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IMPORTANT MESSAGE
FOR L,-) 7Z_
DATE V-ZaTIME - PP)
M
OF
PHONE
AREA C BE 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 jie U
SIGNED
ftiVERSAL. 46005 MAGE IN U.S.A.
NOTES
Commonwealth of Massachusetts
City of Salem
Board of Health Kimberley Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 04/15/2011
ESTABLISHMENT NAME: Dairy Palace
File Number:BHF-2004-000161 187 Fort Avenue
Salem. MA 01970
LOCATED AT: 0187 FORT AVENUE
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
FOOD SERVICE BHP-2011-0425 Apr 15,2011 Dec 31,2011 $140.00
ESTABLISHMENT
FROZEN DESSERTS BHP-2011-0426 Apr 15, 2011 Dec 31,2011 $25.00
Total Fees: $165.00
PERMIT EXPIRES December 31, 2011
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted
in a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,
all plans for such must be submitted to and approved by the Salem Board of Health. Page 1
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: h. ic-1 Pri C9re Date: Page: of
Item Code C-Critical Item DESCRIPTION OF VIOLATION!PLAN OF CORRECTION Date
No. Reference R-Red Item J'r ,Verified�;
PLEASE PRINT CLEARLY '"'%"`^." o-F°^" a
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Discussion With Person in Charge: Corrective Action Required: ❑ No q, Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
violations before the next inspection, to observe all conditions as described, and to Exclusion
p ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
't your food permit.
i /I4 0. /511�Q ❑ Voluntary Disposal ElOther:
I
3-501.)4(C) PHFs Received at Temperatures
Violations Rolafad to Foodborne illness interventions and Risk Acwrdi ng to Law Cooled to
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PROTECTION FROM CHEMICALS 3-Stli.l5 Cooling h4ethods for PRFs
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14 Food or Color Additives 35tJ'..1'b($) Cold PNFs Maintained at or below
3-202.12 A(Mai cs'r 540.0iWF) 410145`F*
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t Establishment Name: �_(�/ CX C._0 Date: 4 (a(z-, (16 Pagd: / of
Item Cobs C-Critical ItemDESCRIPTION OF VIOLATION/PLAN OF CORRECTION
No. R¢Rsrence R-Red ItemVedtled .;
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Discussion With Person in Charge: Corrective Action Required: ❑
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ voluntary Compliance ❑ Employee Restriction
f inspection, to observe all conditions as described, and to Exclusion
violations before the next ins
P ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. //�)
❑ Voluntary Disposal ❑ Other:
ul �
I 501.14(c) ' PHFs Reizived at Temperatures
Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to '
Factors(Mems 1-22) (Cont) 411V45°F Within 4 Homs_} _ -
3-501.15 Cooling Methods Rx PHFs
PROTECTION FROM CHEMICALS `—� 19 PHF Hot and Cold Holding
14 food or Color Additives 3501.16(B) Cold PHFs Maintained at or below
3-202.12 Additives" 540.004(0) 41"/45`F*
3-302.14 Protection fromL'napproeedAdditice," I 3_jt,3i.(6{;�j HntPHlc;`iaintaiuedatorabove
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�" • Commonwealth of Massachusetts
City of Salem
Board of Health
120 Washington Street,4th Floor Kimberley Driscoll
SALEM,MA 01970 Mayor
Food/Retail Establishment Permit
PRiNTF.D: 04/20/2010
ESTABLISHMENT NAME: Dairy Palace
File Number:BHF-2004-000161 187 Fort Avenue
Salem MA 01970
LOCATED AT: 0187 FORT AVENUE
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
FOOD SERVICE BHP-2010-0407 Apr 20,2010 Dec 31,2010 $140.00
ESTABLISHMENT
FROZEN DESSERTS BHP-2010-0408 Apr 20,2010 Dec 31,2010 $25.00
Total Fees: $165.00
PERMIT EXPIRES December 31, 2010
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all
plans for such must be submitted to and approved by the Salem Board of Health. Page 1
` a
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET,4"r FLOOR
TEL. (978) 741-1800
KIMBERLEY DRISCOLL FAX(978) 745-0343
MAYOR DGREENBAUM(l!✓)SALEM.COM -
DAVID GREENBAUM,
ACTING HEALTH AGENT -
2009 APPLICATION FOR
, PnE^RMIT TO OPERATE A FOOD
/ESTABLISHMENT
/� ' I v�
NAME OF ESTABLISHMENT 0� r I" "L&CR, TEL# N19 J JLY'J- `7D�1'oL
ADDRESS OF ESTABLISHMENT hhI g i V J e FAX#
0MAILD�Ld �h I yA �� Q
INGADDRESS(ifdifferent)
EMAIL- Business': 1 Website:
OWNER'S NAME_ �t "r f 'DYj�,S �jaC . - TEL#
ADDRESSYY!
STREET ,;CITY,/ STATE ZIP
CERTIFIED FOOD MANAGER'S NAME(S) H w v ncL- —D"OL00S CERTIFICATE#(S)
(Required in an establishment where potentially hazardoustood is prepared) p F n/
EMERGENCY RESPONSE PERSON ( D S Li n ou fns HOME TEL# (a. )O)
DAYS OF OPERATION 1 Monday Tuesday Wednesday Thursday Friday Saturday Sunda
HOURS OF OPERATION
Please write in time of day.
(For example t tam-11pm) ij
TYPE OF ESTABLISHMENT FEE (check only)
RETAIL STORE YES NO less than 1000sq.ft. =$ 70
1000-10,000sq.ft. =$280
more than 10,000sq.ft. =$420
-- -- . '
RESTAURANT ES NO less th. an5 2seats
(Outdoor Stationary Food Cart$210) 25-99 seats =$280
more than 99 seats =$420
- - - . .... ......................................................---------------------------------------------------------
BED/BREAKFAST/ YES NO $100
CHILDCARE.SERVICESMURSING.HOME
----------------------------------------------------------
------
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE NO $25
TOBACCO VENDOR NO
ALL NON-PROFIT(such as church kitchens) NO $25
'Please pay total with one check payable to the City of Salem.
This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location
in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made, all plans for
such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax
returns and paid all state taxes required under the law.
Signature Date Social Security or Federal Identification Number
CITY OF SALEM MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET,4"FLOOR
TEL. (978) 741-1800
KIMBERLEY DRISCOLL FAX(978) 745-0343
MAYOR DGREENBAUMCC�7�.SALEM.COM
DAVID GREENBAUM,
ACTING HEALTH AGENT
----------------------------------------------------------------------------------------------------------------------------------------------------------------------
Revised 4/24/07 FOODAP2008.adm Check#&Date $
IMPORTANT MESSAGE
FOR CA/✓
DATE �J �� TIME
M LA
}}��
DF (=1f11r� Pa��JOct- `/
PHONE O -a3 el--j l tR
AREA CODE NUMBER EXTENSION
O FAX
❑ MOBILE
AREA CODE NUMBER TIME TO CALL
TELEPHONED PLEASE CALL
CAME TO SEE YOU WILL CALL AGAIN
WANTS TO SEE YOU RUSH
RETURNED YOUR
.. CALLWILL FAX TO YOU
MESSAGE
.�, _ ktx-1 k - ^
3A/
ICY, 3n
SIGNED
OIVERSAL, 48005 MADE IN U.S.A.
NOTES
1 VOTES
1
Commonwealth of Massachusetts
` City of Salem
Board of Health Kimberley Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 04/17/2009
ESTABLISHMENT NAME: Dairy Palace
File Number:BHF-2004-000161 187 Fort Avenue
Salem MA 01970
LOCATED AT: 0187 FORT AVENUE
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
FOOD SERVICE BHP-2009-0440 Apr 17,2009 Dee 31,2009 $140.00
ESTABLISHMENT
FROZEN DESSERTS BHP-2009-0441 Apr 17,2009 Dee 31,2009 $25.00
Total Fees: $165.00
PERMIT EXPIRES December 31, 2009
Board of Health KU
ke
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
t
4
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
l 120 WASHINGTON STREET,4..FLOOR
TEL. (978) 741-1800
KIMBERLEY DRISCOLL FAX(978)745-0343
MAYOR DIONNEQSALEM.COM
JANFT DIONNE,
SENIOR SANITARIAN
aooq
20WAPPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT Nh r 1 TEL#
ADDRESS OF ESTABLISHMENT & flYrlLFAX# l 1�0
91i��)
MAILING ADDRESS(if different) o60rz. ood, D / Pio tij AIA Cp�d�DR/o(
�
EMAIL-Business': //�� ,,,,..,, Website:
U
OWNER'S NAME I_ dos TEL# 7 5 -I 6nla
ADDRESS 9, 6f1fdwooikY.
STREET CITY 0 STATE ( ` ZIP
CERTIFIED FOOD MANAGER'S NAME(S) ' 1Job SC�LfU G .7 CERTIFICATE#(S) T I
(Required in an establishment where potentially hazardous food is prepare ,,I /� //77
EMERGENCY RESPONSE PERSON l� /]S I.I h Lt rG�llS HOME TEL# 1 1 P- - I (Q
DAYS OF OPERATION Monday i Tuesday Wednesday, i" Jhursday i Friday Saturday Sunda
HOURS OF OPERATION 1 1
Please wdteinfimeofday II, ,I'nm
For example Ilam-11 m (�
TYPE OF ESTABLISHMENT FEE (check onlvl
RETAIL STORE YES NO less than I000sq.ft. =$70
1000-10,000sq.ft. =$280
more than 10,000sq.ft. =$420
-- -----------
RESTAURANT YES NO less than 25 seats =$140
(Outdoor Stationary Food Cart$21 25-99 seats =$280
more than 99 seats =$420
BEDBREAKFAST/-------- ---------YE --NO -......-.........--------.....--------------------------------------------$.1.0.-0......
CHILDCARE SERVICES
- .......................................................................................................................
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE $25
TOBACCO VENDOR Q NO $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 fled all state tax
returns and paid all state taxes required under the law.
SSKgnature Date Social Security or Federal Identification Number
------------------------------------------------ -'--- -- �-y'-q- --,-, —
Revised 4/24/07 FOODAP2008.adm Check#&Date "I $ O
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: I)A) t2,\) Pr tura L� Date: q Page: of /
Rem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R—Red Item Verified
PLEASE PRINT CLEARLY "
O "6N I tjU 1 N SP =, elle 1,-3 Ya tiL 12u W v i fL� Yr �'f I o oP
li vim; � � i;ur1 S i1Sr l��
AN V
5q GA
w
.s
t
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 ❑ Employee Restriction/
violations before the next inspection, to observe all conditions as described, and to Exclusion
P Ll Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five doll(?arsrdr susp sion/revocation of El Embargo ❑ Emergency Closure
your food permit. /� �, � �
Ul[i1 I ���^^^000III ❑ Voluntary Disposal ❑ Other:
J-501.14(C) PI]Fs Received at Collol!,�d
eratures
Violations Related to Foodborne Illness Interventions and Risk According to Law to
Factors(items 1.22) (Cont.) 4FF(45`F Within oms.
PROTECTION FROM CHEMICALS 3-501-15 Coaling Methods for PHFs
19
13 Food or Color Additives PHF Hot and Cold Holding
501-16(B) Cl
' old PFIRs Maintained at of below
3-202.12 Addan%es� 590.004(F) 41%45'F*
3-302.14 Protection from Una roved Additives* 3,501.16(A) Hot PHFs Maintained at or above
15 Poisonous or Toxic Substances
7-101.11 klentiryinglnformation-Original 3-501.16(A) Roasts Held at orobove130'F.'h
Containers*
7-102.11 Common Name-WorkingContarncrs* 20 Time as a Public Health Control
7 .201.11 Searation-Storage; 3-501.19 Time as a Public Health Control*
7-202.11 Restriction-Presence and I)se*
5909004(H) Variance Re-ulrement
7-202.12 Conditions of Use*
2203.1.1 Toxic Containers-Prohibitions"` REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11 Sanitizers.Criteria-Chemicals*, POPULATIONS HSPj
7-204.12 Chemicals for Washing Produce,Criteria'I` 21 3-So t I(T) Unpasteurized Pre-packaged Juices grid
7-204.14 Dryin 1 grits,Criteria" Beverages with b4 amine Labels*
n; n
7-205.11 Incidental Food Contact.Lubricants* 3-S01 11(B) Use of PasteurizedELes'
3-801.1 1.(D) Raw or Partially Ccaiked Animal Foal and
7-20(1.71 Restricted Ilse Pesticides.Criteria* Raw Seed Sprouts Not Served.
1-206.12 Rodent Bait Stations'" 3-801.1](C) Unopened Food Package Not Re-served.
7-206.13 Tracking Powders,Pest Control and
Moriitorina*
CONSUMER ADVISORY
TIMFITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
16 Proper Cooking Temperatures for
Animal Foods That are Raw.Undercooked or
PHFs Not Otherwise Processed to Eliminate
3-401.11A(1)(2) Eggs- 155'F 15 Sec.
Pathogens.* Er"""°`vrizwr
Eggs-Immediate Service 145'F15sec* 2.13 Pasteurized Eggs Subsunne for Raw Shell
3-401.11.(A)(2) Comminuted Fish, Meats&Game 3-30
Animals- 155'F 15 sec.
3-401.11(B)(1)(2) Pork and Beef Roast-130'F 121 min* SPECIAL REQUIREMENTS
3-401.11(8)(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
Pouter or Rat tes-165"F 15 sct._` above if related to Foodborne illness
3-401.11(C)(3) Whole-muscle,Intact BeefSteaks 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 1429-
Microwave 165'F* Special Requirements,
3401..11(A)(1)(b) All Other PHFs-145'F'15see. *
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-403.11(-4)&(D) PHFs 165°.F 15 sec. * (Items 23-30)
3-403.11(B) Microwave-165'F 2 Minute Standing Critical and non-critical violations,which do not relate to the
Times ,foodborne illness interventions and risk factors listed above, can he
3-403.11(C) Commercially Processed RTE Food- ,found in the fallowing sections of the Food Code and 105 CNIR
140"b .590.tJOU.
3-403.].1(C) Remaining Unsliccd Portions of Beef Item Good Retail Practices_ FC_ 590.000
Roasts* _23. Mani ey merit and Personnel _.._.._ FC-2 .003
1g Proper Cooling of PHFs 24. Food and Food Protection ___ - FC--3 .004
25 _Equipment and Utensils FC 4 .005 _
3-5(i1.1.4(h) Cooling Cooked PHFs from 140°F to 26 Water,Plumbin and Waste FC 5 .006
XF Within 2 Hours and From 70°F 27. Ph sioal Facilit FC-6 .007
to 41.`F145"F Within 4 Hours. * 28. Poisonous or Tows Materials 7 .00II
3-501.14(B) Cooling PHFs Made From Ambient 29. S ecial Re utrements .009
Temperature Ingredients to 41`PJ45'F 30------- Other -------
(lours* s it :cxtaa.wK
'Denotes critical item in die fIN e1'sl 1999 Food Code or 105 CNIR 590-000. -
Commonwealth of Massachusetts
C F
City of Salem
Board of Health Kimberley Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 04/22/2008
ESTABLISHMENT NAME: Dairy Palace
File Number:BHF-2004-000161 187 Fort Avenue
Salem MA 01970
LOCATED AT: 0187 FORT AVENUE
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
FOOD SERVICE BHP-2008-0444 Apr 22,2008 Dec 31,2008 $140.00
ESTABLISHMENT
FROZEN DESSERTS BHP-2008-0445 Apr 22,2008 Dec 31,2008 $25.00
Total Fees: $165.00
PERMIT EXPIRES December 31, 2008
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all
plans for such must be submitted to and approved by the Salem Board of Health. Page 1
CITY OF SALEM, MASSACHUSETTS
• • BOARD OF HEALTH
120 WASHINGTON STREET,4°1 FLOOR
TEL. (978)741-1800
KIMBERLEY DRISCOLL FAX(978)745-0343
MAYOR ISQ7rI]@SAf.P:M.COAT
JOANNE SCOTT,
HEALTH AGENT
2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT '/
NAME OF ESTABLISHMENT PdV Y 64ZA G� TEL# 979' 7�S / 0 7Z Z
ADDRESS OF ESTABLISHMENT AS 7 AQATh6YL • FAX#
MAILING ADDRESS(if different) T CS D9 m E—
EMAIL-Business': Website:
OWNER'S NAMET11.5// � �>°
IAIXle6OS TEL#
ADDRESS � 1N4�u� /T �6��F1 ✓ O/
STREET CITY STATE ZIP
CERTIFIED FOOD MANAGER'S NAME(S) lfl" fD�LILOU"S CERTIFICATE#(S)
(Required in an establishment where potentially hazardous food is prepared) /
EMERGENCY RESPONSE PERSON ,?A//Y _HOME TEL# �I0'- r ii'? .3 C�
DAYS OF OPERATION Mond I TuesdayWednesd l Thursda FridaySaturdaySunda
HOURS OF OPERATION
Please write in time of day.
For example 11 am-11 pm)
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
---- - t- ------ ----- ---------------- --14040. -
RESTAURANT YES NO less h-an 25- sea-ts =
(Outdoor Stationary Food Cart$210) 25-99 seats =$280
more than 99 seats =$420
BED/BREAKFAST/--------------------YES-------
NO --------------------------------------------- $100
CHILDCARE SERVICES-----------------------------
ADDITIONAL PERMI
MAKE (not just serve) ICE CREAM YOGURT/SOFT SERVE YES NO
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 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 GL 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 a id all statees required under the law.
- !7- 0 8
Signature U0Date ,, `` Social Security or Federal Identification Number
i� b' ' �� � � lk�a �
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... � � �7 � � x. �C � _ 1. �
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- � NUMBER FEE
THE COMMONWEALTH OF MASSACHUSETTS
•
V .... of ....... ................._..,........ ....._..........-_.........
i This is to Certify that ...... .. ..................................................._..................
.
U NAME
..............
_..................
ADD
i
ISJa
HEREBY GRANTED A LICENSE
For ..............................................-....-................._.,.-................
................. ............_.................-. ........--..................-....... .................
..................._ ........................-......................-...._............_.. ....._...__...
- ............._...._.._..
...........---................................_....._.................
This license is granted in conformity with the Statutes and ordinances relating thereto, and
expires.....ler�'.s f?fps ........._..................._unless sooner suspended or revoked.
_. _......... ..._...._......,._... _........_.._...-......__..........
1.8. •--......-... tea _.................
... ...............
FOAMS�33 AM SUt NDN ung 805TON
s
Massachusetts Department of Public Health Salem Board of Health
Division of Food and Drugs 120 Washington Street,4'h Floor
9 Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343
Name r-� Date/ Tvpe of Operations) Type of Inspection
l G.1 C_ Q'CQ GPi ! f 8. Food Service 8 Routine
AddressI ' r f2 . Risk LJ Retail ElRe-inspection
Level ❑ Residential Kitchen Previous Inspection
Telephone G \ ❑ Mobile Date:
OwnerA HACCP YM ❑ Temporary ElPre-operationo I y\( ❑ Caterer ❑Suspect Illness
Person in Charge(PIC) Time ❑ Bed&Breakfast ❑General Complaint
Inspector Permit No. Other
FS �I�.� .a. Our. El
Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco
Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑
action as determined by the Board of Health.
'FOOD PROTECTION MANAGEMENT>, „,.,,,„,,,,,.;,,,,.„,�:,, _�.,,aj ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
_ � x ❑ 13. Handwash Facilities
EMPLOYEE HEALTH
❑ 2 Reporting of Diseases by Food Employee and PIC �l= _ »� __ '•-��ammo
❑ 14. Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded
❑ 15.Toxic Chemicals
FOOD FROM APPROVED SOURCE
E] 4. Food and Water from Approved Source 3"nMFJ7EMPERATURE CONTROLS(Potenflally Hazardous Foods)
❑ 5. Receiving/Condition ❑ 16 Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling
PROTECTION FROM CONTAMINATION'-" `'? "'= El 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 SUSC�EPTIBLEPOPULATIONS(HSP)'
❑21. Food and Food Preparation for HSP
❑ 10. Proper Adequate Handwashing
ElLl11. Good Hygienic Practices 'CONSUMER'ADVISORX,I
22. Posting of Consumer AdvisoriesMI
Violations Related to Good Retail Practices Number of Violated Provisions Related
Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22):
of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code. This report, when signed below
'C N` (Fc-2)(sso.0 by a Board of Health member or its agent constitutes an
24. Food and Food Protection (FC-3)(59
23. Management and Personnel 4)) order of the Board of Health. Failure to correct violations
cited in this report may result in suspension or revocation of
25. Equipment and Utensils (Fc-a)(ss0,00 ).00s) the food establishment permit and cessation of food
26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you
27. Physical Facility (FC-6)(e90.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7)(590.00s) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION:
S:5901nspetlFomS-10.tloc
Inspector's Signature/ � � Print: / 1�
,-ta �l�ra _a4 ���31t A_ w_ iCLOAr P . I D,�_ o_ �t t
PIC's Signature: !! a �A/ -Print: p I 2 ,1 S Page I of�Pages
Y� !1
Violations Related to Foodborne Illness
Interventions and Risk Factors(Items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT 8 Cross-contamination
1 590.003(A) I Assignment of Responsibility* 3-302.11(A)(D Raw Animal Foods Separated from
590.003(B) Demonstration of Knowledge* Cooked and RTE Foods*
2-103.11. Person in charge=duties Contamination from Raw Ingredients
3-302.11(A)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Other'
2 590A03(C) Responsibility of the person in charge to Contamination from the Environment
require reporting by food employees and 3-302.11(A) - Food Protection*
applicants" 3-30215 Washing Fruits and Vegetables
590.003(F) Responsibility Of AFaxl Employee Or An 3-304.11 Food Contact with Equipment and
Applicant To Report To The Person In Utensils*
Char e* Contamination from the Consumer
590.003(6) Reporting by Person in Charge' 3-306.14(A)(B) Returned Food and Reservice of Food*
3 590.003(D) Exclusions and Restrictions* - Disposition of Adulterated or Contaminated
590.003(E) Removal of Exclusions and Restrictions Food
3-701.11 Discarding or Reconditioning unsafe
FOOD FROM APPROVED SOURCE Food*
4 Food and Water From Regulated Sources F9 Food Contact Surfaces
590.004(A-B) Cum iliance with Food Law* 4-501.1.11 Manual Warewashing-Hot Water
3-201.12 Food in a Henneticall yy Sealed Container* Sanitization Tem eratures*
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water
3-202.13 Shell Eggs* Sanitization Temperatures*
3-202.1.4 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitivirtion-temp.,pH,
3-202.16 Ice Made From Potable Drinking Water'` concentration and hardness. *
5-101..11 Drinking Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and
590.006(A) Bottled Drinking Water* Utensils Clean*
Food-
590,006(B) Water Meets Standards in 310 CMR 22.0` 4-602.11 Cleaning Frequency of Equipment Food-
Contact Surfaces and Utensils*
Shellfish and Fish From an Approved Source 4-70211 Frequency of Sanitization of Utensils and
.
3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment'
Shellfish'" 4-703.11 Methods of Sanitization-HotWaterand
3-201.15 Molluscan Shellfish from NSSP Listed Chemical*
Sources* to Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Regulatort,Authorit 2-301.11 Clean Condition-Hands and Arms*
3-202.18 Shellstock Identification Present* 2-301.12 CleaningProcedurc*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201.17 Game Animals* 11 Good Hygienic Practices
Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco*
3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes, Nose and
3-202.15 Package Inte it * Mouth*
3-101.11. Food Safe and Unadulterated* 3-301..12 Preventing Contamination When Tasting*
6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from
3-203,1.2 Shellstock Identification Maintained- Employees*
Tags/Records: Fish Products 13 Handwash Facilities
3402.11 Parasite Destruction- Conveniently Located and Accessible
5-203.11 Numbers and Capacifies*
3-402.12 Records,Creation and Retention* 5-212 i Location and Placement*
590.004(1) Labeling of ingredients"
7 Conformance with Approved Procedures 5-205.11 Accessibility.Operation and Maintenance
with So and Hand Drying
tHACCP Plans - Supplied ry g
3-502.11 Specialized ProcessingMethods* Devices
3-502.12 Reduced oxygen packaging.criteria* 6-301.11 Handwashin Cleanser,Availabilit
8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drying Provision
-Denotes criiiad item in the federal 1999 Food Code or 10J CbiR 590.006. -
l -
} CITY OF SALEM
BOARD OF HEALTH
Establishment Name: T CjAUC'2 Date L�((r- /m5 Page of 2
jnem Code C-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION t ' Z ` 1 Date '
No. .n ,Reference -R—RedItem ">,, ;, .f i,> • a" `z .,. N ri.. ;' .n ,�.y min .. nw .,. ;?,.. : Verified
-x+ n PLEASE PRINT CLEARLY - b 6f - '
� 't1�
Y _
a
s �
I
}
j -
i
i
i
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 LRe-inspection
liance ❑ Employee Restriction/
Exclusion
violations before the next inspection, to observe all conditions as described, and to cheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Emergency Closure
your food permit. ( (;�� C\1 DCC V J�/t sal ❑ Other:
S\/
Violations Related to Foodbarno Illness interventions and Risk Accordba,to Lav Coaled to
Factors(Iteran 1-22) (Cont) 4 I'F/45"F Within A Hotws.
5 +1.7 5 Coolurs Mehiodr lot PHFs
PROTECTION FROM CHEMICALS
L19 P14F Hot and Odd"ding
Food or Color Additives..,._
72 �P-12 Achiiiive,'* t sm, 16(B)3—
Cold PRFs Manitailmd at'ir below
590.0flniff, 41"/45"F�
3-302,14 laoteclion 3-501AWA) Ent PHF�Mairnainedq or above
Poisonous or Toxic Substances 140'F
3-5
01,M(A)
—Time as a—Public—HealthConttaf
7102-l1 Common Narac -Workira,Cvnnnner'*
7-201 Sdpaos6on-��Storae
Prmm—rc
2l)2.I1 Reqrkd4op-Pr(, not and
7-202.12 Coadftvsts of Uw*
7-?03,11 REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS(HSP}7 Satdti7WS,Chleris-ChC10iCAbZ*
-204.11
'7 amicAts for wusb�IaLt'�LXLIIE' it !�I� F-21-1 1-i�)Tll(A) llnpsteuri?cd flre-paibaged Joices and
�---T'
-204.1 2 h
7204,14 1)2tujilil�'Criteria, Rrverascc with Warain" 1-sbzls
3-801.11(B) 1-��of Pa�'ourized Eass'
1 7-205AI Incidental fc,-d Contact lAilmicarts'
pTo—,Tl-(f)-}- R�tw or ParuAk;Ctokcd Animal Food and
66--111 Resnrwi d Use PeNticides,Criteria* Raw Seed Sproac;No Strved,
1 7,06.12 Rodent B;at Saktk'TVs' _L.,mr�envd FL),si�Packag, NL)l
Powders.I' Control and Inwkmg Powder'.
[:TIHK.I T I L C
CONSUMER ADVISORY
i 22
3-60;.11 Consumer Arr�i soi y Posted for Coniumption of
TIMEITEMPERATURE CONTROLS
16 AnimA F-(As DaM Art Raw, Undeiccokvd ol
Pro-ps—rCooking Temperatures for
PHFs Net Odwi m ise Processad to Eligarrare
3-401 11 A(l)(-') Fgg:- 1 55'F 15 Scc. Pathogens,
F hhxiaudt tis 5c,nicc 1,i5'Fl5ioc, I Fig-=Subgilutv foi Raw Shell III
CommithoLd Fish,Nfeats&Ganiv
Animals. Li,5"F I ry sec. �' SPECIAL REQUIREMENTS
3-461.1 I(B)(11)(2) E Pork and fb�ef Roam -130F121 rail"
3-4Q7.1 1(,A)Q" Ratjne•, Select Mcau 155 F 15
catering tnohils,,tood, temporary and
- itsiden tial kitchen optdation�shoald
346I-II(A)C31- Poultr). Wild Ganrc7stuTrel l4iTs', r
SaAfina Cont orae HmbMeal, defiled under the appropriate sections
poult
or liatices 165°7- 15 sm above if related 10 foodborne illness
3-1-7-FT- Whole T-1
01 IUCY-1' -rou'de [Wao BeoflSteaks interventioni and rist, facto m OthcT
I'51T' 590.009 violatioris relathi�, to'm)d retail
4"
l , Tood,Erox)in a bc dcbiwd�under#29-
_
I I
,Miciowave 165'F 'it Requirements-
4rc.ow v
3461-11(A)(1)(b) All Other PHFs- 145"F15 sec,
=7 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
-3-403.11(,A)&-(D) MIN 165'T 15 ate. Uterus 23-3(P)
7 403.11(B) Microwave- 165'F 2 Minute Standing Criaraf and non-crnwal vn)terfivkrs, volfirh do no relate to!ke!
Time, foodborne ratness oaO VCrrti0aLV and riA-Jof iorr lisled ahorn can be
finind in lhcjvilmiotg sefrions 4 the Food Code and 105 CA41?
J 40'Fl 590,000.
-----------
3-401,11(F) Remaining unsbeed portion,"Fil", L Good visa[Practices FC 590,00
RoaA,* 23 Management and Parsanne!_ I FC -2 ..903
Cooling at Pt—iFs Protection i ----- —
Proper C 3 004
FC -4 005
�501140N) Coaling Cooked PHFs bom 140'F to 26, 1 Water,prumingsiand waste i C-5 006
70°F'Within 11 flours and From'01,11' nq p- FC-6 007
to 4 I'F145'F Within 4 Roru�� 2& jLp6Sonous or roxic malena� QFC-7 008
Conlin ------ ........
g PHFrMadt,Fano 1 29� 1 Special Rquiremonia '009
Temperature higredienv,to 410F/45�F - Other
IMPORTANT MESSAGE
FOR Q�
DATE "�� �dU TL
Eh/'��
M_ Myrna,
OF
PHONE �-- O
AREA CODE NUMBER EXTENSION
U FAX
U MOBILE
AREA CODE NUMBER TIME TO CALL
TELEPHONED. PLEASE CALL
CAME TO SEE YOU WILL CALL AGAIN
WANTS TO SEE YOU RUSH
RETURNED YOUR CALL WILL FAX TO YOU
MESSAGEAig
-
' r
SIGNED
FORM 400
666V MARE IN U.S.A. ��� .�
Fax G��r$� 53a 8ai4
NOTES _.
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y x tR . 120 Washin,,/on Stree 4th Floor 1Gmberley OnSooll3
aG^•� 4A
{Mayors*'
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 04/26/2007
ESTABLISHMENT NAME: Dairy Palace
File Number:BHF-2004-000161 187 Fort Avenue
Salem MA 01970
LOCATED AT: 0187 FORT AVENUE
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
FOOD SERVICE BHP-2007-0469 Apr 26,2007 Dec 31,2007 $100.00
ESTABLISHMENT
FROZEN DESSERTS BHP-2007-0470 Apr 26,2007 Dec 31,2007 $5.00
Total Fees: $105.00
PERMIT EXPIRES December 31, 2007
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any revonations, improvements,or equipment changes are made,all
plans for such must be submitted to and approved by the Salem Board of Health. Page 1 of 1
GS
C(ttr OF SAL ►,1Vlnssacusns
®ogs�s,9 WALTN
t 2Q wrst+aap4ri STtteer,4Tn Fcoaaa '
Sm A01
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TEL,},8,78 7411 1800
FAx�7@•.745 03h3 :; �,
Kimberley Driscoll wwwsAi¢u caµ
Mayor JOArme Scorr,mPH R5 GNO
He,At.TN Aw4
2007 APPLICATION FO�'RPERMIT TOf OPERAT;g p v 00D E34AeLISHMENT
NAME OF ESTASL(SHtt11ENT.`' Q trv-?x1,94: TEL # 17W 745 1012
A01)RES5OrFtTABL6HMENT_; J Fer� (�yP Gs FAXN/_�,�QL
MAN.04r,A00RCS$.(it 01e,'40).,_So.�.��Z �kuq ni.e. a' •�4_+-4 `y ._SCI...LR ._. ._.. ...
EWLQL•^4v3iness`•.._..._... .�_ovnter'.5: _�y� ._-...._ . .._�_,_•....._._
OWNSR%NAM)__',.f.+�I3t.S.-_`,1,^_LiG1LtLawTEL# 5�.._
S'fR£ET yCITY
^V STATE P 2iP
CERTrFtEoFOOOMANAGER'S NAMF(iCERTIFICAws(s)
(Rv,1vI(e08i an 0ala0NtlMNCnt Whw*VM4111 Ally haES111CUk a9d i:V tlf3Par M�� �p �—
crat:�LIE14CY R_'SP()NSE,PCR30 .N - �_t^.1Y1Qtt HOME TEL Jt Q f a 5J•a! SO4 _.
1�80`!SOlUPEflAUQN '.'�•Montlau., ._..Tueade �" "�._ .._.._.., _..___.__
Iaouns3roFr�"�iott ; ! 1! 11-1 1. 111-+ it-1J
; ateat:awtttetattagtslssr: �l�r+►-uPfi !t-111 1:1-)1 R � t M
TYP F F"' BLISHMFNT . �' PEE, (check„ onlvl
j Rr TAtt.STA YE5 N() II;3+than 1000sq.(t. �$50
i' tUOQ•1Ct;000o"q.ft. y.t"+t(}t?
mom than 10,000sq.ft. 4200
i
........ .... .
RESTAIiF,,aNT F'S Nt:, iB5alhan253eatS E.
25.9D wills = t 0
mora tholt 98 sez+tx =5200
. .•........ . ........ _.............
HFI1tCiREAKFAST YF..S NO $100
ALtGiT{O_NAL_PERMITS
tj6%E tlroijust 34rvtg)lQE C:RE.AM YOGi.I'n'T, SUPT'SERVE (1 5 r 55
T()BM'kti0VEtvOt3R YF.S;
ALL N0N-PR0f7T($#ch as crl r.;!r Ai(CJren.+) `)'ES J >;
'17k440 pay total will)anv r-.h«rk payable to the G(ty of Salem,
This Permit is not transferable and must us reissued upon change of ownership, The POrmtt must be gusted i
prolrinettt laxation to tho Establishment.
In accurdan•'tr Kith the,State Sailltary Code,b4fore any renovations,improventsnts,or equipment changes ar
mads, all pians for Such must be submitted to aiid approved by the Saten:tsoaro of Health.
t�Patt;;`ipn<,1t4 Gg I}aiilti Jtitl Ilia of All fa}nv„r lean 1.10 n)y ve8t iwowla;. ji 8'vi ueL
h l'rr(i S :iii 9(nip 111v,fe1,1r?K ar ' i"iN;q!p1 i14 i Y r:f rVNe t.!'u l iyt l i tu, . -
.... .. . .._... ....... .....
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10dtdtlt>8:07 4002 9z!'
2.
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11188 c£S+ -ON 3N01id . ... .........
XUJIGHl oluoseued 1408-3
ZAK ENTERPRISES,INC. 5174
CITY OF SALEM-BOARD OF HEALTH 4/26/2007
105.00 .
CENTURY BANK-REGU 105.00
0187 FortAvenue Dairy Palace
City of Salem
FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection
HACCP: ❑
Item Status Violation Critical Urgency
Telephone: i FOOD PROTECTION MANAGEMENT
745-9042 PIC Assigned/Knowledgeable/Duties PASS 0 RED
Owner:
Non-compliance with:
Costas Linardos
i Anti-Choking - PASS
PIC:
Arthur Reppas Tobacco PASS
Inspector:
DEMPLOYEE HEALTH
David Greenbaum
Date Inspected:Correct By: Reporting of Diseases by Food Employee and PIC PASS 0 RED
4/26/2007 Personnel with Infections Restricted/Excluded PASS 0 RED
Risk Level:
FOOD FROM APPROVED SOURCE
Permit Number: Food and Water from Approved Source PASS d❑ RED
BHP-2007-0469 Receiving/Condition PASS ❑ RED
Status:
SIGNED OFF Tags/Records/Accuracy of Ingredient Statements PASS RED
#of Critical Violations: Conformance with Approved Procedures/HACCP Plans PASS RED
0
Time IN: Time OUT:
Urgency Description(s):
BLUE:
Violations Related to Good
Retail Practices (Critical
violations must be corrected
immediately or within 10
days)(Non-critical violations
must be corrected immediately
or within 90 days)
City of Salem Board.of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 26,2007 ) Page I of
' - Item Status Violation Critical Urgency
RED: PROTECTION FROM CONTAMINATION
Violations Related to Separation/Segregation/Protection PASS 0 RED
Foodborne Illness Interventions
and Risk Factors (Require Food Contact Surfaces Cleaning and Sanitizing PASS RED
immediate corrective action)
Proper Adequate Handwashing PASS 0 RED
Good Hygienic Practices PASS 0 RED
Prevention of Contamination from Hands PASS RED
Handwash Facilities PASS 0 RED
PROTECTION FROM CHEMICALS
Approved Food or Color Additives PASS 0 RED
Toxic Chemicals PASS E/1 RED
TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
Cooking Temperatures PASSd❑ RED
Reheating PASS RED
Cooling PASS RED
Hot and Cold Holding PASS 0 RED
Time As a Public Health Control PASSd❑ RED
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
Food and Food Preparation for HSP - PASS ❑ RED
CONSUMER ADVISORY
Posting of Consumer Advisories PASS ] RED
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 26,2007 ) Page 2 of
%r
Item Status Violation Critical Urgency
Violations Related to Good Retail Practices (Blue Items)
Food and Food Protection PASS BLUE
Equipment and Utensils PASS BLUE
Water, Plumbing and Waste PASS BLUE
Physical Facility PASS BLUE
Management and Personnel PASS BLUE
Poisonous or Toxic Materials PASS BLUE
Special Requirements PASS BLUE
Other-See Notes PASS BLUE
GENERAL COMMENTS:
A general cleaning of all units is required.
All other requirements to open have been satisfied.
Expected opening is this weekend.
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 26,2007 ) Page 3 of
0187 Fort Avenue Dairy Palace
City of Salem
FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection
HACCP: ❑
Item Status Violation Critical Urgency
Telephone:,',- Violations Related to Good Retail Practices (Blue Items)
i+�1 ,
`145-9042 i?. Equipment and Utensils PASS BLUE
Owner: ,
$, Comments: Many missing thermometers in various units. Provide visible and accurate thermometers in all units which require
'Gostas Linardos them.
PIC:. „ Ice cream freezers require thorough cleaning.
Arthur Reppas_ r
Inspector: White freezer by cash machine requires general cleaning.
-`John Ge6n Beverage she unit(sodas)requires general cleaning.
Date, " Correct By:
Hobart unit in back has accumulatioon of grime on inside panel. Thoroughly clean and sanitize panel.
Risk Level. Same unit requires general cleaning.
.. Mop stored incorrectly. Mop to be hung so it is allowed to air dry.
Permit Number:
BHP-2006-0453 Physical Facility PASS BLUE
Status:,! 4- Comments: Doors open at time of inspection. Doors to remain closed to prevent entrance of rodents or insects.
VIOLATION Hole in screen at counter. Repair hole.
#of Critical Violations:
-�0 Wall beneath hand wash sink requires general cleaning.
:,Time IN: Time OUT: Behind beverage air unit requires general cleaning.
Urgency Description(s): GENERAL COMMENTS:
BLUE: 822:AII violations from 9/7/2006 have been corrected.
Violations Related to Good
Retail Practices (Critical
violations must be corrected
immediately or within 10
days)(Non-critical violations
must be corrected immediately
or within 90 days)
ss
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 -
GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 19,2006 ) Page 1 of
Item Status Violation Critical Urgency
RED: r 41
Violations Related to
Foodborne Illness Interventions
and Risk Factors(Require
immediate corrective`action)
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 19,2006 ) Page 2 oft
0187 Fort Avenue Dairy Palace
City of Salem
FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection
HACCP: ❑
Item Status Violation Critical Urgency
Telephone: s FOOD PROTECTION MANAGEMENT
745-9042 '_'-` .f PIC Assigned/Knowledgeable/Duties PASS ❑J RED
:`' .
Owner:
C ,`, Non-compliance with:
Costas Linardos
Anti-Choking PASS
PIC: 4.
Arthur Reppas Tobacco PASS
Inspector: j-
ehan EMPLOYEE HEALTH
John
DateJohn,d I n Correct By: Reporting of Diseases by Food Employee and PIC PASS C RED
ivrrrcnvv• _, `fi ` *; Personnel with Infections Restricted/Excluded PASS RED
Risk Level
FOOD FROM APPROVED SOURCE
Permit Number: , Food and Water from Approved Source PASS RED
BHP-2006-0453=A_ Receiving/Condition PASSd❑ RED
Status:
c ` Tags/Records/Accuracy of Ingredient Statements PASS [ RED
Open
#Of Critical Violations: Conformance with Approved Procedures/HACCP Plans PASS [ RED
0 ,
Time IN: Time OUT:
i
Urgency Description(s):
BLUE: „ 9;
Violations Related to Good
Retail Practices(Critical
violations must be corrected
immediately or withi6'10
days)(Non-critical violations
must be corrected immediately
or within 90 days) g,,
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeOTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 07,2006 ) Page I of
Item Status Violation Critical Urgency
RED:,' tE ..,, PROTECTION FROM CONTAMINATION
Violations Related to Separation/Segregation/Protection PASS J❑ RED
Foodborne Illness Interventions
and Risk Factors (Require Food Contact Surfaces Cleaning and Sanitizing PASS ❑d RED
immediate corrective action)
Proper Adequate Handwashing PASS ❑d RED
Good Hygienic Practices PASSJ❑ RED
Prevention of Contamination from Hands PASSJ❑ RED
Handwash Facilities PASS RED
PROTECTION FROM CHEMICALS
Approved Food or Color Additives PASS RED
Toxic Chemicals PASS RED
TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) s
Cooking Temperatures PASS ❑N RED
Reheating PASS ❑d RED
Cooling PASS ❑d RED
Hot and Cold Holding PASS ❑ RED
Time As a Public Health Control PASS RED
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
Food and Food Preparation for HSP PASS RED
CONSUMER ADVISORY
Posting of Consumer Advisories PASS ❑d RED
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 07,2006) Page 2 of
Item Status Violation Critical Urgency
Violations Related to Good Retail Practices (Blue Items)
Food and Food Protection PASS BLUE
Equipment and Utensils FAIL BLUE
i,e' mments: Many missing thermometers in various units. Provide visible and accurate thermometers in all units which require
them.
eam freezers require thorough cleaning.
,Wh a freezer by cash machine requires general cleaning.
erage afire unit(sodas)requires general cleaning.
0 tyebalrt unit in in back has accumulatioon of grime on inside panel. Thoroughly clean and sanitize panel.
am�S a unit requires general cleaning.
—1106—p stored incorrectly. Mop to be hung so it is allowed to air dry.
Water,Plumbing and Waste PASS BLUE
' Physical Facility FAIL BLUE
,_Comments: Doors open at time of inspection. Doors to remain closed to prevent entrance of rodents or insects.
olein screen at counter. Repair hole.
I beneath hand wash sink requires general cleaning.
hind beverage air unit requires general cleaning.
Management and Personnel PASS BLUE
Poisonous or Toxic Materials PASS BLUE
Special Requirements PASS BLUE
Other-See Notes PASS - BLUE
GENERAL COMMENTS:
,746-Owner to fax over exterminator invoice as well as reports for soft serve to BOH.
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 07,2006 ) Page 3 of
Item Status Violation Critical Urgency
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 07,2006 ) Page 4 of
08/08/2006 12:42 9782036296 BIOMARINE PAGE 01
Biomarine
16 EAST MAIN STREET. GLOUCESTER,MA 01930
TELEPHONE:(978)281-0222 FAX;(978)283-6296
CERTIFICATE OF ANALYSIS
Mr.Costas Unardos Report No.:36068
DAIRY PALACE August S.2(06
187 Fon Avenue
Salem,MA 01970
RE.: BACTERIAL ANALYSIS OF FROZEN DESSERT
SAMPLE D c FTIOHI Two samples of frozen sot serve ice cream taken aseptically from the above
establishment and idcntJed as follows:
A) Vanilla Soft Serve
B) Chocolate Soft Serve
MP . N : Theee samples were collected on July 18,20M by Dairy Niece and delivered
to Biomarine.
FINDINGS;
-- SamplelD .. ColMmyiiCwnt7grstn;; AeroNic Pl�e CoanUgrem
36068A t2 10A00
360688 Q 30.000
RF.Ft'RENC Standard Methods for the Examination of Dairy Products,pith Edition.1992.
GUIDELLN>c
Massachusetts Department of Public Health's 105 CMR 561.007"Frozen Desserts and lee Cream Mix Bacterial Counts:"
Anaerobic plate caunu50D00 or a coliform count>50 constitutes o violation.
,--�.- L
7dm GriNesWAulatem'I:IiloKlimadar Ma[latmlLafi Director
Fc:Salem Board of Health
Page 1 of I
FROM : Panasonic TAD/FAX PHONE NO. +532 8814 Sep. 08 2006 10:31RM P01
,r
r
TO t3cai� Tj
Flom lq
1 'a7 Foe-4- 14 Qe
I-lege
�s 01 Coryof- -,zea -5.1 Ps.
FROM Panasonic THD/FHX PHONE NO. : +532 8814 Sep. 08 2006 10:32AM P03
sgCvIte 0E / lnvifte
A•1 Exterminators
P.Q.BOX 310
Lynn,MA 01003.0310
781.502-2731
1 r L
d7
Bill-To: 11484000) Work (14840001::.,9178.532.4044
DAIRY PALACE Location; DAIRY..PALACE:.''.
67 LYNNFIELD STREET FORT AVENUE
PEABODY.MA 01880 SALEM;MA 01870
IMP
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t
-
. 111n1 4rnPi1l( �II Y �I�� '� � .� �1 'S, Vy^l11 ill e6 �
101 REGULAR PEST CONTROL SERVICE 113040
INSPECTITREAT AREAS AS NEEDED SUBTOTAL - $30.00
TAX $0.00
TOTAL $31.00
AMT.PAID $0.00,,
BALANCE 330.03 -:
f
fl,, t tgf .41
5
ti
�tJ a��wywyt ..
'CMfaet OYWanolfla 0w so JayaI' m the Arte of semis eroeUEfa0t t0 a 1112% IheNly aeiMlaCtoty00rnp101i0not a&safviwanerAafm,aa9 earoa t0 pfy 100•
FINANCE CHARGE PER MONTH of annuei WfAIMaaa rate 01 Who CUelemef earoas to mN of eNyl, `abe'/a.
pot od exaenexe lntxe eventofowl"Oon.
.444
TOMER SIGNATURE
PLEASE PAYFROEA-TH1S-E 4
J, 1�1!
+' 9
S�i
FROM Panasonic TRD/FRX PHONE NO. +532 8814 Sep. 08 2006 10:32RM P02
r2
Biomarine
16 EAST MAIN STREET. GLOUCESTER:MA D1930- -
TELEPHONE:(978)281-0222 FAX:(978)283.8206
CERTIFICATE OF ANALYSIS
Mr.Costae Unardos Report No.:36068
DAIRY PALACE
August 8 2006
187 Fort Avenue
Salem.MA 01970
RE: BACTERIAL ANALYSIS OF FROZEN DESSERT
..,.
SAMPLE DPWRIPTION: Two samples of fromn Rol serve ice cream taken aseptically from the above
establishment mud ldenufled.ae.fellows:.
A) Vanilla Soft Serve
B)- Chocolate Solt-Serve-
SAMPLING: Those samples were collected on July 18,2006 by Dairy Palace and delivered
to Bitmmarhle.
:. �J !
Cem simple
rA1Btm^lar dII!I I �'slJ�IptW�814R"tPPnU �aan
36068A Q 10,000-
36068E Q - 3D,000.
REFBRBNCP,:Standard Methods for the Examination of Dairy.Products.16th Editioa._1992.
Massachusetts Deportment of Public.Healtb's_l(WCMR.561.007"Ftweu Demise and-lee Crosm Mix Bacterial Cauma"
An Aerobic plate Count>5000 or a coliform count>50 constitutes a violations
Jim OrolonWARRlatael LAIC Manager aDbn Fla 17 b Dirmor
Fr.Salem Board of Health
PAge 1 of 1
F
06/22/2006 11:29 9782836296 BIOMARINE PAGE 02
Biomarine
16 EAST MAIN STREET, GLOLICESTER,MA 01930
TELEPHONE:(978)281-0222 FAX:(978)288.8288
CERTIFICATE OF ANALYSIS
Mr.Costas Linardos Report No.:35749
DAIRY PALACE, lune 22,2006
187 Fort Avenue
Salem,MA 01970
RE: BACTERIAL ANALYSIS OF FR07.EN DESSERT
RAMPI F DESCRIPTION IPTION: Two samples of frozen sot serve ice cream taken aseptically from the
above establishment and identified as follows:
A) Vanilla Soft Serve
B) Chocolate Soft Serve
SAMPLING: These samples were collected on June I4,2006 by Dairy Palace and
delivered to Biomarine.
CainplelD C61 iformc90"tIgrain; AerbbiCTIIiItcatinlgram
35749A <2 5,600
157498 Q 4,400
REZERFNC>z:Standard Methods for the Examination of Dairy Products.16th Edition, 1992.
GIIIDF.LINEs:
Massachusetts Department of Public Health's 105 CMR 561.007"Frozen Desserts and Ice Cream Mix Bacterial
Counts:"An aerobic plate count X50,000 or a coliform count>50 constitutes a violation.
Jim f;rotlaaWAielslam Ln&Monsgm trim Madc"Ol.ob Director
Fc: Salem Board of Health
Pagc I of I
f
FR�M Panasonic TAD/FAX PHONE NO. : +532 8814 Apr. 13 2006 10:02AM P01
npr is i)f'• :15: 015a joannin 5cor,r, Sa1r'm SOH 11:M 745 0343 p. 1
CITY CI' SALEM, MAS:iACHUSETTS
f \�
Bonn OF Humn,
97107410800
Fix 978 7ag:p3Q
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Cnctrr, l,lpl-i, n , C:HJ
HEALTH AGENT
2006 APPI_It ATION FOR PERM111'0 OPERAIF. A FOOMESTACII:ISHMI NT
C Fo
lNltvv
Dave
k'Q/��, y —mm rn LIF O'4 �v�
-1 d) (�1S�m /1k o.lKe1 C:EI:Iu r [,. Un)
.. Li.0 , d r•'r , I 'li..n, 1 rA1'111q:Ic,10<r '. JfE h:1 n.rla _—. rf N(Ce
1 `Q S lit)11t I r:t. y W 7713.1. '
's -`' .1. '•'/ I� 11 'i Cr )1-)I 1Med j�'�� , hU
,. . I r, rplf11..
t ••.'f, . t:;. :0
ii '..1% yip: 150
GC1. NOMPROW is"Ch as church 00101c"n YES ti?;
-"Von ony octal wilh one Mck papaUy to the t::ily of sawn, .
n F Varr7it is not i wtsierabl;l and 111u 'f bo I'e ISBUed tipUn-ct'mni)e-of mwmn vSh p I ho, Ps-rima m{t3(iie IOw(d
: : Ir rrri'a gni 4:cn;ir:;t in tln' Lata%�!i:.hrlenl.
'n attr rtlan[.n with it,(,. •,tMv Sandary,Coda, be}ore any tunuvnlionti. Clialiges
wn, nlwiu. all Wan,to, such nwsl be subinumd to and approved 6y tho Galvai Goa d of I laaltl,.
i
.`. .: i. WK r,,, -11 000 C� W My l WIN Ole PIMS W pt?tZOPS Of I:-VhU1v that i. i 1 ora l
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_ L
Commonwealth of Massachusetts r
City of Salem Kimberley Driscoll
»I Board of Health Mayor
6' 120 Washington Street,4th Floor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 04/14/2006
WHO'S PLACE OF BUSINESS IS: Dairy Palace
File Number:BHF-2004-0161 187 Fort Avenue
Salem MA 01970
LOCATED AT: 0187 FORT AVENUE
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
FOOD SERVICE BHP-2006-0453 Apr 13,2006 Dee 31,2006 $100.00
ESTABLISHMENT
FROZEN DESSERTS BHP-2006-0452 Apr 13,2006 Dec 31,2006 $5.00
Total Fees: $105.00
PERMIT EXPIRES December 31
PE , 2006
Board of Health
Tbis Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in
it prominent location in the Establishment.
In accordance with the State Sanitary Cotte, beotre any revonations, improvements.or equipment changes are made,all
plans for such must be submitted to and approved by the Salem Board of Healtb. Page 1 of 2
0187 Fort Avenue Dairy Palace
City of Salem
FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection
HACCP: ❑
Item Status Violation Critical Urgency
Telephone: FOOD PROTECTION MANAGEMENT
745-9042 PIC Assigned/Knowledgeable/Duties PASS ❑J RED
Owner � V A
- Non-compliance with:
Costas Linardos Anti-Choking PASS
PIC:
Arthur Reppas r Tobacco PASS
Inspector.
David Greenbaum EMPLOYEE HEALTH
Date Inspected: Correct By: Reporting of Diseases by Food Employee and PIC PASS RED
4/13/2006 Personnel with Infections Restricted/Excluded PASS RED
Risk Level:
FOOD FROM APPROVED SOURCE
rr
Permit Number: Food and Water from Approved Source PASS ❑J RED
BHP-2006-0453 Receiving/Condition PASS RED
Status-
PARTIAL
tatusPARTIAL COMPLY Tags/Records/Accuracy of Ingredient Statements PASS ❑d RED
#of Critical Violations: Conformance with Approved Procedures/HACCP Plans PASS RED
0 =
Time IN:J rTime OUT.
Urgency Description(s):
BLUE:
Violations Related to Good
Retail Practices (Critical
violations must be corrected
immediately or within 10
days)(Non-critical violations
must be corrected immediately
or within 90 days)
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)747-1800
GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 14,2006 ) Page I of
Item Status Violation Critical Urgency
RED: - PROTECTION FROM CONTAMINATION
Violations Related to Separation/Segregation/Protection PASS RED
Foodborne illness Interventions
and Risk Factors (Require Food Contact Surfaces Cleaning and Sanitizing PASS RED
immediate corrective action)
Proper Adequate Handwashing PASS ❑Q RED
Good Hygienic Practices PASS RED
Prevention of Contamination from Hands PASS ❑Q RED
Handwash Facilities PASS ❑d RED
PROTECTION FROM CHEMICALS
Approved Food or Color Additives PASSd❑ RED
Toxic Chemicals PASS ❑d RED
TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
Cooking Temperatures PASS RED
Reheating PASS 0 RED
Cooling PASS RED
Hot and Cold Holding PASS RED
Time As a Public Health Control PASS 0 RED
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
Food and Food Preparation for HSP PASS 0 RED
CONSUMER ADVISORY
Posting of Consumer Advisories PASS Q RED
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeOTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 14,2006 ) Page 2 of
Item Status Violation Critical Urgency
Violations Related to Good Retail Practices (Blue Items)
Food and Food Protection PASS BLUE
Equipment and Utensils PASS BLUE
Water, Plumbing and Waste PASS BLUE
Physical Facility PASS BLUE
Management and Personnel PASS BLUE
Poisonous or Toxic Materials PASS BLUE
Special Requirements PASS BLUE
Other-See Notes PASS BLUE
GEN L COMMENTS:
�136:Owner will contact exterminator for service prior to opening.
T e are some water stained ceiling tiles throughout the establishment. Repair any leaks and replace all stained
ening tiles.
��eater temperature is 940F. Restore hot water to a minimum temperature of 110°F.
Onwer must repair any damaged screens and keep them closed while window is not in use.
UA,
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 14,2006 ) Page 3 of
0187 Fort-Avenue Dairy Palace
City of Salem
FOOD SERVICE ESTABLISHMENT - FOOD SERVICE REINSPECTION Inspection
HACCP: ❑
Telephone: Item Status Violation Critical Urgency Nature of problem or correction
745-9042 Non-compliance with: Done
Owner: Anti-Choking PASS ❑
Costas LinardoS: _ Tobacco PASS ❑
PIC
Arthur ReppaS FOOD PROTECTION MANAGEMENT Done
InspectoC PIC Assigned/Knowledgeable/Duties PASS RED
Janet Dionne EMPLOYEE HEALTH Done
Date Inspected. Correct By. _ Reporting of Diseases by Food Employee and PIC PASS RED
4/15/2005 - Personnel with Infections Restricted/Excluded PASS RED
Risk Level:
FOOD FROM APPROVED SOURCE Done
Permit Number: Food and Water from Approved Source PASS ./❑ RED
BHP-2004-0088 _ _ Receiving/Condition PASS RED
Status e _ Tags/Records/Accuracy of Ingredient Statements PASS ❑d RED
Closed Conformance with Approved Procedures/HACCP PASS ❑d RED
#of Critical Violations: Plans
PROTECTION FROM CONTAMINATION Done
:Time IN TimeOUT Separation/Segregation/Protection PASS RED
c
Notes: Food Contact Surfaces Cleaning and Sanitizing PASS ❑d RED
98. Proper Adequate Handwashing PASS ❑d RED
Urgency Description(s): Good Hygienic Practices PASS RED
BLUE ❑ Prevention of Contamination from Hands PASS ❑d RED
Violations Related to Good
Retail Practices (Critical Handwash Facilities PASSd❑ RED
violations must be corrected
immediately or within,10
days)(Non-critical violations a
GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. May 12,2005 ) Page 1 oft
0187 For- Avenue Dairy Pa/ace
must be corrected Immediately`. PROTECTION FROM CHEMICALS Done
or,Within 90 days) '_ Approved Food or Color Additives PASS ❑d RED
RED'
Violations Related to Toxic Chemicals PASS RED
Foodborne Illness Interventions TIMEITEMPERATURE CONTROLS(Potentially Haz Done
and Risk Factors (Require . Cooking Temperatures PASS ❑� RED
immediate corrective action)
Reheating PASS ❑/ RED
Cooling PASS RED
Hot and Cold Holding PASS 0 RED
Time As a Public Health Control PASS 0 RED
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Done
Food and Food Preparation for HSP PASS RED
CONSUMER ADVISORY Done
Posting of Consumer Advisories PASS RED
Violations Related to Good Retail Practices (Blue Done
Management and Personnel PASS ❑ BLUE
Food and Food Protection PASS ❑ BLUE
Equipment and Utensils PASS ❑ BLUE
Water, Plumbing and Waste PASS ❑ BLUE
Physical Facility PASS ❑ BLUE
Poisonous or Toxic Materials PASS ❑ BLUE
Special Requirements PASS ❑ BLUE
Other-See Notes PASS ❑ BLUE
GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. May 12,2005 ) Page 2 oft
0187 Fort Avenue Dairy Palace
City of Salem
FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection
HACCP: ❑
Telephone: " hem Status Violation Critical Urgency Nature of problem or correction
745-9042 Non-compliance with: Done
Owner: Anti-Choking PASS ❑
Costas Linardos Tobacco PASS ❑
PIC:
Costas Llnardos FOOD PROTECTION MANAGEMENT Done
Inspector: PIC Assigned/Knowledgeable/Duties PASS ❑d RED
Janet Dionne EMPLOYEE HEALTH Done
Date Inspected: OOfreCt By: Reporting of Diseases by Food Employee and PIC PASS ❑J RED
4/13/2005 - Personnel with Infections Restricted/Excluded PASS ❑d RED
Risk Level:
FOOD FROM APPROVED SOURCE Done
Permit Number: Food and Water from Approved Source PASS RED
6HP-2004-0068 - Receiving/Condition PASS d❑ RED
Status: Tags/Records/Accuracy of Ingredient Statements PASS d❑ RED
Open Conformance with Approved Procedures/HACCP PASS ❑d RED
#of Critical Violations: Plans
1 PROTECTION FROM CONTAMINATION Done
Time IN: .Time OUT: Separation/Segregation/Protection PASS 0 RED
Notes: Food Contact Surfaces Cleaning and Sanitizing PASS ❑d RED
86:opening exyerminatlon has Proper Adequate Handwashing PASS RED
not been conducted. Owner to
notify board of health office ' Good Hygienic Practices PASS ❑d . RED
when extenination is complete.
Prevention of Contamination from Hands PASS ❑ RED
Urgency Description(s): Handwash Facilities FAIL Critical 0 REDandsink missing soap. owner to provide
BLUE: soap at handsinks at all times.
Violations Related to Good
Retail Practices (Critical
GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Apr 13,2005 ) Page I oft
0187 Fort Avenue Dairy Palace
violations must be Corrected "` PROTECTION FROM CHEMICALS Done
immediately Or within,10 r, a = Approved Food or Color Additives PASS RED
days)(Non-critical violations'' Toxic Chemicals PASS RED
must be corrected immediately
Or within 90 days) k TIMEITEMPERATURE CONTROLS(Potentially Haz Done
L <a are
RED : x Cooking Temperatures PASS 0 RED
Violations Related to€
Foodborne Illness'Interventions Reheating PASSd❑ RED
and Risk Facto r§ (Require= coaling PASS d❑ RED
immediate corrective action)
Hot and Cold Holding PASSd❑ RED
Time As a Public Health Control PASS ❑d RED
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Done
Food and Food Preparation for HSP PASS ❑d RED
CONSUMER ADVISORY Done
Posting of Consumer Advisories PASS ❑d RED
Violations Related to Good Retail Practices (Blue Done
Management and Personnel PASS ❑ BLUE
Food and Food Protection PASS ❑ BLUE
Equipment and Utensils FAIL Critical ❑ BLUEtp 4sh chest missing thermometer. provide
visible accurate thermometer maintained at
temperature of 0°f or below as mandated.
Water, Plumbing and Waste PASS ❑ BLUE
Physical Facility FAIL Non-Critical ❑ BLUE ,/eiling tile above dry storage not secure.
secure ceiling tile
Poisonous or Toxic Materials PASS ❑ BLUE
Special Requirements PASS ❑ BLUE
Other-See Notes PASS ❑ BLUE
GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Apr 13,2005 ) Page 2 oft
+pp CITY OF SALEM9 MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
yeQm� TEL. 978-741-1800
_ FAx 978-745-0343
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter 94,
Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food
Establishment in the City of Salem is hereby granted to:
Type of Establishment: FOOD SERVICE
Name of Establishment: Dairy Palace
Address of Establishment: 187 Fort Avenue
Owner's Name: Costas Linardos
Restrictions:
Application Date: 4/12/05
Permit for Food Establishment 293-05
Frozen Desserts/Ice Cream 16-05
Permit for the Sale of Tobacco Products
These Permits Expire December 31, 2005
This permit is not transferable and must be reissued upon change of
ownership or location. The permit must be posted in a prominent location
in the Establishment,
In accordance with the State Sanitary Code, before any renovations,
improvements, or equipment changes are made, all plans for such must be
submitted to and approved by the Salem Board of Health.
HEALTH AGENT
CITY OF SALEM, MASSACHUSETTS
a2L BOARD OF HEALTH
`� 91 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343 --
STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT1 A I> �L��I� � TEL# q?rl ylr�C`
ADDRESS OF ESTABLISHMENT i2ti Sly G �//J/���`�OL✓�
MAILING ADDRESS (if different) 7P/� {rUoa(� �p Q�i� a(�N /�f/3 J
OWNER'S NAME �s� �9S ���Tr/y4 J co TEL#�/ 7 n� / So
ADDRESS 2�/j/ (/j�pn �n— 6`� �01
CITY STATE ZIP
CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s)
(required in an establishment where potentially hazardous food is prepared.)
EMERGENCY RESPONSE PERSON &.09,eV HOME TEL#
HOURS OF OPERATION: Mon.—Tue.—Wed.—Thu.—Fri.—Sat.—Sun.
TYPE OF ESTABLISHM FEE check only
RETAIL STORE YES- NO less than 1000sq.ft. $ 551-
1000-10,000sq.ft. j119/
more than 10,000sq.ft. =$250
RESTAURANT YES NO /1� �u� less than 25 seats =$100
25-99 seats =$150
more than 99 seats =$200
BED/BREAKFAST YES NO $100
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE Y O I6
TOBACCO VENDOR YES NO $50
ALL NON-PROFIT(such as church kitchens) YES NO $25
Please pay total with one check
payable to the City of Salem
This Permit is not transferable and must be reissued upon change of ownership. The Permit must
be posted in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment
changes are made, all plans for such must be submitted to and approved by the Salem Board of
Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my
best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law.
Signature 1j �/ Date L� a�ocial Security or Federal Identification Number
---------- T//�( v j 7 --------------------------------
Revised 11/03/03 FOODAP2.adm Check#8 DaleW3 V/)I
�� �� �ob
*� CITY OF SALEM, MASSACHUSETTS
,j BOARD OF HEALTH
ig 120 WASHINGTON STREET, 4TH FLOOR
�o SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter 94,
Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food
Establishment in the City of Salem is hereby granted to:
Type of Establishment: FOOD SERVICE
Name of Establishment: Dairy Palace
Address of Establishment: 187 Fort Avenue
Owner's Name: Costas Linardos
Restrictions:
Application Date: 4/20/2004
Permit for Food Establishment 298-04
Frozen Desserts/Ice Cream 19-04
Permit for the Sale of Tobacco Products
These Permits Expire December 31, 2004
This permit is not transferable and must be reissued upon change of
ownership or location. The permit must be posted in a prominent location
in the Establishment,
In accordance with the State Sanitary Code, before any renovations,
improvements, or equipment changes are made, all plans for such must be
submitted to and approved by the Salem Board of Health.
HEALTH AGENT
CITY OF SALEM, MASSACHUSETTS
00 BOARD OF HEALTH
'� 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
y�q TEL. 978-741-1800
FAX 978-745-0343
STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
2004 APPLICATION FOR PERMIT TOOPERATEA FOOD ESTABLISHMENT
NAME OF ESTABLISH MENT el�/y��"' TEL#
ADDRESS OF ESTABLISHMENT &.7 6471 ,(�(/(/e .
MAILING ADDRESS (if different) c� ��/��.I�
OWNER'S NAME /� t�/%
/T/G
O S TEL#q7f
—\53d- 00g0
ADDRE SF.
CITY S STATE ZIP O/
CERTIFIED FOOD MANA R'S NAME(S)1V rw,4 A er1Wj?,4SCERTIFICATE#(s)
(required in an establishment where potentially hazardous food is prepared.)
EMERGENCY RESPONSE PERSON 6Z 1-,69,Y 46AA HOME TEL# 2f—cr770-00o
HOURS OF OPERATION: Mon. I/ Tue.(/ Wed. ✓ Thu. r/ Fri. ✓ Sat. ✓ Sun. r/
TYPE OF ESTABLISHMENT FEE check only
RETAIL STORE YES NO less than 1000sq.ft. =$50
1000-10,000sq.ft. =$100
more than 10,000sq.ft. =$250
RESTAURANT YE NO less than 25 seats =$100
25-99 seats =$150
more than 99 seats =$200
BED/BREAKFAST YES NO $100
ADDITIONAL PERMITS
MAKE (notjust serve) ICE CREAM, _YOGURT, SOFT SERVE ES $5
TOBACCO VENDOR 1 19— O YESO $50
ALL NON-PROFIT(such as church kitchens YES $25
Please pay total with one check
payable to the City of Salem
This Permit is not transferable and must be reissued upon change of ownership.The Permit must
be posted in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment
changes are made, all plans for such must be submitted to and approved by the Salem Board of
Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my
best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law.
Signat J. Date �p.d4-Social Security or Federal Identification Number
- - -------------------------------------------------------------
Revised 13/03 FOODAP2.adm Check#8 Dat w 13/Z -078— OC/C
KAb�5
j
Massachu$etts Department of Public Health Salem Board SHealth
M 720 Washington Street,4'" Floor
Division of Food and Drugs Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978)741-1800 Fax (978)745-0343
Name ' Dat T of O eration(s) T of Ins ep ction
^
0 $ 17/,YFood Service outine
Address �B7 F.��E r�(/b° Risk E] Retail [IRe-inspection
Level [I Residential Kitchen Previous Inspection
Telephonej� ❑ Mobile Date:
1�or�
HAGGP Y1N ❑ Temporary ❑ Pre-operation
Owner ❑ Caterer ❑Suspect Illness
Person in Charge(PIC) Time E] Bed&Breakfast ❑General Complaint
In: ❑ HACCP
Inspector Vt rt rS Out: Permit No. ❑Other_
Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco
Violations marked may pose an imminent health hazard and require immediate corrective 590.999(E) ❑ 590.009(F) ❑
action as determined by the Board of Health.
';.FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑ 2. Reporting of Diseases by Food Employee and PIC ° <•° - _.
❑ 14.Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded ❑ 15,Toxic Chemicals
FOOD FROM APPROVED SOURCE -- -- -- -- TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑ 4. Food and Water from Approved Source
❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling
PROTECTION FROM CONTAMINATION _1 ❑ 19.Hot and Cold Holding
❑ 8. Separation)Segregation/Protection ❑20.Time As a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR.HIGHLY.SUSCEPTIBLE POPULATIONS(HSP)
❑21. Food and Food Preparation for HSP
❑ 10. Proper Adequate Handwashing
CONSUMER ADVISORY
❑ 11.Good Hygienic Practices ❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices Number of Violated Provisions Related
Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions !9
immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): (�
of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code.This report,when signed below
FC-T-N-1 by a Board of Health member or its agent constitutes an
23. Management and Personnel (Fc-2)(590.003) order of the Board of Health. Failure to correct violations
24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of
/ 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food
j 26. Water, Plumbing and Waste (Fc-5)(590.06) 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:
5:59pinspeclFpmrt-14 tloc
Inspector's Signature: Print:
PIC's Signature: u Print �,� Page of Pages
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT S Cross-contamination
L-1 *591) 3{A) Assigu�ofResy' 3-302.1.1(A)ft) flaw :Animal Ecoids Separated fram3(B) Demone"' Cooked and RTE Foods'11. Person Contamination from Raw Ingredients
3-3tY2.1.1{A)(2) Raw-Animal Focxls Separated from Each
EMPLOYEE HEALTH _ Other-
"90,003(c) Rosponsibility
ther-
"90,003(c) Responsibility of the person in charge to Contamination from the Environment
require reporting by fart employees and 3-302.1 t(A) Foal Protection"
a alicantsa` 3-302.15 Washing Fruits and Vegetables
590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and
Applicant To Report To The Person In Utensils*
Charge* Contamination from the Consumer
590,0f)3(G) Re>arring b Person in Charge"" 3-306.14(A)(B) Returned Food mud Reserviee of Form"
3 590.003(D) Exclusions and Restrictions" i DisposittonofAdulieratedorContam/nated
590.003(E) Removal of Exclusions and Restrictions Food
- 3-701.11 Discarding or Reconditioning Unsat,
FOOD FROM APPROVED SOURCEFood
4 Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-R) Com liance with Food Law* 4-SOl.ti i Manual Wuewashing-Hot Water
3-201.12 Food in a Hermetically Seated Container; Sanitization Tem eratures*
3-201.13 Fluid,Milk and Milk Products* 4-501.112 Mechanical Warewashim,Hot Water
3-202.13Snmtization Ttm eratures*
Shell Eggs*
3-202.A Fg=s andMrIkPtadno[s.Pasteurized* 4-50tA14 Chemical Samtiration-temp., pH,
concerti anon and hardness. ,r
3-202.16 Ice Made From Potahle Drinking Water* 4-601.1[(A) Equipment Food Contact Surfaces and
5-1.01.11 Drinking Water from a22A .raved S Stena`
Utensils Clean:`
590.006(1,11) Bottled Drinkin Water 4-602.11 Cleaning Frequency of EquipmentFood-
590.006(13) Water Meets Standards in 310 CMR 22.0" Contact Surfaces and Utensils*
Shellfish and Fish From an Approved Source
4-702,11 Frequency of Sanitization of Utensils and
3-201.14 Irish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment"
Shellfish'" 4-703.11 Methods of Sanitization-Riot Water and
3-201.15 Nfolluscan Shellfish from NSSP Listed Chemical'
Sources* 10 Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by 2_,01.S 1 Clean Condition-Hands and Artns*
Re uiato AuthEi
3-202.15 Shellstock Identification Present* 2-301.12 Cleaning Procedure*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201.17 Game Animals* li Good Hygienic Practices
Receiving/Condition _ 2-401.11 Eating,Drinking or Usin Tobacco*
3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes, Nose and
3-202.15 Packa e ince it-* Mone
3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When'Pastin L
6 Tags/Records:Shellstock ]2 Prevention of Contamination from Hands
3-202,18 Shellstock Identification* 590.004(6) Preventing Contamination from
3-203.12 Shellstock Identification Maintained* Em t�
Tags/Records: Fish Products 13 Handwash Facilities
3-402.11 Parasite Destruction*
203.11 Conveniently Located and Accessible
3-403.12 Resorts,Creation and Retention* 5- ' Numbers and Capacities*
590.004(J) Labeling of Ingredients' 5-204.11 Location and Plac mast*
with Approved Procedures
5-205.11 Accesstbilrt Otc.rmonandLlahaenancc
7 IHACC Plan t pp Supplied with Soap and Hand Drying
/HACCP Plans Devices
3-502.11 S eciatizedProeecsingMethcals*
3-502.13 Reduced os 'gen tacks 'ag,Criteria* (x301.11 Handwashing Cteanser, Availabilit
8-103.12 Conformance with Approved Procedures* 6-301.12 Haud Dr ing Provision
Denotes critical Item in the iedarai 1999 Ford Code or 105 CMR 590,000_
CITY OF SALEM
nn BOARD OF HEALTH �/
Establishment Name: �l/4f y Pr�L dC� Date: OI /9 /6"/ Page: 2 of 2
Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R-Red Item ? A - Verified
' 'PLEASE PRINT CLEARLY
fs►l 00 os4 Of/ 1es�P s w
N i rf cls .
X rig
2#kA 14"-r7v1J
tA06110 mms4
1& nN 'Z1
Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ° voluntary Compliance o Employee Restriction/
Exclusion
violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. 1 �rJr�C�l
ElVoluntary Disposal El Other:
_507114_(C-)_ PRFs Received at Temperatures
Violations Related to Foodborne Illness Interventions and Risk �� According to Law Cooled to
Factors(Items 1-22) (Cont) 41°F/45`F Within 4 Hours.
PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PRFs 19 PHF Hot and Cold Holding
14 Food or Color Additives
3-202.12 Additives'" 3-501.1(1(8) Cold PIIFs Maintained at or below
590.004(F) 41°7451 F*
3302.14 Protection from Unapproved Additives* 3-501.1 G(A} 1{ot PHFs Maintained at or above
15 poisonous or Toxic Substances
140°F. *
7-101.i l Identifying Information-Original 3-501.1.6(A) Roasts Held at or above 130°E.
Containers*
7-102.11 Common Name-Working Containers* 2g Time as a Public Health Control
7-201.11 .Seoration-Sna ace* 3-501.19 Time as a Public Health Corgro4M
7-202.11 Restriction-Presence and Use* 590.004(H) Variance Re uirement
7-202.12 Conditionsners
7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Smiitizers.Criteria-Chemicals* POPULATIONS(HSP)
7-204.12 Chemicals for Washing Produce,Criteria"` 21 3-801.11(A) Unpasteurized Pie-packaged Juices and
Beverages with 14 umnq I abols*
7-204.14 Di in ents,Cnteua` 3-801.1 I(B) UsLe of Pasteurized F os*
7-205.11 Incidental Food Contact.Lubricants* 3-801 1 I(D) Raw or Partially Cooked Animal Paid and
7-266.11 ResttictedUse Pesticides. Cri eria
Raw Seed S trouts Not Served.'a
7-206.12 Rodent Bait Stations"` 3-801.11(C) Una ened Fcrod Pack, e Not Re-served. �'
7-206.13 "tracking Powders,Pest Control and
Monitoring* CONSUMER ADVISORY
TIME(TEMPERATURE CONTROLS 22 3-603.11 Consmumer Advisory Posted for Consumption of
16 Proper Cooking Temperatures for
Anial Foods That are Raw.Undercooked or
PHFs Not Otherwise Processed to Eliminate
3-401.L1A(1)(2) Eggs- 155°F 1.5 Sec.
Pathiegcns* Er cnvc,+nar
L es-hmuedtate Scrctec L45`P15sec* 3-302.13 Pastaunred Eggs Substitute for Raw Shell
3-401..11.(02) Comminuted Fish, Meats&Game EggO
Animals- 155°F 15 sec. *
3-401,1 1(8)(1)(2) Pock and Beef Roast - 1311°F 721 min*
SPECIAL REQUIREMENTS
3-401.1'1(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) Paltry,Wild Game, Stuffed PHFs, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultr or Ratites-165°F 15 see. * above if related to fnndborueillness
3-40,1.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
145°F* 590.009 violations relating to good retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165°F* Special Requirements.
3-401.1I(,A)(1)(b) All Other PHFs- 145°F 15 sec.
I9 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-403.11(AWD) PHFs 165°F 15 sec. * (Items 23-30)
3-403.11(B) Microwave-165°F2 Minute Standing Critical and non-critical violations, which do not relate to the
Tune* foodborne illness irtteiveniions call iis6-f actors listed above can be
3-403.11(C) Commercially Processed RTE Food- found in the following sections afthe Food Code and 105 GUR
140°F` 590-000.
3-403.1.1(F,) .w Remaining Unsliced Portions of Beef item Good Retail Practices FC 590.000
Roasts* 23. Mang ement and Personnel _ FC-2 .003
Ig Proper Cooling of FHFs24. Food and Food Protection FC 3 .004
25. _ Equipment and Utensils _ FC-4 _ .005
3-501.14(A) Cooling Cooked PHFs from 140"F to 26 Water,Fiumbing and W aste FC-5 .006
70°F Within 2 Hours and From 70'F 27. Physical Facility FC-6 .007
to 41'-F/45°F Within 4 Homs. * 28. Foisonous or Toxic Materials FC-7 .008
3-501.14(13) Cooling PliFs Made From Ambient 29. S eciai Re uirements 009
Temperature Ingredients to 41°F/45°F 30.__ .Other
Within 4 Hours"
Denotes critic,ie n in the federal 1999 Foot Code or 105('MR 590,000.
Jun 21 04 02: 27p p. 1
10marM n a
g 16 EAST MAIN STREET. GLOUCESTER.MA 01930
3¢ TELE°HONE:(976)281-0222 FAX:(978)283-6296
CERTIFICATE OF ANALYSIS
Mr. Costas Linardos Report No.: 30667
DAIRY PALACE June 21,2004
187 Fort Avenue
Salem,MA 01970
RE: BACTERIAL ANALYSIS OF FROZEN DESSERT
SAMPLE DESCRIPTION: One sample of frozen dessert taken aseptically from the
above establishment and identified as Vanilla Soft Serve.
SAMPLING: Samples taken by Sharon D'Amato of Biomarine on June 8, 2004.
FINDINGS:
Sample ID Coliform Count/gram Aerobic Plate
Count/gram
30667 0 15,000
REFERENCE:Standard Methods for the Examination of Dairy Products, 16th
Edition, 1992.
GUIDELINES: Mass. Department of Public Health's 105 CMR 561.009"Frozen
Desserts and Ice Cream Mix-Bacterial Counts":An aerobic plate count>50,000 or a
coliform count>10 constitutes a violation.
- .
ehn 6dnrlctln![;.vU 6irectty
Fc: Salem Board of Health
Massachusetts Certified Laboratory#MA026
Massachusetts.Department of Public Health Salem Board of Health
120 Washington Street,4" Floor
Division of Food and Drugs Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343
Name Date 892
of 0 eration s T of Inspection
% Food Se vice outine
Address Risk ElRetail El Re-inspection
e- Level ❑ Residential Kitchen Previous Inspection
Telephone 1 11>17 ❑ Mobile Date:
Owner HACCP Y/N ❑ Temporary ❑ Pre-operation
lis ❑ Caterer ❑ Suspect Illness
Person in Charge(PIC) Time ❑ Bed& Breakfast ❑ General Complaint
r v In: ElHACCP
Inspector a Out: Permit No. ElOther
Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco
Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑
action as determined by the Board of Health.
FOOD PROTECTION MANAGEMENT ., ' ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
El- -- -----_ 13. Handwash Facilities
EMPLOYEE HEALTH
PROTECTION FROM CHEMICALS
❑ 2. Reporting of Diseases by Food Employee and PIC -
❑ 14.Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded
❑ 15.Toxic Chemicals
FOOD FROM APPROVED SOURCE
❑ 4. Food and Water from Approved Source TIME/TEMPERATURECONTROLS(Potentially Hazardous Foods)
❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling
PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding
❑ 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 21. Food and Food Preparation for HSP
❑ 10. Proper Adequate Handwashing
❑ 11. Good Hygienic Practices ;CONSUMER ADVISORY;: e
[:122. Posting of Consumer Advisories
Violations Related to Good Retail Practices Number of Violated Provisions Related
Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22):
of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code. This report, when signed below
C." ' by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations
24. Food and Food Protection (FC-3)(590.0044)) cited in this report may result in suspension or revocation of
25. Equipment and Utensils (FC-a)(Sso.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)(59o.006) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION:
s 59o�nsp«rFomS-ia.a«
Inspector's Signature: Print: '�77 �
PIC's Signature: Print: S. /L( �� Page/of�•ages
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT R Cross-contamination
1 590-003(A) Assignment of Responsibility" � 3-302.11(A)(1) haw Anima(Fords Separated from
590.003(B) Demonstration of Knowledge* Cooked and RTE Fools"
LI-103.11 Person in charge-duties Contamination from Raw Ingredients
3-302.11(A)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Other*
2 590.003(0) Responsibility of the person in charge to Contamination from the Environment
require reporting by food employees and 3-302A I(A) Food Protection' - -
a licants* 3-302.15 Washing Fruits and Vegetables
590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and
Applicant To Report ToThe Person In Utensils* -_21LContamination from the Consumer
590.003(G) Reporting by Person in Char e'r" 3-306.14(A)(B) Retumcd Ford and Reservice of Food*
3 590.003(1)) Exclusions and Restrictions* Disposition ofAdulteratedor Contaminated
590.003iE) Removal of Exclusions and Restrictions Food
3-701.11 Discarding or Reconditioning Unsafe,
FOOD FROM APPROVED SOURCE Food*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A B) Compliance with Food Law_* 4-501.17 1 Manual Warewashing-Hot Water
3-201.12 Fad 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 Seas* Sanitization Tem cratures*
3-202.14E>as and Milk Pr0dUrts,Pasteurized"` 4-501.114 Chemical Sanitization-temp-pH,
3-20116 Ice Made From Potable Drinking Water* concentration and hardness.'
5-1.01-1] I')rt'nking Water from an roved Svsfemu 4-601.17(A) Equipment Food Contact Surfaces and
l
590.006(A) Bottled Drinking Water* Utensils Clean*
590.006(B) Water Meets Standards in 310 CMR 22.0* 4-6Q'...11 Cleaning Frequency of Equipment Food-
Contact Surfaces and Utensils
Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and
3-201.15 R4oiluscinShellfish'from NSSPListed Chemical*
Sources!, 1p Proper,Adequate Handweshing
Game and Wild Mushrooms Approved by
Regulatory Authority 301,11 301.11 Clean Condition-Hands and Annsp'
3-202.18 Shellstock Identification Present* 2301.12 Cleaning Procedure*
590.004(0) Wild Mushrorns* 2-301.14 When to Wash,
3-201-17 Game Animals* I I Good Hygienic Practices
Receiving/Condition 2-401.11 Eatin=,Drinkin=or Using Tobacco*
3-202.11 PHFs Received at proper Temperatures* 2-101.12 Discharges Fron the Eyes.Nose and
3-202.15 Package Integrity* Mouth-
3-101-11 Food Safe and Unadulterated'° 3-301.12 Preventing Connmmationly�hen Tritan.*
6 TagrlRecords:Shellstock 12 Prevention of Contamination from Hands
3-202.13 Shellstock Identification* 590.004(E) Preventing Contamination from
3-203.12 Shellstock Identification Maintained' _tEM!2•ees*
Tags/Records:Fish Products 13 Handwash Facilities
3-402.11 Parasite Desh oction* Conveniently Located and Accessible
3-402.12 Records.Creation and Retention* 5-263,11 Numbers and Capacities*
590.0040) Labeling of Ingredients' 5-204.11 Location and Placement*
7 Conformance with Approved Procedures 5-205.11 Accessibility, 0 *ration and Maintenance
lHACCP Plans Supplied with Soap and Hand Drying
3-502,11 Specialized Processin�Methods* Devices
3-502.12 Reduced oxygen packaging,criteria" 6-301_1.1 lfndwashine Cleanser.Avaitabilit
3-103.12 Conformance with A rovtxi Procedures"` 6-301.12 [land Drvin e Provision
'�Denotes critical item in the federal 1999 Food Code or 105 Cls1R 59op00.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: d/ L e— Date: "/D Page: z of 2-
Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R—Red Item Verified
PLEASE PRINT CLEARLY -
C V
e
F:P
i e er
r , s
Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
Exclusion
violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
0 Voluntary Disposal 0 Other:
�• --- •. .-.r-•vr..�{'\..t y._. .'.::iY-�-,..'�. '-^:. -+_.t+!'s.-r•+-�..r�r. .�.nr :t......,-.w�°-+ '-.-f'v.•�.r+-.,
3-501.14(0 PRFs Received at'
Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to
Factors(Items 1.22) (Cont.) 41`F1451 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 A,ddthves"
3-501.16(B) Cold PI IFs Maintainer(at or below
590-004(F) 41%45°F*
3-302.14 Protection from Unapproved Additives*
3-501.16(A) Hot PHF,Maintained at or above
IS Poisonous or Toxic Substances
140'F.
7-101..17 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130`F.
Containers*
7-1.02.11. Common Name-Working-Containers* 2Q Time as a Public Health Control
7-201.11 Se.arafion-Strn�a e" 3-501.19 Time as a Public Health Control*
19O.004(H) Variance Re uirement
7-20211 Restriction-Presence and Use
7-202.12 Conditions of Use*
7-203.1.1 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11 Sanitizers.Criteria-Chemicals ` POPULATIONS(HSP) _
7-204.12 Chemicals for Washing Produce,Criteria' 21 3-801.1](A) Unpasteurized Pre-packaged Juices and
7-204.14 Drying Agents,Criteria* Beverages with Warning I-abets*
3-801,11(B) Use of Pasteurized Ev s*
7-206A I ResIncitricted UseFqvxContact.Lubricants` 3-801 11(D) Raw or Partially Cooked Animal Food and
7-206.11 Restricted Use Pesticides.Criteria*
7-206.12 Rodent Bait Stations" Raw Seed Sprouts Not Served.
Uno rened Food Packag-e Not Reserved.
7-206.13 Tracking Powders,Pest Control and 3-801.11(C)
Monitoring-*
CONSUMER ADVISORY
TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
16 I Proper Cooking Temperatures for Annual Foods,chat are Raw. Undercooked or
PHFs _ Not Othem ise Processed to Eliminate
340 1.1 C),g; 155'F 1.5 Sec. Pathog-ens Eff"11 tool
l g,-limnedratc Service 145"Flisec* 3-302.13 Pasteurized Eggs Substitute for Raw:Shell
3-401.11(A)(2) Comminuted Fish,Meats&Came Eggs*
Animals- 155'F 15 sec. *
3-401.11(B)(1)(2) Pork and Beef Roast-130`F 121 ndn* SPECIAL REQUIREMENTS
3-401.11(A)(2) Ratites, Injected Meats-155°E 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
see. » _ catering, mobile food,tcmporary 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
145°F* 590.009 violations relating to good retail
3-401.12 Raw Animas Pols Cooked in a practices should be debited under 1/29-
Microwave 165'F* Special Requirements.
3401 II(A)(1)(b) All Other PHFs- 145'F 15 sec.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-4011](A)&([)) _PHFs 16-5°F 15 sec. * (Items 23-30)
3-403.11(B) Microwave- 165°F 2 Minute Standing Critical and non-critical violations, which de sot relate to the
Time* foodborne illness inrerventlone and risk firctors listed above, can be.
3-403.11(C) Commercially Processed RTE Ford- found in Ike following sections of the Food Code and 105 CAIR
140'F* 590.000.
3-403.1.1(E) Remaining Unsheed Portions of Beef Item Good Retail Practices FC 590.000
Roasts*, 23. Cv1anagement and Personnel _ FC--2 .003
1g Proper Cooling of PHFs 24. Food and Food Protection Fc-3 _T .004
25 _Equipment and Utensils _ FC 4 .005
3-501.14(A) Cooling Cooked PHFs From 140'F to 26 Water. Piumbin and Waste FC S .006
l .--
70'F Within 2 1fours and From 70'F 27. Physical Facility FC-6 .007
to 4 FF/45'F Within 4 Hours. '" 28. Poisonous or Toxic Materials FC-7 .008
3-501,141B) Cooling PHFs Made From Ambien[ ?0. S eclat R uir®mems _ _ .009
Temperature Ingredients to 41°F/45°F 30. Other- �
Within 4 Flours:Po sswtm,ruwrEUzeo�
4 Denotes critical item in the federal 1999 Food Code or 105 CPIR 590-000.
f
CITY OF SALEM, MASSACHUSETTS
+♦ ���---'�---��� BOARD OF HEALTH
1 ` ? 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-74 1-1800
FAX 978-745-0343
STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT _
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter
94 , Section 305A and Chapter III, Section 5 of the General Laws, to operate
a Food Establishment in the City of Salem is hereby granted to :
Owner' s Name : Costas Linardos
Name of Establishment : Dairy Palace
Address of Establishment : 187 Fort Avenue
Type of Establishment : FOOD SERVICE
Application Date : 5/5/2003
Restrictions:
Permit for Food Establishment 295-03
Frozen Desserts/Ice Cream 21-03
Permit for the Sale of Tobacco Products
These Permits Expire December 31, 2003
This permit is not transferable and must be reissued upon change of
ownership or location. The permit must be posted in a prominent location
in the Establishment.
In accordance with the State Sanitary Code, before any renovations,
improvements, or equipment changes are made, all plans for such must be
submitted to and approved by the Salem Board of Health.
HEALTH AGENT
o
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
' • i 120 WASHINGTON STREET, 4TH FLOOR
' 3
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
STANLEY USOVICZ, JR. ,JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT �J2 — TEL# IQ�S�� 14- aQ4,Q
ADDRESS OF ESTABLISHMENT
MAILING ADDRESS (if different) c()
OWNER'SNAME a7� S L► n �Y��J TEL# l '15WP
ADDRE S b
CITY STATE zip r) I q(nf)
CERTIFIED FOOD MANAGE 'S NAME(S) CERTIFICATE#(s) 1
(required in an establishment where potentially hazardous food is prepared.) 2/
EMERGENCY RESPONSE PERSOI_� DtLIQ HOME TEL# 1 �Lo`d '(,I3(v
I b11 — U�i1 )I LiM 11 PM
HOURS OF OPERATION: Mon. Tue. Wed.—Thu.—Fri.—Sat.—Sun.
TYPE OF ESTABLISHMENT FEE check only
RETAIL STORE YES NO less than 1000sq.ft.
1000-10,000sq.ft. 95
more than 10,000sq.ft. =$250
RESTAURANT YES NO less than 25 seats =$9b0
25-99 seats
more than 99 seats =$200
BED/BREAKFAST YES NO $100 F�
ADDITIONAL PERMITS
MAKE ICE CREAM, YOGURT, SOFT SERVE ESQ NO a�—` $5
TOBACCO VENDOR YES NO $50
ALL NON-PROFIT(such as church kitchens) YES $25
Please pay total with one check
payable to the City of Salem
This Permit is not transferable and must be reissued upon change of ownership. The Permit must
be posted in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment
changes are made, all plans for such must be submitted to and approved by the Salem Board of
Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my
best knowledgeAQd belief, have filed all state tax returns and paid all state taxes required under the law.
YhI MQ VRIXb LI—In-6'3 DH — 2k i2 �Q9a-
Signat re Date Social Security or Federal Identification Number
---------------------------------------------------------------------------------
Revised 11/25/02 FOODAP2.adm Check#&Date u3
�l ,�D• ars mt. S-S-D�
...:..,,�,wn.�F�+-w,:^.u•G..�...-�v,. '»w'�:fW9iw�i.vi.lJs-iWal""r8"w*�'r'f`19rt+7'-`T"^4y,6'^'+:.wryy;.,,..9jt11.rtba.+�-N...w..-. .,y..,w..Aol.'.A,...=.s.
� THE COMMONWEALTH OF MASSACHUSETTS
CITY OF SALEM Address: 120 Washington Street, 4th Floor
BOARD OF HEALTH Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 745-0343
Name ,` Date Tv�peration(s) Tyne of Insoection
L,
l �,, -f 1191d.? RrFood Service [iRoutine
Address Risk ❑ Retail ❑ Re-inspection
oir Arf Level ❑ Residential Kitchen Previous Inspection
Telephone /41
7b 9� S-• O°/] El Mobile Date:
Owner HACCP Y/N ❑ Temporary ❑ Pre-operation
C,oS .e J• ❑ Caterer ❑ Suspect Illness
Person in Charge(PIC) Time ❑ Bed 8 Breakfast ❑ General Complaint
Inspector In: //!/5- ❑ HACCP
Out: .-?.n Permit No. p1V3--0J El Other
Each violation checked requires ad explanation on the narrative page(s) and a citation of specific provision(s)
violated. Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti-Choking Tobacco
Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑
action as determined by the Board of Health. Local Law ❑
FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/ Duties
❑ 13. Handwash Facilities
EMPLOYEE HEALTH
El2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS
El3. Personnel with Infections Restricted/ Excluded El 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE
El 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑ 16. Cooking Temperatures
❑ 5. Receiving/Condition
❑ 6. Tags/ Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/ HACCP Plans El 18. Cooling
PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding
El8. Separation/Segregation/ Protection El 20. Time as a Public Health Control
El 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 10. Proper Adequate Handwashing ❑ 21. Food and Food Preparation for HSP
CONSUMER ADVISORY
❑ 11. Good Hygienic Practices
❑ 22. Posting of Consumer Advisories
Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related
Items) Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22):
of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/Federal Food Code.This report, when signed below
C N I by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations
24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of
25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food
26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you
27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing
28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION:
Inspector's Signature: 2- Print:
PIC's Signature: Print: ` Page / of d Pages
FORM 734A HOBBS&WARREN - BOSTON
s.
Violations Related to Foodborne Illness
Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION
8` Cross-contamination
FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from
2 4 590.003(A) Asm nment of Responsibility* Cooked and RTE Foods*
H590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients
2-103.11 Person in Charge-Duties 3-302.1 I(A)(2) Raw Animal Foods Separated from Each
Other*
EMPLOYEE HEALTH Contamination from the Environment
.2� 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) I Food Protection*
require reporting by Food Employees and
3-302.15 Washing Fruits and Vegetables
ft, Applicants'
3.304.11 Food Contact with Equipment and
590.003(F) Responsibility of a Food Employee or an Utensils*
Applicant to Report to the Person in Contamination from the Consumer
Charge*
3-306.14(A)(B) Returned Food and Reservice of Food*
590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated
3 i 590.003(D) Exclusions and Restrictions* Food
590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe
Food*
FOOD FROM APPROVED SOURCE g: Food Contact Surfaces
Food and Water From Regulated Sources 4-501.111 Manual Warewashing-Hot Water
590.004(A-B) Compliance with Food Law* Sanitization Temperatures*
3-201.12 Food in a Hermetically Sealed Container* 4-501.112 Mechanical Warewashing-.Hot Water
3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures*
3-202.13 She]]Eggs* 4-501.114 Chemical Sanitization-tem H,
3-202.14 Eggs and Milk Products, Pasteurized* Hardness* P
gg Concentration and
3-202.16 Ice Made from Potable Drinking Water* 4-601.11(A) Equipment Food Contact Surfaces and
5-101.11 Drinking Water from an Approved System* Utensils Clean*
590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food-
590.006(B) Water Meets Standards in 310 CMR 22.0 Contact Surfaces and Utensils*
Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and
3.201.14 Fish and Recreationally caught Molluscan Food Contact Surfaces of Equipment*
Shellfish*
4-703.11 Methods of Sanitization- Hot Water and
3-201.15 Molluscan Shellfish from NSSP Listed Chemical*
Sources*
"Y'10 Proper,Adequate Handwashing
Game and wild Mushrooms Approved by
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms*
2-301.12 Cleaning Procedure*
3.202.18 Shellstock Identification Present* 2-301.14 When to Wash*
590.004(C) Wild Mushrooms* 11 Good Hygienic Practices
3-201.17 Game Animals* 2-401.11 Eating,Drinking or Using Tobacco*
5 Receiving/Condition 2-401.12 Discharges From the Eyes, Nose and
3-202.11 PHFs Received at Proper Temperatures* Mouth*
3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting*
3-101.11 Food Safe and Unadulterated* 12Prevention of Contamination from Hands
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from
3-202.18 Shellstock Identification* Employees*
3-203.12 Shellstock Identification Maintained* 13 Handwash Facilities
Tags/Records: Fish Products Conveniently.Located and Accessible
3-402.11 Parasite Destruction* 5-203.11 Numbers and Capacities*
3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement*
590.004(J) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance
"7 Conformance with Approved Procedures Supplied with Soap and Hand Drying
/HACCP Plans Devices
3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability
3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision
8-103.12 Conformance with Approved Procedures*
•Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
l
1
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: .%LL Date: P//.W1o3 Page: of
Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
t No. Reference R—Red Item Verified
PLEASE PRINT CLEARLY
/L� ; ✓. �' AT' SIG.«TGL L�LJ..-c/s S.-..A- \ '74yl
• }`fit
�G 71a. L7
e
< Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
inspection, to observe all conditions as described, and to Exclusion
violations before the next ins
P ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
y your food permit. �/ / ❑ Voluntary Disposal ❑ other:
I/�.1�10 . 4rSEt
3-501.14(C) PHFs Received at Temperatures
Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to
Factors(items 1-22) (Cont.) 4't°F145'F Within 4 Hours.
PROTECTION FROM CHEMICALS 3-501.15 Coolin Methods for PHBs
19 PHF Hot and Cold Holding
14 Food or Color Additives
3-501,16(B) Cold P11f s Maintained at or below
3-202.12 ProteAddiction
590.004(F) 41"(45°Fit
3-302.14 Proicctirnt Irotn Una i roved Additives* 3.501.i6(A) Hot MIR Maintained at or above
15 Poisonous or Toxic Substances
140`F. *
7-701.11 ldentifIi Information-Original 3-561.16(A) Roasts Held at or above 130°F.
Containers"
20 Time as a Public Health Control
7-102.11 Common Name-Working Containers',
7-201.11 Separation-storace* 3-501.19 Time as a Public Health Control*
7-202-11 Restriction-Presence and Use* 590,004(H) Variance,Recairentent -
7-202.12 Conditions of
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Contafinersiners-Prohibitions* POPULATIONS(HSP)
7-204.11 Sanitizers.Cxiferia-C'hemi cats"
7-204.72 a Chemictils for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
7-204.14 Drviri-A-e CntCriteria` Beverages with Wanting I.xibels*
3-801.11 B) Use of Pasteurized Elms*
7-205.1.t Incidental Food Contact,'Lubricants* 3-801.1.i(D) Raw or Partially Cooked Animal Foal and
7-261.11 Restricted Use Pesticides. Criteria* Raw Sced S coats Not Seived.
7-206.12 Rodent Bait Stations* 3-801.1 I(C) Unopened Food Package Not Re-served.
7-206.13 Tracking Powders,Pest Contra]azul
nionitorinex
CONSUMER ADVISORY
TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
16 Proper Cooking Temperatures for Animal I'mxk 7bat are Raw.Undercooked or
PHFs Not Otherwise Processed to Eliminate
3Eups155°b 5 Sec.
lre
Ea -Immdiate Service 145`Fl set+ 3-302.73 Pasteurized EtgsE'i„zrn�
Substitute for Raw Shell
3-401.1.1 A)(2) Comminuted Fish.Meats&Game bg n*
(
Animals-155'F 15 sea.
3-401.11(B)(1)(2) Pork and Beef Roast-130'F 121 inin* SPECIAL REQUIREMENTS
3-401.11(Aj(2l 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(.0)(3) Poultry'Wild Game.Stuffed PHF,, residential kitchen operations should be
Staffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-165°F 15 sec. " above if related to foodborne ilhtess
3-401.11(C)(3) •Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
145-F" 590.009 violations relating to good retail
3.401.12 Raw Animal Foods Cooked in a practices should be debited under#F29 -
l4icrowave 165`F° Special Requirements.
3-401.11(A)(1)(b) Al I Other PHFs- 145'F 15,sec.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-403.11(A)&(D) Pf-IFs 165'F 15 sec. * (Items 23-30)
3-403.1.1(B) Microwave-165'F 2 Minnie Standing Critical and non-crilical violations, a hick do not relate to the
Time` foodborne illness interventions and risk factors listed above, can be
3-403.1.1(C) Commercially Processed RTE Food- ,found in the following sections t f the Food Code and 105 Cb#R
14WF- 590.000.
3-403.11(E) Remaining Unsliced Portions of Beef Item Good Retail Practices FC 580.000
Roasts` _23. Mona ement and Personnel FC-2 .003
004 3 FC ti
t
Food P
d F
� and - .
1g Proper Co1 24. 1 Food oling of PHFs --,- --- --
3-501-14(A) Cooling Cooked PHFs from 140"F to 25. Water.Pluand Utensils_
Waste-- --.-FC 5 006 -
70`F Within 2 Hours and Front 70°F 2Z Ph sinal Facilit FG-8 .007
to 41'FI45'F Within 4 Hours. * 28- Poisonous or Toxic Materials FC-7 .008
3-501.14Bj Cooling PHFs Made From Ambient i 29. Special Re_gulrements __ ,009 _
Temperature Ingredients to4l'Fl45`F 1 30 Other
Within 4 Hours*
*Denotes critical item in the feral 1999 Food Codc or 105 CMR 590.000,
IMPORTANT MESSAGE
FOR
� / / // ,, A.M.
DATE `7`- 1,1 b1 TIME"P.M.
M
OF
PHONE
AREA CODE NUMBER EXTENSION
O FAX
❑ MOBILE
AREA CODE NUMBER TIME TO CALL
TELEPHONEO . .:. PLEASE CALL
CAME TO SEE YOU WILL CALL AGAIN
WANTS TO SEE YOU RUSH
RETURNED YOUR CALL WILL FAX TO YOU
MESSAGE
Ca�A �—
,:s-- o \
JtiD�.ocJs /u� 4� a 1
SIGNED
FORM 4009
MADE IN U.S.A.
NOTES `
r w+n'.a*�kwwryn.«.w....�-�o-v.-'.�.-+r:��'�wFJMr.f`�ip!+{.FMN'1yn'-'d'Y+�N ." m^YpMM1'+N'PW��4• ^.P^...•^+...r+�n'.'*+-,
. THE COMMONWEALTH OF MASSACHUSETTS
CITY-OF SALEM Address: 120 Washington Street, 4th Floor
BOARD bF HEALTH Salem, MA 01970-3523
'FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 745-0343
Name / Date Type of Operation(s) Type of Ins ection
/7 %z !✓CAGr �� /7/r
p l od Service u no Ilina
Address Risk ❑ Retail ❑ Re-inspection
Level L ❑ Residential Kitchen Previous Inspection
Telephone
ja El Mobile Date:
Owner / HACCP Y/N ❑ Temporary [ Pre-operation
❑ Caterer ❑ Suspect Illness
Person In Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint
In: ❑ HACCP
Inspector Out: Permit No. ❑ Other
Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)
violated. Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti-Choking Tobacco
Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑
action as determined by the Board of Health. Local Law ❑
FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/ Knowledgeable/Duties
❑ 13. Handwash Facilities
EMPLOYEE HEALTH
PROTECTION FROM CHEMICALS
El2. Reporting of Diseases by Food Employee and PIC
El3. Personnel with Infections Restricted/ Excluded El 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE
TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑ 4. Food and Water from Approved Source
El 16. Cooking Temperatures
El 5. Receiving/Condition
El 17. Reheating
El6. Tags/Records/Accuracy of Ingredient Statements
El7. Conformance with Approved Procedures/ HACCP Plans El 18. Cooling
❑ 19. Hot and Cold Holding
PROTECTION FROM CONTAMINATION
❑ 20. Time as a Public Health Control
❑ 8. Separation/Segregation/ Protection
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 9. Food Contact Surfaces Cleaning and Sanitizing
ElEl 10. Proper Adequate Handwashing 21• Food and Food Preparation for HSP
CONSUMER ADVISORY
❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories
Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related
Items) Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22):
of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/Federal Food Code.This report, when signed below
C N by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations
24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of
25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food
26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you
27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing
28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION:
Inspector's Signature: Print:
PIC's Signature: Print: Page / or 2 Pages
FORM 734A HOBBS&WARREN -BOSTON
Violations Related to Foodborne Illness 1
Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION $
8 Cross-Contamination
FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from
1 590.003(A) Assignment of Responsibility* Cooked and RTE Foods*
590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients
2-103.11 Person in Charge-Duties 3-302.11(A)(2) Raw Animal Foods Separated from Each
Other*
EMPLOYEE HEALTH Contamination from the Environment
2- 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) Food Protection*
require reporting by Food Employees and 3-302.15 Washing Fruits and Vegetables
Applicants
3.304.11 Food Contact with Equipment and
590.003(F) Responsibility of a Food Employee or an Utensils*
Applicant to Report to the Person in
Charge* Contamination from the Consumer
3-306.14(A)(B) Returned Food and Reservice of Food*
590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated
i.3 590.003(D) Exclusions and Restrictions* Food
590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe
Food*
FOOD FROM APPROVED SOURCE 9" Food Contact Surfaces
=>4- Food and Water From Regulated Sources 4-501.111 Manual Warewashing-Hot Water
590.004(A-B) Compliance with Food Law* Sanitization Temperatures*
3-201.12 Food in a Hermetically Sealed Container* 4-501.112 Mechanical Warewashing-Hot Water
3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures*
3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-tem H,
3-202.14 Eggs and Milk Products,Pasteurized* Hardness* p
g8 Concentration and
3-202.16 Ice Made from Potable Drinking Water* 4-601.11(A) Equipment Food Contact Surfaces and
5-101.11 Drinking Water from an Approved System* Utensils Clean*
590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food-
590.006(B) Water Meets Standards in 310 CMR 22.0*
Contact Surfaces and Utensils*
Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and
3.201.14 Fish and Recreationally caught Molluscan Food Contact Surfaces of Equipment*
Shellfish*
4-703.11 Methods of Sanitization- Hot Water and
3-201.15 Molluscan Shellfish from NSSP Listed Chemical*
Sources*
10% Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Regulatory Authority 2-301 Al Clean Condition-Hands and Arms*
2-301.12 Cleaning Procedure*
3.202.18 Shellstock Identification Present* - 2-301.14 When to Wash*
590.004(C) Wild Mushrooms* lY. Good Hygienic Practices
3-201.17 Game Animals* 2-401.11 Eating,Drinking or Using Tobacco*
S Receiving/Condition 2-401.12 Discharges From the Eyes,Nose and
3-202.11 PHFs Received at Proper Temperatures* Mouth*
3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting*
3-101.11 Food Safe and Unadulterated* '`:12 Prevention of Contamination from Hands
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from
3-202.18 Shellstock Identification* Employees*
3-203.12 Shellstock Identification Maintained* 13 Handwash Facilities
Tags/Records: Fish Products Conveniently Located and Accessible
3-402.11 Parasite Destruction* 5-203.11 Numbers and Capacities*
3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement*
590.004(J) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance
7= Conformance with Approved Procedures Supplied with Soap and Hand Drying
/HACCP Plans
Devices
3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability
3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision
8-103.12 Conformance with Approved Procedures*
•Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
ti
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: Date: Page: of a
Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R-Red Item Verified
PLEASE PRINT CLEARLY -
!,7 e� 7a 0,2<,✓
f�/L( Gcl� J-OGJ
v J '
` Discussion With Person in Charge: Corrective Action Required: No ❑ Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
inspection, to observe all conditions as described, and to Exclusion
violations before the next ins
P ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-fide dollars or\susp sion/revocation of L3 Embargo Ll Emergency Closure
your food permit. ` fj.�)
❑ Voluntary Disposal 0 Other:
3-50 C.14tC) PHFs kc,eived at Temperatures
Violations Related to Foodborne illness interventions and Risk According to Law 0Y)led to
Factors(items 1-22) (Cant.) 41'F145'F Within 4 Hours,
PROTECTION FROM CHEMICALS 3-501.75 (L'tsofing Niethocis for PHFs
14 Food or Color Additives 19 1 PHF Hot and Cold Holding
3-f()1'le(B) Culd Plihs, Maintained at or below
�J-202,12 Additi�oq* 590.004(F) 41 '1'15°F'
; z-302 14 P1 otot:jj On from Una piroved AddiM Cs"
115 Poisonous or Toxic Substances Hot PFF,Maintained�a of above
15114W 12 *
'7-101.11 lderrhiyne lelorusalon-Original 3-501.16(A) Roasts Held it or—abo,e 130"R
ContamerS)'
20 Time as a Public Health Control
7-102,11 Common Name-N�orki ng Containers" 3-J01.14 Tun, as a Public Hesith Control"'
7201.11 Sertaration-St Ston t
--- —_Restriction-5-1K -. ,M04t'H) variance Ret uiremeuY
2W711 Presence and Use�'
7-202.12 Condi 6 ons of t REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-20111 Tone,Containers ProProhibitions"` POPUL IONS(HSP)
7-204.11 saaitizcr�.Criteria-clhcmicrflsT
7204,12 Chemicals for Washing Produce.Criteri, 3-801.11(A)21 Unp,isteurized Prc-packaged Juices and
a. Beverages with Warning�LabeW
7-204.14 Dniug Agetuq,Critcri,,O
11 3-801.11(13) Use of Ilisteurized E.-s'
7-205.11 Incidental Food Contact,Lubricants*
7-206.11 Restricted Use Pesticides,Criteria* 3-801.1.1(D) Raw(it Partially Cooked AnimalFood and
Raw Seed Sprouts Not Served. �
7-206,12 Rodent Bait Stations* 3-801.1.1(C) Unopened Food Package Nat Re-served.
7-20613 Tracking Powders, Past Control and
Monitoring'. CONSUMER ADVISORY
TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
1K Proper Cooking
Animal Foods That are Raw.Undercooked or
Temperatures fAnimal
PHFs Not Otherwise Processed to Eliminate
3-401.11A(1)(2) Eggs- 155'F 15 Secrr -2r 'Jo, Patho"vas.44
1 8s-Imuncefige Service,145'F15scc* 3-302.1-, Pasteurized F,gs Substitute for Raw She]]
3-401.11(A)(2) Comminuted Fish. Mears&Came Egi"s*
ArranaN- 355"F 15 sec. *
3-401.11(13)(I)f2) Polk and Beef RoasL- 13WF t2l min" SPECIAL REQUIREMENTS
3-401 A I(A)(2) Ratitcs,Injected Meal- 155'F 15 590.009(A)-(D) Violations of Section 590.009tA)-('D) in
catering, mobile food, temporary and
3-40I.IUA)(3) Poultry, Wild(tarne. Stufled PHi restidentral kitchen operations should be
Stuffing Containing Fish, Meta, debited under the appropriate sections
Poultry of Rattles-165-,F 15 sec, above if related to foodborne illness
3-401.11(C)f3) Whole-musele-Intad BVCf Steaks interventions and risk factors. Other
145'F* 590.009 violations relatinia to good retail
3-401.12 Raw Animal Foo&C(x)ked in practices should be debited under #29-
Microwave 16�,I- * Special Requirements.
3-40IAI(A)(1)(b) All Offer PHIS -- 145'F 15 see. * J
L
17 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-403.11(9&(D) PER, 165"F 15 sea. (Items 23-30)
1
3-403.11(&) Microwave- 165'T2 Minute Standing Critical and non-critical violations, which do no,telale to the.
THAT, foodborne illness bw5rveudons and risk(actors listed above, carr be
3-403.11(C) Commercially Processed RTE Food ,found at the fon lowing.,e(dons cat the Food Code and 105 Cil,[R
L 14WF- 590.000.
T-
3-403.11(E) Remainin- UnsficLd Portions of Beef item Good Retail Practices Fc 590.000
Management 2— .003
Proper Cooling of PHFs 24 rFood and Food Protection FC 3 004
25 Equipment and_Utensi s FC--41005 i
3--501.14(A) Cooling Choked PHFs from 140`F to ----- ----------- ...... .
11 26. Water.Plumbinil and Waste, I FC-5 006
70'F Within 2 Hears and From 70°F
1 27 physical Farilly 1 007
to 41'F/45't Within 4 Hours. 28-iPoisonous or Toxic Materials FC -7
Cooling PffFs Made Fiom Arobient 29, Special Requirements 009
3-501 14(13)
Temperature lngj�dients to-11'F/45'F Ro—I Other
- --- -------
k"Vilhut 4 flouf,3"
Denwe,ealct'I item it I the rodcrA 1999 rood Code o, 101 CN I R 590.000.
Al® 831 Exterminators
,
183 SHEPARD STREET,LYNN,MA 019024597
781.5924791 1-800.5254825 FAX 781.592-7641PLEASE REMIT PAYMENT TO:
72 MAIN ST SUITE 7.WEST HARWICH,MA 02671 IN VOICE P.O." Box 310 Lynn;MA-01903-0310
s 508-032 5888 508-240 1661 804499-5888 _
>M
19774
CURRENT 30 DAYS 60 DAYS - 90 DAYS
Pest and Termde Control Professionals ; „'
IL�CS ° 1$ 1`Y'Y1 .t vJ rFr1$ GII , _ . AMT.NO.
I? IIRI( PALACE u : coNTROLFOR REGUI_AR _FEST CONTROL 4.'00,
d �l "
tR .r ANUF, SAI FhSERVICE CHARGE) _ NUMBER UNIT PRICE AMOUNT
SALEM WSL Idrw"'MA 01 J 7 �,•- MOUSE GL 30
3/0 ISI IIID ArYI. MULTI-CT TRAP ...
DATE PROTECTA
t CHECK NO. PROTECTA LP
RTU BAIT STA =
❑,MC ❑VISA..❑DISCOVERBD
RAT_GLUE - -
EXDATE' SALES TAX
ti TIME IN ..
d C.O.O.❑ CHG❑ N/C❑ -TOTAL DUE
TOTAL AMOUNT PD
DETAILS INxPULL e` - BAIT STATION,_,FS4.ACEMENT;_ seeRey_e eJgr'C 4e ,,,,,.w,+ , �iJ
KITCHEN eATtI DININGRM BASEMENT ATTIC COMMON "•GARAGE
4J ,
Loc
NIT 2
=I x Ya
N x
n
C`, �.:�... L
.Z/�c'y`"' UNIT 4-
rn4�4
.{ R UNIT 5 .._ ..
'esu. -— -
POST APPLICATION REQUIREMENTS - -Loc '
y r f u: UNIT 6
,'K. 3�r ..n &r _
OCCUPIED AREAS MUST A VACATE"FOR HOUR& THOROUGHLY ALLOW k -
UENTILATETREATED AREAS BEFORE THEY ARE'REOCCUPIED.DO NOT ALLOW
,ADULTS CHILDREN,OR PETS ON TREATED SURFACES UNTIL DRY.
:COMRCIAL-`,SANRAT,:ION REPORT' -- ""- - -', ';RESIDENTIAL WARRANTY INFORMATION
MEYES' .. .._.NO,...,_ .. .DWELLING TYPE a_., .'WARRANTY YES❑'.,NO'❑ .:,.
Floors—Clean .... .:... ....... 1 ❑ 1 Family ❑ 3 Family, E] 30 Days ❑ 60 Oays ❑
Counter Surfaces-.Clean:... . :........ ..... ...... ...❑. ---�:....- 2 Family [3 6Family- ❑' ;..90 Days;_._ ❑ 6 Mos_, , ❑
Drain Areas ,CleanQ, ❑. ,_ - -
Rest Rooms=Clean ' ...... ,❑, ' - ❑ .;REASON FOR NO WARRANTY
DiningAreas=Clean .. "-❑._ ❑
Employee'Areas—Clean ..... ......... ... ..... ❑ ❑ - E 5 ..
Locker Areas—Clean ..... ........ ....... ❑ ❑ •'Partial service requesled'z�. .....r.-... .. .❑�,
....-...... •Poonsanitation . ❑
Storage Areas—Organized ..... ...... ❑- ❑ •Kitchen/bathroom cabinets not prepared .... ........ ❑
Comments •Closets/fumiture not prepared .;...... ....... ...... ... ❑k. ;
". r : "•Rodent proofing needed'.. ......... . ........... El ,
•Other
Unitr#- Treated Not Trtd. Sanitatio - Reason
i
CONTRACTING.ENTITIES HAVE.RECEIVED ALL MASSACHUSETTS.DEPARTMENT OF FOOD&AGRICULTURE'S PE TICIDE BUREAU CONSUMER SHEETS,WRITTEN
STATEMENTS,POSTING NOTICES AND HAVE AGREED TO NOTIFY TENANTS 2-7 DAYS PRIOR TO APPLICATION TI E.
THE ABOYMERVICE I EN SA SFACTORILY-`COMPLETED... -- -- INss/
EB SI, NATl1I% , . .. .ter l', „llnoli-^5- it '1 f'C . . ,E' ,TEGD'NO.
MAY 5 2003
CITY OF SALEM
BOARD OF HEALTH
,i
i