ._. _ _ _ -.PROTECTION FROM'CHEMICALS -
❑2. Reporting of Diseases by Food Employee and PIC - -_
El3. Personnel with Infections Restricted/Excluded ❑ 14.Approved Food or Color Additives
❑ 15. Toxic Chemicals
FOOD;FROM APPROVED SOURCE
-'- - MRANTR (P _
❑ 4. Food and Water from Approved Source TIME(TEPETURE.COOLS .oteMlalry Hazardous F.00dS) _
❑ 5. [116.Receiving/Condition Cooking Temperatures
26. Tags/Records/Accuracy.of Ingredient Statements ❑ 17.Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑18. Cooling
_PROTECTION FROM CONTAMINATION _ _ ❑19. Hot and Cold Holding
❑ 8.separation/Segregation/Protectionw ❑20.Time as a Public Health Control
L-y Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FORS,HIGHLY:$USCEPTBLE=POPULATIONS;(HSP):,,
El 10. Proper Adequate Handwashing [121. Food and Food Preparation for HSP
❑ 11. Good Hygienic Practices pCONSUMERADViSORY _ �' '.
❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related
Items) Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22):
of Health. Noncritical(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-2x order of the Board of Health. Failure to correct violations
Food and Food Protection (Fc-3xs90.00 a)o.00a) cited in this report may result in suspension or revocation of
25. Equipment and Utensils (FC-4x590.005) the food establishment permit and cessation of food
26.Water, Plumbing and Waste (FCsx590.006) establishment operations. If aggrieved by this order,you
7. Physical Facility (FC-6x590.007) have aright to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7x590.008) and submitted to the Board of Health at the above address
EH.29. Special Requir ments (590.009) within 10 days of receipt of this order.
Other DATE OF RE-INSPECTION:
Inspector's Signature: Print:
PICsSignature: �. / Print: . Pagejof�Pages
Violations Related to Foodborne Illness
Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT 8 I Cross-contamination
1 590.003(A) AssignmentofResponsibility* 3-302.11(A)(l) Raw Animal Foals Separated from
Cooked and RTE Foods*
590.003(B1 Demonstration of Knowledge* Contamination from Raw Ingredrents
2-103.11. Person in charge-duties 3-302A 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 3-302A I(A) Food Protection*
require reporting by food employees and 3-302.15 Washrn Fruits and Vegetables
applicants* 3-304,1.1 Food Contact with Equipment and
590.003(F) Responsibility Of A Food Employee Or An
Utensils*
Applicant To Report To The Person In - Contamination from the Consumer
Charge*
590.003 Cr Reporting 6v Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food'*
Disposdion of Adulterated or Contaminated
3 590.003(D) Exclusions and Restrictions* food
590.003(E) Removal of Exclusions and Restrictions 1 3-701..11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Food
d Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Compliance with Food Law* -- 4-501..1.1 I Manual Warewashing-Hot Water
3-201.12 Food in a Hermetical)•Sealed Container* Sanitization Temperatures*
3-201.13 Fluid Milk and Milk Products* 4-501.1 I2 Mechanical W'arewashing-Hct 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 Drinkin.Water* concentration and hardness.*
5-101.11 DrinkingWater from an 1 roved S stem" 4-GO I I(A) Equipment Food Contact Surfaces and
590.006(A) Bottled Drinking Water* - Utensils Clean*
590.006(13) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food
SheA/ish and Fish From an Approved Source Contact Surfaces mid Utensils!
Fish - r 4-702.1 t Frequency of Sanitization of Utensils and
3-201.14 Fsh and Recreationally Caught Molluscan Food Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and
3-201.15 Molluscan Shellfrsb fcom NSSP Listed
Chemical*
Sources*
Game and Wild Mushrooms App;oved by 10 Proper,AdequateHandwashing
_
Regulatory Authority 2-301.1.t - Clean Condition-Hands and Arms*
3-202.18 Shellstock identification Present' 2-301.12 Cleaning Procedure*
590.004 C) Wild Mushrooms* 2-301.14 When to Wash*
3-20i.11 Game Animals* - Il 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 hire it'* Mouth*- - - -
3-i0i.1l _ Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasfin *
6 1 Tags/Records:Shelistock - 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* 590.004(E) Preventing Contanimatioa.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(n Labeling of Ingredients' 5-204.1.1 Location and Placement*
7 Conformance with Approved Procedures 5-?05.11 Accessibility,Operation and Maintenance
fHACCP Pians Supplied with Soap and Hand Drying
3-502.11. S cialized 1'rocessin Methods* Devices
3-502.12 Reduced bx gen acka"ng,criteria* 6-301.11 HandwashinE Cleanser,Availability
8-103.12 Conformance with Approved Procedures* 6-301.1.2 Hand Drying:Provision
Denotes critical mmi in-the federal 1999 Faxi Code or 105 CMR 590.0(X).
. . LTi L 1 ,. /� _�•_.rt' • . . � f . . -
..
riticalw
R—Red Item
UtMill'rf'lftll MoMomr-1 ,
0 MAN MAIAOWK�l It"91
Myj AMR,
WIAM-
6 A =1► _. IM� I ,�,iti LlCilAl�1!_ 1.� �a�� .► �=
RUN-
010
. . . .
VAII
--�
1
f
J
t 3-501.14(C) PRFs Received at Temperatures
Violations Related to Foodborne fliness inter✓entions and Risk According to Law Cooled to
Factors(items-r-P2) (Cont.) 41'F/45`FWithin 4Hours.
PROTECTION FROM-CHEMICALS3-501.15 Coolinz Methods for PffFs
14 1 Food Color Additives 19 PHF Hot and Cold Holding
3-501.16(B) Cold P11Fs Maintained at or below
3-20112 Additives* 590.004(F) 4101450 F*
3-302.14 Protection from UnapprovedAdditives* 3-50L16(A) Hot PRFs Maintained at or above
15 Poisonous or Toxic Substances _
140°F. *
7-1 Oi,l1 Identifying Information-,Original 3,501.16(A) Roasts Held at or above 1300F.
Containers* 20 Time as a Public Health Control
7-102,11. Common Name-Workiu Containers*
7-301.11 Separation-Storage* 3-501;19 Attie as a Public Health Control*
7-202.11 .Restriction-Presenceand Use* 590.004H) Variance Requirement
7-202.72 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203:11 Toxic Containers-Prohibitions* POPULATIONS HSP
7-204.11. Sanitizers.Criteria-Chemicals"
7-204.12 Chemicals for WashingProduce,Criteria* 21 3-801.17(A} Beverages
ages ed Warning Laged el ices and
• 7-204.14 in Agents.Criteria*
.Bevesa es with Warning labels*
3-801.11(B) Use of Pasteurized Eggs*
7-205.11 Restricts Food Contact, ,Criteants* 3-g01.11(D) Raw or Partially Cooked Animal Food and
0 7-206.11 Restricted Use Pesticides;Criteria* Raw Seed S it Not Served.
1-206.12 Rodent Bait Stations* 3-801.11 C Unopened Food Package Not Re=served.
7-206,13 Tracking Powders,Pest Control and
Monitoring* CONSUMER ADVISORY
TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer:ativisary Posted for Consumption of
16 Proper Cooling Temperatures far Animal Foods That are Raw.Undercooked or
Proper Pop
Z PNa Otherwise-Processed to Eliminate
3401.1IA(I)(2) Eggs- 155F 15 Sec: per( errs* °ern socr
3-302.13 Pasteurized Eggs Substitute for Raw Shell
Eggs-immediate Service 145'F15see^ _
3-401.11(A)(2) Comminuted Fish.Meats&Game Eggs*
Animals-155'F 15 see.
j
i 3 401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 min* SPECIAL REQUIREMENTS
590.009(A)-(D) Violations of Section 590.009(A)-(D)in
t 3-401AI(A)(2) Ratites,Injected Meats-155°F 15
S sec.* catering,.mobile food,temporary and
3401.11(A)(3) Poultry,Wild Game,Staffed PHFs, residential kitchen operations should be
t Stuffing Containing Fish,Meat, debited udder the appropriate sections
Paul"or Ratites-165'F 15 sec, * above if related to foodborne illness
f 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-
t� Microwave 165°F* Special Requirements.
i 3-40'LII(A)(1)(b) All Other PHFs- 145F 15 sec.*
} 17 Reheating for Not Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-103.11(:4)&(D) PHFs 165°F 15 see,* (Items 23-30)
3-40311(B) Microwave-165°F 2 Minute Standing Criticat,and non-critical violations,which do not relate to the
t '1 udc" foodborne illness interventions and risk factors listed above, can be
3403.11(C) Commercially Processed RTE Food- found in the following sectionsofthe Food Code and 105 CMR
140°F* 590.000.
( 3-403.11(E) Remaining Unsliced Portions of Beef dtcarr : Good Ratali Practices .FC 590.ow
Roasts* i 23. 1 Man ement and Personnel I FG-2 .003 i
1g Proper Cooling of PHFs 1 24. Foal and Food Protection FC-3 .004
+ 125. 1 Equipment and Utensils ! FC-4 .005 j
r - 3-501.14(A) Cooling Cooked PRFs from 140`F to ! 26. 1 Water.Plumbing and Waste 'j FC-5 .006
- 70°F Within 2 Hours and From 70°F 27. - 1 Physical Facility 1 FC-6- .007
to 41`F/45'F Within 4 Hours.* 128. T Poisonous or Toric Materials I FG-7 W8 j
3-501.14(B) Cooling PHFs Made From Ambient 'i 29. Special R2quirements .009 j
Temperature Ingredients to 41°F/45'F 30. l Dtier - -
Within 4 Hours*
Denoms critical item in the federal 1999 Foal Code or 105 CNIR 190.000.
t
fes: !�I ��i»l��R���:����1.1 L!�'.�►.�il��,.,,.;'
WHOM
Or
j on-, IA MAROMISNPIA Awl. ,"MINSWIS /in,
If�1�►Z,"/J�i[!���_. ►" '. r2. ~l17:_ _, _�_ �t�'illSG, fib: �_ _. _' � .. . _ •. __ /... �1►�T_Ju'tY_� _li�[n�
"I PER 6=0119 FIVE "WERIM"rall EMPORIUM,, , P.WRTAT.AVVMWAFfrrAl%-il�
MIRK/21,1.1 tiI-.}{1■� �_ /_. 1� �l . 1M �._'ii,►ME4/�itJ.�►►7.���i�
��,1� �I1� �_�(�►[/�/ji:Il(.�'IVIS�`n'!'�_:r/IlvT u�1����,.��.�r_. .... i�a�►err 1. ,.� ����
As .� -3GI�.�/F�.Tr_/, elP�►71�^ SIL' LL' I! 1�1�
•
r
' - - 3S01.14(C) PHFs Received at Temperatures
r Violations Related to Foodborne fitness interventions and Risk According to Law Cooled m
Factors(items 1-22) (Cont.) _41'Fi45°F_Within 4 Houm
PROTECTION FROM CHEMICALS3-501..15 Cooling Methods for PHFs
14 PHP Hot and Cold Hording
3-501.16(B)' Cold P11Fs Maintained at or below
T47 Food or Color Additives
3-202.12 1 Addifives*_ 590.004(F) 41°1+15°F*
3-302.14 Protection from Unapproved
oved Additives" 3-50LI6(A) Hot PHFs Maintained at(it above
15 Poisonous or Toxic Substances 1400P. *
7-101.11 ldentitying Information-Original 3,501.16(A) Roasts Held at or above 130'F. °
Containers- "
7-102.11. Common Name-Working Containers* 20 Time as a Public Health Control
7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control*
7-202.11 ,Restriction-PresenceandUse* - 590.004(H) Variance Requirement
7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 'Toxic Containers-Prohibitions* POPULATIONS HSP
7-204.11 Sanitizers.Criteria-Chemicals* "
7-204.12 Chemicals for WashingProduce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and
Beverattes wit}(Waratin*Labels*
7-204.14 Drying Agents.Criteria* 3-801-II(B) Useof Pasteurized E
� 7-295-11 Incidental Food Contact Lubricants*
7-206.11 "Restricted Use Pesticides;Criteria* 3-$01.11(D) Raw or Partially Caked Animal Food and
Raw Seed Sprouts Not Served.*
7-206.12 Rodent Bait Stations* 3-$01.11(C) Unopened Food Package Not Re-served.
7-206.13 Traz:king Powders,Pest Control and
Monikttin *- -CONSUMER ADVISORY
71MEMEMPERATURE 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 OtherwiseProcessedto Eliminate
3-401.11A(1)(2) Eggs- 15ST 15 Sec. Pathogens"
r + f
Eggs-immediate Service 145'Fl5sec* 3-302.13. Pasteurized Eggs Substitute for Raw Shell
E *
3401.1 l(A)(2) Comminuted Fish.Meats&Game
i - Animals-155'F 15 sec-
3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 mmSPECIAL REQUIREMENTS
3-401.11(A)(2) Ratites,Injected Meats-155`F 15 590.009(A)•{D) Violations of Section 590.tX}9(A)-(D)in
t
sec.* catering,mobile ford,temporary and
3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be
t Staffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-165'F 15 sec, * above if related to foodborne illness
3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
145°F* 590.009 violations"relating to good retail
3-401.22 Raw Animal Foods Cooked in a practices should be debited tinder#29-
Microwave 165°F* Special Requirements.
'+ 340IAI(A)(I)(b) All Other PHFs- 145F 15 sec.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
l 3403AI(A)&(1)) PHFs 165°F 15 sec. * (Items 23-30)
3403.11(B) Microwave- 165`F 2 Minute Standing Critical,and non-critical violations,which do not relate to the
1 - Tire" foodborne illness interventions and risk factors listed above, can be
3-403.11(C) Commercially Processed RTE Food- found in the following sectionsof the Food Code and 105 CMR
140°F* 590.000.
€tem Good Retail Practices .FC 590.M
3403.11(E) Remaining Unsliced Portions of Beef L
• Roasts*' 23._ i Management and Personnel ' FC-2 .003 1
�)
18 Proper Cooling of PHFs 1 24. Food and Food Protection
25. Equipment and UiensiisI FG-4 'M3-541.14(A) Gaoling Cooked PHFs from 340`F to 2g. ~Water.Piumbi and Waste , I FC-5 .006 1
70°F Within 2 Hours and From 70°F 27. Physical Facility FC-6 .007 !
to 41`F145'F Within 4 Hours. * 128. ' Poisonous or Toxic Materials 1 FC 7 .008 I
3-501.14(B) Cooling PHFs Made From Ambient �29. S ecial R m
uireems 0099
* Temperature ingredients to 41'Fl45'F ' '� i Other --i -
+ Within 4 Hours*
j ^Dene,,c,ilicat ism in use federal 1'.799 Food Code w 105 CMR 590.000.
1
Ulm - . .
O ..- 71: M /�V M =
FrOIN 0 ME No,Wil ,291
ET1LIa(F1�'6 �i�' i. lRiJ. i '.'�►'. !i.-. . . .. . MM IMAU �.R'�1AMj
'►!
F$M til�''�lt ®' AMA . . . i. ft�r..a i .sl�R.1�!�►'JJC�I�!®
09
I .
... . i /
3-501,14(C) PHFs Received at Temperatures
Violations Related to Foodborne Illness Inte"enHons and Risk According to Law Cooled to
Factors(ldems 1-22) (Cant.) 41T-145F Within 4 Houm
PROTECTION FROM CHEMICALS 3-501.15 CODUE Methods far PHFs
14 Food or Color Additives 19 PIF Hot and Cold Holding
3-202.12 Additives* 3-501,16(B) Cold PHFs Maintained at or below
3-302.14 Protection from Unapproved Additives* 590.004(F) 410145 F*
15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above
140`*. *
7-101,11 Identifying Intormation-Original 3_501,16(A) Roasts Held at or above 130'F."
Containers*
7-102.11. Common Name-Working Containers* 20 Time as a Public Health Control
7-201.11 Separation-Storage*. 3-501:19 Time as a Public Health Control*
7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement
7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Containers-Prohibitions* POPULA71DN5 HSP
7-204.11 Sanitizers,Criteria-Chemicals*
7-204.1.2 Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpastetaized Pre-packaged Juices and
7-204.14 Drying Agents.Criteria* :Beverages with Warning Labels*
7-205.11 Incidental Food Contact,Lubricants* . 3-901.11(BUse of Pasteurized Eaas* .
7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food and
7-206:22 Rodent Bait Stations* 3-801.
Seed Sprouts Not Served, *
3-801.11 C Unopened Food Not Re-served.
7-206.13 Tracking Powders, Pest Control and _
Monitoring* CONSUMER ADVISORY -
TIMEtFEMPERATURE CONTROLS 22 3-603.11 Consutner Advisory Pasted for Consumption of
16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or
PHFs Not Otherwise-Processed toEliminate
3-401.11A(I)(2) Eggs- i55`F 15 Sec. patha ens.* �r
E mss-Immediate Service 145°F15sec* 3-302.13. Pasteurizxd Egggsgs Substitute for Raw Shell
I
E *
{ 3.401.11(A)(2) Comminuted Fish.Meats&Game
Animals-155°F 15 see. *
3-401,11(B)(1)(2) Pork and Beef Roast- 130°F 121 min* SPECIAL REQUIREMENTS
3-401.11(A)(2) Ratites,Injected Meats-155`F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
sec.* catering,mobile food,temporary and
3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be
Stuffing Containing 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
1 1450F* 590.009 violations relating to goad retail
3-401.12 Raw Animal Faxls Cooked in a practices should be debited under#29-
Microwave 165°F* Special Requirements.
f 3-401A I(A)(I)(b) All Other PHFs- 145°F 15 sec.
17 Reheating for Hot Holding VIOLA77ONS RELATED TO GOOD RETAIL PRACTICES
r 3-403:11(,1)&(D) PHFs 165-F 15 sec. * (Items 23-30)
3-403.11(B) Microwave 165'F 2 Minute Standing Critical,mrd non-critical violations,which do not relate to the
- Time* - foodborne illness interventians and risk factors listed above, can be
3-403.11(C) Commercially Processed RTE Food- found in the following sections,gf the Food Code and 105 OUR
1400FF- 590.000.
3-4D3.11(E) Remaining Un,{iced Portiere;of Beef t item Goad Retail Practices _FC 690.000
Roosts* 23. + Manattsment and Personnel- � FC-2 .003 - .I
I 1$ Proper Cooling of PHFs 124.-(Food and Food Protection 1 FC-3 004 i
1 25. ! Equipment and Utensils FC-4 005
3-501.14(A) Cooling Ccmked PHFs from 140°F to 1 26, Water.Plumbim and Waste 1 FC-5 � .006
70'F Within 2 Hours and Front 70*F 21 Physical Facility FC-6 007 i
to 41`F/45°F Within 4 Hours.* i 26. Poisonous or Toxic Materials ! FC-7 008 j
3-501.14(B) Cooling PHFs Made From Ambient 129. Sial Requiremards
Temperature Ingredients to 41°F/45°F 30 1 oftr
Within 4 Horns" s_smromm..,.sc:
"Derotes critical item in the federal 1999 Food Cale a 105 CMR 590.000.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: Lin, Page: � of
Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R-Red Item Verified
PLEASE PRINT CLE RLY
64
jI
JD
Discussion With Person in Charge: Corrective Action Required: ❑ No des
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance L3 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 oft my-five dollars or susp nsion/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. (4z_� .1
11 Voluntary Disposal ❑ Other:
3-501,14(C) PHFs Received at Temperatures
Viefulleas Re.)ated to Foodborne fUnsss Interventions and Risk According to Law Cooled to
Factors{ttetnst-22) (Cont) 41'Fl45°F_Within 4Houm
PROTECTION FROM CHEMICALS 3-50!..15 Coolie Methods for PHFs
14 Food or Color Additives 19 PHF Hot and Cold Holding
3-202.12 Additives*' 3-501.16(6) Cold PHFs Maintained at or below
540.003(F) 41
3-302.14 Protection from Unapproved Additives* 145°F*
15 Poisonous or Toxic Substances 3-50I.I6(A) Hot PHFs Maintained at or above
140°F.
7-101 J I identifying Information-Original 3-.501.16(A) Roasts Heid at or above 130°F. "
Containers* Time as a Public Health Control
7-102.11. Common Nameame-Working Containers* 20
7-201.11 Separation-Storage 3-501:19 - Time&%a Public Health Control*
590.004(H) Variance Requirement
7-202.11 .Restriction-Presence and Use*
7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 'Toxic Containers-Prohibitions* POPULATIONS HSP
7-204.11 Sanitizers.Criteria-Chemicals*
3-801.17(A) Un
7-204.12 Chemicals fru WashingProduce,Criteria* Unpasteurized Pre-packaged Juices and
7-204.14 Drying Agents.Criteria* .Beverages with Warning labels*
705.1I Incidental Food tact Lubricants* 3-801116) Use of PasteurizerEM*
3-801.11(D) Raw or Partially Cooked Animal Food and
7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served
7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.
7-206.13 Tracking Powders,Pest Control and
Monitoring* CONSUMER ADVISORY
TIME/TEMPERATURE CONTROLS 22 3-603.11 1 Consumer Advisury Posted for Consumption of
16 Proper Cooking Temperatures for Animal Foods Thai are Raw'.Undercooked or
Prop Not Otherwise Processed to Eliminate
Pathogens.* rn;2onr
3.40i.1IA(1)(2) Eggs- 155F 15 Sec.
E immediate Service 145°Fl5sec• 3-302.13. Pasteurized Eggs Substitute for Raw Shell
3-401.11(A)(2) Comminuted Fish.Meats&Game E
gW
'I Animals-155°F 15 sec."
SPECIAL REQUIREMENTS
3.401.11(B)(1)(2) Pork and Beef Roast- 130°F'121 miu*
i 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 090.009(A)-(D) Violations of Section 590.009(A)-(D)in
sec.* catering, mobile foul,temporary and
} 3-401.1 t(A)(3) Poultry,Wild Game,Staffed 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
ti3-401.11{C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
5 145°F* 590.009 violations relating to good retail
ti 3401.12 Raw Animal Foods Cooked in a practices should be debited corder#29-
y Microwave 1657* Special Requirements.
5 3401:11(A)(10) All Other PHFs- 145°F 15 sec.*
17 Reheating for Not Holding WOLA77ONS RELATED TO GOOD RETAIL PRAC77CES
3-4(}3:11(.1)&(D) PI1Fs 165"F 15 sec. * (items 23-30)
3403.11(B) Microwave- 165`F 2 Minute Standing Critical,and roan-critical violations,which do not relate to the
Titin* - foodborne illness interventions and risk factors listed above, can be
3-403,11(C) Commercially Processed RTE Food- found ut the following sections of the Food Code and 105 CMR
140°F* 590.000.
(fi) RemainingUnsticedFomimsofBec�f i � I Good Retail Practices .FC 590.00(1340311 i
Roasts" i 23._I Man loemerti and Porsonrrel I-FC-2 A03
` 18 Proper Cooling of PHFs 24., i Food and Food Protection FC--3 .004 I
25. 1 Equiriment and Utensils FC-4 .005
• 3-501.14(A) Cooling Cooked PHFs from 140'F to 26. Water.Plumbinq and Waste I FC-5 .006 1
70°F Within 2 Hours and From 70'F j 27. i Physical Facility FC-6 .007
to 41°F1450F Within 4Hours. * r 28. ' Poisonous or Toxic Materials FC-7 .008
3-501.)4(:B) Cooling PHFs Made From Ambient _ ~29. 1 Special R2guiremarns .009
Temperature Ingredients to 41°F/456F x-30. j Other ,
Within 4 Hours*
', 'NnMcs critical rum in the federal 7999 Pocd Cade a'103 CYtR 39{1.0()0.
CIT' or SALEM, MASSACHUsm-rs
BOARD OF HF_AI:rH
120 W_vSHINc,CON STREET,4"'Fixx qn
TcL. (978) 741-1800
K1bf13GRLE,Y llRTSCOLL 1",\x(978) 745-0343
MAYOR liamclinQsalemxom
LARRY RANIDIN,RS/RH IS,GIi0,("T-vs
H I(A I:I'1-1 AG I',N'I'
This Form will be collected during your next Board of Health inspection.
QUESTIONAIRE - GREASE TRAPS 2009
1. NAME OF ESTABLISHMENT: �.<)", Al1c> , S e �1 , 21 �_r C
2. ADDRESS OF ESTABLISHMENT: �-
3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP? �I S
4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT HAVE?
CAPACITY IN GALLONS n oma' l o r
5. HOW IS THE GREASE TRAP MAINTAINED? ON A DAILY BASIS? BY AN IN-HOUSE PERSON OR
BY AN OUTSIDE CLEANING SERVICE?
7-. r\ - I'1 Oy S C.
6. WHAT IS THE FREQUENCY THAT THE GREASE IS REMOVED FROM THE TRAP?
7. WHAT IS THE NAME OF THE FIRM WHO REMOVES AND/OR PICKS UP THE GREASE FROM
YOUR ESTABLISHMENT? 1
8. WHAT IS THE DATE OF YOUR LAST INVOICE FROM THE REMOVAL FIRM?
Massachusetts Department of_.P/ublic-Health Salem Board of Health
Division of Food and Drugs Sal Washington Street,4'h Floor
Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343
Name ' Date e o1d0 eration s Tyoe of Inspection
T
U t 1 XP o 1 o it Food Service ❑ Routine
Address Uh } Risk ❑ Retail 9LRe-inspection
Level ❑ Residential Kitchen Previous Inspe•tion
Telephone y % El Mobile Date:) /F1 i
Owner HACCP Y/N ❑ Temporary ElTemporary
Oki 1( go , ❑ Caterer ❑ Suspect Illness
Person in Charge(PIC) h Time ❑ Bed&Breakfast ❑General Complaint
Inspector Ou:a 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. x-� `I �I �) 4 .
FOOD PROTECTION MANAGEMENT _
�� ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
ElHEALTH _� 13. Handwash Facilities
EMPLOYEE
. PROTECTION FROM CHEMICALS I
[12. Reporting of Diseases by Food Employee and PIC IC-S
El3. Personnel with Infections Restricted/Excluded ❑ 1O'Approved Food or Color Additives
-_ _ El15.Toxic Chemicals
FOOD FROM.APPROVED SOURCE_ TIMElTEM SRATURE CONTROLS(Potentially Hazardous Foods)
E] 4. Food and Water from Approved Source
❑ 5. Receiving/Condition [116.Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling
PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding
_❑ 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing [REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS-(HSP),
El21. Food and Food Preparation for HSP
El 10. Proper Adequate Handwashing
❑ 11. Good Hygienic PracticesLL CONSUMER ADVISOR `Y. � .
❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices Number.of Violated Provisions Related
Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 110 days as determined by the Board and Risk Factors(Items 1-22):
of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection
immediately or within;90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code. This report, when signed below
C x by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations
24. Food and Food Protection (Fc-9)(990.0044))) 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)(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 I DATE OF RE-INSPECTION:
5:5XMSPe 4FOr 14.E �/ M_
Inspector's Signature: Prinks J \_
PIC's Signature: i IJi I m Pant. E C n ti L 6 PageJ__OIL Pages
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT S Cross-contamination
3-302.1.1(X)(1) Raw Animal Foods Separated from
1 590.003(A) Assn* went of Res onsibiHt
Caked and RTE Foods*
590.003(B) Demonstration of Knowledge Contamination from Raw ingredients
2-103.11 Person in charge-duties 3-302A 1(A)(2) Raw Annual 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 Foul Employee Or An
Utensils*
Applicant To Report To The Person In Contamination from the Consumer
Charge* 3-306.14(A)(B) Returned Food and Re ice of Food*
590.003(G) Re ortmgb Person in Char>e`
3 590.003(D) Exclusions and Restrictions* Fo�srtionofAdulterafedorContaminated
590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE _ F1"
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
3-201.1.2 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..1.1 Drinking Water from an Approved System*
4-001..11(X) Equipment Food Contact Surfaces and
590.006(A) Bottled Drinking Water* Utensils Clean*
-
590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food-
Shellfish and Fish From an Approved Source Contact Surfaces and Utensils*
4-702.1 l Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and
3-201.15 Molluscan Shellfish from NSSP listed Chemical*
Sources* 10 Proper,Adequate Handwashing
Game and Wild Mushrooms.4pproved by
Regulatory Auth2-301.11 Clean Condition-Hands and Arms*
orrt
3-202.18 Shellstock Identification Present* 2-301.12 CleaninE Procedure*
590.004(C) Wild Mushrooms` 2-301.14 When to Wash`
3-201.17 Game Animals* 11 Good Hygienic Practices
3 Receiving/Condition 2-401.1 I Eating,Drinking or Using Tobacco*
3-202.1.1. PHFs Received at Proper Temperatures* 2401.12 Discharges From the Eyes,Nose and
3-202.15 Package Inte sit y* Mouth*
3-101.11. Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasdn *
6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification''` 590.004(E) Preventing Contamination from
3-203.12 Shellstock Identification Maintained* Employees"
Tags/Records: Fish Products 13 Handwash Facilities
3-402.11 Parasite Destruction`
Conveniently Located and Accessible
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*
g
Conformance with Approved Procedures
5-205.11 Accessibility,Operation and Maintenance
lHACCP Plans Supplied with Soap and Hand Drying
3-502.11 Specialized Processing Methods* Devices
3-502.12 Reduced oxygen packamig%criteria* 6-301.11 Handwashing Cleanser,Availability
8-103.12 Conformance with Approved Procedures"
6-301.1.2 Hand"Drying Provision
°Denotes growl item in the federal 1999 Food Code or 105 CMR 590.000,
l _
41;.,.
Massachusetts Department of PUNCc Health 4 saierni Board of Health,
120 Washington Street,0 Floor
Division of Food and Drugs Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION,REPORT 1 Tel. (978) 741-1800 Fax (978) 745-0343
Name Date Te of O eration s Tvpe of Inspection
C o a Food Service Routine
Address I Ris Retail Re-inspection
" Le el ❑ Residential Kitchen Previous I pe ion
Telephone
❑ Mobile Date: S if
Owner HACCP YM Catenary ❑ Pre-o era ion
Person in Char a PI Bed& Breakfast ❑ Suspect Illness
9 (PIC) �. . � �\ .Time ❑ ❑General Complaint
In: HACCP
Inspector cll Out: ''J-Tj Permit No. ❑ Other
-
Each violation checke requires an explanation on the narrative age(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) ❑ 590.005(F) ❑
action as determin1 d by the Board of Health.
FOOD PROTECTION MANAGEMENT-- --.� - -� ❑ 12. Prevention of Contamination from Hands �
❑ 1. PIC Assigned/Knowledgeable/Duties
❑ 13. Handwash Facilities
EMPLOYEE HEALTH ' PROTECTION FROM CHEMICALS
❑ 2. Reporting of Diseases by Food Employee and PIC
E314.Approved Food or Color Additives
El3. Personnel with Infections Restricted/Excluded
FOAPPROURCE _ 7-1El 15.Toxic Chemicals
OD FROM OVED S ,
❑ 4. Food and Water from Approved Source TIMErrEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑ 5. Receiving/Condition [116.Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements/ ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans R18.Cooling
PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding
❑ 8.Separation/Segregation/Protection [120.Time-As,a Public Health Control
__-
❑ 9. Food Contact Surfaces Cleaning and Sanitizing rEOUIREMENTS FOR HIGHLY SUSCEPTIBLE-POPULATIONS..(HSP)!
El 10. Proper Adequate Handwashing
E]21. Food and Food Preparation for HSP
_ _
El 11. Good Hygienic Practices [QONSUMERADVISORY `N • ,•.r r-
❑22. Posting of Consumer Advisories _
Violations Related to Good Retail Practices Number of Violated Provisions Related
Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22):
of Health. Non-critical (N)violations.must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board
of Health. today,the items checked indicate violations of 105 CMR
C N 590.000/federal Food Code. This report, when.signed) below
23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constituteslan
'24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations
25. Equipment and Utensils (FC4)(590.005) cited in this report may result in suspension or revocation of
26. Water,.Plumbing and Waste (Fc-9)(990.009) the food establishment permit and cessation of food
establishment operations. If aggrieved by this order, you
:27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION: nn
I�Lcu ��, a�1t
S:5801nspecfFarmB-10.tlx .s
Inspector's Signature: Print: 1
PIC's Signature/ ( Prink J/,�� L Pagel of�Pages
Violations Related to Foodborne Illness
Interventions and Risk Factors(Items 1-22)
PRpTECT1ON FROM CONTAMINATION_
g Cross-contamination
_ FOOD PROTECTION MANAGEMENT 3-302.11(A)(]) Raw Animal Foods Separated from
1 590.003(A) Assia tQt meat of Responsibility* Cooked and RTE Foods*
590.003(6) Demonstration of Knowledge* Contamination from Raw ingredients
2-103.11. Person in charge-.duties 3-302.11(A)(2) Raw Animal Foods Separated from Each
Other*
EMPLOYEE HEALTH Contamination from the Environment
2 590.003(() Responsibility of the person in charge to 3-302.11(A) - Food Protection*
'require repotting by food employees and 3-302,15 WashingFruits and Vegetables
applicants* 3-304.11 Food Contact with Equipment and
590.003(F) Responsibility Of A Fax!Employee Or An Utensils*
Applicant To Report To The Person In Contamination from the Consumer
Charge* 3-306.14(A)(B) ,Returned Food and Reservice of Food*
590.003(G) Reporting by Person in Charge*
3 590.003(D) Exclusions and Restrictions* Food
Di s tron of Adulterated or Contaminated
590.003(E) Removal of Exclusions and Restrictions 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 -
3-201.1.2 Food in a.Hermetically Seated Container* Sanitization Temperatureo,
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water
3-202.13 Shell E¢as* Sanitization Temperatures*
3-202.14 E �s and Miik Products,Pasteurized* 4-501.114 Chermcal.Sanitization-temp.,pH,
3-202.16 Ice Made From Potable Drinkivag Water* concentration and hardness.
5-101.:'1.1 Drinkin Water from an Approved System*
4-6'01_I1(A) Equipment Food Contact Surfaces and
s
590.006(A) Bottled Drinking Water* Utensils Clean*
590.006(6) Water Meets Standards in 310 CMR 22.w- 4-602.11 Cleaning Frequency of Fyuipment 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 Lasted Chemical* -
Sources* 10 Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by 2-301.1.1 Clean Condition-Hands and Arms*
Regulatoty Authority
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* Il Good Hygienic Practices
g Receiving/Conditlon 2-401.11 Eating,Dri2hLnf,or Using Tobacco*
3-202.1.1 PHFs Received at Proper Temperatures* 2401.12 Discharges From the Eyes,Nose.and
3-202.1.5 Package Integrity* Mouth*
3-101.11 Food Safc and Unadulterated* 3-301.12 Preventing Contamination When Tasting*
fi Tags/Records;Shellstock 12 Prevention of Contamination from.Hands
3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from
3-203.12 Shellsloek Identification Maintained* Employees* --
Tags/Records:Fish Products 13 Handwash Facilities
3-40211 Parasite Destruction* Conveniently Located and Accessible
3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities*
590.004(J) Labeling of Ingredients' 5-204.11 Location and Placement*
7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance
/HACCP Plans Supplied with Soap and Hand Drying
3-502.!1 Specialized Processing Methods* Devices
3-502.12 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser,Availability
8-103.12 1 Conformance with Approved Procedures*
6-30112 Hand Drying Provision
'Denotes critical item in the federal 1999 Foal Caie or 10i CMR 590.000.
CITY OF SALEM
BOARD•OF HEALTH
Establishment Name: Cv51411' A(K& IG 1 c oA e Date: 1 Page: of 3 <
Item Code C—Critical ftem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION _ Data. .
No. Reference R-Red Item Verified
r PLEASE PRINT CLEARLY
t n 7n ��I
., � /�!✓ _,l � , rrc s IBJ ,
/ .
f
F
Ii
y Discussion With Person in Charge: Corrective Action Required: ❑ No �O _ Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
violations before the next inspection, to observe all conditions as described, and to Exclusion
P Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twdnty-five dollars or susp Psion/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. /, /r
❑ Voluntary Disposal LiOther: a
. r j
3-S0I.14(C) PRFs Received at Temperatures
Violations Retated to Foodborne illness Interventions and Risk Accordant to Law Cooled to
Factors(fterns 1-22) (Cont.) 41'F/45�F Within 4 Hours.
PROTECTION FROM CHEMICALS 3-541.15 Ceoline Methods for PHFs
14 '-- Food or Color Additives 19 ,..._ PHF Hot and Cold Molding
3-202.72 Add tinea* s501.76(B) Cold PHFs Maintained at or below
- 590.004(M41 145 F*
3_302.14 Protection from Unapprove d Additives° 3-501,16(A) Hot PHFs Maintained at or above
15 Poisonous or Toxic Substances -
1400F.
7-101.11 Identifying Information-Original 3-501.16(Al Roasts Held at or above 1300F.
Containers*
7-102.11. Common Name--Working20 Containers* Time as a Public Health Control
7-201.11 Separation-Storage- 3-501.19 Time as a Public Health Control*
7-202.11 .Restriction-Presence and Use* 590.004(H) Variance uirement -
7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Containers-Prohibitions* -
7-204.11 Sanitizers.Criteria-Chemicals" POPULATIONS HSP
7-204.12 Chemicals for Washing Produce,Criteria* 21 ?-341.I7(A) Unpasteurized Pre-packaged Juices and
7-204.14 Drying Agms.Criteria* I I Beverages with Warning Labels*
3-801-II(B)(B) Use of Pasteurized Eggs*
7-205.11 Incidental Food Contact Lubricants*
Food and
7-206.11 Restricted Use Pesticides;Criteria* 3-$01'.17{D} Raw or Partially Cooked Animal
Rao Seed Sprouts Not Saved.
7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.
7-206.13 Tracking Powders,Pest Control and
Mosritnrin * - CONSUMER ADVISORY____
TIMEMEMPERATURE CONTROLS 22 3-60111 Consumer Advisory Pasted for Consumption of
16 Proper Cooking Temperatures for Animal Foods That are Rax.Undercooked or
PHFs Not Otherwise-Processed to Eliminate
3.40i.1TA(i)(2) Eggs- I55"F 15 Sea
Patbo gens.*
Eggs-Immediate Service 145'F15sec* 3-302.13 Pasteurized Eggs Sabstitute for Raw Sheii
*
3-407.11(A)(2) Comminuted Fish.Meats&.Game E
Animals-155'F 15 ser:. * SPECIAL REQUIREMENTS
3-401.11(11)(1)(2) Port:and Beef Roast-130'F 121 min*
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
3-40.1.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-765°F 15 sec. * above if related to foodborne illness
3401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
145'F* 590.009 violations relating to good retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 1657* Special Requirements.
3-401a(A)(1)(b) All Other PHFs- 145*F 15 sec.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3403.11(A. )&(D) PHFs 165`F 15 see. * (Itettis 23-30)
3-403.11(B) Microwave- 165'F 2 Minute Standing Critical,and non-critical violations,which do not relate to the
Time* i foodborne illness interventions and risk factors listed above, caabe
3403,11(C) Commercially Processed RTE Food- found in the follnndng sections of the Food Code and 105 CMR
140'F* 590.000.
3-443.11(E) Remaining Unsticed Portions of Beef i Item ! Good Retail Practices y .FC 1.59o.OQt1
Roasts* 23, i Management and Personnel i-FC-2 ( .003 E
SS Proper Cooling of PHFs 24 Food and Food Protection l F� .004
125. ( Equipment and Utensils i FC-4 .t)zL5 i
3-501.14(A) Cooling Cooked PHFs from 140`F to 26- Water.Plumbing and Waste i FC-5 .006
70'F Within 2 Hours and From 70'P 27. i Physical Facility i FC-6 007
to 41`F/45'F Within 4 Hours.* . 28._' Poisonous ar itedc Materials FC-7 .008
3-501.14(B) Cooling PHFs Made From Ambiens 129. Special Requirements - ! .609
Temperature Ingredients to 41'F/45'F 30. i Other _
Within 4 Hours*
*Dentes critical iumr in the federal 1999 Fcod Cade ar 10;C:N1R 590.000.
fI
CITY OF-SALEM
/� // (( BOARD OF HEALTH
Establishment Name: ri lDater Pagel of
Rem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R-Red Item Verified
PLEASE PRINT CLEARLY
-/ R t2 ZU v " ,,n
2 S— Y n /! I/ .l 't - `><rI? .,� AJ D N
5)/ i3 �l4 _1�__
- /a21 ><lo � o./I:�/� rc net � �
C So s Q care
D
(SS SV1 ///q- Co vw,c r H ffvi Com?4797,v, vi n„n C , cV r .ff- j)tC L JC/1-(r n/-
)hi -j n
sz C-6CUe - t-�V- Cn al,, e J AtP Cc
elnQI-: d ��� {7 /
vhYS M G
X
0A., u L.I, . 1\11-c
XPIJ l -U(X f- '
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 El 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
I noncompliance may result in daily fines_ of twenty-five d liars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
you{food permit. /” I
Voluntary Disposal ❑ Other:
i
3-501.14(C) PRFs Received at Temperatures '
Violations Related to Foodborne Illness tnteraentlons and Risk According to Law Cooled to
Factors(Items 1-22) (Cant.) 41"171457 Within 4 Hours.
PROTECTION FROM CHEMICALS 3-501.15 CoolingMethods for PRFs
Food PHF Hot and Cold Holding
14 D 'ood or Color Additives 3-501.16(B) Cold PRFs Maintained at x below
3-202.12 r Additives' 590.001((1) Cold41 5'F*
3-302.14 Protection from Una roved Additives" 590.0(1 M Hat PHFS Maintained at or above
15 Poisonous or Toxic Substances 140 *
7-101.11 Identifying Information-Original 3,501.16(A) Roasts Held at or above 130'F. *
Containers* 20 Time as a Public Health Control
7-102.11. Common Brame-WorkingContainers*
3-501.19 Time as a Public Health Control*
7-201.11 Separation-Stora e*
7-202.11 .Restriction-Presence and Use* 590.004(H) Variance Requirement
7-202.12 Conditions of Use' REQUIREMENTS FOR HIGHLY SUSCEP71BLE
7-203.11 Toric Containers-Prohibitions* POPULATIONS NSP
7-204.11. Sanitizers.Criteria-Chemicals*
7-203.12 Chemicals for 1Vashin Produce,Criteria' 21 3-801.11(A) Unpasfeurirmd Pre-packaged Juices anti
Beverages with Warming Labels* .
7-204.14 d Agents.Criteria. 3-sol.l l(B) Use of Pasteurized Eggs* -
7-245.11 Incidental Food Contact. ,Criteants* 3-801.11(D) Raw or Partially Cooked Animal Food and
7-206.11 Restricted Use Pesticides;Criteria* Raw Seed S tits Not Served.
7-205.12 Radent:Bait Stations* 3-801.11 C) Uno ned Fcwd Pack Net Re-served.
7-205.13 Tracking Powders,Pest Control and
Monitoring* CONSUMER ADVISORY _
TIMEII'EMPERATURE CONTROLS 22 3-603.11 Consumer:Advisery Posted for Consumption of
16 - Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or
Not Otherwise Processed to Eliminate
PHFS Pathogear.*`tiO vh,2.I
3-401.11A(l)(2) Eggs- 155'F 15 See.
3-302.13. Pasteurized Eggs Substitute for Raw Sheri
E -Immediate.Service 145'F15sec*
E
3-401.11(A)(2) Comminuted Fish.Meats&.Game
.Animals-155'F 15 see. "
3-401.11(B)(1)(2) Poi and Beef Roast- 130°F 121 min" SPECIAL REQUIREMENTS
Violations
of Section
3-401 A I(A)(2) Ratites, Injected Meats-155`F 15 590.009(A)-(DD .Vooaatians of Sect on 590.OQ9(A)-(D}in
sec.* catering,.mobile food,temporay and
3-401.1.1(Ai(3) Poultry,Wild Game,Stuffed PHFS, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-1650F 15 sec, * above if related to foodborne illness
3-401.11(C}(3) Whole-muscle,intact Beef Steaks interventions and risk factors. Other
145°F* 590,009 violations relating to good retail
3-001.12 Raw Animal FaNis Cooked in a practices should be debited under#29-
Microwave 165'F* Special Requirements.
3401:11(A)(1)(b) All Other PHFS-145 F 15 see.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3403.-1 i(A)&(D) PHFS 165-F 15 sec. * (Items 23-30)
3-403.11(B) Microwave-'165`F 2 Minute Standing Critical and non-critical violations,which do cwt relate to the
Time* foodborne illness inters entions and risk factors listed above, can be
3403.i I(C) Commercial ly Processed RTE Food- found in the following sections of the Food Code and 105 CMR
140*Ft 590.000.
3-403.11(E) Remaining Unslic:ed Portions of Beef i ftin i C+ Ratafl Practices .FC 550.E
Roasts* 23__T atlamant and Personnel FC-2 '.00.3 - i
1
1g Proper Coaling of PHFS 1 24. I Food and Food Protection FC--3 .004 _moi
25. 1 Equipment and Utensils A FG-4 .005 __
3-501.14(A) Cooling Cooked PHFS from 140°F to ! 26, Water.PlUmbi and Waste FC-5 A06
70'F Within 2 Hours and From 70`F 27. , Ph .sicai Faciii FC-6 - .007
to 4 VF/45°F Within 4 Hours. * L28; ' Poisonous or Toxic Materials FC-7 008
3-501.14(B) Cooling PHFS Made From Ambient 29. B eeial R uiramarns ti ' -009 .1
Temperature Ingredients to 41°17/45°F 30 1 Other
Within 4 Hours*
"Denotes critical hent in the L-decal 1999 FwA Cale ca'105 CMR 590.000.
Commonwealth of Massachusetts
r City of Salem
Board of Health Kimberley Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 01/06/2011
ESTABLISHMENT NAME: Custom House Rotisserie
File Number:BHF-2010-000056 282 Derby Street Unit 2
SALEM MA 01970
LOCATED AT:
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
FOOD SERVICE BHP-2011-0182 Jan 1, 2011 Dec 31,2011 $140.00
ESTABLISHMENT
Total Fees: $140.00
PERMIT EXPIRES IDecember3l, 2011
Board of Health
14:U1 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 DGRELNIMUNI&ALEM.COM
DAVID GREENBAuM,RS
ACTING HEALTH AGENT
2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT I (vLCuSom AGUS.4 O/fSSCri � TEL# G,% `+ � I- a4y9
ADDRESS OF ESTABLISHMENT FAX#
MAILING ADDRESS(if different)
EMAIL- Business': Website: -ed",
OWNER'S NAME TEL# 4r7�a- �y5- 2�i0 7
ADDRESS 619_iCD
STREET CITY STATEZIP
S�wSof•.
CERTIFIED FOOD MANAGER'S NAME(S)�11 c .n 1 1 ci +�Loo+� CERTIFICATE#(S)%97396
(Required in an establishment where potentially hazardous food is prepared) 11
EMERGENCY RESPONSE PERSON �j1 ���, w_ry% C� y%,�Uo o HOME TEL#
DAYSiOFOPERATION Monday ...=('", :Tuesday; : Wednesda t; sThuis ay n'i „F.nday} S_atuNa `>,';: x Sundays „
HOURS OF OPERATION i
Please w to in time of day. 1%r3 7`.
For example Ilam-11 pm CIO&
TYPE OF ESTABLISHMENT FEE (check only)
RETAIL STORE YES less than 1000sq.ft. =$70
1000-10,000sq.ft. =$280
more than 10,000sq.ft. =$420
— --------- (YES NO---------------- ----------------------------------------------------------------------
RESTAURANT less than 25 seats =$140
(Outdoor Stationary Food Cart$210) 25-99 seats =$280
more than 99 seats =$420
------------------------------------------------------------ -----------------------------------------------------------------------------------------------
BED/BREAKFAST/ YES NO $100
CHILDCARE SERVICES/NURSING HOM---------------------------------------------------------------------------------------------------------------------------------
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO� $25
TOBACCO VENDOR YES (LN- $135
ALL NON-PROFIT(such as church kitchens) YES $25
'Please pay total with one check payable to the City of Salem.
This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location
in the Establishment.
In accordance with the State Sanitary Code,before any renovations, improvements,or equipment changes are made,all plans for
such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state lax_
returns and paid all tat taxes required under the law.
1J/ / as�iv oti �1�ay
Signature Da Social Security or Federal Identification Number
Revised 10/7/11 FOODAP201 Ladm Check#&Date /D
CITY OF SALEM
BOARD OF HEALTH /
Establishment Name: C V SToar Dov )` {Lo 1 I S t i.LN t� Date: -30 - 1 o Page: / of
Rem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Dete
No. Reference R-Red Item Verified
PLEASE PRINT CLEARLY
It✓ner ' LXO)
2M
u� v � a�3catc, l. 1a - y- Ip
Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ .Yes
I have read this report, have had the opportunity to ask stions and a, e, . correct all ❑ Voluntary Compliance ❑ Employee Restriction/
/ !!�� Exclusion
violations before the next inspection, to observe all co itions as desof t5e. , and to
} � ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Foo�de. I under ri at
noncompliance may result in daily fines of twenty-fie liars or h ion/r o ation of ❑ Embargo ❑ Emergency Closure
your food permit.
0 Voluntary Disposal 0 Other:
x
3-501.14(C) PHFs Received at Temperatures
Violations Related to Foodborne Illness.Interventions and Risk According to Law Cooled to
Factors Mains 1-22) (Cont.) 41°F/45°F Within 4 Hours.
PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs
14 Food or Calor Additives 19 - PHF Hot and Cold Holding
3-202.12 Additives* 3-50116(B) Cold PHFs Maintained at or below
3-302.14 Protection from Unapproved Additives* 590.004(F) 410/450 F*
15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above
14VE *
7-101,11 Identifying Information-Original 3-50L16(A) Roasts Held at or above 1.30'F.
Containers*
7-102.11. Common Name-WorkingContainers* 20
Time as a Public Health Control
7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control*
7-202.11 Restriction-Presence and Use" 590,004(H) Variance Requirement
7-202.12 Conditions of Use*
7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS HSP
7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pte-packaged Iuices and
7-204.14 Drying Agents.Criteria* Beverages with Warning Labels*
3-801.11(B) Use of Pasteurized Ea *
7-205.11 Incidental Food Contact,Lubricants* 3-801..11(D) Raw or PartiallyCooked Animal Food and
7-206.11 -Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served*
7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.
7-206.13 Tracking Powders,Pest Control and
Monitoring* CONSUMER ADVISORY
TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
16 Proper Cooking Temperatures for Animal Foals That are Raw.Undercooked or
PHFs _ Not Otherwise Processed to Eliminate
3-40i.11A(i)(2) Eggs- 155T 15 Sec. Pathogens.' r
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-155F 15 sec. *
3401.11(B)(1)(2) Pork and Beef Roast- 130'F 121 min* SPECIAL REQUIREMENTS
3-401.11(A)(2) Ratites,Injected Meats-1550F 15 590.009 A-(D) Violations
of Section 590.009(A)-(D)in
* catering, food,temporary and r •
sec. g Po
3-401.1I(A)(3) Poultry,Wild Game,Staffed PHFs, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-l65'F 15 sec. * above if related to foodborne illness
340LIl(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
145'F y` 590.009 violations relating to good retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29
Microwave 165°F* Special Requirements.
3.401A I(A)(1)(b) All Other PHFs-145'F 15 sec.
17 RoheaNng for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3403,11(A)&(D) PHFs 165T 15 sec. * (Items 23.30)
3-403.11(B) Microwave- 165°F 2 Minute Standing Critical and non-critical violations,which do not relate to the
Time* foodborne illness interventions and risk factors listed above, can:be
3403.11(C) Commercially Processed RTE Food- found in rhe following sections of the Food Code and 105 CMR
1400F* 590-000.
3403.1l(E) Remaining Unsliced Portions of Beef Hem I Good Retail Practices .FC 590,W0 1
Rte* 23. Manigiement and Personnel FC-2 om
18 Proper Cooling of PHFs - 24.- Food and Food Protectiont FC-3 .004 I
25. Equipment and Utensils FC-4 _005
3-501.14(A) Cooling Cooked PHFs front 140°F to 26. Water,Plumbing and Waste FC-5 006
70'F Within 2 Hours and From 70'F 27. - Physical Facia FG-6 .007
to 41°F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FG-7 .008
3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .009
Temperature Ingredients to 41°F/45°F 30. Other I __
Within 4 Hours* s.tuo;;mme�.it za
'iknotes critical iwaz in the federal 1999 Foci Code or 105 CMR 590.0(10.
L_ _
S? Commonwealth of Massachusetts
s
City of Salem
Board of Health Kimberley Driscoll
120 Washington Street,4th Floor
Mayor
SALEM,MA 01970
Foo"etail Establishment Permit
DATE PRINTED: 09/29/2010
ESTABLISHMENT NAME: Custom House Rotisserie
File Number:BIiF-2010-000056 282 Derby Street Unit 2
SALEM MA 01970
LOCATED AT:
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
FOOD SERVICE BHP-2010-0557 Sep 29,2010 Dec 31,2010 $140.00
ESTABLISHMENT
Total Fees: $140.00
i
I�
t PERMIT EXPIRES IDecember3l, 2010
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted
in a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,
all plans for such must be submitted to and approved by the Salem Board of Health. Page 1
CITY OF SALEM, MASSACHUSETTS
• BOARD OF HEALTH
120 WASHINGTON STREET,4"'FLOOR
TEL. (978) 741-1800
KINIBERLEY DRISCOLL FAX(978) 745-0343
MAYOR DGREENBAUM&ALEM.CONI
DAVID GREENBAum,
ACTING HEALTH AGENT
2010 APPLICATION FOR PERMIT TO.OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT C45FOvl {--6w, ,O_ Rcrk- SSErlP-, TEL#
ADDRESS OF ESTABLISHMENT 002. LAAi T 7_ (b9?* ST- FAX# 9-79-'?q
MAILING ADDRESS(if different) -Z5- lam. L,tn 6jn Sr SIP(B4t i IM,o . 0197 O
EMAIL-Business': Website:
OWNERS NAME� ,tUAyvt UFA- L� l�nTEL# �I7� -yZ� -7�Z1
ADDRESS 35- .I "r, 1P, o ICJ?O
STREET T .,,,\ CITY STATE nom,, I�-ZIIP
CERTIFIED FOOD MANAGER'S NAME(S) lb01 0(k,, (M Oyarrn A4A CERTIFICATE#(S) 4qqe2`t 1
(Required in an establishment where potentially hazardous food is prepared) -p
EMERGENCY RESPONSE PERSON Ix1LI LIA ✓• \lafr,LLX7v� HOME TEL# �Z� -�As -� I
DAYS OF OPERATION. Monday _.Tuesday I Wednesday I Thursday Friday Saturday Sunday
HOURS OF OPERATION AM CV ;}4,,t1 Pwl ArIA OV-1
Please write in time of day. ;
(For example Ilam-llpm ��J ( �Oa IO- 1�;D0 (0 ` (p%Du �O r- 10 X10-1p U - 1pIZ - � �
TYPE OF ESTABLISHMENT FEE (check only)
RETAIL STORE YES NO less than 1000sq.ft. =$ 70
1000-10,000sq.ft. =$280
more than 10,000sq.ft. =$420
-------------------------------------- ------------ ----
RESTAURANT ES NO less than 25 seats =$140
(Outdoor Stationary Food Cart$210) 25-99 seats =$280
more than 99 seats =$420
BED/BREAKFAST/ YES NO $100
CHILDCARE SERVICES/NURSING HOM-----------------------------------------------------------------------------------------------------------------------------
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25
TOBACCO VENDOR YES $135
ALL NON-PROFIT(such as church kitchens) YES N $25
'Please pay total with one check payable to the City of Salem.
This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location
in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for
such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax
retu s an paid II sltte�ied under the law.
6-2v-10 aa2s-v38a�r'
4ignature Date Social Security or Federal Identification Number
-------------- ------------------------------------- --�-------------------------------------------
Revised 424/07 FOODAP2008.adm Check#&Date $
IMPORTANT MESSAGE
FOFI
DATE 9 ' 3 I�-� TIME P.M.
M tennis _ iJ170
of CvSkOm H ,1�Q 15�31i Q
PHONE
AREA CODE NUMBER EXTENSION
❑ FAX
❑ MOBILE
AREA CODE NUMBER TIME TO CALL
TELEPHONED PLEASECALL
CAME TO SEE YOU WILL CALL AGAIN
WANTS TO SEE YOU RUSH
RETURNED YOUR CAL WILL FAX TO Y
MESSAGE
VC k qe- asci
n Si --
�es n b
vj�Ar4 An
SIGNED 10
psFORM 4009
MACE IN U.S.A.
NOTES
IMPORTANT MESSAGE
FOR Ukjk'd
� - A.M.
DATE a TIME 8, Q P.M.
M
OFC �*D
PHONE(i73)
OBE NUMBER EXTENSION
❑FAX
❑MOBILE
AREA CODE NUMBER TIME TO CALL
TELEPHONED PLEASE CALL
CAME TO SEE YOU WILL CALL AGAIN
WANTS TO SEE YOU RUSH
RETURNED YOUR CALL WILL FAX TO YOU
MESSAGE
SIGNED
ONNERSAL. 48005 MADE IN U.S.A.
NOTES
IMPORTANT MESSAGE
FOR3A M
--��
DATE a ' 'Q TIMEJ�tiLP
OF aa 11
PHOT lE 9� LA23 -a<5o&l
AREA OE NUMBER EXTENSION
❑ FAX
❑MOBILE
AREA COOE 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 C;(-
o-n L�Cfi �-F
plan r�eariea J
-r
SIGNED
ONIVERSAL_ 48005 MADE IN U.S.A.
NOTES
CITY OF SALEM
BOARD OF HEALTH
Date: August 30, 2010
Name of Establishment: Custom House Rotisserie
Address: 282 Derby Street Unit 2
Owner(s): William Van Loon
Phone: 978-423-2821
The proposed owner William Van Loon and chef Denis Griswold presented a Floor Plan
and Menu for review in accordance with the State Food Code. The floor plan is
approved with the addition of hand wash sinks as discussed. The proposed menu is
approved
Any changes to the approved floor plan must be approved by the Board of Health prior
to implementing them.
CERTIFICATION
There must be at least one full time CFM at this location. Please provide a copy
Chef Griswold's certificate upon recertification.
A "Person in Charge" or "PIC" must be available at this location when the CFM is
not present. The PIC must have knowledge of sanitation techniques, holding
temperatures, operations, etc.
CHOKE-SAVING
There must be someone trained in choke-saving techniques at the establishment
during all hours of operation.
FLOOR PLAN
Hand wash sinks must be well located in all food preparation areas. The hand
sinks must have a wall hung soap and paper towel dispenser. These must be stocked at
all times. The hand sink must be used for hand washing only. Hand was sinks will be
added as discussed
All floors, walls, and ceilings where food, utensils, paper products, etc, are
stored, prepared or served must be intact, impervious, and easily cleanable. A 3 bay
sink will be used for washing, rinsing and sanitizing all equipment and utensils
MENU/FOOD PREP
All food must be held at 41°F or lower, or 140°F or higher, at all times.
Therefore, soup and other hot items should be brought to the appropriate internal
temperature before being held hot.
Food may not be added to containers in holding unit. Instead, a sanitized
container with new product may replace the existing container and the old product may
be placed on top of the new product. Food must be cooled and heated quickly.
There may be no bare hand contact of ready-to-eat foods. Gloves, tongs, or
tissues must be used when handling such food.
All refrigerator/freezer units must have internal thermometers maintained at
proper temperatures as stated above.
UNDERCOOKED FOODS
The consumer advisory must be added to the menu.
EXTERMINATION
Monthly services of a Licensed Pest Control Operator are required. Please keep
receipts for inspections.
SANITIZING SOLUTION
Sanitizing Solution must be accessible at each prep station and for the patrons'
tables. Test strips corresponding to the kind of sanitizer, must be on hand to check
concentration of solution. Solution must be made daily, tested, and the results recorded
on a log sheet for examination by Board of Health inspectors.
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.
Outside area of premises, including the dumpster area must be kept clean and sanitary.
Anppltaf as submitted a check was not submitted.
f David Gr en aum Date
Acting,Health Agent
William Van Aotl 0ate
Denis Griswold Date
i
EXAM FORM NO. 4289
SC E R TI F 2 C A T E N 0....4948047
n
�t.
�A. ,
e afe° Cert i icll�abon
r-Wi
"We tw
.T° ,D ONNA� 1VI1' fC�Rfl/ t�D
for successfully completing the standards set forth by the National Restaurant Association Educational Foundation.
for the ServSafa®Food Protection Manager Certification Examination,which is accredited by the American National
Standards Institute{ANSI}—Conference for food Protection{CFP},
Pmsented by the National RestaurantAasolation Educational Foundation
8/15/2006
DATE OF EXAMINATION
8/15/2011
DATE OF EXPIRATION !
Local laws apply.Check with your local regulatory agency for recertificetwn requirements,
it op
[ T (t l
National ResTaurant AssociaCion
Mary KAdolf EDUCATIONAL FOUNDATION
President and Chief Operating Officer
National Restaurant Association Educationat Foundation wwW.nraeEorg
02008 The National Restaurant Assariation Educational foundation
rrnnvnas ut]OOT
DRA l' CUSTOM HOUSE ROTISSERIE MENU
SIDES
MASHED POTATOES AND GRAVY
HOMEMADE MAC AND CHEESE
HERB ROASTED BLISS POTATOES
APPLE AND SAUSAGE STUFFING
SWEET BUTTERY CORN
SAUTE GREEN BEAN
CUSTOM HOUSE FRESH CRANBERRY SAUCE
BOSTON BAKED BEANS
SIDE SAUCES
SWAMPFIRE
ARTICKOKE AND CORN RELISH
GRIZZY'S SPICY BBQ
THAI BASIL SWEET CHILI MIRIN SAUCE
ROOT BEER GLAZE
ROTISSERIE CHICKEN
LEMON PEPPER WITH HERBS DE PROVENCE
FRESH GARDEN HERBS AND GARLIC OIL
PEKING CHICKEN SERVED WITH GLAZE
DINNER COMBINATION
1)HALF OF ANY OF THREE ROTISSERIE CHICKEN WITH TWO SIDES AND
CORN BREAD
2)SLICED TENDER BREAST FROM ANY OF OUR SAVORY ROTISSERIE FLAVORS SERVED
WITH TWO SIDES AND CORN BREAD
3)THREE PIECES DARK MEAT WITH TWO SIDES AND CORN BREAD
4)CHICKEN POT PIE WITH YOUR CHOICE FOUNTAIN DRINK
r
5) FAMILY MEAL SPECIAL TWO WHOLE,ROTISSERIE CHICKEN QUARTERED SERVED
WITH,CHOICE OF THREE SIDES,CORN BREAD AND FOUNTAIN DRINKS
6)BILL'S TURKEY DINNER SPECIAL WITH SLCED SLOW ROASTED TURKEY,APPLE
SAUSAGE STUFFING HOME MADE CRANBERRY SAUCE,MASHED POTATOES AND TURKEY
GRAVY
7)CUSTOM HOUSE MEATLOAF MASHED POTATOES GRAVY,GREEN BEAN NST LIKE
MAMA USE TO MAKE
8)SLICED DELMONICO RIB WITH BEEF AUJUS YOU'RE CHOICE OF TWO SIDES,CORN
BREAD AND FOUNTAIN DRINK
SANDWICHES
THREE PIGS IN BASKET
SUCKLING PULLED PORK SLIDERS SERVED WITH CUSTOM HOUSE COLESLAW,SEA SALT
CHIPS
CUSTOM HOUSE CBLT SANDWICH
SLICED ROTISSERIE CHICKEN WITH APPLE SMOKED BACON,LETTUCE,AND VINE RIPE
TOMATOES,CRANBERRY AOILI
LEMON CHICKEN SANDWICH
SLCED LEMON PEPPER ROTISSERIE CHICKEN,BABY ARUGULA,ROASTED RED PEPPER,
SERVED ON RUSTIC BAGUETTE WITH BALSAMIC MAYONNAISE
HAND SLICED RIB EYE SANDWICH
SLOW ROASTED HAND SLICED,RIB EYE SANDWICH
SOUR CREAM HORSE RADISH SAUCE,BABY SPINACH,CANDIED RED ONION,SERVED ON
SOFT ARTISINAL ROLL
r
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,0 Floor
Division of Food and Drugs Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343
Name l I� Dat Type of Operation(s) TVDe of Inspection
I s ec�I _ � 3� �i // ® Food Service ❑ Routine
Address J NAL R' k ❑ Retail 2-Re-inspection
Level ❑ Residential Kitchen Previous In pectin
Telephone GZ-2 [I Mobile Date:Tempor
y�� n/
Owner t 7 ( ^� HACCP YM Catererary ❑ Pre-opera tio
El ❑ Suspect Illness
Person In Charge(PIC) (l Time / ❑ Bed&Breakfast ❑General Complaint
Inspector �` 0 / (/ Permit No. [1 HACCP
OU _ E3 Other
Each violationdhecked requires an explanation on the narrative pages) 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) E) 590.009(F) ❑
action as determined by the Board of Health. � ,,
\\\ FOOD PROTECTION MANAGEMENT.__ ❑ 12. Prevention of Contamination from Hands
❑ 1 PIC Assigned/Knowledgeable/Duties
El\ 13. Handwash Facilities
E EMPLOYEE HEALTH
` PROTECTION FROM CHEMICALS':.
❑ 2. Reporting of Diseases by Food Employee and PIC --
❑ 14.Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded
_ ❑ 15.Toxic Chemicals
E^FOOD FROM APPROVED_SOURCE -
❑ 4. Food and Water from Approved Source TIME/TEMPERATURE 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
PrROTECTION FROM CONTAMINATION = _ , __„.._ 3 ❑ 19. Hot and Cold Holding
❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing .REQUIREMENTS FOR HIGHLY SUSCEPTIBLE.POPULATIONS_(NSP)
El 10. Proper Adequate Handwashing
El 21. Food and Food Preparation for HSP
_
El 11.Good Hygienic Practices CONSUMER.ADVISORY __
❑22. Posting of Consumer Advisories
i
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 determinedby 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 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
5. Equipment and Utensils (Fc-4)(440.004) cited in this report may result in suspension or revocation of
25.
Water,Plumbing and Waste (FC-4)(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
28. Poisonous or Toxic Materials (FC-7)(590.0011) 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, c 5X)nsp 0 14.4 1
Inspector's Signator Print:
PIC's Signature: ^J Print:/ - 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 3-302.11(A)(]) Raw Animal Fonds Separated from
1 590.003(A) Assig tment of Res nsibility* Cooked and RTE Foods*
590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients
2-103.11. Person in charge-duties 3-302.1.1(k)(2) Raw Annual Foods Separated from Each
Other"
EMPLOYEE HEALTH Contamination from the Environment
2 590.003(C) Responsibility of the person in charge to 3-302.1l(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 UEensils*
Applicant To Report To The Person In Contamination from the Consumer
Charge* - 3-306.14(A)(B) Returned Food and Reservice of Food*
590.003(G) Reporting by Person in Charae*
3 590.003 F
(D) Exclusions and Restrictions* Disposition tipn of Adulterated or Contaminated .
Food
590.003(E) - Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Food*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces -
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water
3-201.12 Food in a Hermetically Sealed Container" Sanitization Temperatures*
3-201.13 fluid Milk and Milk Products* 4-501.11.2 Mechanical Warewashing-Hot Water
3-202.73 Shell Eons* Sanitization Temperatures*
3-202.14 Eggs and Milk Products.Pasteurized* 4-501.114 - Chemical Sanitization-temp.,pH,
202.16 Ice Made From Potable Drinking Water* concentration and hardness.* _
5-101.11 Drinking Water from an A roved S tem*
4-601,11(A) Eduipmcm Food Contact Surfacers and -
590.006(A) Bottled DrinkingWater* LJtenstis Clean*
590.006(B) Water Meets Standards in 3 10 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food-
Shellfish and Fish From an Approved Souare
4-702.11. Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan Foci Contact Surfaces of Equipment*
Shclllish* 4-703.11 Methods of Sanitization-Hot Water and
3-201.15 Molluscan Shellfish from NSSF Listed Chemical*
Sources*
Proper,Adequate H
10 p eq andwashfn
9
Game and Wild Mushrooms Approved by
Requkitoty Authority 2-301.1.1 - Clean Condition-Hands and Arms*
3-202.18 Shellstock.Identification Present" 2-301.12 Cleaning Procedure* -
590.004(C) Wild Mushrooms* 2-301.14 1 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 PHBs Received at Proper Temperatures* 2-401.12 Discharges From the.Eyes,Nose and -
3-202.15 Package Irte rite* Mouth*
3-101.11 1-nod Sate and Unadulterated* 3-30112 Preventing Contamination When Tasting*
6 Tags/Records:Shelistoek 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from
3-203.1.2 Shelistock identification Maintained* IEmployees*
Tags/Records:Fish Products 13 Handwash Facilities
3-402.11 Parasite Destruction* Conveniently Located and Accessible
3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities*
590.004(1) Labeling of ingredients` 5-204.11 Location and Placement*
7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance
/HACCP Plans Supplied with Soap and Hand Drying
3-502.11 Specialized Processing Methods* 6.301.11 Devices lin Cleanser, Availability
3-502.12 Reduced oxygen packaging. criteria*
8-103.12 Conformance with Approved Procedures*
6-301.12 Hand Drying Provision
4 Denotes critical item in the federal 1999 fond Code or l05 CMR 590.000.
)
1
, 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 jel. (978) 741=1800 Fax(978) 745-0343
Name D Type of Operation(s) Type of Inspection
3 ( Food Service "'ftutine
Address V Risk Retail [Ne-inspection
Telephone
Level El Residential Kitchen Previous Inspection
_-7
TT
El Mobile Date:
Owner I HACCP YM [ Caterer ❑ Pre-operation
1 ❑Suspect Illness
Person in Charge( l9( Time ❑ Bed&Breakfast ❑General Complaint
Inspector - M2k} Permit No. ❑El HACCP
Each violation cffecked 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 y_ _,v _____ ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
El[EMPLOYEE HEALTH 13. Handwash Facilities
- PROTECTIONFROMCHEMICALS�-
•,,,:,..
❑ 2. Reporting of Diseases by Food Employee and PIC �� "'`
El3. Personnel with Infections Restricted/Excluded El 14.Approved Food or Color Additives
FOOD FROM
rAPPROVE- D SOURCE El 15.Toxic Chemicals
__ - r _ _ _
El _ _4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements 17117. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling
PROTECTION FROM CONTAMINATION ) r 'T9. Hot and Cold Holding
❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control
El 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 ADVISORY-
❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices Number of Violated Provisions Related
Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22):
of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 30 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-z)(ss order of the Board of Health. Failure to correct violations
24. Food and Food Protection (FC-3)(590..004)004)) cited in this report may result in suspension or revocation of
25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food
26. Water,Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you
27. Physical Facility (Fc-6)(590.007) have a right to a hearing. Your request must be in writing
�28. Poisonous or Toxic Materials (FC-7)(590.006) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION:
Inspector's Signature: Print:
PIC's Signature: Page of 2 Pages
Violations Related to Foodborne Illness
interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION
g Cross-contamination
FOOD PROTECTION MANAGEMENT 3-302.11(.A)(1) Raw Animal Foods Separated from
1 590.003(A Assig Ment of Res nubiii„ t,-v* Caked and RTE Feuds*
540 003{l}} Demonstration of Knowledge Contamination from Raw Ingredients
2 f 03 11 Peron to charge-dutle, 3-302.1.1(A){2) Raw Animal Powis Separated from Each
__- Other'`
EMPLOYEE HEALTH Contamination from the Environment
2 590.O03(C) Responsibility of the person in charge m 3-3011](A) Food Protection*
require reporting by faxi employers trod 3-342.15 WashingFruit's and Ve*etables
a Aieants* 3-304.11 Food Contact with Equipment and
590.003(17) Responsibility Of A Food Employee Or An Utensils*
Applicant To Report To The Person In Contamination from the Consumer
Char " 3-306.14(A)(.B) Returned Food and Reservi e of Food*
590,(}03 G) Re ord g b Person in Charge* Disposition of Adulterated or Contaminated
3 590.UO3(D} Exclusions and Restrictions* Food
590.003(E) Remov=al of Exclusions and Restrictions 3-70..1] Discarding or Reconditioning Unsafe
Faxi*
FOOD FROM APPROVED SOURCE Food Contact Surfaces Food and Wafer From Regulated Sources
590.004{A$) Com Ili with 1^ood l a ' 4 501,111 Manual Warewashing-Hot Water
Sanitization Te ratures*
3-201.12 Food in a Hermeflcall Scaled Container* 4-501.112 Mechanical Warewashing.Hot Water
3.201,13 Fluid Milk and MilkPss3ucts* SanitzabonTcn Temperatures*
3-202.73 Shell Eggs* 4-501.114 Chemical Sanitization-temp.,pH,
3_gQ2,14 Fg<>s and Milk Prodacrs,Pasreuxized* concentration and hardness.'p
3-202.16 lee Made From Potable Drinking Water 4-601,11{A} Equipment Food Contact Surfaces and
5-101.11 Drinkin Water tion an A roved S ,tem" Utensils Clean*`
59fl.006(.A) Bottled Drinkin !6'atcr* 4 602.1 1 Cleaning Frequency of Equipment F xxl-
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils*
ShWffish and Fsh From an Approved Source 4-762.11 Frequency of Sanitization of Utensils and
3-201.14 Fish and Rec'eationally Caught Molluscan Food Contact Surfaces of Equ pmenr"
Shellfish* .._. 4-703.11 Methods of Sanitization-Hot Water and-
3d&j
20115 Molluscan Shellfish from NSSP listed Chemical*
ources* 1Q Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by 2-301.11 Clean Cou lition-Hands and Arms*
Ae mato Aufhor2301.12 Cleanin k'rocednre*
Shel st«kidenhfrcation Present* 2-301 i4 When to Was1t*Wild Mushrooms* Good Hygienic Practices
Game Animals* 2-401.11Eatin ,lldnkin or Usin Tobacco*
RecelvinglConditionPHFs Received at Pro er Tem etatures°" 2-401.12 Discharges[From the Eyes,Nose and
Mouth*Package lot-itv* 3-301.12 Preventin ContaminationWhen Tasting*Food Safe and Unadulterated* 12 Prevention of Contamination from Hands
6 Tagst'l , ords:Shettstock
590.064(E} Preventing Contamination from
3-202.18 Shellstock Identification* Ent iovices*
3.203.12 Shellstock Identif�rcation Maintained* 13 Handwasfi Facilities
Tagsifsecords:Fish Products Conveniently Located andAccessiWa
3 402.1] Parasite Destruction* 5-203.11 Numbers and Ca acities*
3-462.12 Records.Creation and Retention` 5.204.11 l.+x;atian and Placement'
590,0040) Labeling of ingredients"
Conformance with Approved Procedures 5 205.11 Accessibilit .O?eration and Maintenance
7 Supplied w#fr Soap and Hand Drying
/HACCP Pians Devices
3-502.11. Specialized ProcessingNlethods* 6-301.11 Handwashin Cleanser, Avaitabilit
3-502.12 Reduced ba' gen packaging,criteria* 6-301.12 Hand Di n Pro¢sion
8-103.12 1 Conformance with roved Procedures"
Denotes critical item it,the reder:d 1999 Food Cade or 105 Cl,4R 590.000.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: r Date: Page:_ of
Rem Code C-Crltical Item DESCRIPTION OF VIOLATION/P AN OF CORRECTION
NDate-
o. Reference - R—RedItem Vedned
PLEASE PRINT CLEARLY
Av tie) i
(i 3
fit.( N10
f- j1 r =`S
3 42!c G
6 — r ►/
e I o torn cy,
n s r-=
J —F i
�t ` n /
l aU
Discussion With Person in haig'e: Corrective Action Required: ❑ No Yes
1 have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employed 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 Ll Emergency Suspension
noncompliance may result in daily fines of twsmy-ffive doll�Lspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. / V
oluntary Disposal ❑ Other:
3-503.14(C) PHFs Received at Temperatures
Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to
Factors(Hems"t-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
3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below
3-302.14 Protection from Unapproved Additives* 590.004(F) 410/450 F*
15 Poisonous or Toxic Substances 3-501,16(A) Hot PRFs Maintained at or above
140°F. *
7-101,11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130°F.
Containers*
7-102.11, Corntnon 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-PresenceandUse* 590.004 H) Variance Re uirement
7-202:12 Conditions of Use*
7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11 Sanitizers.Criteria-Chemicals'* POPULATIONS HSP
7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801A I(A) Unpasteurized Pre-packaged Juices and
7-204.14 Drying Agents.Criteria* Beverages with Warring Labels*
7-205.11 Incidental Food Contact,Lubricants* 3-801.11(8 Use of Pasteurized Eggs*
" 3-801.11(D)(D) Raw or Partially Cooked Animal Food and
7-206.11 Restricted Use Pesticides,Criteria*
Raw Seed Sprains
7-206.12 Rodent Bait Stations* - Not Served.
3-801.11(C) Unopened Food Package Not Re-served.
7-206.13 Tracking Powders,Pest Control and
Monitoring* - CONSUMER ADVISORY
CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
TIME/TEMPERATURE CAnimal Foods That are Raw,Undercooked or
16 Proper CooldngONTRTemperatures for
PHFs Not Otherwise Processed to Eliminate
3-40LI IA(I)(2) Eggs- 155°F 1.5 Sec. Pathogens,'
Egs-Immediate Service 145°F15sec* 3-302.t3 Pasteurized Eggs Substitute for Raw Shell
3-407.11(A)(2) Comminuted Fish.Meats&Game
Eggs*
Animals-155'F 15 sec.*
3-401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 true* SPECIAL REQUIREMENTS
3-401.I1(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
sec * catering, mobile food,temporary and
3401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-165°F 15 sec. * above if related to foodborne illness
3-40I.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
145°F 4' 590.009 violations relating to good retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165'F* Special Requirements.
3-401A I(A)(1)(b) All Other PHFs-145°F 15 sec.
17 Reheating for Not Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-403Al(A)&(D) PHFs 165°F 15 sec. * (Iteitis 23-30)
3-403.11(B) Microwave- 165'F 2 Minute Standing Critical and non-critical violations,which do not relate to the
Time* foodborne illness interventions and risk factors listed above, can be
3-40311(0) Commercially Processed RTE Food- found in the following sectionsofthe Food Cade and 105 CMR
140°F* 590.000.
3403.11(E) Remaining Unsuited Portions of Beef Hem I Good Retail Practices I FC 59awo I
Roasts* - 23 Manartianent and Personnel "FC-2 .003 "
18 Proper Cooling of PHFs 24.. Food and Food Protection IF FC-3 .004
( 25. Equipment and Utensils i FG14 .005
3-50L14(A) Cooling Cooked PHFs from 140°Fto 26. Water.Plumbinq and Write FC-5 .006
70°F Within 2 Hours and From 70'F 2T. Physical Facilityi FC-6 .007
to 41°F/45'F Within 4 Hours.* 28. Poisonous or Toxic Materials
3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements - .009
Temperature Ingredients to 41°F/45°F 30. I Other I __
Witton 4 Hours* s:s�ero xc.z
'Nmotes critical Irani in the federal 1999 Food Cade or 105 CMR 590.000. -
; f
r a
CITY OF SALEM
f BOARD OF HEALTH
Establishment Name: tI r Date: Page: of
Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date-
No. Reference R—Red Itemverified
'—ury(R PLEASE PRINT CLEAP'Y '
f - �
r
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 El Employee estriction/
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 oflllaars or s s pension/revocation of o Embargo ❑ Emergency Closure
your food permit. `'
❑ Voluntary Disposal 0 Other.
r
3-501.14(0) PHFs Received at Temperatures
Violations Related to Foodborne Illness Interventions and Risk According to Uaw Cooled to
Factors{Items 1-22) (Cont.) 41'F/45�F Within 4 Hours.
PROTECTION FROM CHEMICALS 3-501,15 Ce din Methods fur P
HFs
14 Food or Color Additives 19 PHF Hot and Cold"ding
3-501.16(B) Cold P11Fs Maintained at or below
3-202.12 Additives* 590.004(M 4107450 F*
3-302.14 Protection from Una roved Additives* 3-501.I6(A) Hot PHFs Maintained at or above
15 Poisonous or Toitic Substances 140T. #
7-101.11 Identifying Information-Original - 3-501.16(A) Roasts Heid at or above 1.30°F.
Containers* 2U Time as a Public Health Control7-102.11. Common Name-Worlds Containers*
3-501,19 Time as a Public Health Control'
7-201.11 Separation-Stora * - -
7-202.11 ,Restriction-PresenceandUse* 590.044(H} VarianceRc Requirement
7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Tonic Coxttainers-Prohibitions* POPULATIONS NSP
7-204.11. Sanitizers.Criteria-Chemicals*
7-204.12 Chemicals far 6Vashi Prndu x,Criteria* 21 3-841.11(A) Unv ragesiwitted Pre-packaged Juices and
.Bevern es with Warning Labels*
7-204.14 Drying Agents.Criteria' 3-801.11(8} Use of Pastautizecl E
7-245.11 Incidental Food Contact,Lubricants* 3-801.11(l)) Raw or Partially Cooked Animal Food and
7-206.11 Restricted Use Pesticides;Criteria* Raw Seed Sprouts Not Served.*
1-206.12 Rodent Bait Stations* 3-WIAI(C) I Unopened Food PacKalte Not Re=served.
7-206.13 Tracking Powders,Pest Control and
[Monitoring' CONSUMER ADVISORY
TIME/TEMPERATURE CONTROLS 22 3.643.11 Consumer Advisory Posted fox Consumption of
16 Proper C ONTRoldnq Temperatures for Animal Foods That are Raw.Undercooked or
Not Otherwise Processed to Eliminate
PHFs
340i,IIA(i)(2) Eggs- 155°F 15 Sec. Patlto ens.*
Segs-immediate Service 145'F15sec* 3-302.13, 1 Pasteuzized Eggs Substitute for Raw Shell
3-40Ll l(A)(2) - - Comminuted Fish.Meats&Game
E
Animals-155'F 15 sec. * SPECIAL REQUIREMENTS
3.401.11(B)(1)(2) Pork and Beef Roast-130'F 121 moo*
3-40IJ I(A)(2) Ratites,Injected Meats-155`F IS 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
sec.* catering,.mobile food,temporary and
3.401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be
Staffing Containing Fish,Meat, debited udder the appropriate sections
Poultry or Ratites-165017 15 sec. * above if related to foodborne illness
3401.11(C)(3) Whole-muscle,Intact Beef Steals interventions and risk factors. Other
1450F* 590.009 violations relating to gad retail
3-401.12 Raw Animal Fools Cooked in a practices should be debited under#29-
Microwave 165F* Special Requirements.
3401.11(A)(1)(b) All Other PHFs- 145'F 15 sec.
17 Reheating for Hot Holding VIOLA77ONS RELATED TO GOOD RETAIL PRAC77CES
3-403:11(,3)&(1)) PHFs 165-F 15 sec. * (Items 23-30)
3-403A 1(B) Microwave 165`F 2 Minute Standing Critical and non-critical violations,which elo not relate to the
Tittle* - foodborne illness interventions and risk factors listed above, can be
3-403.t 1(C) Commercially Processed RTE Food- found in the following sectionsof the Food Code and 105 C6fR
1400F* 590.000.
3-403.11(E) Remaining Unsliced Portions of Beef 1 Rem i Good Retail Practices FC 590.50o i
Roasts': { 23. Ti_M__anaoement and Personnel i I -2 .CC3
gg Proper Cooling of PHFs 24. Food and Food Protection FC-3 .004
25. E u1 meM and Utensils t FC-4 .005 j
3-501.14(A) Looting Cooked PHFs from 340`F to . Water.Pt robina and Waste i FC-5 .006 _
74"F Within 2 Hours and From 70`F 27. ' Physical Faci' FC 6 .007
to 41`F145°F Within 4 Hours.* 128. ' Poisonous or Toxic Materials ! FC-7 .048
3-501.14(8) Cooling PHFs Made From Ambient 29, 1 Sjpeciai R uiremeras - .009 1
Temperature Ingredients to 41'F/45'F ' 30. I Other
Within 4 Hours*
'Demres critical nera in the 1-doral 1199 Ford Cale or 10 CMR 90.0()0.