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DE FRANCISCO & SONS - ESTABLISHMENTS De FRANCISCO & SONS 53 MASON STREET 0 n o 0 1� u a � r r. I yam\ I � J �,s _�� n .__.... ___ -._ 4 .rMQ: �16."F'2';;. .}C"OSfh` irr.p.G"c"e" .,., ..:'� •--._�; .- ^c_ .. .x.BJ"x;..f^^, ,rp'S'�, N�S:d,e,� wM�a"�rre+�._sK 'SUE Y;l Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street,4th Floor — % SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2006 WHO'S PLACE OF BUSINESS IS: John DeFrancesco and Sons File Number:BHF-2004-0033 P.O.Box 270 Salem MA 01970 LOCATED AT: 0053 MASON STREET SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2006-M9 Jan 3,2006 Dec 31,2006 $100.00 ESTABLISHMENT Total Fees: $100.00 PERMIT EXPIRES December 31, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 2 of 6 ' e CITY OF SALEM, MASSACHUSETTS `� 1y BOARD OF HEALTH 3 s 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 6�Oi Q L.J M1N6 TEL. 978-741-1800 STANLEY J. USOVICZ, JR. FAX 978-745 0343 MAYOR WWW.SALEM.COM JOANNE.SCOTT MPH RS CHO F 2j „ c awy ti � upa.Y � m t �'[ ,t e '-` �p '� 2• �Yr 4 n _ 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT�UlJ`C�C��sANCt°SC_D/' !� :X��TEL# 4� g 7y`/ 3 X03 ADDRESS OF ESTABLISHMENT J3 TJdZAI ST MAILING ADDRESS (if different) � l Ja1l aid OWNER'S NAME he 6- oe-eSCb TEL# ADDRESS CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME TEL# HOURS OF OPERATION: Mon.—Tue.—Wed.—Thu.—Fri.—Sat.—Sun.— TYPE on. Tue. Wed. Thu. Fri. Sat. Sun.TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 -------------- - ------.. ..........----.....--------------------------- - --- ......-------- ............._..-------------------- RESTAURANT YES NO 'more is seats $100 25-99 seats =$150 v more than 99 seats =$200 . ........ ---------- ------ .......... ------ ...-----.... ----- ....----- ----- ......... ......---- BED/BREAKFAST YES NO $100 -- --------------- --kl. -------------.....-----......---------------------------------.....----------------...---------......-------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem . This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MG ter 62C, S99tion 49A, I certify under the pains and penalties of perjury that I, to my best o ed an belief, II state tax returns and paid all state taxes required under the law. OYa� /8873 Sig ture Date ocial Security or Federal Identification Number ----------------------------i --------------------------------------------------------------- vised 11/03/05 FOODAP2.adm Check#&Date a .0a / —pQ ^i`" �v '€)"""`.y♦S *fa^t+- 3" 3 '" Jgrc"',T�F^^H- * :f„r-a. `~"i. ''"'F i (;'+ `Y md'w +Aves r F {iy ,"z..• a�TeYOrrSAt�EMi MASSAGEiUSire -Aj HEALT " i"'t y.BOARDiOF H =s';e #•:'`, a +wt.,.tx':. 1 jaA3; � S;Cri'�„t.4 ^aHINGTON STREET, 4TH FLOOR s c Ma },1 ,�M"MA01970 .a , t r ;,,TEL. 978.741-1800 1. w - 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 111, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: Wholesale Distrib. Name of Establishment: John DeFrancesco and Sons Address of Establishment: 53 Mason Street Owner's Name: John DeFrancesco Restrictions: Application Date: 12/20/2004 Permit for Food Establishment 243.05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. c'yt76 - HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH rr-51 7=i120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 ; [� Clguv�o .� TEL. 978-741-1800 FAX 978-745-0343 DEC 16 2004 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT CITY OF SALEM 2005 APPLICATION F R PERMIT TO OPERATE ,,��A� FOOD ESTABBLI$J OF HEALTH f IA�CA� WJ NAME OF ESTABLISHMEN{ � �WEL# I !p- ADDRESS OF ESTABLISHMENT -53 r ►QWt,_,),) Cl MAILING ADDRESS (if different) 4V r^ N� OWNER'S NAME Q CSS TEL# ADDRESS gpS(, G� C� _ CITY�,p M STATE ZIP CERTIFIED FOOD FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON � (( K) HOME TEL# HOURS OF OPERATION: Mon. (r3 Tue. Wed. Thu. A Fri. J Sat. VI Sun. �C TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 l— more than 10,000sq.ft. =$250 RESTAURANT YES NO /J ((f V J less than 25 seats =$100 L 25-99 seats =$150 O 11 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge-and- ief, hav led all state tax returns and paid all state taxes required under the law. Signatu to I� lD Social Security or Federal Identi 'cation Number ---------- ----- - ---- �J' 7 Revise 11/03/ 3 FOODAP2.adm Check#&Date / / 1� k4assachusetts Department of Public Health Salem Board of Health 120 Washington Street,4t" Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date T e Operation(s) T e f inspection JBL 4�SGd t� Cd P 6 ood Service outine Address �Sar✓ �, Risk ❑ Retail ElRe-inspection Level ❑ Residential Kitchen Previous Inspection Telephone 3g6,� L_., ❑ Mobile Date: Owner HACCP YM ❑ Temporary ❑ Pre-operation Ot ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed 8 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 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 _ �q. " ❑ 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 El 14.Approved Food or Color Additives El3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals � - 'TIMEREMPERATURE CONTROLS(Potentially Hazardous Foods FOOD FROM APPROVED SOURCE _ El 4. Food and Water from Approved Source ly( ) ❑ 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 """ - 11-1- "I ❑ 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 ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below G x by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.0 43 order of the Board of Health. Failure to correct violations 4. Food and Food Protection (Fc-a)(sso.00a) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S.5001nsp CtFOm 14.tl Inspector's Signatur Print: PIC's Signature: Print: Page / 0f Pages Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 1 590.0030) 1 Assignmem of Responsibility* 3-302.11(A)(1) Raw Animal Foods Separated from 590.003(B) I'DelloustrationofKnowledge* n Cooked and RTE Foods*, - 1 2 ]03.11. Person in charge-duties Contamination from Raw ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.1 t(A) Food Protection* o= applicants* 3-302.15 Washiu Fru3tsandVe*ztables 590.003(F) Responsibility 01'A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The.Person In UtensilSa - -c.. s - Chat ee* Contamination from the Consumer 590.003(G) Re orting,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(5) 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) Com dance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12. Food in a Hermetically Seated Container* sanitization Tem rerahnes* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warew�ashine Hot Water 3-202.13 SheiiF s` Sanitization Temperatures* 3-202.14 5g,=s and Milk Products-Pasteudzed'w - 4-501.114 Chenueal Sauitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. 5-101.11 Drinking Water hum anApproved S stem* 4-60LII(A) Equipment Food Contact Surfaces and Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning,Frequency of Equipment59(1.006(B) Water Meets standards n Approved CMR 22.0* Contact'Surfaces and Utensils" Food- Shellfish a and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan _ Food t*Contact Surfaees.of E ui ri n Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-20115 Molluscan Shellfish from NSSP Listed IChemical" Sources* to Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Anus* Re Mato Authorit 3-202.18 Shellsuxk Identification Present* 2-301-1.2 Cleatinn Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices $ ReceivinglCondition 2-401.11 Eating,Drinking or Using,Tobacco* 3-202.1 t PIIFs Received at Proper Tem eratures- 2-40112 Discharges From the Eyes, Nose and 3-202.15 Packa e hue rit,* Mouth" 3-101.11. Food Safe and Unadulterated* 3-301.12 Preventin>Contamination Alien Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-20118 Shellstoek Id6itification* 590.004(E) Preventing Contamination from 3-203.12 Shelkiock Identification Mamtained'* En A( ees* Tags/Records: Fish Products 13 Handwash Facilities Conveniently Located and Accessible 3-40111 Parasite Destruction* _ _ 3-4-02.1'2 Records,Creation and Retention" 5-203.11 Numbers and Capacities,'; Location and Placement* 590.004(.1) Labeling of Ingredients' 7 Conformance with Approved Procedures 5-205.11 Accessibility.O aeration and Maintenance JHACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced ox• en racka>ing,, criteria* 6-30IJ I Handwashin Cleanser, Availability _ 8-103.12 Conformance with Approved Procedures'" 1 6-301.12 Hand Ilrying Provision *Denotes critical item in the federal 1999 Food Caie or 105 CMR 596.000. CITY OF SALEM BOARD OF HEALTH Establishment Name:(_02M Date: 11A&f Page: Z of 2-- Item /Item Code C-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY 1P f bKd FWD ! r3,U444 JP (�P't& /dtF IJ 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. ❑ Voluntary Disposal ❑ Other: V�u'ti .S4.'I�.c�'v tir`ti yrti • -�...-... .. •. n-.r- 'e--�✓" "�. 3-501.14(C) PRFs Received at Temperatures Violations Related to Foodborne illness interventions and Risk - According to Law Cooled to Factors(items 1.22) (Cont.) 4I'F145T Within 4 How s. PROTECTION FROM CHE_M_ICALS3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below 590.004(F) 41°1450 F* 3-302.14 Protection Pram Unapproved Additives*15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 140°F. * 7-101.11 identifying Information,-Orio nal 3-507.16(A) Roasts Held at or above 130°F_ Containers* 7-102.11 Compton Name-Workin,Containers* 20 Time as a Public Health Control 7-201.11 . r Separation-Storage' 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence mud Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11. Sanitirzrs,.Criteria-Chemicals^' POPULATIONS(HSP) 7-2(14.1.2 Chemicals for Washing R'cxlnce,Criteria"' 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Dr�ind A cots,Criteria" Li Beverages with Warning labels* 3-801.1-1(B) Use of Pasteurized 7-205.11 Incidental Food Contact.Lubricants* Bias* 7-206.11 Restricted Use Pesticides.-Criteria* 3-80L l I(D) Raw or Partially Cooked Animal Food and 7-206.12 Rodent Bait _ Raw Seed Sprouts Not Served. 7-206.13 Tracking Powders,Pest Control and 3-801.11(C) Unopened Food Package Not R e-served. Monitoring* ;. CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Proper Cooking Temperatures for Animal Foods'1'hat are Raw,Undercooked or (6 PRFs Not of Otherwise Processed to Eliminate 3401.11A(1)(2) Eggs- 155'F 15 Sec. Pathogens.* 'eeAv r?OOi Eas-Tmmediaw Service 145'Fl Ssee* 3-302.13 Pasteurircd Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish,Meats&Game Eggs* Animals- 155'F 15 sec. * ' 3-401.11(13)(1)(4) Pork and Beef Roast-130°P 121 non* SPECIAL REQUIREMENTS t 3-401.11(A)(2) Ratites,Injected Meats-155°F t5 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 Poultr'or Ratites-165% IS sec. * above if related to foodborne illness 3-401.1 t(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 165F* Special Requirements. 3-401_11(A)(1)(h) All Other PRFs-145°F 15 sec. ]7 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.14A)MD) PRFs 165'F 15 sec. * (items 23-30) 3-403.11(B) Microwave- 165°F 2 Minute Standing Critical and non-critical violations, which do not relate to the Time' foodborne illness bnervennons and risk factors liated above, can be 3401 11(C) Commercially Processed RTE Food- found in the following.sections of the Food Code rand 105 CMR t401F* 590.000 3-40311(E) Reutaunina Uml(ced Portions of Beef item Good RetailPractices - 590.000 Roasts* _23. Maria amen and Personnel_ FC-2 .003 1g Proper Cooling of PRFs 24. Food and Food Protection _FC-3 .004 ts FC-4 3-' ' r 26. _Mater25. umPlumb nDand'Waste FC 5 ) '005 501.l4(A) Coolies Cooked I HNs frorn 140'F io -0 P 1.006---__.._. 70`F Within 2 Hours and From 70°F 27. Physical Facili FC-6 I .007 to 4l'Ft45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 i .008 3-50L14(B) - Cooling PRFs Made From Ambient29. S ©vial R uirements '009 _ Temperature Ingredients to 41'F(45'F 30 ,Other._ _. -- Within 41 fours,'x 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590-00(r i.� CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH g{ 120 WASHINGTON STREET, 4TH FLOOR . 1f SALEM, MA O 1970 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: Wholesale Distrib. Name of Establishment: John DeFrancesco and Sons Address of Establishment: 53 Mason Street Owner's Name: John DeFrancesco Restrictions: Application Date: 12/2/2003 Permit for Food Establishment 71-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT .�` 0(-t:4i'44MDV CITY OF SALEM, MASSACHUSETTBOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 NOV 20 2003 TEL. 978-741-1800 FAX 978-745-0343 CI fY OF SALEM STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT�a &M�'�esC0 Y���"TELT#' t IT ADDRESS OF ESTABLISHMENT S3 lrI ) I MAILING ADDRESS (if different) bnk @--7o SAl'ete'( 14 ni47o -Oa-70 OWNER'S NAME `1 tJrt A MCPS PO TEL# '� ADDRESS CITY STATE ZIP CERTIFIED FOOD 1RANAGER'S NAME/S) , _ CERTIFICATE#(s)___.____ (required in an establishment where potentially hazardous food is prepared.)U EMERGENCY RESPONSE PERSON �)k kD HOME TEL# HOURS OF OPERATION: Mone 3 Tue.(-2) Wed.(-r3Thu.6_3 Fri.�)-,:Sat. 1a Sun. " TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 .0 RESTAURANT YES NO I 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 YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapt r 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best kno dge a eiief, ve I all state tax returns and paid all state ax s re wired under the law. Signatu e S ial Security or Federal Identification Number Rp " Il, ��, Eb--- ----- --- ---- ---- ------------- --- --- - Revise 11/03/ 3 FOODAP2.adm Check#&DategSJ -�///-� ai Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 4t" Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date Typeot Operation(s) T ft Inspection JQ! Gel /1 1 Food Service ® �loutine Address Risk ❑ Retail ❑ Re-inspection Telephone Levels El Residential Kitchen Previous Inspection y *6 5 („i ❑ Mobile Date: Owner HACCP YM ❑ Temporary ❑ Pre-operation } El Caterer El Suspect Illness Person in Charge(PIC) Time EJBed&Breakfast El General Complaint Ins ector In: [_1 HACCP P Out: Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provisions) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT_ "" e ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties EMPLOYEE HEALTH ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS- ❑ 2. Reporting of Diseases by Food Employee and PIC El3. Personnel with Infections Restricted/Excluded El 14.Approved Food or Color Additives FOOD FROM APPROVED SOURCE ' -- ' - - ❑ 15.Toxic Chemicals ❑ 4. Food and Water from Approved Source ; TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements [117. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION'S ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) _I E] 10. Proper Adequate Handwashing E321. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices ;.CONSUMER ADVISORY',-. _< ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board of Health. today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations ,25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 26. Water, Plumbing and Waste (FC-5)(590.006) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: s:sso�nspecrForms 14 d. f Inspector's Signature• Print: PIC's Signature: ] ! / Print: YJ. /1 Page of 2- Pages i Violations Related to Foodborne illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Crass-contamination I590.003(A) Assignment of Responsibility* - 3-302.11(A)(7) Raw ?,nkna7 Fads Separated front 590.003(B) Demonstration of Knowledge' Cooked and RTE Foods* 2-103.17 Person in char e--duties Cc ramination from Raw ingredients 3-30211(.A)(2) Raw Anneal Foods Separated frorn Each EMPLOYEE HEALTH Other' 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporring by food employees anti 3-302.11(4) Food Protection* applicants* 3-302.15 Washin Emits and Veeetab7as 590.003(F) Responsibility Of A Pond Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Repor'ro The Person In Utensils* Charge* Contamination from the Consumer 590.003(6) Re portingb Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food" 3 590.003(D) Exclusions and Restrictions* Disposition ofAdulteratedorContaminated 590.003(5) Removal of Exclusions tinct Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Fhod" L4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance:with Food Law*. 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Tem eratures* 3-201.13 Fluid Milk and Milk Product-s* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Tem eratures* 3-202..4 Eg¢s and Milk Pr+adi cls.Pasteurized'" 4-501.114 Chemical Sanitization-temp„ pH; 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. 5-101.11 Dritil in Water fctxn an A r roved Svstem" 4-601.1 I(A) Equipment Food Contact Surfaces and Utensils Clean 540.006(4) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 510.006(8) 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 Moliuscan 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 e Wato uthorit Game Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms* AMA 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices 5 Receiving/Condition 2-401.11 Latin ,Drinking or Usin Tobacco* 3-203.11 PHFs Received at Pro r Tem eratures* 240112 Discharges From the Eyes, Nose and 3-202.15 Package Integrity, Mouth- 3-101.11 Food Safe and I)naduttera ed'* 3-301.12 Preventing Contamination When Tasting* h Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(5) Preventing Contamination from 3-203.12 Shellstock Identification Maintained" Em Io�es" Tags/Records:Fish Products 13 Handwash Facilities ' 3-402.11 Parasite Destrnctiott* Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-20111 Numbers and Ci aclties*-,F...� 5)O 004(J) Labeling of Ingredients' S-204.11 fAration and Placement* 7 Conformance with Approved Procedures 5-a-.05.11 Accessiblhty. O rerurion and Maintenanec /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 S eciatizrd Processing Methals* Devices 3-502.12 Reduced oxygen packa'ing.criteria* 6-301.11 Handwashine Cleanser,Availability 8-103.12 Conformance with Approved Procedure's" 6-3(11.12 Hand Drving Provision 'Denotes critical item in itte Ueral 1999 Faxl Code or 105 CMR 590.600. CITY OF SALEM BOARD OF HEALTH Establishment Name:j Ok",jrteg-e,) Date: /"/20/o4 Page: Z of Z Item Code C-Critical Item DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date No. Reference R-Red Item Verified PLEASE PRINT CLEARLY .- f LO ✓t7 f*J u!vft 1 r.J f eX-d-d It . () OrM'Mie 41ZY1-LM e,,aQgC 6_1` 011i 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. ,Q I C� /M—ic� L3( /J 1�? A� Voluntary Disposal ❑ Other: v 3-501.14(()­ PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to taw Cooled tc Factors(items 1-22) (Cont.) 41'F/45`F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 v Food or Color Additives 19 PHF Hot and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below 3 202.12 Addtuves`" - 590.004(F) 41°/45° F^ 3-302.14 Protection from Unapproved Addibvzs* 3-501.16(A) Her PHFs Maintained at or above 15 Poisonous or Toxic Substances 140'F. 7-101.11 Identif}ging Information-Original 3-501.16(A) Roasts Held at or above 150°17. Containers 7-102.11 Common Name-Working Containers' 20 Time as a Public Health Control 7-201.11 Separation-Storaae" 3-501.-19 Time as a Public Health Control* 7-202.11 Restriction-PresznceandUse* 590.004(}1) Variance Requirement. 7-202.12 Conditions of Usc* U E RQIREMENTS FOR HIGHLY SUSCEPTIBLE 7.203.1.1 Toxic Containers-Prohibitions* REQUIREMENTS LA NS(HSP)7-204.11 Sanitizers,Criteria-Chemicals* - 7-204.12 Chemicals for W ashiuc Produce,Criteria* 21 3-801.11(A) Unpastounzed Pre-packaged Juices and Beverages with W arnme I tbcls* 7-204.14 Dr m E ems,C.ritetia* 3-801.11(}3) Use of Pasteurized F �,s* 7-205.11 Incidental Food Cont act.Lubricants* - Raw or Partially Calked Animal Food and 7-206.1.1. Restricted Use Pesticides.Criteria* Raw Seed Sprouts Not Served. 7-206.12 Rodent Bait Stations* 3-801.II(C) UnolpenedFociPackaa eNotRe-served. 7-206.13 Tracking Powders,Pest Control and Monivama-* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.1 I Consumer Advisory Posted for Consumption of lfi Proper Cooking Temperatures for Animal Foods'fhat are Raw.Undercooked or PRFs Not Otherwise Processed to Eliminate 3-401-11 A(l)(2) Eggs- 155'F 15 Sec. 1'atho<ens a Enecov room Eggs-Invocclirte Service 145'Fl5sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2,) Comminuted Fish,Meats V Game G es* Animals-155'F 15 sec. * 3-401.11(13)(1)(2) Pork and Beef Roast- 130'1- 121 mita SPECIAL REQUIREMENTS _ 3-401.11(13)(2) Ratites,Injected Meats-155'2 15 590.009(A)-(D) Violations of Section 590.009(A)-(U)in sec.* catering,mobile food, temporuy and 3-401.]1(A)(3) Poultry,Wild Game, StuffedPFiFs, residential kitchen operations should be Stuffing Containing Fish, Meat, debited under tate 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 v'iolat'ions relating to good retail. 3-401.12 Raw Animal Foods Crooked in a practices should be debited under/#29- Micaowave 165'F* Special Requirements. 3-401.1I(A)(1)(b) All Other PHFs-145'F'15 sea try Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(]--)) PHFs 165'F 15 sea := (Items 23-30) 3-403.11(B) Microwave- 165'F 2 Montle Standing, Critical and non-critical vlohrtions, which do not relate to the Tinterfoodborne illness interventions mrd iiskfactors listed above, canoe 3-403.11(() Commercially Processed RTF.Food- found in the followuig sections of the Food Code and 105 CMR 14(CF* 590-000. 3-403.11(E) Remaining UnslicedPortions ofBeef Item GOOdRetailPractices _ FC 590.000 Roasts* 23. Marra oment 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 3-501.14(13) Cooling Cooked PHFs from 140°F m pg Water,Plumbing and Waste FC 5 70°F Within 2 Flours and From 70'F 27. Ph skal Facility__ FC-6 .607 to 41'F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29- S eaial R uiremeMs _ 009 Temperature lugredientsto41`F/45'1` _30. _Other _ -�- Within4Hours* mr J"' "Denotes m'itical hent in the l vlend 1999 Food Code or 105 CKIk 5901)00. i f Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street, 4'" Floor Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name - Date Type of Operationfs) T e s �, ection %I O M � = A� �S t-31 d ) L/ ' t ❑ F d Service outine Address q A44 S0 ^ Risk etail ❑ Re-inspection Telephone Level ❑ Residential Kitchen Previous Inspection 7 v 3 a c 3 ❑ Mobile Date: Owner ^ HACCP YM El Temporary ElPre-operation U 071 r( Crsj/✓CSC J ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) S-V 'AIS Time ❑ Bed&Breakfast ❑ General Complaint El HACCP Inspectorp �r,�lEMr3 V7> Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. .FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties EMPLOYEE HEALTH El 13. Handwash Facilities - PROTECTION FROM CHEMICALS - ❑ 2. Reporting of Diseases by Food Employee and PIC El3. Personnel with Infections Restricted/Excluded El 14.Approved Food or Color Additives - FOOD FROM APPROVED SOURCE El 15.Toxic Chemicals - ' TIME/TEMPERATURE.CONTROLS - ' ❑ 4. Food and Water from Approved Source (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 t ❑ 8. Separation/Segregation/Protection [120.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP), ❑ 10. Proper Adequate Handwashing E]21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices e:CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions (j immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): 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 ofCHeaNh. 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 26. Water, Plumbing and Waste (FC-5)(590.006) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S 14 d. Inspector's Si a �j �, -Wint: ' PIC's Signatur : - Print: 1 Pagel Off Pages Violations Related to Foodborne illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 I 590.003(A) I AssigjrmeTit of Responsibility* 3-302.11(A)(1) Raw Animal Foods Separated from 590.003(B} 1 ,Dentonstiation of Knowledge* Cooked and RTE Foods* 2 103.11. Person to charge-duties Contamination from Raw Ingredients 3-302.11(.x)(2) Raw Annual Foods Separated from Each EMPLOYEE HEALTH Other- 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(x1) Food Protection* applicants* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge" Contamination from the Consumer 590.003((1) Re ortrn b Persoa in Oharge* 3-306.14(A)(B) Returned Food and Reservice,of Fcod* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(F) Removal of Exclusions and Res fictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Fes* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law'r� 4-501.111 Manual Warewashing-Hot Water 3-201.1.2 Food in a Hermeticall•Scaled Container* Sanitization Temperatures' 3-201..13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-HotWater 3-202.13 Shell E� s* Sanitization Temperatures* 3-202.14 E <>>s and Milk Products.Pasteurized* 4501.114 Chemical Sanitization-temp.,pH, concentration and hardness. 3-202.16 Ice Made From Potable Drinkin.-Water* 5-101.11 DrinkingWater frtmt an A .roved S stem* 4-(i01.1't(A) Equipment Food Contact Surfaces and Utensils Cleats* 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 Reereadonal'ly Caught Molluscan ,Food Contact Surfaces of E ui mens* 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 Re ulatoAuthorit 2-301.11 Clean Condition-Hands and Anns* 3-202.18 Shellstocls Identification Present* 2-301.12 Cleanim,Procedure* 590.004(0) Wild Mushrooms* r 2-301.14 When to Wash* 3-201.17 (lame Animals* I I.t Good Hygienic Practices 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco" 3-202.11. PHFs Received at Proper Temperatures* 2-401,12 Discharges From the Byes, Nose and 3-202.15 Package htte it=* Mouth* 3-101.11 Food Safe and Unadulterated F 3-301,12 Preventing Contamination When'lastm--* 6 Tags/Records:Shelistock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers acid Capacities* 590.004(1) Labeling of Ingredients` 5-204.11 Location and Placement* � Conformance with Approved Procedures 5-205.11 Accessibilit 1.Operation and Maintenance tHACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced oxygen rackaLtng, criteria* 6-301.11 Handwashin Clemrser,Availability 8403.12 Conformance with Approved Procedures* 6-301.12 Hand Dm*Provision '*Denotes critical item in the.federal 1999 foal Code or 105 CMR 590.000- - CITY OF SALEM BOARD OF HEALTH Establishment Name: J oxkr Date: ! ' o`/ Page: Z— of Z Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified n PLEASE PRINT.CLEARLY a 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/Fe�eral Food Code, I andstand that noncompliance may result in daily fine of t e y ' e doll rs %pension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 0 Voluntary Disposal ❑ Other: `�..•-Jti.,....h^r..r�+•-rw'+rn+T-•r'rFrn'.rvI`r'."'r.�'(•fY..'n•"'.,vra-r!y.�......'!•a.�s+.-•` +R:..^+r�.-.:•.,.'Mr..•�s�r.....Ja a+'y'1I^.'1,.���� 3-501.14(() PRFs Received at'remperatures Violations Related to Foodborne illness Interventions and Risk According to I nw Cowled to Factors(items 1.22) (Cont.) 41`F/45`F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 CoolingMethWs'for PHFs PHF Hot and Cold Holding Food or Color Additives 19 14 3-501.16(8) Cold PRFs Maintained at or below 3-202.12 Additives" 590.004(F) 41°/45'F` 3-302.14 Protection foam this roved Additives* 3-501.16(A) Her MIR Maintained at or above 15 Poisonous or Toxic Substances 14WF. 7-101.11 Identifying,Information-Oris nal 3-501.16(A) Roasts Held at or above 1.30'F. Containers" 20 Time as a Public Health Control 7-..102.11 Cotmnon Name-Working Containers* 3-50I.19 Time as a Public Health Contra('` 7-201.11 Separation-Stora e" 7-202.11 Restriction-Presence and Use'" 590.064(H) Variance Rec uirement 7-202.12 Conditions of Ilse* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-263.11 Toxic Containers-Prohibitions` POPULATIONS(HSP) 7-204.11 Sanrozers,Criteria Chemicals -- 7-204.12 Chemicals for Washin=Produce,Criteria"" 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drvinn Agents.Criteria* Beverages with Warning-L.abzis* 3-SO1.11(B) Use of Pasteurized E*as* 7-265.1.1 Incidental Food Contact,Lubricants* 3_g(I I 'l l(D) Raw or Pmtially Cooked Animal F<ad and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served. 7-206.12 1 Rodent Bait Stations* 3-801.11(() Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY _ TIME/TEMPERATURE CONTROLS 22 3-603.11 Consurner Advisors 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- 1-55'F15See Padto ens' F. ""' inonr Eggs-Into edi ate Servi ce 11 sOF I Slee* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 7401 A I tA)(2) Comminuted Fish.Meats&Game Eggs! Animals- 155'F 15 sec. SPECIAL REQUIREMENTS 3-401..11(11)(1)(2) Pork and Beef Roast- 130'F 121.min 3-40LlI(A)('2). Ramos,hyected Meats- t55'F 1S 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 Fisb,Meat. debited under the appropriate sections Poultry or Ratites-165°F 15 sec. above if retated to foodborne illness 3401.1 l(C)(3) Whole-muscle,Intact Beet Steaks interventions and risk factors. Cather 145`F oc 590.009 violations relating to good retail 3-40L12 Raw Anhnal Foods Cooked in a practices should be debited under#29- Miciowave 165`F'* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs- 145'F 15 sec 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3.403.11(A)&(D) P1IFs 165F 15 sec. * (Items 23-30) 3-403.11(B) Microwave- 165'F 2 Minute Standing Critical and non-criticai violations, which do not relate to the Time* foodborne illness interventions and risk{actors listen above, can be 3-403.1I(C) Commercially Processed RTE Fail- found in the folloning sections of the Food Code and 105 CMR 14017* 590.000. 3-403.1.1(E) Remaining Unsliced Portions of Beef Item Good Retail Practices FC 590.000 23. Management FC 2 .003 Roasts"` 25 E24 1 oqu�ipmnednt atlnUtens Is Anel_ I_FC 4 .005 18 FC 3 .004 Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from FlWFt'o 26 Water.Plumbing and Waste FC 5 .006 70'F Within 2 Hours and From 70'F 27. Physical Facial IFC-6 .007 to 41°F/4501-Within 4 Hours.* 28Poisonous or Toxic Materials IFC-7 .008 3-501.14(8) Cooling PHFs Made From Ambient29. Special Requirements _ -- .009 - * Temperature Ingredients t'a41'F145'F 30. Other _ _� ___-------- Within _�Within 4 Hours* ` """'2d'. *Denotes critical item in the Federal 1999 FoW Code or 105 0411590.000. ca CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH f 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 ,�oiy TEL. 978-741-1 800 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 : John DeFrancesco Name of Establishment : John DeFrancesco & Sons Address of Establishment : 53 Mason Street Type of Establishment : Wholesale Distrib . Application Date : 12/19/2002 Restrictions : Permit for Food Establishment 108-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2003 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. / - . Y HEALTH AGENT BOARD OF H°mir CITY OF SALEM. MASSACHUSETTS � �FlLTf�I . 120 MASHIN ON STRFFT. -0rH .(ta SQL, MA 01970 GSL 1 lJ /" � YrnveW 1 :378-7-11 190r F,%. 978-7<45-030:' ..i" w. LEM STANLEY USC>Vi,C;. Jr. _ B(7,rw�EI7 �."'F HEALTH ,7 9ehTT. Nt P7-1- R�;. C'."7 hinroi'z , hi�ni ni n.r,eo-n 2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT 1 NAME OF ESTABLISHMENT 74 ZKa `JakN :)3 rjRP, CeSCIS Ct N EL#_ ADDRESS OF ESTABLISHMENT SpTJ MAILING ADDRESS (if different) OWNER'S NAME O6rwl IV6Al,J(,'PSCC7 TEL# t aq,3' 3 ADDRESS BOY a`10 � CIT'("s p _ STATE -4 7_1P— CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) i (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON �2 A),��jA&)C�-M HOME TEL# 'fit f 3 HOURS OF OPERATION: Mon.'4ai3 Tue.V Wed.L/Thu. `/ Fri.f Sat.&-1aSun._,_ ' TYPE OF ESTABLISHMENT FEE check only RETAIC STORE }r. BYES A NO less than 60sq'.ft. =$ 50 a a e ' e ;,.y1040 10,004sq ft.`: =$100 . eru _' ._ �`�' � � 1S4�1J0' j w more than 10 OOOsq.ft. =$250 v3 RESTAURANT YES NO ) 08 less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NPN-PROFIT(such as church kitchens) YES NO $25 Please pay total with one chesk 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. Punkn t to la pt ction 49A, I certify under the pains and penalties of perjury that I, to my bewI g dbell , h e filed all state lax returns and paid all state taxes re uir under the law. ignat a Date Social Security or Federal Identification Number ------ --------------------------------------------------------------------------------------- ------------------------ Rev ed 11/25/02 FOODAP2.adm Check#&DateSL�CJ�- �