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DERBY DELI - ESTABLISHMENTS DERBY DELI 245 DERBY STREET u _. a � � 5 �,� t,�- 2s�► l .._ .� u �� i i t _ _ _ ....--- —_._--- ._._.._ _..,... _.._ __ .. ___... ..._..w..__..___.�.� �a . - __.—._.._. __. � _... _. .,_. ____ . ._.._.._._. _ � ._____ - II e �� 0 it 3 Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/06/2011 ESTABLISHMENT NAME: Derby D"eG Inc. File Number:BHF-2004-000153 245 Derby Street Salem MA 01970 LOCATED AT: 0245 DERBY STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2011-0242 Jan 1,2011 Dec 31,2011 $280.00 ESTABLISHMENT Total Fees: $280.00 PERMIT EXPIRES IDecember3l, 2011 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4r"FLOOR TEL. (978) 741-1800 KIIbtBERLEY DRISCOLL FAx(978) 745-0343 NfAYOR DGREENBAUNI&ALEM.CONI DAVID GREENBAUII,RS ACTING HEALTH AGENT 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT perky Deli Tn� TEL 'I q/- Z V(IZ- ADDRESS OF ES T ABL2HfviENT LIS 9<-rNY T�- FAX# /✓/19 MAILING ADDRESS(if different) 24S II y. y S-)- 2,-A6.,l i Inn 0/970 EMAIL-Business': ` / NSA Website: 1111AOWNER'SNAME VO.Ss,koST2 k�S nn TEL#090321- N2-2— ADDRESS 10 �SMOVA Y 4 NA"U' la I n1 q UZ 1q(g STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) �/Q.SS I'QS I2,V7ei CERTIFICATE#(S) 63V6U12 (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL 32 1. 1 ZZ :DAY50F,OPERATION Monday Tuesday. "':Wednesday Thursday '; R,Friday;a , I :,Saturday ;): ==,•Suntlayv.;rl HOURS OF OPERATION 1 Please write in time of day. „ A I For example 11am-11 IAIM 1G�Y�A +—lA✓4i IQdt— IAK /�] J 4M' Am /�j .— lam 174,, 1Ar� ' /Qt —10n TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 ----------------------------.................. - - ----- -----------------------------------------.......................................................------ RESTAURANT YES N0 less than 25 seats =$140 _ /Ofddoor Stationary Food Ca^.$21 25-99 seats 80 more than 99 seats = 420 --------------------------------------------------------------------------------------------------------------------------------------------------------------- BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES/NURSING HOME --6b-1----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that 1,to my best knowledge and belief,have filed all state tax res and paid II state%quired under the law.12-212610/ u O 2Z/2010 Signature Date Social Security or Federal Identification Number Revised 10/7/11 FOODAP201 Ladm — Check#&Date S2U 230-P, .� L.-i..s.F.AT✓kti+7'}....a.7Y.r.R'~<d�.�1C2`Tr?-w.r�+�,.+5rr�'Rf.lrf..TU.�Ti'Ue`rw5 ('`71y,naF "4N S�IP"NQ...f.Y'.I. .Y4rRlhf,?ati�...,+W'57�..rtrf !d M,1y A,ra. V Massachusetts Department of Public Health Salem Board of Health 120 Washington Sreet, Division of Food and Drugs Salem, MA 01970-t35230 Floor FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name Date ` T e of O eration s Tvpe of Inspection Qn� � �� ( ) Food Service gRoutine Address A �$ Risk ❑ Retail LJ Re-inspection 4A / Xr L " `Q Level ❑ Residential Kitchen Previous Inspection Telephone /lu r 1 ;, ( ' ❑ Mobile Date: C El Temporary ElPre-operationOwner\ �� _ 1 ( �� rte` D�� HACCP Y/N El Caterer El Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ElGeneral Complaint �i1 0) /Vl QA In:9:1O�I IM El HACCP Inspector Y )4) �\F C� J A Out: Permit No. �p v ❑ 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)r©.. 590.009(F) action as determined by the Board of Health. I FOODPROTECTIONMANAOpEMENT, „ Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 590.003(A) Assignment of Responsibility* 3-302.11(A)(]) Raw Animal Foals Separated from 590.003(B) Demonstration of Knowledge* - Cooked and RTE Foods* 2-103.11 Penson in charge duties Contamination from Raw ingredients 3-302.1.1(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* a plicants'` 3-302.15 Washin Fruits and Ve etables 590.003(F) Responsibility Of A Foot Employee Or An 3-304.11. Food Contact with Equipment and - Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) Reportingg by Person in Charge* 3-306.14(A)(B) Returned Food and Resecvice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 _ Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically 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* 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanifi/.ation-temp_,PH, 3-202.16 Ice Made From Potable Drinking Water" concentration and hardness.* 5-101.I.1 Drinking Water from an Approved System- 4-601..1'I(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food- Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Lasted Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatoryffgulafory Authority 2-301.,11 Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(0) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* Il Good Hygienic Practices Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.1.2 Discharges From the Eyes, Nose and 3-202.15 Package Integrity* Mouth* 3101.11Food Safe and Unadulterated 3-301. g 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 3-203.12 Shellstock Identification Maintained` Em lovees* 13 Handwash Facilities Tags(Records:Fish Products 3402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacifies* 590,0040) Labeling of Ingredients 5-204.11 Location and Placement* g Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance lHACCP Pians Supplied with Soap and Hand Drying 3-502.11 S ecialized Processing Methods* Devices 3-502.1.2 Reduced oxygen acka 'ng.criteria* 6-301.11 Hardiwashing Cleanser,Availability 8-103.12 Conformance with A roved Procedures* 6-301.12 Hand Drying Provision °Denotes critical item in the federal 1999 food Code or 105 CMIZ 590.000. - S CITY OF SALEM i BOARD OF HEALTH 3 Establishment Name: Date:. Page: of ; nem Code C–Critical Item `' DESCRIPTION OF VIOLATION/PLAN OF CORRECTION _ Date t No. Reference R–Red Item , it Verified ( PLEASE PRINT CLEARLY TiV1n p.S l2th G.� I1– ne,r�^_ rte. (� ry i N lk s I I ��. '� •. ^.i IT 1., /%�n,�.�.�� J��/'A/ 'I�1_I't ,.♦'.rte: 17�,� f 0 . 01� � 1r G 1 I `G.tG w ' UCrTYY 1� 4��".0�)�t't 010% /n.. .lP/n.. N(n.�n Ilan. r']l/No. �,i/I..YAe�/„ • , N (;.f' e, ,.nn- �. 11 , ..i . O 1104 V2 rv* Inan �(Qa �) nowO_ /-1 / ”/nn/'�./ �,. . n., )"`51 �00/�' V'71° nn t _. . ` r\ 14.14.lJi(, (T a-4 � '5 — .�/11n, I { n I^n ..�l;,n ,�,E� �,I/lo/_U/�rig/1 1' 41 AA QV_,�.c`l l�_0 �,(G7�� (0/1l 11+CA.vV a:1 0/ 2 v... \. Gyn),�1.�1�1 (0 { Q ..�•.l(i1 ��.�i n..n/� �/^, t'1!e i i, V v iA A\ �� t k r, � �•,-/ ,, a„-{', �''K' I) �/`4t�/.4v'I., ."t {IIJt v�!"f'^� _ //i/7 '� �� i.^.1Q-( P rn .l/l,r�� r_-17!'O A4a ).�- J nl ow fa�r� l - 1� P�(�(.4 i P of - �n ,v f-r- � ) / / 1 Ok'rAA/ Ui. Discussion With Person in Charger /�, Corrective Action Required: ❑ No al Yes Voluntary Compliance ❑ Employee Restriction/ I have read this report, have had the opportunity to ask questions and agree to correct all I Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that i noncompliance may result in daily fines of twenty-five dollars or suspe lion/revocation of ❑ Embargo ❑ Emergency Closure �your food permit. ��/ `_ s �� ❑ Voluntary Disposal ❑ Other: F 3-501.14(0) PHFs Received at Teniperatures Vlotations Rolafad to Foodborne Illness interventions end Risk According to LawCooled to Factors(items 1.22) (Cont) 41"F/4.5`F Within 4 Howl. * _ PROTECTION FROM CHEMICALS 3-5(11.15 Cooling,Methods for PHFs -- 14 PHF Hot and Gold Holding Iq FoodColor Additives 3-501.16(B) Cold PHF,Maintained at or below 3-2(72.12_ Additives* 540.004(F) 410/450 F' _ 3-302.14 Protection from Unapproved Additives* z_yf;i 16(:A) Ilnt PHF y Mauitauted at or aFu+ve 15 Poisonous or Toxic Substances 7-101.11 Identifying Information -Original 140" F.z t'amm zet s' i ill 16th) M Rutsts Held at or above 13P'h 7 102 11 Common�;tme Rinkia;T C ru tip r:" + �0 I Time as a Public Health Control — + 241.1 �arSrtrgU+O'Ii(k1 ,9i �_� �mc acr P�ubefiurucN+neeautrth Control, 7 2021keruc6oll uw- L r - � iiape2c - 7.202.12 C_ondiuon,of Use' 7-203 11 Toxic C ont tm,i Prohibition ' REOUIREMENTS FOR HIGHLY SUSCEPTIBLE 204.11 Sanroret, Criteria Chcmic++ POPULATIONS(HSP) - 7204.12 _ Chejw +k for hi Cntrira"' F2t ;- o111t 17 (inp leutrcd trepactaged 7utce,c arzd 7-704.14 Drying At uta.<rlt1u e e lfevvratrra,Willi %Ya11111111 laWW _ �4 KtU I1(F3+ Us ut Pu umvcd 1 - O5.11 Incrd uta( F and r unto" 1 dii+cants'. .- 7206_I 1 R,e ou.i d U,ec Pe rycrdt .Crirai+ ----'� F $l't iI III)) k�tn r rPaiital, t'+ait.(d 4mnnai Foca`and -- — — _ R t Sc ( Slip ut�'tic 4r>,c i i l+uc ns _._ .,.. .. 1 i + ';t l 1+`t Ln +hc t id trax3 Ptr -.i. V< R+ senei!. 7 JG.1_ Rcxlcni 0+�t t 206.13 Ira nn.,P019er f_:,Cowio! and `'-.--- -- ---�-- --- - -- -----.--� CONSUMER ADVISORY _ T1MElTFtRPERATURE CONTROLS 22 3 )03 11 1 (ka sunt t Ar r scar% iloslod for f onunnption of ----r---- i .t u,l + v*1 trial +r !a k. C.nderws�ked c + 16 Proper Cooking Temperatures for i \nt Ofllc r cc 3'm , i PHFs � � i , u _Elolanarr t1+ 1+i + - i1tE t1SSr _. _ F e mtned+ate s r ict t 5`F]5^ec, + .f.', F �tez rn I t s€ Sl,hsw-fQi-Raw Shelf 401,1 At(,.. i Curnm;iri .ed rich; 14eu „ (,,alit iai kis 1 5 ` 0 ♦ . _f SPECIAL REQUIREMENTS _ t .�+}1.11 .1�r. ,4.at}o`d(Ai. r7t--t--117 l-_ u) St'•csts s }Ci.Cx}jAe ilia rtn+ , lr.i.c yr Art ais- t 51 '1(_ ea erinz nattily t xaL tenporai ti and 4pk.I7r/r, a) { i' tilt( \k+Id t,an Sm1 YHC�� [ � + "Calc; rat t S itctrut c)i z r-allots socxda Ikr 1 Su f4 w Con an m f to 4+ .t, ( i 1y11 tl)d'r flrc npprc miatc ser 1;O115 tt . u7lit r >.; r' 1I~i-z' +r tr t,tl�'ir iJ'-k4?aCx.'?k .Iz _J> 3-401A &. . r zCCst + s ,.r `?i,_Yr' s:-u:Jb rcla,,wz 1" _. R ,+ tm;to Hot Holding, VIOLATIONS REE -A?GU T,0 C"OOD RETAIL. ^.HACT!C,E, (Items 23-30) --40'.11 iii �.- rtt..0 n_�.- 16.'F v %bulli+" Standing I C'++t ,r.rl r r r <11, I !u' ( exure"rteitte a fa,lit 'i,o1, c1:=ud,i eelir' 03.E1iC) liar" ial} Po.,c,ca; R EEFtaq wt'dii;luj r >k a„se;..m 1 iudC"deand 14, ,_+dl{ F3-403,11(1':3 I12cmmng Lu Lred Pht..s of lfie,'� 17Fem F < oad Rats Practices P£ 54D.tt(h7t - .. 1�last � Maria yeine t t'G Pt r tai ' FY; 7 130-1 ` L(g�_____�_..._� Proper Cooling of PHFs_ _ x.21 F ,)o t d ax1 P 0 t ,, .. cC a O('4 I � '-5ii1.14M) �CsKdin+ C.xt}, dP}l(':- r xr i ;i Flo ( �2b Ruipr+en anu,iJteos + _ f�._ 1 ( - �� Water % bi q arzf VIJe _ FC-5 Ot,6 _ i 7 r 1 1Vdhirt T 11ou ane Fn m rG'i p + � l / F`+ • �E`d to _ FC_ 6 J`r 4 How-' 23 pos nous ot mic t er , , i PC 7 1 i-SOL I4I81 ( ti ht PFIR %1 der tont Ambient _.' RC3 r + Comps rawta it rest cu;',to4J 114i-1, + - -te T ' Commonwealth of Massachusetts ,.r City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED;, 01/04/2010 ESTABLISHMENT NAME: Derby Deli Inc. File Number:BHF-2004-000153 245 Derby Street Salem MA 01970 LOCATED AT: 0245 DERBY STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions I Notes FOOD SERVICE BNP-2010-0060 Jan 4,2010 Dec 31,2010 $280.00 ESTABLISHMENT Total Fees: $280.00 PERMIT EXPIRES December 31,2010 Board of Health l This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS • BOARD OF HEALTH -120 WASHINGTON STREET,4`FLOOR"— TEL. (978) 741-1800 KIMBERL EY DRISCOLL FAX(978) 745-0343 �Fc r MAYOR DGREENUAUM@SALEM.COM, U ` 9 DAVID GREENBAUM, ACTING HEALTH AGENT 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT ViPTAO DA TEL#0 q 9 ) r/4//-?VV ADDRESS OF ESTABLISHMENT �v FAX# W4 MAILING ADDRESS(if different) SAYAA> EMAIL- Business': A/& Website: y� OWNER'S NAME V a,SS l I,DS Tir TEL#(199 '3 J- I SZZ ADDRESS 10 `)23m6;,,A a 02Itd STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) VASSII os �Zt�9.7? CERTIFICATE#(S) 63G; (Required in an establishment where potentially hazardous fo di prepared) EMERGENCY RESPONSE PERSON T�Nt.S -51INaa 1 HOME TEL#69Q72/49-22, �DAY$`OPQP,ERATION , -+` Mpntla r 4" Tuesday, aNed'n_estlay ' Thursdaymw`_!,.' F,rldayRWSaturday -`;Sunday HOURS OF OPERATION ! Please write in time of d ay. il� _ 1 For example 11am-11pm '� —1' lip ) cII qN�-1 i /•r-�7 MSI / Wt I1p iiI TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 1 0,000sq.ft. =$420 ------------------------------------------�21---- ----------- ---------------------------------------------------------------------------------------------------- RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart0 seat ore than 99 seats = ------------------------------------------------------------------------------------------------------------------------------------------------------------------ BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES/NURSING HOME - ------------ ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 'Please pay total with one check payable to the City of 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 MGLapter 62C, ion 49A, I certify under the pain and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns an aid state taxes re fired under the law. Signature Date Social Security or Federal Identification Number. ----------------------------------- ----------------------------- Revised 424/07FOODAP2008.adm Check#&Date 9 93 $' 0� Commonwealth of Massachusetts c e City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/30/2008 ESTABLISHMENT NAME- Derby Deli Inc. File Number:BHF-2004-000153 245 Derby Street Salem MA 01970 LOCATED AT: 0245 DERBY STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE 131-!P-2009-0297 Dec 30,2008 Dec 31,2009 $280.00 ESTABLISHMENT Total Fees: $280.00 PERMIT EXPIRES December 31,2009 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS • BOARD OF HEALTH 120 WASHINGTON STREET,4:'FLOOR TEL. (978) 741-1800 KUvIBERLEY DRISCOLL FAx(978) 745-0343 MAYOR )DIONNL'e SALEw.COM JANET DIONNE, ACTING HEALTH AGENT 2009 APPLICATION �FOR I PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT �py 1 /1 t -.Tx c- TEL# 14I -2 LI ADDRESS OF ESTABL!SH:^ENTZ ` US D-e�1y FAX# N MAILING ADDRESS(if different) �Awt 2 EMAIL-Business': N1� Website: k14 OWNER'S NAMES SS; I i ds' —F2-'k kASpp TEL#�TT S 17 32 I– �82Z- ADDRESS 10 (�mo A A N M d he,-, ll1 K� U 2 1 L/ STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) VilAs5'i i 03 '72%'Vo�s CERTIFICATE#(S) 3L/01S 13 (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON T2v e. S 4-0, HOME TEL# (T91 3Z I• S?Z2 DAYS OF OPERATION ='Monday +'.J "' Tuesday = I r-Wednesda ! ?; Thursda v ' s Frida Saturdayz Sunda HOURS OF OPERATION Please verde in time of day i 4 7 , For exampe 11 am-11 pm19 A -M'�_A QFi_ Qw1 AN`�l{r•1. Aix— ver; qnr ' _ A+ti Ah" TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 ----------------------------------- - - --- ------ RESTAURANT ES NO less than 25 seats = (Outdoor Stationary Food Cart$2 0 99 set ="280 more fl an 99 seats =$420 BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES ---------------------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 "Please pay total with one check payable to the City of 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 ChaP)er 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 aid all s taxes required unhar the law. !Z9— 13t) -it) s?&, Signature �� Date Social Security or Federal Identification Number ------------------------------------------------ -------— -- ------ '----------------------- Revised 424/07 FOODAP2008.adm Check#&Date A 00 l/ 0245 Derby Street Derby Deli Inc. City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: j FOOD PROTECTION MANAGEMENT 741-2442 PIC Assigned/Knowledgeable/Duties PASS RED Owner: I Non-compliance with: Vassilios Tzikas Ann-Choking PASS PIC: Vassilios Tzikos Tobacco PASS Inspector: John Gehan EMPLOYEE HEALTH Date Inspected:Correct By: I Reporting of Diseases by Food Employee and PIC PASS RED 2/22/2007 Personnel with Infections Restricted/Excluded PASS RED Risk Level: FOOD FROM APPROVED SOURCE Permit Number: Food and Water from Approved Source PASS ❑d RED BHP-2007-0188 I Receiving/Condition PASS / RED Status: i 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 OU 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. Feb 22,2007 ) Page 1 of Item Status Violation Critical Urgency RED: PROTECTION FROM CONTAMINATION Violations Related to Separation/Segregation/Protection PASSd❑ RED Foodborne Illness Interventions and Risk Factors (Require Food Contact Surfaces Cleaning and Sanitizing PASS ❑d RED immediate corrective action) Proper Adequate Handwashing PASS RED Good Hygienic Practices PASS 0 RED Prevention of Contamination from Hands PASS 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) Cooking Temperatures PASS RED Reheating PASS ❑J RED Cooling PASS 0 RED Hot and Cold Holding PASSd❑ RED Time As a Public Health Control PASS ❑d RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food and Food Preparation for HSP PASS ❑d 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®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 22,2007 ) 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 Comments:general cleaning of continental unit required. Thermometer missing from white freezer. Provide visible and accurate thermometer. 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 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. Feb 22,2007 ) Page 3 of y ' l Commonwealth of Massachusetts City of Salem s Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Foo"etail Establishment Permit DATE PRINTED: 01/08/2008 ESTABLISHMENT NAME: Derby Deli Inc. File Number:BHF-2004-000153 245 Derby Street Salem MA 01970 LOCATED AT: 0245 DERBY STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2008-0292 Jan 7,2008 Dec 31,2008 $280.00 ESTABLISHMENT Total Fees: $280.00 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 9 of 11 �. v QTY OF SALEM, MASSACE IUSEM y 1)'' /re BOARD OF HEALTH 120 WASHINGTONSTREET,4 FLOOR, sn - - - _- TEL. (978) 741-1800- KIMBERLEY DRISCOLL FAX(978) , 0343 dr�° MAYOR ISCOTTOSAtEM COM -- - NOV �O JOANNE SooTT, I? HEALTH AGENT & r �>FN kFM 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLIS�H/MENT NAME OF ESTABLISHMENT 'Ve \"6V Vim`` I ( Tvv� TEL# q 7 1 Lt 1-24A/2— ADDRESS OF ESTABLISHMENT � FAX# MAILING ADDRESS(if different) same r+ EMAIL-Business': Website: Al OWNER'S NAME S i }}kaS TEL# ( T) 321 ' 1<922- ADDRESS 10 Q eA(W Q –4 M i o 2 l y g STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) V0.SS1 Irl S L 2\V�as CERTIFICATE#(S) "3 (Required in an establishment where potentially hazardous food is prepared) - EMERGENCY RESPONSE PERSON TQ(eS4-0, T2A 14A_S HOME,TEL# (w0 3L I^ 1 R,2Z-DAYS OF OPERATION 1 Monday Tuesday Wednesday Thursday Friday Saturday Sunda HOURS OF OPERATION �/ Please ample lla 11prnof Will., - flM �/ M— l 1 7 II 1� For exam le 11am-11 m 1 rr � . �1}pn" aM 1 l� �/�nti 1}1''1 �'Nf IRM pn1� 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 RESTAURANTSvEsNO les an 25 seats -$140 (Outdoor Stationary Food Cart 2 - 9 seats _ X80 re an 99 seats 20 -------------------------.....----------------------------------------------------------..--------...------------..........---------------------------- BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES -------------------- ---------. -------------------------------------- -------------- ITI ---- ADDONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 'Please pay total with one check payable to the City of 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,Sect n 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 ate taxes requ' � under the law. F 1 y -3 D S?b' Signature Date Social Security or Federal Identification Number --------------- --------------------- -------------- --------------- --------------------- Revised 4/24/07 FOODAP2008.adm ChcckN&Date S '7 1D ao CITY OF SALEM, MASSACHUSETTS BOARD OFHEALTH DECEIVE® 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 DEC - 4 2006 FAX 978-745-0343 CITY o SALEM wWW.SALEM.COM " Kimberley Driscoll JOANNE SCOTT, MPH, RS, GHO BOARD OF HEALTH Mayor HEALTH AGENT 2007 APPLICATIO FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT DO-16V V� 1t 7=v. TEL# 0`7 2 '7V1- 24/c/2, ADDRESS OF ESTABLISHMENT '2W51' US U44_1 / S FAX# r MAILING ADDRESS(if different) ElAA;L-Eusu.ess r t Owner's: F r, OWNER'S NAMEyQt SIlIQS" llT2iKl� nth TEL# 2-1- If X22- ADDRESS l0 Ven ftil O " e� V d N t�e','7 M 0 L 1 V?5 STREET zip CITY STATE *� y CERTIFIED FOOD MANAGER'S NAME(S) Vt Ck%s i/i0 S TZk� CERTIFICATE#(S) � ✓/ (Required in an establishment where potentially hazardous food is prepared) —� EMERGENCY RESPONSE PERSON Tejy-tz S t -� ( f ) HOME TEL# SCS 0_32 1• I S 2�Z-- OATS Of OPERATION Monday _ Tuesday Wednesday Thursday Friday Saturday Sunday HOURS Of OPERATION �ry Please write to time of day. �� A0 3Un `� "g `-li?pM �.{�• M�tti,;,, �A t,., -(��r c7�iw; ��,� [For examplettam-1/ami 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 ES NO less than 25 se.. ats $1 25-99 seats more than 99 seats = 200 BEDlBREAK_A __-......YE5 _._NO .._........_.. $...1.0. fl..._...........__..._.._......._... !) C� + ........... ..... _...._... ..._ r!. ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVENO $5 CYES TOBACCO VENDOR NO 50 ALL NON-PROFIT(such as church kitchens) YES NO S25 `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 pians 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 beiwf. have filed all st to tax return and paid all state to es r cared under the taw- / / fg� 11 tC��o . Signature ate Sociai Security or Federal Identification Number Y - - -------------- ------ - - - - - -- - - Revised 11713106 FOODAR2007.aern Check#&Daie--............... .... .. . ..... ..... . �� k r. w .ik.H � i: ♦z' n• �" iW� �i "Tip" ' { ; ��Cth s a 6usettys ��c'.w � }"!f"w City of Salem 3 �`�.d fic" t � '�x '",'.Ni.4^ ^9 'INFJ BoBCdr FGmlieliey 1 120 Wash�ugton Street,4th Floor r ,. M -^ ':'39 �r�`=:q' 1aa°sw..'� ..t ��f SALEM,MA 0197.0 Food/Retail Establishment Permit DATE PRINTED: 12/20/2006 ESTABLISHMENT NAME: Derby Deli Inc. File Number:BHF-2004000153 245 Derby Street Salem MA 01970 LOCATED AT: 0245 DERBY STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2007-0188 Dec 20,2006 Dec 31,2007 $150.00 ESTABLISHMENT TOBACCO VENDOR BHP-2007-0202 Dec 20,2006 Dec 31,2007 $50.00 Total Fees: $200.00 PERMIT EXPIRES December 31, 2007 Board of Health L 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 5 of 18 � F 11Y'¢i S° cs,Nk 'u' £.y is � ��-cam X :COURf000KET NO m^ ibNO. _O a O rm i. + } ORATION NO CITY OF"SALEM � VIOLATION NOIICE� E OAST,RBST IN ;..,,, ITIAL) ' ^eY- � �' s- ' - � � n%F�STREETADDRESS CITVROWN ' STATE ZIP I .n i-� � - (A .n,2l.r-� .�_ W1 _ Ol.�j. ON EP.DATE DATE OFSITN IF _41 LICE S t" rY^'uV, d_ �7� _ - - ._ - ❑ — c ._ '; rn d 7 3 1 to 7 _ OWN - - - - rry _ burnt('a(ei m s9W = STREETADDRESS CurrOWN .STATE - ZIP iS 7er1. SI Sala rA Vv\A of t7o = mif REGISTRATION NO. STATE EXP.DATE MAKEI YPE I YEAR COLOR • _ _ - ._ -- O O r DATE P F(VII TION TIME ,/ DANE` RATIO R/TEN P sRur�uL y/�] U6 II OOD PM /�z.� O v LJ YES w NO ❑ LOCATION OF VIOLATION - EN��p RCINGD'EPT. — 2 a OE{ENSE - CHAP. SECT. FINES an ACEf EA` VIOZ A 710 >•u SQA%E a0 v ZZ � ''i r ze _> .. Rin ES A/3[is yA167�r . 961. 11 Y-o C.4c, p m _ C ❑ . OFFICj''ER/ I.D.NO. TOTAL @@ O(✓ O 9 r-lelLL IL FINEDUE $ /OO. � OF ICER CERTIFIES COPY GIVEN TO VIOLATOR OIT m X / ❑ IN HAND fri,( BY MAIL \ D D DO NOTMAILCASH-PAY ONLY BY POSTALSTAL NOT Z ORDER OR BY CHECK MADE PAYABLE TO: f°0 CITY CLERK CRY HAIL 93 WASHINGTON STREET - - SALEM,MA)707970 TEL.(5081745-9595%251 1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE PAYMENT IN THE AMOUNT OF s} $ CASE# J O SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION I. o .: ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL ! rn 0 Security Features Included. Detailsonback. 0245 Derby Street Derby Deli Inc. City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 741-2442 Equipment and Utensils FAIL BLUE Owner: Comment: No sanitizing log available at time of inspection. Log to be maintained daily. Vassilios Tzikas PIC: Continental Freezer has no visible thermometer. Provide thermometer. Vassilios Tzikos Inspector: I GENERAL COMMENTS: John Gehan 866:AII violations unless noted have been corrected from 9/25/2006 Date Inspected:Correct By: 9/25/2006 Risk Level: Permit Number: BHP-2006-0053 Status: SIGNED OFF #of Critical Violations: 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®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Oct 04,2006 ) Page I oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Oct 04,2006 ) Page 2 oft CITY OF SALEM BOARD OF HEALTH Name of Establishment: Derby Deli Address: 245 Derby Street Owner(s): Vassilios Tzikas Phone: 978-741-2442 Date: June 26, 2006 The owner of this establishment presented a revised Floor Plan and Menu, for added grill and fryolator, for review in accordance with the State Food Code. FLOOR PLAN There will be a fryolator, grill and burners added in area on the left side of the establishment when entering. MENU/FOOD PREP The owner proposes adding beef, chicken and Iamb kabobs to the menu. UNDERCOOKED FOODS There must be an asterisk and advisory on the menu regarding undercooked foods. The wording and the model brochure were given to the owner. The proposed change in floor plan and change in menu have been approved. Jc&Fne Scott Date Health Agent Owner Date uO"Aa was wash 1 S�hk Stak-Aiess5w Sov\��IZe cou }ev^ S� nkS L - 0E ILJ � pfe P `T461e 0 0 O A F('eZZe�f Re�Yi�ev�o�R�-r�gera�f DERBY DELI CAFE&GRILL SALEM ALL ORDERS AVAILABLE FOR TAKE OUT TEL ( 978 ) 741-2442 FAX ( 978 } 741-2442 245 DERBY STREET SALEM MA 01970 MONDAY-SATURDAY 10:30AM-16PM OPEN SUNDAYS 12NOON-8PM S�1 ALJ Q w cc l F- S HOT SANDWICHES HOT SUBS ( panini style) (lean shaved steak sandwiches ) CHICKEN PROVOLONE Grilled chicken breast, PLAIN STEAK...................................................$ 4.50 provolone cheese,pesto spread,field greens and tomatoes on toasted he focaccia bread $ 5.50 STEAK&CHEESE.............................................$ 4.99 TURKEY BACON SWISS Smoked Turkey, Swiss cheese, crisp bacon,honey Dijon spread, STEAK&ONIONS ..............................................$ 4.99 mayonnaise,field greens and tomatoes on toasted herb focaccia bread $ 5.50 STEAK&MUSHROOMS ..................................$ 4.99 SWISS CHICKEN Grilled chicken breast, Swiss cheese,Honey Dijon spread, field greens and (Add $ .50 for any 2 combo $1.00 for any 3combo) tomatoes on toasted herb focaccia bread $ 5.50 CHICKEN MOZZARELLA Grilled chicken breast, HOT VEGETERIAN Served with grilled fresh mozzarella cheese, pesto spread,field greens mushrooms,onions, green bell peppers and and roasted peppers on toasted herb focaccia bread .American cheese on subroll $ 4.99 $ 5.50 COLD SANDWICHES SPECIAL SANDWICHES SMOKED TURKEY Smoked turkey served with lettuce, tomatoes, mayonnaise$4.75 GYRO SPECIAL Strips of beef served with lettuce, ROAST BEEF Roast beef served with lettuce, onions,tomatoes, parsley, and Tzatziki spread in tomatoes, mayonnaise $ 4.95 pita bread $ 5.50 TUNA SALAD White meat tuna salad served with lettuce and tomatoes $ 4.75 CHICKEN GYRO Grilled chicken breast, served CHICKEN SALAD White meat chicken salad with lettuce,tomatoes,onions,parsley, and Tzatziki served with lettuce and tomatoes $ 4.75 spread in pita bread $ 5.50 FRESH MOZZARELLA&TOMATOES Fresh mozzarella cheese, pesto spread, field greens, tomatoes, sprinkled with olive oil and basil on French baguette bread $ 4.75 LUNCH SPECIALS FROM THE GRILL (French baguette,Sliced Wheat/White or Wraps) ( one skewer kabob) GRILLED CHICKEN CAESAR WRAP Romaine lettuce, Parmesan cheese, and Caesar dressing$ 6.25 BEEF KABOB One skewer kabob grilled with onions and green bell peppers served with rice, and GREEK SALAD W/CHICKEN IN WRAP Lettuce, pita bread $ 6.99 tomatoes, Feta cheese and Greek dressing $ 6.25 CHICKEN KABOB One skewer kabob grilled with VEGETERIAN WRAP Fresh tabouleh made with onions and green bell peppers served with rice, and tomatoes, onions, peppers,scallions, parsley,,bulgar pita bread $ 6.99 wheat, lemon juice,and olive oil with home made homus spread $ 4.50. LAMB KABOB One skewer kabob grilled with onions and green bell peppers served with rice, and pita bread $ 6.99 j DINNERS SALADS DINNERS FROM THE GRILL (served w/pita bread) (two skewers) 'k GREEK SALAD BEEF KABOB Two skewers kabob grilled with r Crisp romaine lettuce, cucumbers,shredded red - onions, and green bell peppers,served with rice, cabbage, green bell peppers, black olives,and Feta fresh vegetables and a small salad on the side$ 10.50 4 cheese,with Greek dressing$ 5.25 CHICKEN KABOB Two skewers kabob grilled GREEK SALAD WITH CHICKEN with onions,and green bell peppers,served with Grilled chicken breast over Greek salad $ 6.50 rice,fresh vegetables and a small salad on the side$ I 10.50 CAESAR SALAD LAMB KABOB Two skewers kabob grilled with Crisp romaine lettuce, fresh baked croutons, onions,and green bell peppers,served with rice, shredded Parmesan cheese, and creamy Caesar fresh vegetables and a small salad on the side$ 10.50 dressing$ 5.25 CAESAR SALAD WITH CHICKEN GRILLED CHICKEN BREAST Grilled chicken Grilled chicken breast over Caesar salad $ 6.50 breast served with rice, fresh vegetables and small salad on the side$ 8.50 GARDENSALAD Crisp romaine lettuce,cucumbers,shredded red Cabbage, carrots,green bell peppers,and black FISH olives $ 4.75 SWORDFISH KABOB One skewer kabob grilled CHICKEN SALAD{ OVER GARDEN SALAD) with onions, green bell peppers,served with rice, White meat chicken salad,served over crisp fresh vegetables and a small salad on the side$ 12.95 romaine lettuce,tomatoes,cucumbers,shredded red cabbage, green bell peppers, and black olives$ 5.50 SURF & TURF TUNA SALAD ( OVER GARDEN SALAD) BEEF KABOB One skewer beef kabob and One skewer Shrimp kabob served with rice,fresh White meat tuna salad, served over crisp romaine vegetables and a small salad on the side$ 13.50 lettuce, tomatoes, cucumbers,shredded red cabbage, green bell peppers,and black olives $ 5.50 CHICKEN KABOB One skewer kabob and One skewer Shrimp kabob served with rice,fresh vegetables and a small salad on the side$ 13.50 BEVERAGES Soda.........$ 1.45 Juice........$ 1.45 (preparation time for grilled items 10 to 20 minutes ) Consuming raw'or undercooked nUats,poultry,seafood,shellfish,or eggs may increase your risk of foodborne Illness, especially if you hove certain medical condition All prices aro subject to 5%meal tax, r Large Format Box # 21 - 2l0 Doc # Image # 2 IM `NL -DATA 0245 Derby Street Derby Deli Inc. City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: FOOD PROTECTION MANAGEMENT 741-2442 PIC Assigned/Knowledgeable/Duties PASS ❑J RED Owner Non-compliance with: Vassilios Tzikas Anti-Choking PASS PIC: Vassilios Tzikos Tobacco PASS Inspector: John GehanEMPLOYEE HEALTH Date Inspected: COrr2Ct By: . Reporting of Diseases by Food Employee and PIC PASS ❑J RED 3/23/2006 Personnel with Infections Restricted/Excluded PASS ] RED Risk Level: - FOOD FROM APPROVED SOURCE Permit Number: - Food and Water from Approved Source PASS ❑d RED BHP-2006-0053 Receiving/Condition PASS ❑D RED Status: `Open _ Tags/Records/Accuracy of Ingredient Statements PASS ❑Q RED #Of Critical Violations: Conformance with Approved Procedures/HACCP Plans PASS ❑d RED 3 Time IN:. TimesOUT Urgency Description(s): BLUE: Violations Related to Good- Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeOTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 23,2006 ) Page I of Item Status Violation Critical Urgency RED: PROTECTION FROM CONTAMINATION Violations Related t0 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 RED Good Hygienic Practices PASS RED Prevention of Contamination from Hands PASS RED Handwash Facilities FAIL Non-Critical 0 RED _ Comments: Handwash sink requires"hand wash only"sign. Provide sign in visible area. PROTECTION FROM CHEMICALS Approved Food or Color Additives PASS ❑d RED Toxic Chemicals PASS RED TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) Cooking Temperatures PASS ❑Q RED Reheating PASS Q RED Cooling PASS 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 0 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. Mar 23,2006 ) Page 2 of Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and Food Protection FAIL Critical BLUE Comments:Soup thawing at room temperature. All thawing foods must be tawed in refrigerator at 41'F or otherwise as food code mandates. Equipment and Utensils FAIL Critical BLUE ,Coffinents: Continental refrigerator requires general cleaning. /Icce�e scoop stored incorrecty. Scoop must be stored with handle up in order to prevent contamination. ,i m,es stored between bars on rack. Knives must be stored correctly in appropriate holder. 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: 535: 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. Mar 23,2006 ) Page 3 of "'8`L;'(?e". "7�4YisrneR.aAt'a....,;.sre=aa..,,�>.si��'�'ir�+Sr ha.,*w +t r•y�,'}pd+a.'aitl±i�nn , , tv swJ'a"' '" '� Yyh 1w�'atr ,� ;� Commonwealth of Massachusetts ? ' :Yi4 " City of Salem ., . Board of Health 120 Washington Street,4th Floor sr SALEM,MA 01970 41 V 1 14 Food/Retail Establishment Permit DATE PRINTED: 01/02/2006 WHO'S PLACE OF BUSINESS IS: Derby Deli Inc. File Number:BHF-2004-0153 245 Derby Street Salem MA 01970 LOCATED AT: 0245 DERBY STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires. Fee Restrictions/Notes FOOD SERVICE BHP-2006-0053 Jan 2,2006 Dec 31,2006 $150.00 ESTABLISHMENT TOBACCO VENDOR BHP-2006-0054 Jan 2,2006 Dec 31,2006 $50.00 Total Fees: $200.00 PERMIT EXPIRES December 31, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements, or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 21 of 26 1 CITY OF SALEM, MASSACHUSETTS s ;y BOARD OF HEALTH ( 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 0N6 TEL. 978-741-1800 ry � /n STANLEY J. 11SOVICZ, .JR. FAx 978-745-0343 78 745 0ZOo 343 - C,/ O�L D yy , �' MAYOR JOANNE SCOTT, MPH, RS, CHO - `" �O,c _ HEALTH AGENT __. _._ O,�`S'�GF y��N 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Derby -D e- ll —1t1C TEL /# 97$- 7W- 241clZ ADDRESS OF ESTABLISHMENT 2 U S �-e-Yw $t dQ . rng 01970 MAILING ADDRESS (if different) Q A�YI OWNER'SNAME VNSSIlinS 2 11i�QS 11 TEL rlSl 321- 187-2- ADDRESS �MOKa �d CITY STATE ZIP 0 CERTIFIED FOOD MANAGER'S NAME(S) w s3111's) '772-t>-r CERTIFICATE#(s) 3 23 6- (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON \/0,S->i'N) `C'Z� HOME TEL# 7$1-32/•/ �32Z HOURS OF OPERATION: Mon.7-(OTue.7- lOWed.7-(oThu.7- /o Fri.17- toSat.7-(o Sun. 7-10 TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 - ........... NT - ........................... ............... . . .... ............-- . ............. -- .......... RESTAURAES NO less than 25 seats =$100 25-99 seats = 15 more than 99 seats =$200 ------------------------------------------------------------------------------ ..------------ BED/BREAKFAST YES NO $100 - ------------------------------------------------------------------------------.........----------------------------------- ADDITIONAL PERMITS VAKE_(not just_serve) ICE CREAM YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR] 3%-O(0 <:yg!D NO 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/piled all state tax r turns and paid all state taxes required under the law. !2 3 0 �-13r�30 g Signature ate Social Security or Federal Identification Number - -- - ----------- --- ---------- - - -- - ----- ------------------ -- ---------------------------------------- --- -- Revised 11/03/05 FOODAP2.adm Check#&Date Z`3�g lR2 f eS CITY OF SALEM, MASSACHUSETTS • : BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 _ -OJ STANLEY J. USOVICZ, JR. FAX 978-745-0343 MAYOR W W W SALEM.COM JOANNE SCOTT, MPH, RS, CHO I September 21, 2005 HEALTH AGENT Derby Deli 26 Congress Street Salem, MA 01970 Dear Owner: On Tuesday August 23,2005 personnel from the Tobacco Control Program conducted a compliance check to determine if your permitted establishment would sell a tobacco product to a minor. A 17-year-old female purchased cigarettes from a clerk in your store. Documentation is now on file at the Board of Health regarding that sale. Derby Deli is in violation of Section 111(A)of the Salem Board of Health Regulation Affecting the Purchasing of Tobacco Products. According to this section, the sale of cigarettes, chewing tobacco,snuff,or any tobacco in any of its forms to any person under the age of eighteen shall be punished by a fine of(One Hundred Dollar fine)for the First offense. FOLLOWING THE THIRD(3RD)OFFENSE,THE BOARD MAY CONSIDER POSSIBLE REVOCATION OR SUSPENSION OF THE PERMIT. The North Shore Tobacco Control Program and the Salem Board of Health have worked with you and your employees to demonstrate methods to ensure compliance with this regulation. Therefore, you are ordered to pay a fine of$100.00 for the violation stated above. A check or money order payable to the City of Salem must be at the Board of Health office, 120 Washington Street,4th floor,within ten days of receipt of this notice. Should you be aggrieved by this Order,you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven (7) days of receipt of this Order. At said hearing, you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports,orders, and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. If you have any questions regarding this notification please call me at 741-1800. Sinc rely yours, anne Stott �� Health Agent JS/mfp CERTIFIED MAIL: 7003 3110 0005 1992 1943 cc. North Shore Tobacco Control Program Christina Harrington, Board of Health Chairman and Members s< DERBYDELI INC. 2273 ✓ /N /""6 245 DERBY STRET SALEM,MA.019 D 5-701712110 DATE .$� as (I•,a, ._DOLLARS f 'V CITIZENS BANK ' Maxmcbusects . i1' 02273u' 1 0 . 2 l i0 70 L 7 5o. l i 3 746496 5u' y vtc • »v4 ra Fli vl v "?�" - CITY OF SALEM9 MASSACHUSETTS BOARD OF HEALTH _ 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 .� TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Derby Deli Inc. Address of Establishment: 245 Derby Street Owner's Name: Vassilios Tzikas Restrictions: Application Date: 11/29/2004 Permit for Food Establishment 86-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 24-05 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 Boar�th. HEALTH AGENT • CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH A&104e 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO e �1HOFS. MAYOR HEALTH AGENT OF(Yg1FM 2005 APPLICATION FOR P RjMIT/TO OPERATE A FOOD ESTABLISHMENT 7Fq�'�/y NAME OF ESTABLISHMENT Dp�ty V�/lt ADDRESS OF ESTABLISHMENT 2(/S DA/yl, S?' lircA�2 M# 01`yj2 MAILING ADDRESS (if different) OWNER'S NAME VGRSSIIIQS _T_Zii TEL Z ADDRESSY4 CITY—b Q 2 n STATE Nl k1 ZIP C 2 I g Z CERTIFIED FOOD MANAGER'S NAME(S) VASsr l/e1 -T i k&S CERTIFICATE#(s) 3U93736 (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSONT- 2je. � � TZ HOURS OF OPERATION: Mon?(6 Tue.?-(0 Wed.7-(OThu. -(C! Fri.?-(CSatr/-N Sun.12- /6 TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than I000sq.ft. =$ 50 1000-10,000sq.ft. =$100 r �lj more than 10,000sq.ft. =$250 RESTAURANTYE NO `bl9 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 YES NO $5 TOBACCO VENDOR aq-05 � NO (22 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. SignatureDat Social Secun or Federal Identification Number `� � °-}�-- 4�8-1 - 730-s'-c---------------------- Revised 11/03/03 FOODAP2.adm Check#&Date ' 0245 Derby Street Derby Deli Inc. City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Telephone: Item Status Violation Critical Urgency Nature of problem or correction 741-2442 Non-compliance with: Not Done Owner: 4 Anti-Choking PASS ❑ Vassilios Tzikas Tobacco PASS ❑ PIC: - Vassilios Tzikos FOOD PROTECTION MANAGEMENT Not Done Inspector: PIC Assigned/Knowledgeable/Duties PASS RED David Greenbaum EMPLOYEE HEALTH Not Done _ Date Inspected: Correct By: Reporting of Diseases by Food Employee and PIC PASS RED 4/13/2005 .. Personnel with Infections Restricted/Excluded PASS 0 RED Risk Level: <' FOOD FROM APPROVED SOURCE Not Done Permit Number: Food and Water from Approved Source PASS RED BHP-2005-0166 Receiving/Condition PASS ❑v RED 'Status: " Tags/Records/Accuracy of Ingredient Statements PASS 0 RED SIGNED OFF #of Critical Violations: Conformance with Approved Procedures/HACCP PASS ❑J RED Plans 1 - - PROTECTION FROM CONTAMINATION Not Done Time IN: Time OUT: Separation/Segregation/Protection PASSd❑ RED Notes:- Food Contact Surfaces Cleaning and Sanitizing FAIL Critical RED Cutting board is stained and scored. 92: Resurface or replace cutting board. : 4 ;r * x, Proper Adequate Handwashing PASS ❑d RED Urgency Description(s): Good Hygienic Practices PASS RED BLUE: Violations Related to Good Prevention of Contamination from Hands PASS RED Retail Practices (Critical Handwash Facilities PASS RED violations must be corrected immediately or within 10 days)(Non-critical violations GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Apr 13,2005 ) Page 1 oft 0245 Derby Street Derby Deli Inc. must be corrected Immediately PROTECTION FROM CHEMICALS Not Done or,within 90 days) Approved Food or Color Additives PASSd❑ RED RED: Violations Related to Toxic Chemicals PASS RED Foodborne Illness Interventions TIME/TEMPERATURE CONTROLS(Potentially Haz Not Done and Risk Factors (Require.'' Cooking Temperatures PASS ❑Q RED immediate corrective action) Reheating PASS RED Cooling PASS Q RED Hot and Cold Holding PASS ❑d RED Time As a Public Health Control PASS ❑d RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP PASS ❑d RED CONSUMER ADVISORY Not Done Posting of Consumer Advisories PASS ❑d RED Violations Related to Good Retail Practices (Blue Not Done Management and Personnel PASS ❑ BLUE Food and Food Protection PASS ❑ BLUE Equipment and Utensils PASS ❑ BLUE Water, Plumbing and Waste FAIL Non-Critical ❑ BLUE Repair ladies room toilet immediately. Physical Facility PASS ❑ BLUE Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other-See Notes PASS ❑ BLUE Board of Health will notify owner if proposed location for ice machine is approved. d GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Apr 13,2005 ) Page 2 oft CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH • 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 ' FAX 978-745-0343 STANLEY LISOVICZ, 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 : Vassilios Tzikas Name of Establishment : Derby Deli Inc . Address of Establishment : 245 Derby Street Type of Establishment : RETAIL FOOD Application Date : 04/02/2003 Restrictions: Permit for Food Establishment 281-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products. 62-03 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. �fJ-t�11.��,✓ HEALTH AGENT a CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH • 120 WASHINGTON STREET, 4TH FLOOR sE - 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 P-C-7'W y l/2I T c TEL#OrIW)'7 U1 -2L(4Z ADDRESS OF ESTABLISHMENT Z LI S Dey-piv S ) MAILING ADDRESS (if different) >Q ,nA-e— OWNER'S NAME VOASSdtos TliiL&s l TEL# 7g �2�-1922- ADDRESS 10 D2�tvlo,.,A. Y a CITY MaPAQA STATE MY} ZIP UZII( $? CERTIFIED FOOD MANAGER'S NAME(S) '91 )uv,m 4osV,Au14x CERTIFICATE#(s) '3c97?'Z/ (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON T2,(2sJA T2tky.0 HOME TEL# 7B1 321—(fiZZ HOURS OF OPERATION: Mon.'&-- Tue.rF 10 Wed.` -1010 Thu.1?p-to Fri&LILSat.yi•-lo Sun.1, - 9 TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1000sq.ft. -$ 50 - 1000-10,000sq.ft. 7 more than 10,000sq.ft. $ RESTAURANTYES NO �.63 less than 25 seats *=$20 25-99 seats more than 99 seats BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVE YES NO //-- ,p3 $5 TOBACCO VENDOR YE NO V°� 50 0/ O ALL NON-PROFIT(such as church kitchens) YES NO $25 PleasePaY 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 , --Dat Social Security or Federal Identification Number Revised 11/25/02 FOODAP2.adm Chedc#&Date 100 3Z'%/? ort,5Q. ._-'.".-.-.-- .,.... .�.,r--...-.�.....�-�.•�..:..-..+-..r- ..�»-.n....-....--..............�.�r�,�,...�4�e;M�"we��%ar+�r`^.'.''^..1.- -..--r^..-.-..--.zr�.,:..-...c-.a..:.--.-.- 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 D to Typg Qf r i n T f In i n Food Service Routine Address 'l S- Risk ❑ Retail ❑ Re-inspection 9' Level ,�// El Residential Kitchen Previous Inspection Telephone _ //f �� '/`� ❑ Mobile Date: OwnerHACCP Y/N ❑ Temporary ElPre-operation \ \ \ �Z -- ❑ Caterer ❑ Suspect Illness Person In Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In: ❑ HACCP InspectorC�} 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 (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 EJ2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS EJ3. Personnel with Infections Restricted/ Excluded ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE El 4. Food and Water from Approved Source TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) El 16. Cooking Temperatures 1:15. Receiving/Condition El6. Tags/ Records/Accuracy of Ingredient Statements El 17. Reheating El7. 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 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)(590.006) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: Inspector's Signature: Priq: ell PIC's Signature / Print:`.- Page/ofPages FORM 734A HOBBS&WARREN - BOSTON i Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION 8Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 1j 590.003(A) Assignment nment of Responsibility* Cooked and RTE Foods* H590.003(8) 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 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) I Food Protection* 'e 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 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 `3t 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* P'p gg Concentration and Hardness 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 2-301.11 Clean Condition-Hands and Arms* I2-301.12 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* 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(7) 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 3-502.12Reduced 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. CITY OF SALEM I 6\\ BOARD OF HEALTH �j� Page. of I Establishment Name: �� Date: 9 � Item Code C-Critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R Red Item Verified } PLEASE PRINT CLEARLY t v i \Z <2>C3�� V 7z-__c4 Q�Cz +5 Is q Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes i { I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ 'r violations before the next inspection, to observe all conditions as described, and to Exclusion ❑ 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: s 1 3-501.14(0) PHFs Received at Temperatures Violations Related to Foodborne Illness interventions and Risk Accoi din,to law Cooled to Factors(items 1.22) (Cont.) _ 4'I°F(45`'F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PIIFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-501.16(B) Cold PliFs Maintained at or below 3-202.12 Additives_ 590.004(F) 41°(45°F" 3-302.14 Protection frorttUnat roved Additives' 3-501.16(A) Hot PHFs Maintained at rn-above L15- Poisonous or Toxic Substances �, 140°1_,. 7-101.11 Identit'.ing Information-Original 3-501.16(A) Roasts Held at or above 130'F. Containers* 20 Time as a Public Health Control --T-102 11 Common Name-Working Containers* - 7-201.11 Se oration-Stora e* 3-501.19 Time as a Public Fiealffi Cwntol"' 7-202.11 Resmction-PresenceandIJso'' 590.00d(H) VarianceRequirement 7-302.12 Conditions of Use* 7-203.11 1 oxic Containers-Prohibitions"' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Saniti2 rs.Criteria Chetnictlsw POPULATIONS(HSP) 7-204.12 Chemicals for bVashht�Produce. Criteria" 21 3-801.1 I(.4) Unpasteurized Pre-packaged Juices and 7-204.14 DrpiR A tints,Criteria* Beverages with Wanun.Labels* 3-501.1 I(B) Use of Pasteurized E.- 7-205.1.1 Incidental Food Contact,Lubricants'^ 3-801.11(D) Raw or Partially Cooked Animal Foodmid 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served. 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods,That are Raw. Undercooked of PHFs Not Otherwise Processed to Eliminate 3-401.1 1A(i)(2) Eggs- lis°h 17 Sec Pathogens F s Immediate Service 145°Flfisec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Enos 3-401.t I(A)(2) Comminuted Fish.Meats&Came Animals- 155'F 15 sec. * 3-401.11(B)(1)(2) Pork and Beef Roast- 1.30°F 121 mer* SPECIAL REQUIREMENTS 3-401.1 L(A)(2) Ratites, Injeu'ed Meats-155°F 15 590-009(A)-(D) Violations of Section 590.009(A)-(1'))in sec. * catering, mobile load, temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited tinder the appropriate sections P0LdtrV 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 Animal Foods Cooked in a practices should be debited under#29- Mierowave 165`F Special Requirements. 3-401.11(A)(1)(b) All OtherPHFs- 145°F 15 sec. * 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-103.11(A)&(D) PHFs 165'F 15 sec. *` (Items 23-30) 3-403.1](13) Microwave-165°F 2 Minute Standing Critical and non-criocai violations, which do not relate to the Time* ,lbodborne ilbtess interventions and risk factors'listed above, (oil be 3-401.II(C) Commercudly Processed RTE Fond- firand in the following sections of the Food Code and 105 CYVIR 140°F* 590.0(0. _ 3-403.11(E) Remaining Unsliced Portions of Beef Item Good Retail Practices 1 FC 590.0oo Roasts* 23._ Management and Personnel FC-2 .003 1 24. Food and Foal Protection FC-3 004 1=8 Proper Cooling of PHFs 26. Water. Plumbin _ 25. Equipment and Utensils _ FC A 005 3-501.14(A) Cooling Cooked PHFs from 140°C to and Waste -FC 5 006- -�{ 70'F Within 2 Hours and From 70°F 27. Physical Facility i FC-6 .007 to 41°F145°P Within 4Hours, * 28. . Poisonous or Toxic Materials 1 FC-7 ,008 3-501.14(B) Cooling PHFs MadeF'rom Ambient 29. S ectal Requirements .009 Temperature Ingredients to 41°F145°F 30. Within 4 Hours* *Denotes clificat item in the federal 1999 Food Code or IV,CNIR 390.000. CITY OF SALEM ^� BOARD OF HEALTH Establishment Name: Demi LAI V5 A. Date: Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified PLEASE PRINT CLEARLY :. r(l a . r n aecL ' diBs � dwKc O - / a-..( -A�i e-s�r li/ s ,,� gave d rc✓ nor P IF — Al 1 ,9 - !� a ia✓ r ,s sxasf ,e a e d . E�Clta ,. o � ccs i> -4i Gc� r// oC( ur Il. _'2n / . 11 C�c ec. Gc vi i'y�e r r Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all L.3 Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion ❑ 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 0 Other: 3-501.14(2) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk - According to Law Cooled to Factors(items 1-22) (Cont.) _ -it F145"F%Ihm 4 Hours. PROTECTION FROM CHEMICALS 3-50t.15 Coolin Metho s for PHFs 19 Food or Color Additives 19 PHF Hot and Cold Holding ' 3-501.16(13) Cold PHIS Maintained at or below 3-20212 Addinse 590.004(F) 41°/45'F, 3-302.t4 Protection froth Unapproved Additives* 3-501.,-T Poisonous Hot PHFs Maintained at or above Poisonous or Toxic Substances l40`F. * 7-101.11 Identityiug Information-Original 3-501.16(A) Roasts Held at or above 130"F. Containers* 20 7-102.-11 Common Name-Workinn,Containers* Time as a Public Health Control 7-201.1.1 Se.aration-Storage* 3-500.4 Time caPnbHeFIealthControl " 7-20211. Restriction-Presence and Use* 590.004(H) VmianceRuuiroment _ 7-202.12 Conditions of IJse* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Probibitions* POPULATIONS(HSP) 7-204.11 Smuti7ers.Criteria Chemicals* 7-244.12 Chemicals for Washing Produce. Criteria 21 3-801A I(A) Unpasteurized Pre-packaged Juices and Beverages with Wanting Labels* 7-204.14 Diving Agents.Cnterra" 3-501.11(B) Use of Pastem-ized Evers* 7-206.11 Incidental Food Csticid, ,Criteriar' 3-801,111(D) Raw err Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served. "' 7-206.t2 Rodent Bait Stations# 3-80111(C) Unopened Food Package Not Re-serval. 7-206.13 Tracking Powders, Pest Control and Monitoring, CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consmnor Advisory Posted for Consumption of I6 Proper Cooking Temperatures for Animal Foods Twit are Raw. Undercooked or PHFs Not Otherwise Processed to Eliminate 3-4(l1.lLA(1)(2) Eras 155'F15Sec. Pathogens."`.r se:,a m:zooi ltiRs-Immediate Service 14i"FISsa�r 3-302.13 Pasteurized Eggs Substitute for Raw Shell , Comminuted Fish Meats&Game E 3-401.11(4)(2) C. d 9=s* ktitnals- 155'F 15 sec. ' SPECIAL REQUIREMENTS 3-401.1l(B)(1)(2) Poll,and Beef Roast- I30TFt2tmin* 3-401.1 I(A)(2) Ratites,hrjeded Meats- 155'P 15 590.009(A)-(DI Violations of Section 590.009(A){1))in sec * catering,mobile food, temporary and 3-401.11(A)(3) Poulny,Wild Game.Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited ander the appropriate sections Poultry or Rallies-I65'F 15 sec. * above if related to foodborne illness 3-461.1 t(C)(3) Whole-muscle. Intact Bcef Steals 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 1129 - Microwave 1(15°F* Special Requirements. 3401.11(A)(1)(b) All Other PHFs - 145'F 15 see. * I7 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-103.11(A)&(D) PHFs 1650F 15 sec. " (Items 23-30) 3.403.11(B) Microwave- 165'F 2 Minnie Standing Critical and non-crih'cal violations, which do not relate to the Time* foodborne ilhtess interventions and risk,focimss listed above, can be 3-403.11(C) Canntercially Processed RTE Food- found in the following sections of the Food Code and l05 CAIR 14WF* 590.000. 3-401.1.1(E) Remaining Unsliced Portions ofl3cef h Item I Good Retail PracticesFG 590.000 0_23. Management and Personnel FC-2 .003 Roasts* - - -� Ig Proper Cooling of PHFs _P4. Food and Food Protection FC-3 .004 -- e 25 Equipment and Utensils FC 4 ___.005 _ 3-501.14(4) Cooling Cooked PHFs from 140°F to 2� Water Plumbingand Waste FG-5 006 70'F Within 2 Hours and From 70°F 27. Ph sical Facilit I FC-6 .007 to 41'Fl- 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 129 I S ectal Raquirements_ .009 30 Other Tempemtua ingl'adients to 41°F/4SF -• Within 4 Hours* s.wmI,M,�-2 � *Denotes critical iter in the federal 1999 Food Code or 105 CMR e90.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: T Date: 3Z/� Pager of l Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No.. Reference. R—Red Item "' ,. Verified PLEASE PRINT CLEARLY Q ! T f / P, C� / i ar 7 Z02 Urc l: 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 El 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 0 Other: 3-501.1.4(0) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Coaled to Factors(items 1-22) (Cont.) 4'1'F(451F Within 4 Hours. PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs _____ -� to PHF Hot and Cold Holding 13 Food or Color Additives - - 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Additives' 590.004(F) 41'As'F* 3-302.14 Protection from Unapproved Additives'" 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances e 140°E 7-101.11 Identifyinglnt<xination-Original 3-501.16(A) Roasts Held at or above 1.30°F. * Containers* 20 Time as a Public Health Control 7-102.11 Cormnon Name-Working Containers°' 3.501.1.9 Time as a Public. tIealth Control' 7-701.11 Se tuadan-Sola e°` 7-202.11 Restriction-Presence and Use* 5901)04(H) Variance Res uiremenl' 7-202.12 Conditions of Use* 7-203.11 1"oxicContainers-Prohibitions" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Saninzets.Criteiia-Cheirtictk^ POPULATIONS HSP 7-204.1.3 Chemicals for WashingPrcxlnee Criteria* 21 3-801.i.i(A) Unpasteuriztl Pre-packaged Juices and 7-204.14 Diving Agents.Criteria* Beverages with Warning Labels' 7-205.11 Iucideartal Food Contact,Lubricants* 3-801.11(B) Use of Pasteurized Ls* 7-206.11 Restricted Use Pesticides,Criteria* 3-901.1l(D) Raw or Partially Cooked Animal Food and Raw Seed S gouts Not Served. 7-206.1.2 Rodent Bxit Stations* 3-801.11(C) Unopened Food Parka=e Not Re-sarved. - 7-206. Tracking Powders, Pest Control and Monitoring* CONSUMER ADVISORY TIME([EMPERATURE CONTROLS 22 3-603.11 Consumer Ad%isory Posted for Consumption of Animal Focxls That are Raw.Undercooked or 16 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate PHFs Pathosc.ns' Eggs-[mmediatzooi 3-401.11A(1)(2) Eggs- 155^F 15 ate Service 14SFlgsee*Sec. 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell 3101.1 I(A)(2) Comminuted Fish,,Meats&Game 13g rs* 5nimak-155 F l5 sec. * SPECIAL REQUIREMENTS 3-401.11(B)(1)(2) Pork and Beef Roast '13WFt2lrnin* 3-40L I (A)(2) Ratites,Injected Meats- 1.55'F 15 590.009(A)-(1)) Violations of Section 590.009(A)-(D)in sec. catering, mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Game..SmtYed PHFs- residential kitchen operations should be 3tufdebited under the-Irl-n riai: se icss nng Containing Fish,Meat, rc r• i Point[-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 Annual Foods Cooked in a practices should be debited under#29- Microwave 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 3403.1.l(A)&(D) PFIFs 165'F 15 sec. " (Items 23-30) 3-403.1l(B) Microwave- 165'F 2,Minute Standint; Critical and uon-critical violations, which do not relate to the 'Time* foodborne illness interventions and risk faclois listed above, tali be 3-103.11(C) Commercially Processed RTE Food- found in the follorving sections of the Food Code and 105 CMR 140017* 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef Item Good Retail Practices QFC 590.000 nn 24 Ftood and Food Protectanage ion el FC 2 .003 Roasts 1R Proper Cooling of PHFs _ FC S .004 25 Equipment and UtensilsFC 4 _.005 3-501.14(A) Cooling Cooked PHFs from 14WF to 26 i Water Plumbing and Waste FC S .006_ 70'F Within 2 Hours and From 701, 27. - Physic Facilit FG-6 .007 to 41-17(45'F Within 4 Hours *` 28 Poisonous or Toxic Materials FC 7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29 SbeclaiRequirements 009 Temperature Ingredients to 41'F/45'F I K Other _ �- -- ---- ----- Within 4 Hours* *Denotes critical ami in the federal 1999 Food Crate or l0i CMR:190.000. c CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH e e 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Derby Deli Inc. Address of Establishment: 245 Derby Street Owner's Name: Vassilios Tzikas Restrictions: Application Date: 12/4/2003 Permit for Food Establishment 119-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 30-04 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 • , �� e CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR NOV a SALEM, MA 01970 7 2003 TEL. 978-741-1800 FAX 978-745-0343 0 Ld Iq"h1��OF S,-'U-EM STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO BOARD HEALTH MAYOR HEALTH AGENT a 2004 APPLICATION FOR PER{�MIT TO OPERATE A FOOD ESTABLISHMENT { NAME OF ESTABLISHMENT 6'I -[3ZQELl TOC TEL#(ga)1"V1-ZVV2- ADDRESS OF ESTABLISHMENT 24S De4L 019'76 Q MAILING ADDRESS (if different) SeMn p 1 OWNER'SNAME 'Vmssd bs :1 2ikAC TEL#�7S//32)-lR2L ADDRESS__ ,( _ Pi n10 CITY STATE __-_ — --ZIP CERTIFIED FOOD MANAGER'SNAME(S) gSsi�inlziked CERTIFICAT #(s)3(193'73E (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON Vo 55 )i6) TZ: 6,zo HOME TEL r!8 3Z/-/SZZ HOURS OF OPERATION: Mon. .40 Tue. S-/0Wed.`�'-loThu. 7-10 Fri. F-(OSat.F-/0 Sun. S- TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO q less than 1000sq.ft. =$50 �. -1 000s .ft. =� 9 1000 0, 100 Q $ more than 10,000sq.ft. =$250 RESTAURANT NO less than 25 seats ® 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT S VEYES. NO $5 TOBACCO VENDOR <eNO ALL NON-PROFIT(such as church kitchens) YES NO PleaseP Y a 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. Signatures / Date Soc' Sec nor Federal Identification Number ---------------- ---- ------- - 1! _/0 0 3 - 'aQ= r�Sb----------------------- Revised 11/03/03 FOODAP2.adm Check#8 Date Massachusetts (Department of Public Health Salem Board of Health 120 Washington Street,4th Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Dat Type of Operation(s) Mot of Ins ection G&MNG M6�d ❑food Service outine Address AQ7.4y Risk ®'Retail ❑ Re-inspection Telephone Level ❑ Residential Kitchen Previous Inspection S//_2 qq 2 M ❑ Mobile Date: Owner HACCP Y/N ❑ Temporary ❑ Pre-operation U S9 / i[iC J' ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) 57 Time ElBed& Breakfast E] General Complaint Inspector A 6 Out: Permit No. ElOther 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) [_1 action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT,., El 12. Prevention of Contamination from Hands E] 1. PIC Assigned/Knowledgeable/Duties PA13"/Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS' - ❑ 2. Reporting of Diseases by Food Employee and PIC _ .. El3. Personnel with Infections Restricted/Excluded [114.Approved Food or Color Additives ._FOOD FROM APPROVED SOURCE El 15.Toxic Chemicals _ _ _ El 4. Food and Water from Approved Source ' =TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods)' ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding �S'eparation/Segregation/Protection El 20.Time As a Public Health Control Q� FOOd Contact Surfaces Cleaning and Sanitizing ' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP),'' . El 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP .'. El [CONSUMER ADVISORY11. Good Hygienic Practices El22. 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 o7�--Nth. 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)(590.006) 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. maoc 61 Inspector's Signature: � _ „grin[: ,r PIC'-Signature: / Print: t Page! of ages Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT DL Cross-contamination Y I 590.003tA) I -Assignment ofkesponsibility, 3-302.1.1(A)(]) Raw Animal FooclsSeparated from 590.003(B) D_emonchation of Knowledge-- Cooked and RTE Foods* 2-103.11 Person in charge-duties � Contamination from Raw ingredients 3-302.11(A)(2) Raw Animal Fonds Separated from Each EMPLOYEE HEALTH _ Other* 2 59QQ03(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protectionr applicants* 3-302.15 WashineFruits andVeeetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant'I'o Report'fo The Person In Utensils* Char«e* Contamination from the Consumer 590.003(G) Ke ar in by Person in Chas e* 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.003(D) 1 Exclusions and Restrictions* DisposifonofAdulterated orContaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding of Reconditioning Unsafe FOOD FROM APPROVED SOURCE Foul" Food and Water From Regulated Sources F9 Food Contact Surfaces 590.004(A-B) Cam 7liance with Faxl Iaw 4-501.111 Manual Warewashme-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Tenu eratures" 3-201-1i Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13Shelf Eo.s* Smritization Tem eratures* 3-202.1.4 Eg sand Milk Products.Pasteurized'* 4-501..114 Chemical Sarntization-temp.,pH, 3-202.16 Ice Made From Potable Drinkino Water` Equipment F and hardness. 5-101JI I Drinkuu*Water from an A raved Svstent" 4�01.11(A) Equipment Food Contact Surfaces and Utensils Clean* 590.Ot}6(A) Bottled Drinking Water* 4602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.W 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 Cauglut Molluscan Food Contact Surfaces ofF ui menti Shellfish* 4-703,11 Mtahods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Came and Who Mushrooms Approved by Regulatory Authority 2.301.11 Clean Condition-Hands and Arms"` 3-202.18 Shellstock Identification Present* 2-301.12 Cleamw,Procedure* 590.004(C) Wild Mushrooms* 2-301.74 When to Wash* 3-201.17 Game Animals* i l Good Hygienic Practices g ReceivingfCondition 2-401.11 Eating,Di inkin or Using TobaccWc 3-202.11 PHFs Received at rimer' an, eratures* 2101.12 Discharges From the Eyes,Nose and 3-202.15 Package Integrity, Mouth- 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventive Contamination When Tasting* (; Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Ideati'ticatiun* 590.004(5) Preventing Contamination from 3-203.12 Shellstock Identification Maintained'" Employees* Tags/Records:Fish Products 13 Handwash Facilities 3-40211 Parasite Destruction* Conveniently Located and Accessible .' 3-402.12 Records.Creation and Retention* 5-203.11 I Numbers and Ca achieO; 590.004(:1} Labeling of ingredients' 5-204.11 Location and Placamanf* 7 Conformance with Approved Procedures 5-2(15.11 Accessibility.O reration and Mainlenancc IHACCP Plans Suppiied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced oxygen pricka=in«. criteria* 6-301.11 liandwashing Cleanser, Availabifit 5-103.12 Confotrnavice with Approved Procedures" 6-301.12 Hand Dr in,Provision, �'Denotes critical iLLm in the Federal 1999 p(m)d Cole or 105 C'MR 590.000. z CITY OF SALEM BOARD OF HEALTH Establishment Name: QA.RQY 6N-it / /NC Date: 47 y Page: 2 of Z- Item Code C-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item - Verified PLEASE PRINT CLEARLY /3 P_ A1ArVW4X1 S/ d R BB �� 1 PQiEii 4� C I N r J .5'�-er D Sum S C � c�ct�.-�►rfr c!N r ! S �Uf4�D � r2d PrO 6a deo9 15ek yj!ENT- s'3 co at ry Olt( r � rkeAa ar.D�iaalE r✓ � ea d� tOvlse N14 ® !f I i AJ& CaU 64t Qft-4W (2ej s✓0Ci c,4-t V1 OLACY.,fAr . ld�t6 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 ❑ 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 ollars .r uspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: 1 ' / I 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to I.aw Cooled to Factors(Items 1.22) (Cont.) 41`F45'F Within 4 Homs. PROTECTION FROM CHEMICALS3-561.15 Cooiirc�Methods for PHFs Food or Color Additives 19 PHF Hot and Cold Holding 14 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Addurves'r 590.004(F) 41'145° F'^ 3-;702.14 Protection from Unapproved Additives* 3-501.16(A) Ilost PHFs Maintained at or above 15 Poisonous or Toxic Substances 140'F, 7-101.11 Identifying Information-Original Containers* 3-501.16(A) Roasts Held at or above 130130'F.0° 7402.11 Common Name-Working Containers* Zg Time as a Public Health Control 7-201.11 Separation-Storage" 3-701.19 'Time as a Public Health Control* 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Rea at rement 7-2 .12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-?0303.(1 Toxic Containers-Prohibitions'' POPULATIONS(HSP) _ 7-204.11 Sanitizers.Criteria-Chemicals- F-7- 7-204.12 Chemicals for Wr ashing Produce,Ci 21 3-80'11)(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drying Agents.Criteria* Beverages with Warning Labels'* 3-901.,11(B) Use of Pasteurized F os* 7-205.1.1 Incidental Foal Contact Lubricants* 3.901.110) Raw or,Partially Cooked Animal Food and 7-206.'11. Restricted Use Pesticides. Cnterin* Kaw Seed S trouts iilot Served. 'k 7=206.12 Rodent Bait Stations* 3-901_11(C) Unopened Food Package Not Re-served, 7-206.13 Tracking Powders.Pest Control and Monitoring* CONSUMER ADVISORY TIMEfTEMPERATURE CONTROLS ;1-36" 11Consumer Advisory Posted for Consumption of Proper Cooking Temperatures for Animal Foods'That are Raw,Undercooked orPHFs Not Otherwise Processed to Eliminate 3-461L1A(1)(2) Eggs- 155'F15Sec. Pathogens b gs-Immediate Service 145°F15sec= 02.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish,Meats&Game Eggs" Animals-155'F 15 sec.' 3-401.11(13)(1)(2) Pork and Beef Roast-13WF 121 min* SPECIAL REQUIREMENTS _ 3-401.11(A)(2) Ratites,Injected Meats-155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. * catering, mobile food,temporary and 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, residential kitchen operations should be, St'uf'fing Containing Fish, Meat, debited under the appropriate sections Poultr or Ratites-165'P 15 sec. * above if related to foodborne illness 3-101.11(C)(3) Whole-muscle,Intact Beef'Steaks interventions and risk factors. Other 1450F* 590.009 violations relating to good retai't 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165'F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs- 145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.1 I(A)&(D) PHN 165'F IS sec. * (Items 23-30) 3-403.11(&) Microwave- 165'F 2 Minui'e Standing Critical and non-critical violations, which do not relate to the Time" foodborne illness interventions and ruk factors h.olecd above, can be 3-403.11(C) Commercially Processed RTF Food- found in the follm,ing sections of the Food Code and 105 CAM 140°F* 590.00.0. -- 3-403.11(E)� Remaining Uusliced Pardons of Beef Item Good Refaff Practices FC 580.P00 -- Roasts* 23. Matra ement and Personnel FC-2 .003 ----n..__....------- L.lg Proper Cooling of PRFs 24. Food and Food Protection FC-3 .004 20 _ Eguipmeni and Utensils _ FC .005 3-501.14(A) Cooling Cooked PHPs from t40`F to 26Water Plumbic c and Waste FC 5 006 70'F Within 2 hours and From 70".F 27. Ph sic_al FacilitesFG 6 .007 to 41'F/45'F Within 4 Hours. * 28. Polsonovs or Toxic Materials FC- 7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special R uirements ! .009 Temperature Ingredients to 41'F145'F 30, Other Within 4 Hours' 'Denotes critical item in the[*=neral 1999 Food Code or 105 CMR 590.000. ' Salem hoard of Health Massachusetts Department of Pub�fc Health 120 Washington Street,4r^ Floor Division of Food and Drugs 1 * Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT TeL (978) 741-1800 Fax(978)745-0343 Name Date Tvne of Ooerationfs Type of Insoection a - '/'Ve_ 3- 3-OV (✓f] Food Service ❑ Routine AddressS7` Risk ❑ Retail ElRe-inspection a57 Level t El Kitchen Previous Inspection Telephone y �yy Y t ❑ Mobile Date: Owner HACCP YIN ❑ Temporary ❑ Pre-opera ion S ❑ Caterer [ISuspect Illness Person in Charge(PIG) Time ❑ Bed&Breakfast HACCP General Complaint /fMG In: Inspector = P /y out: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, El1 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 .. ❑ 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 [: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 / C immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report, when signed below by a Board of Health member or its agent constitutes an 23. Management and Personnel (Fc-2)(s90.0 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-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.59UInspectl»m6140oc •. ns ector' ign re• / /1Jr �. / ;; Print: PIC's Signature: / �/ Print: Page of Pages t Violations Related to Foodborne Illness interventions and Risk Factors(items 7-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Grass-contamrnaton 1 590.0030) Assi<nment of Responsibrhtv'� 3-302.11(A)(i) Raw Animal Foods Separated from 590.003(B) Demonstration of Know ledge,' Cooked and RTE Foods* 2-103.11 Person in charge-duties Contamination from Raw ingredients 3-302.1.10)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other" 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require repotting by food employees and 3-30".11(A) Food Protection ` a piicants"" 3-302.15 Washing Fruits and Vegetables_ -5u()003(F) Responsibility Of A Food Employee Or An .11 Food Contact with Equipment and App,hcam To Report'ro The Person In Utensils* -Char Contamination frorn the consumer 590.003(G) Re arfrnab Person in Charge` 3-306.14(A)(B) Returned Food and Reseivice of Food* 37 590.003(D) Exclusions and Restrictions* Disposition ofAdulterated or Contaminated 590.003(F,) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCEFood' L4Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Com alian^e with Food Law* 4-501..111 Moroni Warewashin¢-Hot Water 3-201.12 Food in a Hermeticallti Scaled Container* Saninzation'lem reratures* 3-201.13 FluidMilkilk Products* 4-501.112 Mechanical Warewashing-Hot Water Sanitization Tcm cratures" 3-202.13 Shell Faas* 3.202,14 E<>as and Milk Prodnds.Pasteurized* 4-50L114 Chemical Samnzaiion-temp.,pFl, concentration and hardness. ` 3-202.16 Ice Made From Potable Drinkin«Water" 4-601.1 i(A) Equipment Food Contact Surfaces and 5-101.11 .Drinkin Water frrnn an A roved S seem* Utensils Clean* 590.006(A) Bottled Drinkin Water` 4-6(r.11 Cleaning Frequency of Equipment Food- 590.00600 Water Meets Standards in 310 CMR 22.0"` Contact Surfaces and Utensils' Shellfish and Fish From an Approved Source 4-702 0111 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment, Shellfish* 4-703.11 Methods ofSanitization-I-lot Water and 3-201.'15 Molluwan Shellfish from NSSP Listed chemical* Sources' 20 Proper,Adequate Handwashing Caine and Wild Mushrooms Approved by 2-301.1 1. Clean Condition-Hands and Anes* Re Mato Authortt 3-202.18 Sbellstock Identification Present* 2-301.12 Cleatuns Procedure* 590.004(0) Wild Mushrooms* 2-301.14 When to Wash* 3-201.1.7 Game Animals' 11-_1 Good Hygienic Practices g Receiving/Condition 2- 401.11 Eating,Drinking or Using Tobaccoes` 3-202.11 FHFs Received at Yro ger Tem eratnres'k 2-401.12 Discharges From the Eyes, Nose and 3-202-15 Package Lite illy* 1Vtonth* 301 3-201.11. Food Safe and Unadulterated 3- ..12 PreventaiL Contamination When T4 astina` :Shetistock 12 Prevention of Contamination from Hands 6 Tags/Records 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 ShellstockIdentification Maintained" Emaloeees* Tags/Records:Fish Products ]3 Handwash Facilities Conveniently Located and Access;ble 3-402.11 Parasite Destruction* 3-403.12 Records.Creation and Retention* 5203.11 Numbers mid Ca iacities* 590.0040) Labeling of Ingredients' S-204.11 Location and Placement* 9 Conformance with Approved Procedures 5 205.11 Accessibility.Operation and Maintenance /HACCP Pians Supplied with Soap and Hand Drying Devices 3-502.11 S et7atized Processing MedacKls* 6-301.11 Ilandrvashoj Cleanser,Availability . 3-502.12 Reduced oxvaen aekaan',criteria* E;-103.12 Conformancewith o-1) roved Procedures' 6-301,12 HandDryina Pmvisiou *Denotes crib l item in the federal 1999 Food Codc or 105 ChIR 590.000. - CITY OF SALEM BOARD OF HEALTH Establishment Name: �E'/g Z>_-L/ ::tzyc Date: -3- 3-o V Page: of f Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified r J -PLEASE PRINT CLEARLY /J Ne /3a,5A ,c /vk io,Ws a, e2 v %y 9 /3G �' /moi. Al 410rrA r -/, .LdS// LG/ " . Q/S YA-ezW P v , 1 7` dS,4; R ' 1r , i4 tea . a t a -1 rn fs— /i�adPs :/✓ter1i/ ' c�oLi� s�� /✓e�rsiGs z/Sec' J x Slm /v F°a / 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 ❑ Voluntary Compliance ❑ Employee Restriction/ r violations before the next inspection, to observe all conditions as described, and to Exclusion comply with all mandates of the Mass/Federal-Food Code. I and?rstand that Ll Re-inspection Scheduled ❑ Emergency Suspension noncompliance may result in daily fines of twenty-five dollars or .'Lspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. r / . ❑ Voluntary Disposal ❑ Other: i 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.) __ 41°F/45°F Within 4 Haus. PROTECTION FROM CHEMICALS 3-50L15 - Coohne Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-501.16(B) Cold PHFs Maintained at'or below 3-202-12 Additives* 590.004(1`) 41 '/45�F" 3-302.1.4 protection from Unapproved Additives* 3-501.16(A) Hot PHFs Maintained at of above 15 i Poisonous or Toxic Substances 40°P. 7-101.11 identifying Information-Original 3-501.16(A) Roasts Held at or above 130°F. Containers" 7-102.11 Coalition Name-Working Containers" 20 Time as a Public Health Control 7-201.11 Separation-Stora c* 3-501.19 Time as a Public Health Control" 7-202.11 Restriction-Presence mid lase" 59rW04(l1) Variance Re111WC ent 7-202.12 Conditions of Use" 7-203.11 '1'oxicContainers-,Prohibitions"' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Smnihzzrs.Criteria-Chemicals* POPULATIONS(HSP) _ 7-2(14.12 Chemicals for W&shin g Praluce.Criteria* 21. 3-801.11(.x) 1Jnpasteuriaed Pro packaged Juices and 7-204.14 Drvin,,A-ents.Criteria* Beveraees with WarrimAL bels* 7-205.11 incidental Food Contact,Lubricants* se 3-801.11.(B) Uof I>asteurized E�'�'s* 7-206.11 Restricted Use Pesticides,Criteria* 3-801.1 I(D) Raw or Parhally Cooked Animal Food and Raw Seed S nrouts Not Served ' 7-2(16.12 Rodent Bait Stations* 3-801.11(C) IUno coed Food Package Not Re-screed. " 7-206.13 Tracking Powders,Pest Control and Moratoria¢" CONSUMER ADVISORY TIME(TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw,Undercooked or 1G Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate *eR�o+.z rro2mi 3-401.11A(1)(2) Eggs- 155"1`15See, Pathot,•ns. Eggs-Imm diate Service 145°Fl5secc1 3-302.13 Pasteurized Eggs Substitute for Raw Shelf ER, 3-401-1 I(A)(2) Comminuted Fish.Meats&(Jame Animals- 155`F 15 sec. * 3-401.11(B)(1)(2) Pork and Beef Roast-130°F t21 min" SPECIAL REQUIREMENTS 3-101.11(A)(2) R totes,Injected Meats- 155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec * catering, mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Game.Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratii'es-165°F 15 sec. ` above if related to foodborne illness 3-401.11(C)(-,) Whole-muscle,Intact Beef Steals interventions and risk factors. Other 450F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited udder#29- Microwave 165°1`'1 Special Requirements. 3-401A I(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) PHFs 165"F 15 sec. " (Items 23-30) 7403.1 l(B) Microwave- 165°F2 Minute Standing Critical and non-critical violations, evhich do not relate to the Time* foodborne illness iruervenrions and risk fitclors listed above, call be 3-403.11(C) Commercial IN,Processed RTE Food- found ix the following sections of tire Food Code and 105 CWR 140°F: 590.000. 3-403,11(E) Remaining Unsliced Portions of Beef Item ! Good Retail Practices FC 590.000 t RChists* 1__23, Management and Personnel IFC-2 .003 18 Proper Cooling of PHFs 24 Food and Food Prote tion_ FC.3 .004 25 W,ter iP utmbtl Utensilsand W '___.. F 4 005 ; 3-SU L 14(A) Cooling Cooked PHFs from 140`F to q P - C n 2 q este FC-S .006 7('F Within 2I{ovrs and From 70°F � 27 ( Ph rapes Facility FC-6 00T---! to 41"F/45"F Within 4 Hours. * 28. l Poisonous or Toxin Materials FC-7 .405 3-501.14(B) Cooling PHFs;Made From Ambien[ 1 29 S�enal R�uirements 009 Temperature ingreehen[s to41'F/4S'F Within 4 Hours' "Denote,,critical item in the federal 1099 Food Code or t45 CNIR 190.000. 0245 Derby Street Derby Deli Inc. City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: FOOD PROTECTION MANAGEMENT 741-2442 PIC Assigned/Knowledgeable/Duties FAIL Critical d❑ RED Owner: LIGemment: Person at establishment is not a certified food manager. PIC to demonstrate knowledge of establishments at all times. Vasslllos TZikas Violations Related to Good Retail Practices (Blue Items) PIC: Food and Food Protection FAIL Critical BLUE Inspector: I, t_Cemment: Raw poultry stored on top shelf.All Potentially hazzardous foods must be stored in proper order. John Gehan t.,46escoop incorrectly. Scoop to be stored with handle outside of ice or in a designated labled container. Date Inspected:Correct By: 9/25/2006 Equipment and Utensils FAIL BLUE Risk Level: �. Comment: No sanitizing log available at time of inspection. Log to be maintained daily. Permit Number: BBeeverage Aire unit in back holding poultry missing thermometer. Provide thermometer. BHP-2006-0.053 _ /frue unit requires general cleaning. Status: .Continental Freezer has no visible thermometer. Provide thermometer. _PARTIAL COMPLY #of Critical Violations: GENERAL COMMENTS: 2 Time IN: Time OUT: 848:Owmer to fax over last three months of extermination reports to BOH. _ Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 25,2006 ) Page I oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 25,2006 ) Page 2 oft Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4th Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name ' Date T e of O eration s Tvpe of Inspection '�✓� / /flC �! 21 07 Food Service ❑ Routine Address 2 y� rRik El Retail El Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: Owner I / /' HACCP Y/N El Temporary E3Pre-operation ❑ Caterer ❑Suspect Illness Person in Charge(PIC) Ste« Time ❑ Bed&Breakfast ❑❑ General HACCP Complaint In: 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'&o-, 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. *; FOOD PROTECTION MANAGEMENTa ' !` v, ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties El 13. Handwash Facilities EMPLOYEE HEALTH r s , r 1 "a a;�, '? I. - _-„ ,,,_,..,.., .� �€ ,-.,,,,,,,,�,h.u..��. -s,,,�.v,.„. PROTECTION FROM CHEMICALSa a El 2. Reporting of Diseases by Food Employee and PICS, a =»�_ ra �-� - � L _ �•� ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals ; FOOD FROM APPROVED SOURCE n,„,,,i;,,,,,_ , T,,; ., „d.Fa ✓ rs. _ . ❑ 4. Food and Water from Approved Source $-.TIMErrEMPERATURE CONTROLS(Potentially Hazardous Foods)xN'i ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling ^- � » � T ❑ 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION a '"' � 1.. S. Separation//Segregation/Protection ` � " � El 20.Time As a Public Health Control ❑ Q 9 Food Contact Surfaces Cleaning and Sanitizing �`REQUIREMENTS FOR HIGHLY$V$CEP-fIBLE P4PULA710N (N$Pj g ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing El 11. Good Hygienic Practices i>nCONsUMEiADVISORY' g! " ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. ' * 590.000/federal Food Code. This report, when signed below C by a Board of Health member or its agent constitutes an 23. Management and Personnel (Fc-2) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (Fc-0)(5550.090.0 004))) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S:MnVp fFom 14.do l Inspector's Signature: Print: ( {e PIC's Signature: Print: Page/ of ZPages - v Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT F8 Cross-contamination 1 590.003(A) Assignment of Responsibility* '3-302.11(A)(1) Raw Animal Foods Separated from 590.003(B) Demonst anon of Knowledge* Coked and RTE Foods* 2-103.11. Person in charge-duties Contamination from Raw ingredients 3-302A I(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(,0) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Foal Protection* applicants* 3-30215 Washing Fruits and Ve. etables 590.003(F) Responsibility OPA Food Employee Or An 3-314.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) Re orcin 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(F) 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* 4-5o I.t I t Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Tem eratures" - 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashino Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.t4 Eggs and Milk Products.Pasteurized* 4-501.114 Chenncal Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness.* 5-101.t 1 Drinking Water from an Approved System* 4-601,11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water" Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.1 t Cleaning Frequency of Equipment Food Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* - 4.702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Re ufato Author" 2-301.11 Clean Condition-Hands and Alms* 3-202.18 Shellstock Identification Present* 2-301.1.2 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201..17 Game Animals* 11 Good Hygienic Practices Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2`101.12 Discharges From the Eyes,Nose and 3-202.15 Packioze Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventin Contamination When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification * 590.004(E) Preventing Contamination from 3-203.1.2 Shellstock Identification Maintained* Em lovees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(J) Labeling of Ingredients' 5-204.1.1 Location and Placement* g Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans - Supplied with Soap and Hand Drying 3-502.11S ecialized Processing Metluxls* Devices 3-502.12 Reduced oxygen packaging,criteria* 6-301.11 Handwashin Cleanser, Availability 8-103.12 Conformance with Approved Rocedures'K 6-301.12 Hand Drying Provision "Denotes critical item in the Weral 1999 F(x J Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: t�'4-jl fey �2 �r � � Date: �I2S��o 7 Page: 2 of 21— item Coded CCnncal Itemf DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION 4'� r. •Date No `Reference R 'Red Rem . ° �' 3 • ss • �> nas ;y,'. ��' .rr x a a,� �, x r Verified PLEASE PRINT CLEARLY 2 on ra2w- G� �� l PGvr vc_S ilk PvSJ/ G�Cr�is a v d- i J]ti U J 74 54" - , Zw 161 !'1 X/r� iP �Gc0�• la ( l� v> 1CtJci / tieIX J / (z SC, t�-1 16 / C Le 1/, 16G�' �� X00 4o SGr,n r Ze � } i i; Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes „ S l7 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 dol ars or suspension/revocation of ❑ Embargo ❑ Emergency Closure j your food permit. j( ❑ Voluntary Disposal ❑ Other: 14(CT NlFs Received at Tempe-Tatures Violations Related to Foodbarne,fitness Interventions and Risk Accx)rdiag I o Law Cooled to Factors(Item 1-22) (Cont,) 43 F/45'F Within 4 Hours, 3 CiKiling kficaliods for PHFr PROTECTION FROM CHEMICALS — PI 9' PHF Hot and Gold Holding =t4 Food or Color Additives L ---- 3 50(.16,,B) Cold PHTir Maintained at or below 7 20112 i AddnikkG,k� 590-'i)04ff) 41 V45"F- 3-302A Is POlson ' ous or Toxic Substances 3-Y)l 16(A) 1101 PHFLq MaiplaMaintained ,It of above 101.11 Idernifying faint mation - Orwina Ccxaaiaers� 3-501'ititA) Rwm Held kit or above 130"T. 7 102,11 Common ame, L 2�q Time as a Public Health Control N 2.701 1 19 Ti n I c a N s a b I i c�l h—C.. 1.—� 7-20 1.1 i 'Separ U 7-L'201 Rcstric6oa -pre"xIlce kwd U�kt* - :L—1i 7-1-02.12 Colldniekn�of Use- REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULA IONS HSP --�Initl7trq.crion-oi-Cl 7�04 if 21 T�—ol Tfi'v) 11 7 2 .�12 Chenlicitfs for a), ce,(-.'fitccial 'N'kk� ±Locii I Pre-packaged Joices,wid Bever"I"les —20�i4 Awents�Criteria, nit±Lal—11111- L I 3-80f�11(13) U'se of Pitelen ri7ed E 7205,11 Incidental RiiyJ Contact,Lubi icarnsl� 'I 1-206 1 801 (Dw) Raor Pailiallk.Cksikkd Animal Foix!and �d LSe Peqicides,Critertal 7-206A2 R(xlerli Bkt;t si;lnonll^ 1,'—111((-7, j ell Te ilf�j racll king Powdem -ii Control and _L_ _ CONSUMER ADVISORY TIMErrEMPERATURE CONTROLS Ck)nsurmrAn'tsory Nmed fur(.'( q mpt on of 16 Proper Cooking Tompe(atures tW-- -,cl& 1-hat an Re Un er ke I, PHFs Not Od)�,re,Ise fr<g,emed io Hnninaw -5-401 1 hkktl)k-' Egg., 1,55'F 15&ee. 11 Illediate.selvict: 145'Fl5sekc' 31'134W11`172(1 Eea�:Suhsutine to!,Raw ShOl I(A)( ) Clarionnuied Fich,Maws&- Girnk: ---- 3-401.1 l(B)(1)(2) Polk and Bed Rmist 1)01 1 121 minxl� SPECIAL REQUIREMENTS 3 41)1.11 kik)U) PLItne" fill I cm,;d Mcete - 155 F 15 Violate )1`K of'sectitill 90.(X)9(Ai-(D)in I catering. mobile (md, temporai'l;and 401 11(A)(i) I reside rilial kitchen operations should be S'niffinit,Coni tinng Fish, Meal, debited under the appropriate kiections �or Ratit-ii-is5°F, 15 sec. " 1 Iloultry above if rclated to texxiborne Illness 3-401ANC)(3) Whklle-alti'Sclo,Intact Beef Sickiks Other 1 590.009 vlolatiow relaun (I Cow retail practicc�s ��hould be dcbitiILn�er #29 - ---- Kra�ffkxd,C�wlwd III a ,1-40 1.12 tiLta2' Microwave 10'F 145"F 15 5m C17 1 1 1-(Al(l)(b) At' Other P1 L 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3 .103.11(A)&.(k) 1 5 T I wc. (Items 23-30) Microwave- 10"F 2 Minute Standing Cellioilao"!nom-,rite-a!vio,'Mioro,whir hdono; relare to rhe Time" favdiloriie illizess inwt ventiow and read Ju tort It stent above, skin be 3-403.1 1(C,) corvinerrially llqvesied RTF Ford- fiekmi in thcfol?'Ouing secrioml of che Food Code and)05 COIN 140'F' 401 J I(E) Rem annni"umi"'Tpo"twn' if ITer j Item Good Retail Practices K 003- Proper Coutin—got P—HFS — -Fowand Food Proie�iio*r -- .......... E UPLIni and 11 FC-4 00 HJ4(A) Cociling C(x)kk,,d PRF's from 14017 to 125- - L --d 5C V�nter.plvll�irIg I 1�j t 700F Within 2 Hours and From 70"F -I-,------ -��( PhVS�c�tt Faciftli w 4 I' MY F Wiffini 4 How 1_Pciawouc N Tow Matenats FC -7 008 3 501.14(ll� Coou PHF�Made Front Ambient -Speejal Rem�remlant3 009 Temperature lninekfieni�I(,411,i,15 F 1 30 ther L Within --- 4 Ifela Defl(AeS LtIMAi Item in lh�K'derai 1999 Food 105 CMR 59+)(00 1 -. =.--n'+..":v4;`✓ Y'^y�+-.. 1,1 �.A `�9^.,.i:9_., a+r.`+�+-, t.:.e.�i'n,4':f.,'u`�°'r4z;yl.-wTRti t..lid �+.a�Rb,,,,,�r�+i`ti4..*w..rP'.rv.btri.;y'a. b 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 (� \ Date Type of Operations) Type of Inspection 1)Pn T,-U- ` }p (� ❑ Food Service ❑ Routine Address Q ,On n , \ ( A y L Risk ❑ Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection TelephoneC( (� (1 ElMobile Date: Owner } HACCP Y/N ❑ Temporary ❑ Pre-operation ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) 1 Time / ❑ Bed&Breakfast ❑General Complaint )r , n D InJ} �5 1/L ElHACCP Inspector , In e o, Out:-IPermit No. ❑Other Each violation checked requiresan\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;) D� 590.009(F)� action as determined by the Board of Health. Nom+ iN, aw+ �wmu_ v. FOOD PROTECTIONMgNA £MENT _„ - : ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties a � ❑ 13 Handwash Facilities EMPLOYEE HEALTH .°:, �z� :� �,.:-,�0ia�tv'rss`��" � ua PROTECTION FROM CHEMICALS � a e��x ^, ❑ 2. Reporting of Diseases by Food Employee and PIC ` a� t-^ .d•-•- • t�e° ��S_ - •�) -_� m _^ A_m ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15 Toxic Chemicals F000 FROM APPROV£p SOURCE m 1 r " _" ❑ 4. Food and Water from Approved Source f'..TIME/TEMPERA7URf GDNTROLS(PoMrn�lty Hazardous Foads)"`1 pp ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures M ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATlON'"� �'' f ;i �`F7 � ❑ 19. Hot and Cold Holding m ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing tiREQUIREMEHTS FOR HIGHLY,StIS EI PTIBil,00pU(.ATIONS(HSP)„, T: El21. Food and Food Preparation for HSP ---❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices - s_'GG'NSUMER-1 1 'dRY � "� ti+�y M1 �€i� i`=, 9��M� "'� . ,ad d a�a ❑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 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food 26. Water,Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(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: m 5:5901nspectFam614.tlac Inspector's Signature: 0 Print: O� (2 `` PIC's Signature: �- ( � Print: �'-"'� Page-l of�ages v Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION ��-- FOOD PROTECTION MANAGEMENT S Croi ss-contamination I 596.003(A) Assig mem of Responsibility* 3-302.1.I(A)(]) Raw Animal Foods Separated from 590.003(3) Demonstration of Knowledge* Cooked and RTE Foods* 2-103.11. Person to charge-duties Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require repotting by food employees and 3-302.11(A) Food Protection- a plicants* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Char*e* Contamination from the Consumer 590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(F_) Removal of Exclusions and Restrict ons Food 3-701.1.1 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* 4-501.1.11 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Scaled Container* Sanitization Tem eratures* 3-201.13 Fluid Milk and Milk Products* 4-501.11.2 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* - Sanitization Temperatures* 3-202.14 Eggs and Milk Products.Pasteurized* 4-501.114 _ Chemical Sanifimtion-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_II(A) Equipment Food Contact Surfaces and Utensils Clean* 590.006(A) Bottled DrinkingWater* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0 Sheiltlsh and Fish From an Approved Source_ Contact Surfaces and Utensils* - 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-HotWaterand 3-201-15 Molluscan Shellfish from NSSP Listed Chemical* Sources* ig Proper,Adequate Handwashing Regulatory Aurharit Gama and Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms* ut 3-202.18 Sbellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.1.7 Game Animals* 1.1 Good Hygienic Practices g Receiving/Condition 2-401-11 Eat[n .Drinkin or Usines Tobacco* 3-202.11. - PHFs Received at Proper Temperatures* 2401.12 Discharges From the Eyes, Nose and 3-202.15 Package Integrity' - Mouth* 3-101.11 Fetal 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* uc Tags/Records: Fish Products 13 Handwash Facilities Conveniently Located and Accessible 3-402.11 Parasite Destruction* 3-402.12 Records,Creation and Retention" 5-203.11 Numbers and Capacities* 590.004(7) Labeling of Ingredients' 5-204.1.1 Location and Placement* Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced ox gen packaging,criteria,* 6-301.11 Handwashin Cleanser,Availability 8-103.12 Conformance with A. roved Procedures' 6-301.1.2 Hand D 'n.aProvision -Denotes critical item in the federal 1999 Food Code or 105 CMR 590,000, i CITY OF SALEM _ BOARD OF HEALTH 3 rt t Establishment Name: .. A , r�� e , Date: — �-( Pager of Item Code C—Critical Item �� DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date l No. Reference R—Red Item Verified PLEASE PRINT CLEARLY / _ l �4�6 n I �c v {7;� .F�. -'. � n�_nnn., A_nnn. rt 1)A li_�I nA ! %� y.l 17 1 ', r, n.X A r n n 8 I e-1I( D - ... 0-0 4 l Ala nn Q/� OA0 (_ 0A , v a .nrl :M c� 1� ( vimr ,v' 1/1tio _On h (n� p �0 ./\� /n in. �I/(' �TP �! ` A r. P 6 d� 0e ) Iv /it 1Aan rA. �C , /.'1 -7,in 0/ YA . V "UTP, (IIM - Gf C f ( 1Q\( AR.(jri n�0 Discussion With Person in Charge: Corre tIve Action Required: ❑ No ® Yes rti I have read this report, have had the opportunity to ask questions and agree to correct all Voluntary Compliance ❑ Employee Restriction/ r Exclusion violations before the next inspection, to observe all conditions as described, and to Z) 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 sus ension/revocation of ❑ Embargo ❑ Emergency Closure r your food permit. i ❑ voluntary Disposal ❑ Other: yr I PHFs Received at Tempatatures Violations Related to Foodborne Illness Inlerventions and Risk According to Law Cooied to - Factors(Items 1.22) (Cont) _ _ 41 � - '^:.•,...,.,,.,*v.•....Wy.wr,.J1..^,r�r�+r•^hf:l+,1 +.gYl+-�v."�!w/".k.�d".r.,.lin'^c��w.r-...,,tYaro.�4'^r"R-.=.w1«4.*"_.f r«.+w.-.-^'MRi��•r"wT�Vw-' Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4'"Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name T _ p' / voe of Operation(s) Type of Inspection t)42j) f(� 1-p ' U)'Food Service ®`Routine Address \ � ig ❑ Retail r Re-inspection . OA (i R I �� 0 � Lev I ❑ Residential Kitchen Previous Inspection Telephone -1 k � ❑ Mobile Date: Owner T HACCP YM [I Temporary [IPre-operation kknn , tAS i 7 ro ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) 0 `M Time / ❑ Bed&Breakfast ❑❑ General HACCP Complaint ,j In: Inspector 3C)r h P Out: Permit No. ElOther Each violation checked require§-an-explanation on the narrative page ) 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) 0� action as determined by the Board of Health. O D PROTECTION MANAGEMENT, z El 12. Prevention of Contamination from Hands [$�1 PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH El 2. Reporting of Diseases by Food Employee and PIC a PROTECTION FROM CHEMICAL$ a ,V At ❑ 14.Approved Food or Color Additiv / E] 3. Personnel with Infections Restricted/Excludad O El15.Toxic Chemicals / FOOD FROM APPROVED SOURCE MX, =k,-? o '� rTIME/TEMPERATURE CONTROLS(Potentially Hazardous Fods)n�*•,.� E] 4. Food and Water from Approved �r 3� ��m= � e. •w• ._ , , ❑ 5. Receiving/Condition � ❑ 16 Cooking Temperatures E:1V 6. Tags/Records/Accuracy of Ingredient Statements � ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans / ❑ 18. Cooling f'PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding OK ❑ 8. Separation/Segregation/Protection //1 ❑20.Time As a Public Health Control0 ❑ 9. Food Contact Surfaces Cleaning and Sanitizing (�1/ .:REQUIREtJFENTS FOR WIGHLY SUSCEPTIBLE POR_TIONS(HSP)t,, ❑ 10. Proper Adequate Handwashing V f- ❑21. Food and Food Preparation for HSP 0 El 11. Good Hygienic Practices ' 5a' ❑22. Posting of Consumer Advisories (1 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 s. N ' by a Board of Health member or its agent constitutes an 23. Management and Personnel (Fc-2)(590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.0044)) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007)' ` have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(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 LtIA-_1 DATE OF RE-INSPECTION:r 1X0s:ssolnsPecrFo�me.ta.dac `�eFG�wInspector's Signature: (,Z (Q Wit: ce �V\ PIC's Signature: / ' "� Print: Page of Rages Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT $ Cross-contamination 1 590.003(A) Ansi invent ofResporisibilit * 3-30111(A)(1.) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge°` Cooked and RTE Foods* 2403.11. 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 foal employees and 3-302.11(A) Foal Protection* applicants* 3-302.15 'WashingFruits and Vegetables 590.003(F) Responsibility 01A 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.(X)3(G) Reporting by Person in Char�e* a-306.14(A)B Returned Food and Rcsetlice of Food" 31 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(F,) 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 F 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-5017 11 t Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Tem erainres* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-IIot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.14 Eg>s and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. * * 4-60LlI(A) F.,quipment'Food Contact Surfaces and 5-101.11 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food- Contact Surfaces and Utensils" SheJliJsh 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 E ui ment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* to Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authodt 2-30111 Clean Condition-Hands and Arms* 3-202.18 ShellstockIdentiScationPresent* 2-301_12 CleaningProcedurc* 590.004(C} W1Id Muster wms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices Z' 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 Packa a htte it y* Mouth* 3-101.11 Food Safe and Unadulterated* 3-30'1.12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identifcation * 590.004(E) Preventing Contamination from 3-203.12 Shellstock Tdenti.fication Maintained* Employees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacifies* 590.004(J) Labeling of Ingredients* 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying _ 3-502.11 Specialized Processing Methods* Devices 3-502.1.2 Reduced oxMn Eackaging,criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with A roved Procedures" 6-301.12 Hand Drying Provision *Denote cridctil item in the federal 1999 Fond Cale or 105 CkIR 590.000. 4 CITY OF SALEM - (� , BOARD OF HEALTH Establishment Name: \ 3ZAL� Date: X 0 Page: - of !Item q Code= � -C-Critical nem .¢"- ;f;"�`' ,,, .� DESCRIPTION OF VIOLATION/.PLAN OF CORRECTION t ,. n'� .., Date- TMsm .Nope Rete_re_nce y R _Red Item_ /r; a .� -. .. . . ,.- a s�,y.- '�� „_ °"a,-. _ r " ', , '�a `,te r; Verified U` 1, �1 ..:f��krie,,%`s`.�l tt�� a,- r h'ra, 1`- s�+ mss•3' PLEASE PRINT CLEARLY 1� l) f, 71�_ I n�✓ �-�"I�A 0.') �1cQOra�� r / ,9 .t t '1 ,I'. � 1 y, �-�t U 1 v i 1 `J_0' VA,lJf �1�o 'J i1 — 1/ Y �.� n n -.n, 'rGIP Ylr�t��J1 / Xt rY l/ I) ��f? ( �1 51 1,l q-'f/t PA n n tuA o.J � fi :J I F1 `> T/A l 1 .0 .l JL L� filo I//, '0 X\ o- "^, .a.r? Aon III A OAADni n I � Ak -h, ) �1 �U C. rna an, — ti1 �a 1-f' a.4 'I ,vtPOGj� . _ kX 1 JAA01 J�AG�o nnnl I / IKr..n Z Y". n ^ , V �n— ISC- �(X) _rIPilNhr biA C-I r?,-(A U0 U t , - 2� _ LA_� I Discussion With Person in Charge: Corrective Action Required: ❑ No o Yes I have read this report, have had the opportunity to ask questions and agree to correct all i,,,'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: Violations Related to Foodborne 111nsrs interventions and Risk A-,Wrdi to to Laav Cooled to Factors(theins 1-22) (Cort') I F145 €-Within 4 H(ws, T PROTECTION FROM CHEMICALS tL1 Food or Color Additives PHF Hot and Gold 1- 1-501,16(ft) Cold PHF%Maorreifl,l at ar cellAv -120212 Adsiva,' 590,044f 41`/45"F* Protwion frrria_lata any� d Poisonous at Toxic Substances L(A.16(A) flot pifFsMainiallIed 1:olaiso7ve Lis— 140"R 7-1©1.11 Identifying hifosination - Orqginal Koa�,ts Held at orabove 130'F. Cojaairtcr,�* Time as a Public Health Control 7 16111 Comrson Narnn�WOO Ing Cootailler,7 3-iol 19 fily'r as a Public Health Control- c�Re M ell 1,202.11 Rertriclion-presclice and fllse* varfanc 7-202.12 coarfifiorrs of tjso" 7-203.I I 'toxic Conlamel"- REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSp 7-20sli.1 1 slalili��cls,Criteria-chuoliclls- 1-2 FT 3-Wl.1)(A) 1"immTeurizod Ple-packagcd Juices,wid 7-204J4 -Pa, 111A -- 8(),,.I I(B) Use of Pa,fellriwd Et-,* M7 3--2, x205.11 llrkidtntal Rmsd Con(w,I uhricanri"� _d01 11(f)) I Ria or Parooliv Cooked Animal Food and =7- O�,-�1Relricted U c Poqiides ,Critei irt 7,06.12 Rollers B,tij Stations, Not Served. r-,—! -- �-901A 06 1� Tracking Powders, Pest Crittrol and tonttarin __ CONSUMER ADVISORY 22 37,7( , 1 of TIMEITEMPERATURE CONTROLS 16 Proper Cooking Temperatures for— -1vilim')i Fcuds'Plat al-c Raw, Undenwked or PHFs zs E}0 rt flne'es'sed to 1-t1ineirrate 3-40i HA(l)( 1�w, 155�F 15 J-',��Limikwdiatc Service 1459"15sec, —t, r I-,-ed—F�,�S zis�,lwl—1.11 RTI—S—he I lqltw�d F-ish, Ideals-& (ointe t----i- "c Comn —------- animus- 15 F 15 sec. SPECIAL REQUIREMENTS 401AI(B)ll)(2) —Pork and bcol Roitst 130' 127 ral0 -- — --- —1 3-d0 1.11(A)(2) Refitc,%,hiicojA Mcnis - 1,5s)F 15 5906()`liA)-J))7 Biot It ofSection 590J)09(A,-(D) in I critcrilig. inobilof(rod,hemporary and 3 40LlllAJ(3) lroultry, Wild(Ilune, Stuffed PHR, resident al kitchen oircrations should be Swflijot Containing Fisht h1 at., debited under tire appropriate ;cctions Poultry o Ramos-165 , 15 sec. shove if w1lukrit to N)dborne illness 11Vhrtemu.cicIntactBefSteaks intervemions and risk factors, Other kav, lerwar 1451� 590.009 violations relating to'ood retail - jl o,0,�F,,ked Jo a jrracflcc� shoold he debiteid under#29 - Micor"a" 105'F spevird 3-40f,l](A)(l)(b) ;Ml Other PliFs - 145'1 15 sc� 47 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES -3 401i](A)&(7)) fll-lfs 165"T1 see (heur,,23-30) ;.403.17(B) Microwaw-165°F2 Minute Siandin" Cricicai end non-critical riolatl,ins, which do nor rNare t)rhe Time, foodborne iUrze.m interventions cont ioA Jar,tars lived above cart be 7150-31 FW-j-- C—on,,fnk=iallv Pirxe�sed' RTE Kxld- fiowd in eft efiret owns,se,tions of the Food Code and 105('111)? 140 T, x90.00 ,, Renrainin - --FC-- i;").17ions of fi�ef - -1--------- now nail 1 59010w FC--2 Roost,* '003 24, R�ndwd Food!Protection I Proper Cooling of PHFis K�j .004 25 Planqutensils FC-4005 sill I ol' i,d PHF� from 14()'F to ----- 50 1. it A) C fing Cook ...Lj�q PEn ---------- 2C, 006 Within 2 Hours imd From .0°F' P.IlyricF"Fwillhi Ff -6 007 Lo 41'1`145�PA"iflon 4 Hour,,,. Poolonous or Toxic Materials FC -7 008 14B) Cooling.PHR Made Fosir Ambient 2cTRnl�l 5en-1 Tl3 Tempaawre Ingreditarls lo 41`F!45'F Other Within4 Ihmis' Dereqes entreat go n in the foilleral 1949 Pox'(",sre or 105(,Nflt 591)0M,