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DERBY FISH & LOBSTER - ESTABLISHMENTS,I DERBY FISH & LOBSTER 215 DERBY STREET II a d 0 ° n 0 h 11 , I! { Y 1,�a+Y,.� t •,',c r q �,I NOR Ia rfmr�n �'�d t+Prn. rl"» �' ni "^: t i 3 S x vl V�i' y. > mss•. .§ y',rt y 'Csr .r 'L�.id J•t t ,i'S' .'�' n•rkP;,r,+,tx '9' .'tFp 1>sa a?.ntr„r�YA'q �tr1 i .+{ ap r�t'u a � � . i > f l�.y F � y � 3x x y a T y'�'r .n Pt tu� c J�. � - •xr,��£ z +�.vi J�X,� 4 7„ t -, S �tF. . ><µ n>7��.,,4 n§ �hl'.t •`+�: le,¢.}I � 'I I S! �� S�1 Esc.,. s r /�yw�pry�pt�[y� Irwoa Cff.xio gt t .x VIOLATION NOi10E � �$,. .a n III , ,.. A (LAST FIRST,INITIAL) Jr., 10 4'rY-�q '\a c '. c. STREETgOBR / ESS CITYfrOWN STATE 21P li/ °+rh41bp'4`' Sx x. Sy`7 n� d'4�4 LICENSE No LIC.EXP.DATE DATE OF BIRTH' zPAN • `�'.' � `8 T�• '} O ER'S NAME(LAST,FIRST,INC�AL)64 D ��3 t A/ rruvr(.e JOCK y) - STREET ADD[iESS PTYOFOWN STATE 0� v' REGISTRATION NO. STATE EXP.DATE MAXEMYPE YEAR COLOR lJT C .o4 3 DAT OFVI LATION TIME DATE ITATIO WAnTEN PERSONAL n ' 1 3 Q U 7 ❑OAM PM 3/a 7/0 7 Imuar_YES ,y Y. LI ! NO LOCATION OF OLATION ENFORCING DEPT 1:11 L..eibySt Sti11M -F OFFENSE //� CHAP. SECT. NES m 'm t W3 .1113"rB � O Ort C U Lu OFFICER / I.D.NO. TOTAL @ ( O f� 1:4W 0�0 8 O .J t"7t5��1C FINFINE DUE $�Z,J. i. C" •• U)W CD ^3 j a �FJf/iER_CERTIFFIIE CQPY GIVEN TO VIOLATOR O0 fn C4 N 9 C13 X / :C ❑ IN HAND m - O Do not mail cash-Pay only by postal note,money U) �-�' F o M order or by check made payable to: W � r¢ a City Clerk-Mail to:Board of Health 120 }� O.z 3 C4 2 0 0 0 Washington Street Salem,MA 01970-3523 w�w O - Telephone#(978)741.1800 I W .n G c �' �a HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON . Q Q U I REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE PAYMENT IN THE AMOUNT OF S CASE# i SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL 0215 DERBY STREET Derby Fish & Lobster City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 745-2064 Food Contact Surfaces Cleaning and Sanitizing PASS ❑.� RED Owner: Comments:Sanitizer reading to strong. Sanitizer to be readingbetween 50-100ppm as mandated. Joe Carnevale PIC: Sanitizer not readily available at all work stations. Sanitizer to be at all work stations with proper concentration. Joe Carnevale Inspector: John Gehan Date Inspected:Correct By: 3/27/2007 Risk Level: Permit Number: BHP-2007-0190 Status: SIGNED OFF #of Critical Violations: 0 i 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 GeoTMSO 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 28,2007 ) Page I of Item Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Food Protection PASS BLUE Foodborne Illness Interventions and Risk Factors (Require Comments:Tongs stored incorrectly on cookline.Utensils to be stored in appropriate designated containers. immediate corrective action) Can opener found with accumulation of grime. Thoroughly clean and sanitize opener. Equipment and Utensils PASS BLUE Comments:All Beverage air units on front cookline require general cleaning. All shelves on cookline require general cleaning. Entire cookline requires thotough cleaning. Market Forge unit still being used improperly. Unit to be repaired or discarded by reinspection. Ther are refrigeration units not being used as designed. All units to be working as designed or discarded. Seafood disolay case missing thermometer. Privide visible and accurate thermometer. Walk in refrigerator floors walls and ceiling require general cleaning. Walk in freezer has large amounts of accumulated ice. Owner to have unit serviced and repaired by reinspection. No test stripps available at time of inspection. Strips to be on hand at reinspection. Physical Facility PASS Critical BLUE Comments:There are many water damaged water stained ceiling tiles. Find source of leak and repair. Replace all damaged tiles. Employee sink handle in restroom in disrepair. Repair handle to working order. Ciling tiles in dry storage room in disrepair. Replace any damaged tiles. Dishwash room walls and ceiling require thorough cleaning. Other-See Notes PASS Critical BLUE Comments:Odor of smoke noticed by office area. Owner observed moving ashtray from desk to behind door area. Smoking is not permitted in any establishment. Owner subject to monetary fine. 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. Mar 28,2007 ) Page 2 of v Item Status Violation Critical Urgency GENERAL COMMENTS: All violations from 3/20/07 have been corrected. Owner to contact BOH upon completion of ceiling tiles. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 �I, GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 28,2007 ) Page 3 of COURT DOCKET NO. CITATION NO. QCITY O SALEM PD `+ 298 VIOLATION NOTICE [j NAME(LAST,FIRST,INITIAL) -� fie. r/7 PIva(4-1JU-e STREETA'17 S CITY/TOWN STATE ZIP LICENSE NO. ' LIC.EXP.DATE DATE OF BIRTH OWNER'S NAME(LAST,FIRST,INITIAL) ADDRESS X90 _'f SI �./ ""iN 'pA/YI O`cy, 7(i REGISTRATION NO. f STATE EXP DATE MAKE/LYPE YEAR COLOR DATE OF VIOLATION TIME DATE CITATION WRITTEN PERSONA). 1 7 J NJUPY 3 � 6 ? ❑PM {/� ❑VES ❑NO LCOTION OF VIOLATION ENFORCING DEPT. L;/5` ,L wrls .5*/, S<L►rn OFFENSE K(!llri{/f'- J'/0/417d[Y/ Y7�" CHAP. SECT FINE$ A1d S/,p le _crl7// ft7 f6tte ..v/Joktit� �/r rSks ./�S �/t�kf' 12.1.ni B C OFFICER i 7e I.D.NO. TOTAL �(jb J FINE 12J- 1 Z DUE .OFFICER CERTIFIES COPY GIVEN TO VIOLATOR /)} ( / ❑�JIN HAND L�V MAIL DO NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY ORDER OR BY CHECK MADE PAYABLE TO: CITY CLERK CITY HALL 93 WASHINGTON STREET SALEM,MA 01970 TEL.(508)745-9595 X 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 $ CASE# SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL 0215 DERBY STREET Derby Fish & Lobster City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 745-2064 Food Contact rfaces Cleaning and Sanitizing FAIL RED Owner: :;,nt,,,, om : Sanitizer reading to strong. Sanitizer to be readingbetween 50.100ppm as mandated. Joe Carnevale PIC: not readily available at all work stations. Sanitizer to be at all work stations with proper concentration. Joe Carnevale _ Inspector: John Gehan Date Inspected:Correct By: 3/20/2007 Risk Level: Permit Number: BHP-2007-0190 Status: Open #of Critical Violations: 3 Time IN: Time OUT: 7 I 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. Mar 20,2007 ) Page I of Item Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Food Pr on FAIL BLUE Foodborne Illness Interventions and Risk Factors (Require omment:Tongs stored incorrectly on cookline.Utensils to be stored in appropriate designated containers. immediate corrective action) n opener found with accumulation of grime. Thoroughly clean and sanitize opener. Equipment and Utensils FAIL BLUE mmm nt:All Beverage air units on front cookline require general cleaning. IIIA 'shelves cookline require general cleaning. ire cookline requires thotough cleaning. —Market Forge unit still being used improperly. Unit to be repaired or discarded by reinspection. er are refrigeration units not being used as designed. All units to be working as designed or discarded. ood disolay case missing thermometer. Privide visible and accurate thermometer. alk i refrigerator floors walls and ceiling require general cleaning. freezer has large amounts of accumulated ice. Owner to have unit serviced and repaired by reinspection. o test stripps available at time of inspection. Strips to be on hand at reinspection. Physical Facility FAIL Critical BLUE Comm f:There are many water damaged water stained ceiling tiles. Find source of leak and repair. Replace all damaged tiles. 0momwe sink handle in restroom in disrepair. Repair handle to working order. Ci/ling file dry storage room in disrepair. Replace any damaged tiles. ishwash room walls and ceiling require thorough cleaning. Other-See Notes FAIL Critical BLUE Comment:Odor of smoke noticed by office area. Owner observed moving ashtray from desk to behind door area. Smoking is not permitted in any establishment. Owner subject to monetary fine. 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. Mar 20,2007 ) Page 2 of • Item Status Violation Critical Urgency �OV I 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. Mar 20,2007 ) Page 3 of i!y3`... 4`�dA+` rL,`sJ4Y.'Z r„�y�x �..�T+lP.Jny-✓l' xf� �.: 1�M. ! :Y>ti�'# tl.t.r..•• oX. ,N0.. rT � y�OLAT10ti{NOTiCE � v,+ STREETADDRESS - CfTY/TOWN STATE ZIP 11- 21S l7e� by S� Su(eoA • vHA 01S70 _ "� ' T D .EXP.DATE DATE OF BIRTH p g 39 RD ` OWN avIry Ile.(e � 10e � g $D� STREET ADDRESS Cl /TOWN STATE ZIP m i5 7eYl, SC ✓lA AAA G 17o REGISTRATION NO. STATE EXP.DATE MAKE/TYPE I YEAR COLOR 0 O � ! DATEPF VI TION /TIME DACTE RATIOI/�WRITTEN R n�� F, "��S-7U6 //�OGEl PM /��, ! O�j ❑YES LLJ _ ❑NO O LOCATION OF VIOLATION ENFPpRCINGDEPT - '�f OF¢{ENSE CHAP. SECT. FINES - I - ArE-PC A' ✓tLc h1ro� rU S q'_�. SGN 72 03 WE A ire E$-iA3r/S if Id 97') B � - 4 �. e r�o>r � o I m C Lo I 0 OFFICER/ / I.D.NO. TOTAL FIN @@ /,� 0(r J j''Ivl it DUE W IW m OFFICER CERTIFIES COPY GIVEN TO VIOLATOR I O - 1 --, omm El HAND = �,"��Z j X / ` "Al �1 BY MAIL � W \ � ?>> i � � z j ADO NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,AONEY : o x I ORDER OR BY CHECK MADE PAYABLE TO: CITY CLERK CITY HALL 93 WASHINGTON STREET ar SALEM,MA 01970 TEL.(508)745-9595 X 251 j I HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON ! ; REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE I } PAYMENT IN THE AMOUNT OF 5CASE p Pb O SIGNATURE O W SEE OTHER SIDE FOR FURTHER INFORMATION o ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL OT O0 r F- Scully Features Include. ED Delausonoac4. `0215 DERBY STREET Derby Fish & Lobster City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: I PROTECTION FROM CONTAMINATION 745-2064 Handwash Facilities FAIL ❑d RED Owner: Comment: Back handwash sink not dispensing soap. Owner to provide soap and repair dispenser. Joe Carnevale Violations Related to Good Retail Practices (Blue Items) PIC: Equipment and Utensils FAIL BLUE Joe Carnevale Inspector: Comment:All refrigerated units behind counter require general cleaning. John Gehan Market Forge unit requires general cleaning. Date Inspected:Correct By: 9/25/2006 - Market forge unit holding alcohol inside. Unit to be in working order or discarded. Risk Level: Utensils stored incorrectly on cookline. Tongs to be stored in proper designated area. Ice scoop stored incorrectly. Scoop to be stored so that handle isexposed or in a designated labeled container. Permit Number: BHP-2006-0085 Microwave on front line requires thorough cleaning. Status: Microwave by monitor requires general cleaning. SIGNED OFF #of Critical Violations: Side of ice machine requires thorough cleaning. I 1 Vent above cookline requires thorough cleaning. Owner to fax over contract and invoice of new cleaner to BOH. Time IN: Time OUT: No sanitizing log available at time of inspection Log to be maintained daily. Urgency Description(s): BLUE: GENERAL COMMENTS: Violations Related to Good 867:AII violations from 9/25/2006 have been corrected. Retail Practices (Critical violations must be corrected Market Forge unit to be discarded by next routine inspection. 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 r 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, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741.1800 FAX 978.745-0343 Kimberley Driscoll www.SALEM.COM Mayor JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT I / I`y' A +-1,,OG-ST� TEL# q'7k 7 s�i;lo& % ADDRESS OF ESTABLISHMENT a 1— 71DO-r_6 <27— FAX#`�7� MAILING ADDRESS (if different) EMAIL--Business': Owner's: OWNER'S NAME �aSek?k 0 c TEL# ADDRESSlC�/I�D�tr�AtS -+�Ti7 JAt 2M1AA 0/570 STREET' CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) Q{P/ Q AAW—et/n L t= CERTIFICATE#(S) 3!J p70 Gj (Required in an establishment where potentially hazardous food is preparedly EMERGENCY RESPONSEPERSON;PW4 HOMETEL# DAYS Of OPERATION_ tMonday _Tuesday �Wednesday ThnlsdaV Friday Saturday Sunday HOURS OF OPERATION Please write InUmeOfday, ryl_-tfj�ir/ Ifor example llam-lteml TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 - -.. -------- 0§ N ..... .. - -- - .......... ... . ... _.. ... -- ...- ...-- - --- ----_---- -- RESTAURANT O less than 25 seats 25-99 seats =$1 more than 99 seats =$200 - -- - - - - -----..._........------ ....._.....- $100...--- ----------------- - -- ---- .. BEDtBREAKFAST YES -- --- ...._-... .... - _.. ... .......... .... -- -- - ---- - --- - - ADDITIONAL PERMITS MAKE (notjust serve) ICE CREAM, YOGURT, SOFT SERVE YES $5 TOBACCO VENDOR YES �,�� $50 ALL NON-PROFIT(such as church kitchens) YES 'tom $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have fj{ed state tax returns and paid all state taxes required under the law. Signature Dale Social Security or Federal Identification Number - ------------------ ---- .. ----- -------------- ---7 - -- - - - ---- - Revised 11/13/06 FOODAP?.007.atlm Uheck#&pate .3 C.J (°,� �./bL. I5b O 6 Aw;A Irv: 1 w � ryl ,L1m x� j ai +v".yY r Comonwealth o[Massachusett§� m , s N atv is �ia� Cityof Salemrnt � tr . 3 F « € a e .$Hard of Health> , .xf ld �.b iat+ ; �. +m 4 a#. 1Gmbe1ley Dnsooll 120 Washington Street,4th Floor ` a , }° ; t ; L v r i ■� r a arc ZrMr?c_ '&.S,i w x., i .� ie"<. 4 e .i �. a :,•a: c:xJT.`t . 'c1. ' .1"•T;_SS ayor_T'_ ' "F'T`..«.. '�,a SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/20/2006 ESTABLISHMENT NAME: Derby Fish &Lobster File Number:BHF-2003-000005 215 Derby Street Salem MA 01970 LOCATED AT: 0215 DERBY STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2007-0190 Dec 20,2006 Dec 31,2007 $150.00 ESTABLISHMENT Total Fees: $150.00 PERMIT EXPIRES December 31, 2007 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 6 of 18 COURT DOCKET NO. CITATION NO. CITY SALEM ^0^0 VIOLATION NOTICE a 3 NAME(LAST,FIRST,INITIAL) /1cff r�pi� �cC STREETADDRESS CITV/TOWN STATE ZIP 21S Pev 1,y SF SC'(- ,o IVA 0670 LICENSE NO. LIC.EXP.DATE DATE OF BIRTH OWNER'S NAME(LAST,FIRST,INITIAL) i rOE :Z. ef JG GJ STREETADDRESS CITIY/TOWN STATE ZIP - +� i,'!: 4 ,.( �{ I'VVF 64117(- REGISTRATION NO. STATE EXP.DATE MAKE/TYPE YEAR COLOR DATE OF VIOLATION TIME DATE CITATION WRITTEN 1EN5011AL 11 AM _/O NJ RV OLQ PM 1 ANYES O LOCATION OF VIOLATION ENFORCING DEPT. OFFENSE CHAP. SECT. FINES ALE Lf ILf AiftlN `r y P-t Lv I} ,4 GIS B Gyn/E-7u % ('q)(,-I C R ('U OFFIC/ER I.D.NO. TOTFIN AL ..f �hflt / iL DUE �' 0` /// OFFICER CERTIFIES COPY GIVEN TO VIOLATOR � / ❑ IN HAND X (/ ❑ BY MAIL 'DO NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY ORDER OR BY CHECK MADE PAYABLE TO: CITY CLERK CITY HALL 93 WASHINGTON STREET SALEM,MA 01970 TEL.(508)745-9595 X 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 $ • CASE N SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL N UMassachusetts Department Foodborne • • Worksheet Pfaaa•t�rripteteartdSendorFaxta rtreesSorrs9 t� Daft.• 10 11010bMDPH Food Psotedw Program Food Protectim Program:(617)983-e712 305 South Street,Jamaica Plain.MA 92130 Division of Epidemiology.(617)9836800 #: Faac(617)983-6770 Enterics Laboratory: (617)9836609 r t Person Completing Information o p�} Name d capcar g 4?y: �, - W': ( )-41 - Iwo - Affiiiation: XLocal BOH (town):Sa LR W%* ❑State DPH(division): ❑Other. Reporter/Complainant Name: Aff Matto : Consumer sec a ❑ Laboratory division, ❑Local BOH facility, ❑Medical Provider address, ❑State DPH town,etc. — O Other Illness Information #Persons iii:© Symptoms: (mark it reported for anvone}: Diarrtrea �y'�/VomitIng �j,{Nausea �Abdom3naicramps �❑ Fever ❑ Bloody stool ❑ Headac e ❑ Muscle aches ❑Chills ❑ Loss of appetite Fatigue Dizziness ❑ Burning in mouth ❑ Other symptoms: ........................ ......... ./ ............ Onset: —r i Eadiesi Date. t l tp Tirne _ ❑AMPM \ ? Latest (if> 2 ill) Date Time _ ❑AM PM y ....................Duration: ess than 24 Hours ❑ 24-48 Hours ❑ More than 48 Hours ❑ Ongoing ❑ Unknown III Persons: Age 1 Name Addressrrown d (yrs) Occupation Med. Provider/ `a 1 I Asarre as reporter(above) 1 .r 2 T 3 Medical attention received (byanyone}? Yes ❑ No ❑ Unknown r If Yes, specify agave: f ; Stool specimens submitted (byanyone}? Ll Yes Yi No ❑ Unknown --r To SLI '? ❑ Yes 0 No O Unknown Medical diagnosis reporter \ Food History .Obtain history back 72 hours poo, to symptonrr,,or it orqani6m identified, b(n min and max incubationp,zriods (See p 2) r If> 2 ill, followohovrr time home fni connnon meals roods ogly N Restaurant/store where Date& Time' Exp Foods consumed aur iased nam(; town Place consurned rf �� op P 10 snmp(ns 00 C) 14Nn, StcamtrS \Sher ltb '�t�ts -7- blob � MOPH Foodborne Food History(condntll it Restaurant/store where Date&Tlme2 l Foods consumed purchased name,town Place consumed O B O same(as leM O Home ' O Other(specify): [Is O Same(as left) O Home _ O L - O Other(specify): OD O B O Same(as k#) O Home O L O Other(specify): OD 06 ❑Same(as kft) O Home O L O Other(specify): OD 013 O Same(as left) O Home O L - O Other(specify): OD Cp, Food Testing Food(s) available for testing? ❑ Yes_ ❑ No ❑.Unknown > Sent to SLI '? ❑ Yes ❑ No O Unknown If Yes, specify food(s) &sources. Product and Manufacturer Information for Commercially-Processed Food(s) Product name: Code/lot# Expiration date. / / Package size/type: Manufacturer Address: Incubation Periods for Selected Organisms Min Max Min Max Min Max B cereus (short) 1 hi G his I- coli 015TH7 3 days 8 days Staph aunnl5 30 nun 8 his 1 H Cercus (long) G his 74 hie I Iepnitrls A 15 days 50 days Shlg(-lhr l7- his %his Canq,ylohar;lcl 1 d;ry l0 day;c S:rinroncll<, (non-typhi) G his I) hn; Vlhl n)Cholvl:n lcw Ins 5 days Cyclospora 1 day 14 days Salmonella Typhi 1 wk 3 wks l V1r1+1 GI 12 his 48 his C Perfringens G hc; )4 hrs Shellfish pasonnul nuhutm: h:w hl': yr1"1111;1 ?.days 7 days 0215 DERBY STREET Derby Fish & Lobster City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) 745-2064 _ Hot and Cold Holding PASS ❑� RED Owner. ` a Comments: Joe Carnevale Violations Related to Good Retail Practices (Blue Items) PIC:,_m_, Food and Food Protection PASS BLUE Joe Carnevale Inspector: w *_ _ Equipment and Utensils PASS BLUE John Gehan Physical Facility PASS BLUE Date Inspected. Correct By: 4/20/2006 r GENERAL COMMENTS: Risk Level: 588: Owner was questioned on smoking within establishment. Owner stated that he was smoking in the office. Inspector explained that smoking is not allowed in any establishment under Massachusetts General Law. Owner Permit Number: stated "I forgot'. Inspector to talk to Health Agent about possible consequences. Violation may start at a $100.00 BHP-2006-0085` fine. Status: Open All other violations from 4/20/06 have been corrected. #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. Apr 27,2006 ) Page I oft i Item Status Violation Critical Urgency RED: Violatidns 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. Apr 27,2006 ) Page 2 oft 0215 DERBY STREET Derby Fish & Lobster City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: M. FOOD PROTECTION MANAGEMENT 745-2064 - - PIC Assigned/Knowledgeable/Duties PASS ❑Q RED Owner: ,,. .. Non-compliance with: Joe Carnevale Anti-Choking PASS PIC: Joe Carnevale Tobacco PASS Inspector - John Gehan _ EMPLOYEE HEALTH orrect By: Reporting of Diseases by Food Employee and PIC PASS RED Date Inspected: C 4/20/2006 Personnel with Infections Restricted/Excluded PASS 0 RED Risk Level: FOOD FROM APPROVED SOURCE Permit Number: - Food and Water from Approved Source PASS RED BHP-2006-0085 Receiving/Condition PASS RED Status: Open zz Tags/Records/Accuracy of Ingredient Statements PASS ❑J RED #of Critical Violations: - - Conformance with Approved Procedures/HACCP Plans PASS ❑d RED 3: :.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 GeoTMSO 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 20,2006 ) Page 1 of Item Status Violation Critical Urgency RED: PROTECTION FROM CONTAMINATION Violations Related to Separation/Segregation/Protection PASS RED Foodborne Illness Interventions and Risk Factory(Require -> Food Contact Surfaces Cleaning and Sanitizing PASS ❑d RED immediate corrective action) Proper Adequate Handwashing PASS ❑d RED Good Hygienic Practices PASS RED Prevention of Contamination from Hands PASS ❑d RED Handwash Facilities PASS 0 RED PROTECTION FROM CHEMICALS Approved Food or Color Additives PASS RED Toxic Chemicals PASS ❑d RED TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) Cooking Temperatures PASS RED Reheating PASS ❑d RED Cooling PASS ❑d RED �nd Cold Holding FAIL Critical ❑d RED omments: Potentially Hazardous foods holding at 47' F on counter. All potentially hazardous foods to be held at 41'F or below as mandated. Owner disgarded food at time of inspection. Time As a Public Health Control PASS ❑Q RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food and Food Preparation for HSP PASS ❑d RED CONSUMER ADVISORY Posting of Consumer Advisories PASS RED City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 20,2006 ) Page 2 of Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and Foo rotection FAIL Critical BLUE Comments: Uncovered foods in walk in refrigerator. All foods in storage must be covered. ✓Onions and potatoes stored beneath sink in wash area. potatoes and onions to be relocated. Equipment and Utensils FAIL Critical BLUE ments: Microwave at end of counter requires thorough cleaning. ,-Frontline requires thorough cleaning. 1.�everage Air unit beneath sandwich area requires thorough cleaning. �orough cleaning beneath stove required. Bev-Air unit in disrepair. Repair unit. -I Thorough cleaning required behind deep fryer area. Sa " er running near 400ppm in establishment. All sanitizer to be maintained at 200ppm as mandated. o sanitizer log available. provide log and keep maintained daily. I coop stored incorrectly. Ice scoop to be stored with handle outside ice. Microwave oven above computer monitor need thorough cleaning. k m refrigerator and feezer has no internal thermometer. Provide visible and accurate thermometer. yw31 -in refrigerator has accumulation of dust on fans. Remove dust and clean fans. ezer has accumulation of ice on floor. Freezer to be repaired by licensed company within one week. Owner to fax over work ordert H. op stored incorrectly. Mop to be stored to prevent growth of bacteria. Water, Plumbing and Waste PASS BLUE Physical Facility FAIL BLUE L106mments: Ceiling tiles that are water damaged or missing throughout establishment must be repaired or replaced correctly. 1 08"amaged ceiling tile above front stove. Find source of leak and replace tile. '119"'issing ceiling tiles missing in dry storage area. Replace tiles. ry storage walls has accumulation of mold on them Thoroughly clean and sanitize area and repaint walls. Correction to be done within one week. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeOTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 20,2006 ) Page 3 of Item Status Violation Critical Urgency - Management and Personnel PASS BLUE Poisonous or Toxic Materials PASS BLUE Special Requirements PASS BLUE Other-See Notes PASS BLUE G:ERAL COMMENTS: 5:Owner had no extermination reports in establishment. Owner to fax over last three months to BOH by Monday April 24, 2006. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 20,2006 ) Page 4 of 4 04124/2006 12:20 9787457012 ANTHONY P CARNEVALE PAGE 01 t Anthony P. Carnevale Certified Public Accountant 15 FRONT STREET Salem, MA 01970 (978) 744-3050 FAX TRANSMISSION TOCOMP 9 7s�- 03113 DATE: ATIYNTION OF: (TIME' FROM, - /d. d oE�13j� tOS ; .R`qF PAGES FNCL NG IS ONE: SUBJECT: —�� FAX OPERATOR: .. PLEASE NOTE:IF YOU DO NOT RECENE ALL OF TME PAGES; CACI FAX OPERATOR AS SOON AS PO&"aLE ORIGMAtS I VALL FOLLOW VIA MAIL- VALL NOT COURIER MESSAGE: 0 yov� Ego e3- 'r ACCOUNTING,TAX AND MANAGEMENT CONSULTANT ANTHONY P CARNEVALE PAGE 02 04!2412006 12:20 9787457012 1 P.VM `, . } E erminators INVOICE PLEASEALyn PAYMENT T0: t s"wi ., ,STAEET,LYNN,MA 0190.2-aas7 A.O:Rb><alp Lynn,MA 01903-0310 Al7E 781.972•T73T T•BbIDCE9•aa2s FAX78149Z-7841 CURRENT- 30 DAYS SO DAYS 90b.AVS- Peat and Termite Control Professionals '4"S4:` Qi.fiE� Vi,6 0.4Y 't 4,`.'i. i7{CA RT tlr Mr rMe nnTE CO ) ACCs.no, i.31,77OVt1EGH_0. JJ 003 0403 Mort i:'itf'f 'z 0,.106 DERBY RESTAURANT COMOLM RGOULAR V+ST CONTROL sMrk0iiiiggg :50, 00 ir"i..`..> DERBY. ST, - .NUMBER UNTr PRICE ANIOUNT, , SALEM MA 01970 MOUSEGLBD 745-f t�JE,4 03/0-1/C.16 31341-i.G7 AM DATE 016 NULTI-GT TRAP . . yr�" RROTECTAA ' PRTECTA LP �_- CHECK No> NltJ.9AR STA; . COMMENTS' [3 MC QVISA ❑DISCOVER RATGLUEGD I N6rT-.0 T I T Rk:AT ACCT.It V1T/C0LJNTER/DiR/RRIN0 BS i 399TCR 1RNISlFRtktT, OF CGUNTER Trt: E%PyDTATE' sALESTAX U. , fq" C.Op,'• CNG[ITOTAL OUE " �!�^ `C ry_ Aa� Gi/tOtlCi TOTAL AMOtlN1�iPD t "'.8� � � :. f 041 4/4 Xf lnCOMMEN# C,oMMEACIAL SAN[ Anom REPDRT VES NO Counter Surfieeh ❑. ❑. _ Drain Areas.''.Cleah .........,.....-.. 0 . ❑ . Raaf Rooms'—Cloan ........................ Dining Areas-Crean ..................... D. q Areas—Glean .•... .............. LocEMpioyea —Clean .... - ... . D ❑• RESIDENTIAL WARRANTY-INFORMATION' StorrgsAmas—Org&*od _ . D DWELLINGTYPE WARRANTY YES NO GorianL,1L5 t Family .;D 3 Family 0 3DOWS, D 60 Days 2Family .O 6 Family Cl 90 Days ❑ 6 Mos, 0 3. REAaOM FOR NO WARRANTY F -Partial eerviterequasted..:..:............ ............................:...............❑ POST APPLICATION REOUIREMENTS, - -Poor sanitation....::::...........................:..........................:.............................p . . ,KRcheNbatMObm cabinets net Prima(ad.._......_.........._.:..:............ .....:.i.Q OCCUPIED AREAS MUST BE VACATED FOR - HOURS.' - •Clcselatfurnittue not prepared. •"" ....... «•... ' THOROUGHLY VENTILATE TREATED AREAS BEFORE THEY ARE REOCCUPIED:DO NOT ALLOW ADULTS.CHILD#IEN,OR PETS ON -Rodent PrcwRng'naedarl '-"""' ""' """"-."'^""•'"""""'❑ TREATED 6URFACES UNTIL DRV, •Qihor. :ONTPAG'i1NOENTMESHAVERMEn1EDALLMA89ACYRJSETTSDEWMXNTOFfOODdAOHtCULTURE'SPE MOt TTMEBt �YSEAU.CONSUMEA SHEETS,NRB . STATEMENfk,POSTING NOIICESAND HAVE AGREED.TO NOTIFY 7ENANT92-7•� RfaORTO APPLICATONtiME, - AB S�RVICENAS.KEEN-6A'714FACTORI4.Y COMPLETED. ins'o-t' VI STOMER'SIGNATURE -� (('yy 4C.a H aI(at A ' 'TELW.NO SEE REVERSE SIDE FOR PER NT INFORMATION Whito--Oatoo Coot C+n'iAA,v—euctemer Coov -"Pt a—n:,..n r!x« 6 04/24/2006 12:20 9767457012 ANTHONY P CARNEVALE PAGE 03 4 A Eabor U.LYNN,M INVOICE PAYMENT TO: 103.SXEPARb STREET LYNN MA 0190t•e6B1 liTiVOICE P.O.Box 310 Lynn;MA 07803-0370 Z41-692 2Tat t40_04p25a025 FAX Tet.SWTEdt CURRENT' 30 DAYS 60 DAY6 80-6AY8 Posland.TDYTn CORtroIPror�sfdnelS Ci;iC'.�iItT9 I,-, IT fA arh ar perF 04Y TYPE ant[' Iel7 E.'.:. .1dC'r NO... 117 (' o Y':(.1"I: 003* 0309 Mora 101 DERBY RESTNURP.NeiTk *c2KMf "E0 Rf:6L1LAR PEST =EONTRTUL E At +'y .; OEREY ri t'r .Y'N . N M9ER U IT PIi10EN, A UNI' 11111_fM IqF' s ' 411 17LTt "a ' MOUSE GL ED /45 r0(3Itt. 2i'/fbE.J IIF; JT 3(h-'1� F}pq h1umcT T11AP _ - DATE. PHC(ECTA - -: CHECK NO. PROTECTA LP COMMENTS —�J— RTUGAITSTA 0 MC ❑VISA ❑DISCOVER RAT GLUE ED INSPECT/TREAT ACCT,0 — KIT/COUNTER/I)R/RRJNO Eli; I.OHSTER r —= Ti NKIFIZONT OF COUNTER EXP.DATE su6sTA1Y CmX0 . CHOO NCO TOTALDUE TOM AMOUNT PD, esu w NTS � //]� iT10i Ct�M141E 'sC i Kock k COMMER61AI,SANITATION,REPORT Fidors—Clean r a ti NO Counter Sudacea Ctcan ::, ........_,0 ❑ Drain Areas—Clean ............:........... L) O ROM Room—Clean .......,.'... ❑ ❑ Dining Arms—Clean ` ,......... a ❑ . EmployeeAreas—Claan ,.......t[:;._..,...., ❑. ❑ . Ser —CMg •.,.•...,• StOTage Areas—Organized ....... .. ....... ❑❑ Q RESIDENTIAL WARRANTY INFORMATION ........ Comments DWELLING TYPE WARRANTY YES 0 NO❑ 1 Fernly O . 3Family ❑ _- 36 Days '❑ - - 60 Days ❑. 2 Family ❑ OF" Q � 90 Days 0 6 Mos. ❑, . - REASON FOR NO WARRANTY PadtW service reeuested...................._:.».„.,....................... ».„..„.„„..„..d . POST APPLICATION rWgq F#M6NT5 -Pow sanllelion.................. ............,.,..........................,,.........»1 . OCCVPIED AREAS MUST SE VACATED FKitchwAYAthroom Cabineth not pmpate0 ............_....... » .....Q. *CtanelsAurrautenot prepared THOROUGHLY DON NOT AL TREATEDOW ADU AA'V9�BEFORE THEY ARE. . P e1'�re ..REOCC ❑ TREATED SURIED.DO NOT ALLOW AD' BIPICDREN,OR PETS ON -Rodent proofing needed... ... ..;....„................................._...... _...Q TREATED SURFAGE9 UNTIL ORV. +41tler - , :ONTRACTING ENTITIES HAVE RECEIVED ALL MASSACHUSETM DEPARTMENrOF-FOOD&AGRICULTURE'S P$SRCIDF E IN UREAL CONSUMERSHEETS,WRITTEN STATEMENT$,POs CEBAND HAVE ASSEED TO TMTRFV TENAWV2-T 'AYE PRIOR TO APRM1AitON TIME ABOVE _ IC�BEEN SATISFACTORILY COMPLETE xroe.1 U$TOMER 61aNA111RE _ p SiGNATtlfl� SEE RMRSE SIDE FOR' , RTiNEN"NFORMATION' While—0111'*Cc” Canary—fliniumor Coav 04/24/2006 12:20 9787457012 ANTHONY Y P CARNEVALE PAGE 04 AlExterminators INVO PLEASE REMIT PAYMENT TO: 1933 PARD Strom,LvjN'MA ICE POL Box 310 Lynn,MA 0190-0310 AS 7111.352-2787 1400626.025 VAX 781.902-1041 CURRENT 300AYS Peat'and Termite Control Professionals I j 90 DAYS it 17'�O (it fry T fit t1l li!1 fe m DAY TYPE DME ACCT.NO, 14 fn" r,imly, GON go,,. -poi Wt. 00, —Fog NUMBER UNITPRfCE AMOUNT ;31p4';Lri MOUSE CLOG 1)g 0 V! Aft! -;,16 MULTI-CT TRAP DATE PROTECTA PROTE611TA LP CHECK N0. RTUBAIT STA COMMENTS MC 0 VISA 13 DISCOVER RAT GLUE DD 1NGI-'1E(;T/1 Rr.f.)T K,VT/CnbN11R/Wq/RR/N0 pt,,, :;,UCV' ACCTS— T-ANK/FRONT (IF COUNTER EXP DATE SALES TAX Coln CHO 0 ❑ TOTAL DUE TOTAL AMOUNT PD ADDIMONALCOMMENTRi... COMMERCIAL SAitiffAMN REPORT NO ......... YES 0 Counter Surfaces—Clean ............. [3 0 DnanAreca—Cleam ...... 0 [2 PAST Ro"—Clean ........ ........ 0 0 DInlng Arem—Clean —.......... .... ... 0 10 1 Ernoloyse Areas—Clean .... .....1 0 0 Locker Areas—Clean ...... ......... ...... L) 0 RESIDENTIAL WARRANTY INFORMATION Storep Areas—Organized ......... El 0' DWELLING TYPE W 2C NTY YES 0 NO Q 0=Comments I Family 0 3 Family 0 Y, E3 60 Days 0 2 Family 0 - 6 Family 0 wDayts 0 6mos. [Y REAWRIFORNOWARRANTY 4palvalservice nquested........__....1.11-1.1...... ......I...... __Z] POST APPLICATION REQUIREMENTS •Pon.1'itRI00......—.................I..................... ............................ -Kitchen/bathmom Cabinets not ..................... OCCUPIED AREA$MUST BE VACATED FOR—HOURS, VC110401tturniture,W pmp.mij............................... ....n1•....... PereUPIED.00 NOT ALLOW ADULTS,0"ILDREN,OR PETS ON UGRLV VENTILATE TACAT40 ARLAC REFOSE THEY AnC -floderl pm0I1n4 needvd__ .... ............. .......... ....... TREATED SURFACES UNTIL DAY. -Other CONTRACTING ENTITIES HAVE RECEIVED ALL MASSACHM OF FOOD&ArritcuUnuRes PESTICIDE TIME IN RUW-AUODMSLMM614ES9,WRnTENSTATEMEMS 0W%tN00TWVCE=ANffD HAVE AGREED TO NOTIFY TENANTS 24 DAYS PRIM TO APPLICATION I WICE"AS BEEN SATISFACTORILY COMPLETED CySTOMER SIGNATURE SEE REVERSE SIDE FOR PERTINENT-WFORMATION Whfto—Offica Copy comfy Copy PInk—M.mmtzqnea vow 04/24/2006 12:20 9787457012 ANTHONY P CARNEVALE PAGES 05 Diversified Services Co. Inc Invoice PO Box 1032 Invoice Number:, Billerica, MA 01821 2621 Invoice Date_ Oct 0, 2005 Voice: 978-750-0241 Page:. Fax: 1 D. uplicare Sold To: Ship To Derby Fish a Lobster 215 Derby Street Salem, MA 01970 3 Customer ID Customer PO i Payment Terms, Der { I Net 30 Days I Sales Rep Shipping.Method a Ship Dale Due Date Glenn I Airborne - { 10/4/05 Quantity i Item , I Description I Unit Price I Extension- i { 1.00 PA99-022 p.cetylene I 12.55 1 12.55- F. I 1.00 IJG21-505 i+aragon defrost timer 8145-20 i 225.00 I 225.00 1 1.00 IS/B freight and shipping'charge ( 8.50 I 8.50 l ' .1.00 t #Ru 'ruck charge i 15.00 1 15.00 1 2.50 Il (.abor I 72.50 1 .181.25 1 I I (ervice on freezer ( I l I I I i I I I I I I ! ! t I I i i I I I I I i I I I I I I I I I I I I I 1 I I l i I I I I I I 1 I i I I I I I I i I I f I I { ! I I I I I t 1 P I I I 1 ! I Subtotal 442.10' Sales Tax 11.88 Total Invoice Amount 454.18 Check/Credit Memo No: Payment/Credit Applied TOTAL s454_1e I nt +� l�- � �Y. "� tr L .v ,_�! ..-.•.vy�'Afi.4„aKM'.'3x3mSeK" �'.' "+.°j'+.'.. -r�k Cv � "o :1 'G isd. ° j �w.�Y��}, -.f�va Commonwealth of Massachusetts'. `. ' to •<a f> r *`z' ' f;4.City of Salem ._' ' ... Board of Health 120 Washington Street,4th Floor a SALEM,MA 01970 S Food/Retail Establishment Permit ONNO DATE PRINTED: 01/03/2006 WHO'S PLACE OF BUSINESS IS: Derby Fish & Lobster File Number:BHF-2003-0005 215 Derby Street Salem MA 01970 LOCATED AT: 0215 DERBY STREET SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2006-0085 Jan 3,2006 Dec 31,2006 $150.00 ESTABLISHMENT Total Fees: $150.00 PERMIT EXPIRES IDecember3l, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health.. page 7 of 23 °� CITY OF SALEM, MASSACHUSETTS „ BOARD OF HEALTH j s 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 "Ne TEL. 978-741-1800 STANLEY J. LISOVICZ, JR. FAX 978-745-0343 MAYOR W W W.SALEM.COM JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT -,69 6 1 -V/514' ADDRESS OF ESTABLISHMENT /S —D G 213 V MAILING ADDRESS (if different) OWNER'SNAME S0SW/-1 TEL# 7� 7Y5 -136 - ADDRE S /�40,,U A,6 t.s (Lr�) CITYSTATE i/I /I ZIP (91q -7() CERTIFIED FOOD MANAGER'S NAME(S) -I-DStI 04 44ye;l W . CERTIFICATE#(s)?, 5 203 (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON TOSS-Pel 0M(L ��g t e HOME TEL# HOURS OF OPERATION: MOn.Y-f Tue.- -Y Wed.=Thu. FrL4-P Sat. TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YESNO� less than 1000sq.ft. =$ 50 C 1000-10,000sq.ft. =$100 more than I0,000sq.ft. =$250 . . .. - ........... - .............. RESTAURANT YES NO less than 25 seats =$100 99 seats =_ 150 more than 99 seats =$200 --------------------------------------------------------------------------- BED/BREAKFAST YES N $100 .............. . ---------.-.------------------.......----------------.-....-..--------------------------....---------------------------------- ADDITION.4L P5 ERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES $50 ALL NON-PROFIT(such as church kitchens) YES N $25 *Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best n wledge lief, have filed all state tax returns and paid all state taxes required under the law. / a//0s o _3(/ 3 -�-90V - p�- - Date Social Security or Federal Identification Number Pe'natur'e ------------------------------------------------------------------ -------------------------------------------------------------- ised 11/03/05 FOODAP2.adm Check#&Date blas-� Oz /Os- /�D as IMPORTANT MESSAG FOR J DATEa'-'� TIME 41 M OF- PHONE F PHONE AREA CODE NUMBER EXTENSION U FAX Q n U MOBILE (21 /, R S AREA CODE NUMBEREY�iI TO CALL TELEPHONED PLEASE CALL CAME TO SEE.YOU WILL CALL AGAIN WANTS TO SEE:YOU. RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE.... 7.... w �. a fs 2 ] 1� 7-S [jam SIGNED O FORM OA MARE IN A. NOTES CITY OF SALEM, MASSACHUSETTS o e BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 STANLEY J. USOVICZ, JR. FAx 978-745-0343 MAYOR W W W.SALEM.COM JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT December 21,2005 Joseph Carnevale Derby Fish&Lobster Corporation 215 Derby Street Salem,MA 01970 Dear Mr. Carnevale, The City of Salem Water Department has notified us that your water service has been restored and payments have been received. Therefore, all food operations at Derby Fish&Lobster Corporation,215 Derby Street,Salem, Massachusetts,are approved to resume effective December 20,2005. Sin;oaii'ne erely, = Health Agent +j r G JJcry �'J G y L h .r U : f CITY OF SALEM, MASSACHUSETTS r ; BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 STANLEY J. USOVICZ, JR. FAx 978-745-0343 MAYOR W W W.SALEM.COM JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT December 19, 2005 Joseph Carnevale Derby Fish & Lobster Corporation 215 Derby Street Salem, MA 01970 Dear Mr. Carnevale: The City of Salem Water Department has notified us that your water service has been shut off. Lack of water service to your establishment creates an imminent health hazard requiring immediate suspension of the food establishment permit. Therefore, all operations at Derby Fish & Lobster Corporation, 215 Derby Street, Salem, Massachusetts, shall immediately cease and desist. This emergency closure shall be in effect until the Salem Water Department notifies the Board of Health that water service has been restored. 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, 120 Washington Street, 41h Floor, within ten 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. Sincerely, Joanne Scott Health Agent �.� CITY OF SALEM, MASSACHUSETTS �Pv DEPARTMENT OF PUBLIC SERVICES � 120 WASHINGTON STREET, 4TH FLOOR 3 p. SALEM, MASSACHUSETTS 01970 BRUCE D. THISODEAU, P.E. DIRECTOR OF PUBLIC SERVICES/CITY ENGINEER STANLEY J. LISOVICZ, JR. TEL: 978-745-9595 EXT. 321 MAYOR FAX 978-745-0349 TO: Joanne Scott, Dir. Of Public Health FROM: Raeleen Par ub. Services Business Manager/Water Registrar DATE: December 19, 2005 RE: Water Shut off at Young World Nursery, 3 Green Ledge St. and Water Shut off at Derby Fish and Lobster, 215 Derby Street Please know that water services have been terminated today and approximated 10:30 am. at the two above listed locations for non payment of past due water and sewer charges. It is the department's intention to restore water services to these locations as soon as the charges are collected. I will keep you informed of the status of these businesses as soon as payment has been made. Thank you for your services and support. CITY OF SALEM9 MASSACHUSETTS e DEPARTMENT OF PUBLIC SERVICES 120 WASHINGTON STREET, 4TH FLOOR 9 SALEM, MASSACHUSETTS 01970 'TU1R BRUCE D. THIBODEAU, P.E. DIRECTOR OF PUBLIC SERVICES/CITY ENGINEER STANLEY J. USOVICZ, JR. TEL 978-745-9595 ExT. 321 MAYOR FAX: 978-745-0349 TO: Joanne Scott, Dir. Of Public Health FROM: Raeleen Parub. Services Business Manager/Water Registrar ,J DATE: December 19, 2005 RE: Water Shut off at Young World Nursery, 3 Green Ledge St. and Water Shut off at Derby Fish and Lobster, 215 Derby Street Please know that water services have been terminated today and approximated 10:30 am. at the two above listed locations for non payment of past due water and sewer charges. It is the department's intention to restore water services to these locations as soon as the charges are collected. I will keep you informed of the status of these businesses as soon as payment has been made. Thank you for your services and support. CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH s 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 STANLEY J. USOVICZ, JR. FAX 978-745-0343 MAYOR wW W.SALEM.COM JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT December 19, 2005 Joseph Carnevale Derby Fish & Lobster Corporation 215 Derby Street Salem, MA 01970 Dear Mr. Carnevale: r water service has been notified us that ou a The City of Salem Water Department has no y shut off. Lack of water service to your establishment creates an imminent health hazard requiring immediate suspension of the food establishment permit. Therefore, all operations at Derby Fish & Lobster Corporation, 215 Derby Street, Salem, Massachusetts, shall immediately cease and desist. This emergency closure shall be in effect until the Salem Water Department notifies the Board of Health that water service has been restored. 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, 120 Washington Street, 4`h Floor, within ten 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. Sincerely, panne Scott �S bsS )jv t'i" Health Agent r y� lt" Z . ,.. y..wry • ..K_ '.�n}..:.s.> `" f � ,•y s .::..x n r : ✓la..rvq r +pp CITY OF�SALEM, MASSACHUSETTS .]L BOARD OF.HEALTH 120 WASHINGTOr;STREET, 4TH FLOOR a 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 Fish & Lobster Address of Establishment: 215 Derby Street Owner's Name: 'Joe Carnevale Restrictions: Application Date: 12/2/2004 Permit for Food Establishment 148-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT CITY OF SALEM, MASSACHUSE C92 114n BOARD OF HEALTH VVV vv�l�J! 120 WASHINGTON STREET, 4TH FLOOR SALEM, ham, 01970 NOV 3 0 2004 TEL. 978-741-1800 FAX 978-745-0343 CITY OF SALEM STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH MAYOR HEALTH AGENT 2005 APPLICATION ��-- <i<p r kFOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT J S/J0/39-re d-1, '2 TEL# An179-7y-a 77 -"96V . ADDRESS OF ESTABLISHMENT �� '✓ �� MAILING ADDRESS (if different) / /� /� 7 OWNER'S NAME f efe'{3y 'I'S� % 063-reC (20 TEL# 5'��1��,��G�G � r ADDRESS 0 /;) CITY S5 4 e--i STATE. /",i9 zip_0/7-5-0— CERTIFIED 2 -5-0—CERTIFIED FOOD MANAGER'S NAME(S)TU-7- (?/4a,y)E?✓hLLSCERTIFICATE#(s) S.v3 (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON (PIT HOME TEL# Q7Y-7�6 414 Y HOURS OF OPERATION: Mon.R--q-Tue 9-i Wed.2-'� Thu..9-7 Fri.0 4 Sat.!;7--q Sun TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than I000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES NOS 6� less than 25 seats =$100 25-99 seats more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. rsuant o MGL C apter 62C, Section 49A, I certify under the pains and penalties of perjury that 1, to my be t kn d belief, hav 'led alls to xJeturns and paid all state taxes fequired under the law. . 1off - Or/ oa- �/37'Dy Ignature Date Social Security or Federal Identification Number --------------------- ----- ------I-------.-,--- --- ---------- Revised 11/03/03 FOODAP2.2dm Check#& Date j 3;L3l 111,U)61 0215 DERBY STREET Derby Fish & Lobster City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: - PROTECTION FROM CONTAMINATION 745-2064 Food Contact Su aces Cleaning and Sanitizing FAIL Critical ❑� RED Owner. mmem: Counter cutting boards are stained and scored. Resurface or replace the cutting boards. Joe Carnevale (" Handwash Facil" FAIL Critical 0 RED PIC.' m = Joe Carnevale C ment:The kitchen handwash sink.found obstructed. Keep the handwash sinks clear and accessible at all times. Inspector: _ Violations Related to Good Retail Practices (Blue Items) David Greenbaum.. Food and Food Protection FAIL Critical BLUE Date Inspected: Correct By: cment: Keep flour containers properly covered. 11/30/2005 EquipAa��crowave FAIL BLUE RISK Level: canopener has an accumulation of grime. Thoroughly scour the canopener. at the counter has an accumulation of food spills and splatter. Thoroughly clean the microwave. Permit Number ®.. counter cooling unit has an accumulation of grime amd mold. Thoroughly clean and sanitize the cooling unit. !:BHP-2005-0196` Physical Facility FAIL Non-Critical BLUE Status: —Comm The walls ain dry storage have an accumulation of mold. Thoroughly clean and sanitize the area and repaint. VIOLATION ^- ThelAeare some missing ceiling tiles in the back areas. Replace all missing ceiling tiles. #of Critical Violations: 1 ll and soda lines behind the ice machine have an accumulation of dust. Thoroughly clean the walls and soda lines. TaP-sink has an accumulation of dirt and debris. Thoroughly clean the mop sink. 3 3- 04 entire establishment in in need of a thorough cleaning including under and around all equipment. Time IN: rime OUT:_ GENERAL COMMENTS: Urgency Description(s): 390:Reinspection will be in one week, all violations to be corrected. 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®2005 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Dec 01,2005 ) 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®2005 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Dec 01,2005 ) Page 2 oft uJ c 0215 DERBY STREET Derby Fish & Lobster City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) :745-2064 = s Physical Facility FAIL BLUE Owner. Comment:The walls in dry storage area have an accumulation of mold. Thoroughly clean the walls and repaint. Joe Carnevale _ Reace any missing ceiling tiles oin the back area. PIC' These items to be corrected by the next routine inspection. Joe Carnevale - GENERAL COMMENTS: Irispector. " David Greenbaum° 399:AII other violations cited in the 11/30/05 inspection report have been corrected. Date Inspected: Correct By:, 12/8/2005 - Risk Level: y Permit Number: , BHP-2005-0196`a� Status. SIGNED OFF #of Critical Violations: 0 T' - 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®2005 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Dec 12,2005 ) Page 1 oft r 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®2005 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Dec 12,2005 ) Page 2 oft U215 DERBY STREET Derby Fish & Lobster City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Telephone: Item Status Violation Critical Urgency Nature of problem or correction 745-2064 Non-compliance with: Done Owner Anti-Choking PASS ❑ Joe Carnevale s _ Tobacco PASS ❑ PIC: _ Joe Carnevale FOOD PROTECTION MANAGEMENT Done Inspector:Carnevale PIC Assigned/Knowledgeable/Duties PASS RED Janet Dionne& -= EMPLOYEE HEALTH Done orrect By: Reporting of Diseases by Food Employee and PIC PASS ❑d RED Date Inspected—Fc 4/28/2005 Personnel with Infections Restricted/Excluded PASS [] RED Risk Level: FOOD FROM APPROVED SOURCE Done Permit Number: Food and Water from Approved Source PASS ❑d RED BHP-2005-0196 Receiving/Condition PASS ❑d RED Status: Tags/Records/Accuracy of Ingredient Statements PASS ❑d RED Closed j Conformance with Approved Procedures/HACCP PASS [] RED #of Critical Violations: q Plans PROTECTION FROM CONTAMINATION Done Time IN: Time OUT:;. Separation/Segregation/Protection PASS RED Notes: Food Contact Surfaces Cleaning and Sanitizing PASS ❑J RED .116:hood vents Set to be Proper Adequate Handwashing PASSd❑ RED cleaned serviced tonight 4/28/05. Invoice to be Good Hygienic Practices PASS ❑Q RED sent/faxed to board of health Office for our records. ' Prevention of Contamination from Hands PASS RED Handwash Facilities PASS ❑d RED Urgency Description(s): BLUE: Violations Related to Good GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Apr 28,2005 ) Page 1 oft 6215 DERBY STREET Derby Fish & Lobster Retail Practices (Critical PROTECTION FROM CHEMICALS Done violations must be corrected Approved Food or Color Additives PASS ❑d RED immediately or within 10 days)(Non-critical violations Toxic Chemicals PASS RED must be corrected immediately TIME/TEMPERATURE CONTROLS(Potentially Haz Done or.within 90 days) Cooking Temperatures PASS ❑Q RED RED: z Violations Related to Reheating PASS O RED Foodborne Illness Interventions and Risk Factors (Require cooling PASS D RED immediate corrective action _ Hot and Cold Holding PASSd❑ RED Time As a Public Health Control PASSd❑ RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Done Food and Food Preparation for HSP PASS Q RED CONSUMER ADVISORY Done Posting of Consumer Advisories PASS ❑d RED Violations Related to Good Retail Practices (Blue Done Management and Personnel PASS ❑ BLUE Food and Food Protection PASS ❑ BLUE Equipment and Utensils PASS ❑ BLUE Water, Plumbing and Waste PASS ❑ BLUE Physical Facility PASS ❑ BLUE Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other-See Notes PASS ❑ BLUE all other violations cited in 4/21/05 report have been corrected.Thank you GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Apr 28,2005 ) Page 2 oft DepartmentMassachusetts FOODBORNE ILLNESS COMPLAINT WORKSHEET Please Complete and Send or fax to: Questions? Calk Date: /ZI 105 MDPH Food Protection Program Food Protection Program: (617) 983-6712 305 South Street,Jamaica Plain, MA 02130 Division of Epidemiology: (617) 983-6800 #: Fax: 1617) 983-6770 Enterics Laboratory: (617) 983-6609 //�� PERSON COMPLETING INFORMATION Name. l7 �r-� �: 1 ! /O 1 L�� PDD Affiliation: Local BOH (town): r",, ❑ State DPH (division): ❑ Other: c I / GI F�EPORTER / COMPLAINANT p 901- Name: 0. JTZfa7r) �L a: l�a / ) `3 7� Affiliation: Consumer specify, ,/ orf e4 ❑ Laboratory division, �f ��!/ � � l ❑ Local BOH facility, 1 l ❑ Medical Provider address, JA O Vrh ❑ State DPH town, etc. ❑ Other ILLNESS INFORMATION # Persons ill:0 Symptoms: (mark if reported for anyone): ADiarrhea ,gvomiting ❑ Nausea ><Abdominal cramps ❑ Fever ❑ Bloody stool ❑ Headache ❑ Muscle aches ❑ Chills ❑ Loss of appetite ❑ Fatigue ❑ Dizziness ❑ Burning in mouth ❑ Other symptoms: .....................................................................................��..............❑AM PM Onset: > i Earliest Date: / 1Q� Time: S.L�L Latest (if > 2 ill) Date: / / Time: ❑AM ❑PM ................................. .... .... ................ .................................: Duration: Less than 24 Hours ❑ 24-48 Hours ❑ More than 48 Hours ❑ Ongoing ❑ Unknown Ill Persons: Age Name AddresslTown V (yrs) Occupation Med. Provider/ W 1 Alsame as reporter(above) 2 3 4 Medical attention received (by anyone)? ❑ Yes No ❑ Unknown fir yes, specify above: T Stool specimens submitted (by anyone)? ❑ Yes o ❑ Unknown –> To SLI '? ❑ Yes ❑ No ❑ Unknown Medical diagnosis reported? N FOOD HISTORY — Obtain history back 72 hours prior to symptoms, or, if organism identified, b/n min and max incubation periods (see p.2) — If > 2 ill, follow above time frame for common meals(foods) only J k Restaurant I store where 1 Fxn3 e Irl oS ToA611 ,C-0*41e' ASame bas left) ❑Home h o5ther (specify): t I ❑ L (ii3oWG OD IfIU e A arInar DcR-1wy 1sN�lA ctb S 1 State Laboratory Institute,305 South St-,Jamaica Plain,tv1A,02130 - (617)522-3700 Sept 1999 (99SeptForm.doc) 2 Always record Time if possible:otherwise,choose B=breakfast,L=lunch,D=dinner Discard Previous Versions 3 Total#persons(both ill and well)who consumed indicated food(s) MDPH Foodborne FOOD HISTORY (continued) # Restaurant/store where Date & Timq' Exp' Food(s) consumed purchased (name, town) Place consumed 1- BKM16S ' 0-ast 1 CO Q,, Same(as left! o Home ❑ I11V L 7-a n110L 1 QC ❑ Other(specify): ❑ 6 r -wAto S,-Toco f 00 O _ Same(as)err) ❑Home Other(specify): I15 6 no YL�L CC{Rc /M to (maybe) Sta{ood / 4cr 6; a rolne 0 ❑Same(as left) ❑Home 0 L ((eauroi4 ❑ Other(specify): 11 D ori 1 n 9+on 1 k, 0 B ❑ (as— left) 11 L 11 Other(specify): 0 B ❑Same(as left) 13 Home p L ❑Other(specify): 0 D NOTES FOOD TESTING Food(s) available for testing? ❑ Yes No ❑ Unknown —4 Sent to SLI '? ❑ Yes No ❑ Unknown —> ff Yes, specify food/sl & sources: Product and Manufacturer Information for Commercially-Processed Food(s) Product name: Code/lot # Expiration date: / / Package size/type: Manufacturer: Address: Incubation Periods for Selected Organisms Min Max Min Max Min Max B. cereus (short) 1 hr 6 hrs E. coli 0157:H7 3 days 8 days Staph. aureus 30 min 8 hrs B. cereus (long) 6 hrs 24 hrs Hepatitis A 15 days 50 days Shigella 12 hrs 96 hrs Campylobacter 1 day 10 days Salmonella (non-typhi) 6 hrs 72 hrs Vibrio cholerae few hrs 5 days Cyclospora 1 day 14 days Salmonella typhi 1 wk 3 wks Viral GI 12 hrs 48 his C. perfringens 6 hrs 24 his Shellfish poisoning minutes few hrs Yersinia 3 days 7 days 1 State Laboratory Institute,305 South St.,Jamaica Plain.MA,02130 - (617)522-3700 Sept 1999 (99SeptForm.doc) 2 Always record Time if possible;otherwise,choose B=breakfast,L=lunch,Dinner Discard Previous Versions 3 Total#persons(both ill and well)who consumed indicated food(s) nb 4/21/05 Memo- Send to file Based on a complaint of a patron that got sick at this establishment an inspection was conducted. The following were noted: No Violations were seen at time of inspection. Shellfish tags were available at time of inspection and observed. The patron had Muscle Marinara. The Muscles are received from Patriot Lobster and Seafood.Once delivered,they are placed in the Walk-in refrigerator in covered buckets on ice.The Walk-in had a temperature of 40 degrees F. The Muscles and other seafood tested.Had a temperature of 39 degrees F. When needed the muscles are then placed in the fish display case where they were had a temperature of 40 degrees F.The display case had a temperature of 40 degrees F. The muscle marinara is made to order.The cook takes the Muscles from the display case. Gloves were being wom at time of inspection.The muscles are then placed in a pan with garlic butter and cooked on stove.Wine is then added cooked.Marinara sauce is added and then all is placed over pasta and served. Marinara sauce is made from canned tomatoes,garlic and other spices,red wine and water.It is cooked in back area. Then held at heating station until used. Janet Dionne Sr. Sanitarian 4/21/05 Memo- Send to file Based on a complaint of a patron that got sick at this establishment an inspection was conducted. The following were noted: No Violations were seen at time of inspection. Shellfish tags were available at time of inspection and observed. The patron had Mussels Marmara. The mussels are received from Patriot Lobster and Seafood.Once delivered,they are placed in the Walk-in refrigerator in covered buckets on ice. The Walk-in had a temperature of 40 degrees F. The Mussels and other seafood tested.Had a temperature of 39 degrees F. When needed the mussels are then placed in the fish display case.The mussels in the display case had a temperature of 40 degrees F.The display case had a temperature of 40 degrees F. The mussels marinara is made to order. The cook takes the Mussels from the display case. Gloves were being wom at time of inspection. The mussels are then placed in a pan with garlic butter and cooked on stove. Wine is then added and cooked.Marmara sauce is added and then all ingredients are placed over pasta and served. Marmara sauce is made from canned tomatoes, garlic and other spices,red wine and water.Marmara sauce was held at proper hot holding temp. Janet Dionne Sr. Sanitarian I ' C� v, `e - ai UV Apr 03 05 O5:56p Dina Onests 03 319 0645 p. 1 industrial Steam Cleaning Invoice 1712 Beulah Rd I1e VkWU6VA 22182 (7O3)31"567 t32 as TO Jab SW Doft Fish Darby Fish 215 Derby St 115 Derby St Salem MA Worn MA p Tom$ 8atvldd age 3x a ♦3/2005 Daaetlgfon Amaatt C h mially Strain Ciwn khcbM arheust syu m Aa directed by impM W tare 325.00 Travel and imus mo Sec 25.00 TO $350,0n Faymeab reeeh+ed agar 30 Qays will be$*CO to s 1.5%almMly finance chugs i0 39Gd HSIdASd3Q6666IbL I9:0Z S00z/Bb/170 "- x- 02;5 DERBY STREET Derby Fish & Lobster City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Telephone: Item Status Violation Critical Urgency Nature of problem or correction 745-2064 Non-compliance with: Done "Owner: Anti-Choking PASS ❑ Joe Carnevale Tobacco PASS ❑ PIC Joe Carnevale m FOOD PROTECTION MANAGEMENT Done PIC Assigned/Knowledgeable/Duties PASS ❑d RED Inspector: Janet Dionne „I EMPLOYEE HEALTH Done Date Inspected: COrreCt By: Reporting of Diseases by Food Employee and PIC PASS ] RED 4/21/2005 Personnel with Infections Restricted/Excluded PASSd❑ RED Risk Level: FOOD FROM APPROVED SOURCE Done Permit Number: Food and Water from Approved Source PASS ❑Q RED t BHP-2005-0196 Receiving/Condition PASS ❑d RED Status: Tags/Records/Accuracy of Ingredient Statements PASS ❑/ RED Open t ., #Of CfItiC81 VIOIatIonS: Conformance with Approved Procedures/HACCP PASS RED Plans 3 Time IN: Time OUT: Notes: 107: z Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical: violations must be corrected immediately or within 10 days)(Non-critical violations GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Apr 22,2005 ) Page I of 021.5 DERBY STREET Derby Fish & Lobster must be corrected immediately PROTECTION FROM CONTAMINATION Done or within 90 days) Separation/Segregation/Protection PASSd❑ RED RED:'' Violations Related to Food Contact Surfaces Cleaning and Sanitizing FAIL Criticald❑ REDutting boards throughout stained and Foodborne Illness Interventions scored-resurface or replace and Risk Factors (Require Proper Adequate Handwashing PASS d❑ RED immediate corrective action) Good Hygienic Practices PASSd❑ RED Prevention of Contamination from Hands PASSd❑ RED Handwash Facilities FAIL RED - issing sign-provide sign-hand wash sink-handwashing onlly. aiko there was scrubbers and glass ✓cleaners at sink indicating that utensils coffee pots are being washed at hand sink. only handwashing is permitted at hand sink. all dishes to be cleaned in back area to get cleaned and sanitized between uses. PROTECTION FROM CHEMICALS Done Approved Food or Color Additives PASS ❑d RED Toxic Chemicals PASS RED TIMEITEMPERATURE CONTROLS(Potentially Haz Done Cooking Temperatures PASS ❑d RED Reheating PASS ❑d RED Cooling PASS ❑d RED Hot and Cold Holding FAIL Critical RED 1✓clam chowder held at 138°f. clam chowder was reheated at time of inspection and shall be held at 140°f or above. Time As a Public Health Control PASS RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Done Food and Food Preparation for HSP PASS ❑d RED CONSUMER ADVISORY Done Posting of Consumer Advisories PASS 0 RED GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Apr 22,2005 ) Page 2 of 0215 DERBY STREET Derby Fish & Lobster Violations Related to Good Retail Practices (Blue Done Management and Personnel PASS ❑ BLUE Food and Food Protection FAIL Critical ❑ BLUE age" air,,win refrigerator,cajun soning, cXtons, had some uncovered ,,K all food in storage must be covered at all times. %,/A11 dry ingredients not in original containers to be labeled. $ ki reezer had food stored on floor. all "foo o be kept at least 6-8 off floor. Equipment and Utensils FAIL Critical ❑ BLUE ife in knife rack had accumulation of food debris thoroughly clean and sanitize between uses. C opener had accumulation of food ebris.thoroughly clean and sanitize. L.s ize log not being maintained. maintain ally. tFFyyeee bay sink to be labeled wash, rinse, L.,fanitize. el produce bay of three bay sink. wa7ucin freezer had accumulation of ice. U,owner stated there was a leak and that he has corrected it. remove all ice build up from Floor of walkin. of counter refrig. unit needs thorough cleaning of mold accumulation on fans. b rageair unit had old lettuce and food ebristhoroughly clean unit. elves,walls throughout establishment, cookline need general cleaning of crumbs and food debris and splatter. knivpslteing stored between/under tainers. knives to be stored in proper knife rack or in cantainer with sanitizing solution at 50-100 ppm to sanitie between uses. X. icrowave needs general cleaning of food GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Apr 22,2005 ) Page 3 of 0215 DERBY STREET Derby Fish & Lobster splatter. �.- hood vents to be serviced and cleaned. ice machine had accumulation of mold uild up thoroughly clean and sanitize. Water, Plumbing and Waste PASS ❑ BLUE _ Physical Facility PASS ❑ BLUE ,seme ceiling tiles cracked or not secure. repair ceiling tiles. Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other-See Notes PASS ❑ BLUE P� GeOTMSO 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Apr 22,2005 ) Page 4 of CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH g} 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 Fish & Lobster Address of Establishment: 215 Derby Street Owner's Name: Joe Carnevale Restrictions: Application Date: 12/2/2003 Permit for Food Establishment 89-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT CITY OF SALEM, MASSACHUSETTS '� BOARD OF HEALTH I�Ij • s 120 WASHINGTON STREET, 4TH FLOOR I/ NOV hr',ry a g' SALEM, MA 01970 NOV 18 200`1 TEL, 978-741-1800 FAX 978-745-0343 Cl f Y OF SALEM STANLEY USOVICZ, JR. BOARD OF HEALTH JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT 6D ? til '�� 1JJ-`. Mn TEL# 97 d"- /�S-; // 06, 7' ADDRESS OF ESTABLISHMENT �C/S /e-2/3y SxT S,449/�I lv?4 0 7 MAILING ADDRESS (if different) OWNER'S NAME:yJ2- TEL# ADDRESS CITY S 2 STATE ,,5P74 ZIP O/ 5 7U CERTIFIED FOOD MANAGER'S nIAME(g)TDL C Al?A/P✓19L Ls CERTIFICATE#(c)�/ S 0703 (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON `IDL' C/(/( //r?✓bLL' HOME TEL#yz� rY5�j� HOURS OF OPERATION: Mon�Tue.! Wed. -! Thu.�Fri.ELSat.qsun/—P TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 0 more than 10,000sq.ft. =$250 RESTAURANT � � NO less than 25 seats =$100 E 25-99 seats . _$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. ursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my b st kn wle and b 6 f, have filed II state t x r turns and aid all state taxes re wired under the law. �I �g� ✓r -7f 3 p o y-3/33 42 gnature Date Social Security or Federal Identification Number ------------- ------- ------ Revised 11/03/03 FOODAP2.adm Check#&Date Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4t" Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name Date Tvoe of Ooeration(s) Type of Inspection IV/.r# LoBd1rA/t /O c [Food Service Routine Address Risk ❑ Retail ❑ Re-inspection 0QArg_,fy Sr Level ❑ Residential Kitchen Previous Inspection Telephone -71VC, M ❑ Mobile Date: OwnerHACCP YM ElTemporary ElPre-operation Idic cefingl4gVA-Lx ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In: [I HACCP Inspector t ^ M Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provisions)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT _ ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties W35, Handwash Facilitie2� EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC = El3. Personnel with Infections Restricted/Excluded E3 14.Approved Food or Color Additives FOOD FROM APPROVED SOURCE [115.Toxic Chemicals ❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 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 Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) El 10. Proper Adequate Handwashing ❑ 21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices `CONSUMER ADVISORY " ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions Z 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 p of Health. today, the items checked indicate violations of 105 CMR CX 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 26. Water, Plumbing and Waste (FC-5)(590.006) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: �It�/Qy S:5901ns dFomr 74d c I Inspector's Signature: / _ Print: PIC's Signature:,f l l ,�� J� -- _ Print: 0 C]&)_I.(�.P-A 4� Page of Pages Violations Related to Foodborne Illness Interventions and Risk Faders(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT I )O�.�03(N) ks�ignnreni of ReK2�11b'li"- 590003(,13) Dcmorisfration(if KnowledEL-- Cooked and RTF,Ryods- LL-011 U---1—perna-21—cha%LTLn —dt — Costamation from Rate Ingt epents 3-30211(A)(21 Riw Animal Foods Separated froin Each - EMPLOYEE HEALTH Other* ,710(C Responsibility of the person in charg W -- Contnioation from the EnVZnmerW require repotting by tbW employees and 3-302-I I(A) ._ Fooxl Pa nervr)0 — 3-30115 wushlylF rtsand Veaetabl Al 010s 590.003(F) kcspon,,4ility Of A Food Empforce dr—An 3--3 A�1 T-o)d Coal ret with F,qumment and Applicant To Report To Th Pcrion In Utensdsr Cha j"e* 590.003(G? 3 306.1 4'A)f B) Returned Food and Roocooicc of Food' 3 590.))0;(17) F.ccluuone and Restriction,t Disposition 590.003 L; Rvinoval of ExdusionF and R:1:i1r:11�t'1n11 -- Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food" T—Food andWater From RegulatedSourcesFood CoWtmi-iTURa-C`e;---- 590.0014(A-131 Compliance with Food Law' 4-5t)I I I I Manual Warewashiin,- Hot Nater 3-201�12 F(xxI in a Hermeticaily Sinded Corsainer* — 3 --j- -201,73 Fluid Milk and Milk Produce 4-501.1.12 iliuJumi,;at Warewashm- Hoi Witer 3-2024 Sh"li Egg,' Sanitizatipri Ten )e!��ures* �L ___,_ -hemical sailitization-temp PH, 4-50111,1 C 3-201.14 Finn,and %1UProducts.Pasteurizcd* , concentration and hardness 3-202416 fee isladc FroaPotz0jic Droikina,Wat--' �- A-6011 I(A) Equipaltot Food coinact su�la�e� md 5-10;.11— Drinkinp Water from tat Approv,�d System* Uiennls Cleau� 190.00Bottled Drinkinv,Watei* ...... 6(A) 4-60211 Cleaning Frequency of Equipment Ford- 59().006(B) Water Meets Standards in 310 CMR 22-0'r Contact SurfaceF'and t ltexv;ils� Shp#fish and Fish From an Approved Source — 4-102.11. I tequencof sawk,iiion of Utensils and 3-201.14 Fish and Recreationally Caught A101111scan Food Cont act Surfaces of Pquiprnetttz` sho'llfish* 4-703.11 'methods of sanaWllon-- Hot Water and 32,03.-,5 Molluscan Shellfish foun NSSP Listcd Chmlcal- Sources* Proper,Adequate Handwasom- Game and Wild Mushrooms Approved by F-16 T- 9 - Aulhotify 1 2301A I Clean Condition- Hands and Ai:ms"` _Eeqij)jtoj�u F2-;61.3.2 Clisinim,Provedinel' 3-20118 1 5a.0.004"Ci 1 Wild fvlushroirms� 2 3101 14 -mleo to Wash* 3-201.17 Garne Animals" ti Good Hygienic Practices ReceivingfCondition -101.1.1 Eafilw'DrinkitiL2Luw'% 3 202.13 Pf IFs Receives Temperinui es* 2401.12 Discharges From the E yes,Nose and 3-201 i.i ---- Mouth —J_-3()1.12 Containination `ikrhen Ta 3-tt'i'Tt Fo(Z'Safe and1'14�In 'i"Ien Tafelqt --- Shellstock LIZ-- Prevention of Centanyineflon from Hands 3-212.-8 Shellstock Identification— 590.004(E) Preventing Contamination from -3-203.1 '�Mistoi:R luentin cation Maintained* _L11-IL ON—ee 3 FHandwash Facdifies Tags/Records:Fish Products Conveniently La,-,,—tedanj�oasbk� 3-402.1 t Parasite De,truction* -1-401,12. Records,Cncaflon arid Retention* 72ETT' NumbciyandC�aamties* 1 590.0040) Labeling of Ingredients' .... 5-204,11 Location and PI[cement" Conformance with Approved Procedures 5-^05'11 /fIACCP Plans Supplied with Soap and Hand Drying 3-,Y)2,1 J _S�iahzcd Processm,ALelloW Devices 6 V)I,l I Iiandeashhw Cleanser.Avaibbibty 5-i02 I Z Reduced oxvLen packagins,on"Afal — — -301,12 fiand Dr�im,Pro%i%ion EEET--12—-LO-11-iL) !-AP�)ros� d pluiredores, 1,6 'Deno;e,critical nein jii flic federal 1999 Food(Lfsie or j(l5("NjR 5)()000, CITY OF SALEM BOARD OF HEALTH // / Establishment Name:.0G�(d-/�t/ ill 4a8s'r'ax- Date: /0— oy Page: Z of Item Code C=Critical Rem DESCRIPTIONOF VIOLATION/PLAN OF.CORRECTION Date No. Reference R—Red Item - Verified PLEASE PRINT CLEARLY.. �-N C P00 W�1ie /I-( A . 4"_ ogntnO?JS C044a ©PxKAF.c ffitr JW ceu .r/ aF 0"" teA&Baits 19 C x & 19 3 C s Q s, j#f- Srf..,a- 52" IRA044 06 X2 - A*%Qr'1r1 /Uu � C ! _ cwt Agillu4L d n0sa S A+tjP 3'p i t ftyA *twtr r dvO � r falt4 F4$12J, j Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ 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-fi a dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. LiVoluntary Disposal ❑ Other: ti r 3-50 L H(C) PHFs Received at Temperatures Violations Related to Foodborne fitness Interventions and Risk According to Law Cooled to Factors(items 1-22) (Cont.) 41"F/45'F Within 4 flours. 19 PROTECTION FROM CHEMICALS 3-SOI,'15 Coohna Methods for PHFs 14 Food or Color Additives PHF Hot and Cold Holding 3-202.12 Additives" 3-501.16(13) Cold PFIFs Maintained at or below 590.004(F) 41°145°Fes` 3-302.14 Protection from Toxic Substa Additives* 3-501,16(A) Hot PHFs Maintained at or above 1S Poisonous or Toxic Substances 40'F, * 7-101.11 klentifying Informtio an-Ori 1 nal 3-501A6(A) Roasts Held at or an .. F.oae 130` Containers* 7-102.11 Common Name-Workim, Containers* 20 Time as a Public Health Control 7-201.11 Se oration-Storage' 3-507.19 Time as a Public Health Control" 7-202-11 Restriction-Presence and Use* 590.0(k1(H) VarumceRe uirement 7-202.12 Conditions of Use 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers,Criteria-Chemicals* POPULATIONS(HSP) _ 7-304.1.2 Chemicals for Washinu ProdUCe,Criteria" 21 3-80L l I(A) Unpasteurized Pte-packaged Juices and 7-204.14 Drying Agents.Criteria' _ Beverag=es with W'arninu.Labels* 7E7O 20511 Incidental Food Contact-Lubricants* 3-801.11(8) Use of Pasteurized Pp,as* Restricted UgsPesticides.Criteria* 3-801 A I To Raw or Partially Cooked Animal Food and 2Rodent Bait Stations3-801.11(03 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Food,That are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate _3-407.17A(1)(2) Eggs- 155°F 15 Sec. Pawogens.*Eaecn.e uvaroi F es-hrmiedtate Service 145°F15sce, 3-30'_.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Como innted Fish,Meats&Game E"gs' Animals- 155°F 15 sec. '" 3-401-I 1(8)(1)(2) Pork and Beef Roast- 130"F 121 mini 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 Came, Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited udder the appropriate sections Poulk or Ratites-165`17 I S sec. * above if related to foodborne illness 3-401A I(C)(3) Whole-muscle,Intact Beef Steaks interventions and rick factors. Other 145°F* 594.009 violations relating to good retail 3-411.12 Raw Annual Foods Cooked in a practices should be debited under#29- Microwave 165`F* Special Requirements. 3-40L11(A)(1)(b) All Other PHFs-- 145'F 15 sec. * I7 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165'T I5 sec. " (Items 23-30) 3-403.11(B) Microwave-165°F 2 Minute Standing Critical and non-crificat viola tuns, which do not relate to the Time* foodborne illness inter veniian,s and risk factors listed above, can be, 3-403.11(C) Commercially Processed RTE Food- ,found in the following sections of the Food Code and 105 CMR '1400F* 590.000. 3-403.11(6) Remaining Unslieed Pardons of Beef Item Good Retail Practices_ FC 590.t1PD Roasts* 23. Mena guest and Personnel _ FC-2 .003 18 Proper Cooling of PHFs 24._ Food and Food Prdection _ FC--3 004 25 Equipment and UtensilsFC 4 .065 3-501..14(A) Cooling Cooked PHFs from 140`17 to -- - - --- 26 Water,Plumbing and Waste FC 5 ,006 70'F Within 2}lours acid From 70°F 27. Ph sic_a!Facili -FC-6 � 007 to 41.'F/45"F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(13) Cooling PHFs Made From Ambient 29. S eCial Re uirements .009 Temperature ltngredients to 41 017/45`T 30. _ Other Within 4lours`i it r.ar z.ao, *Denotes critical item'm the lederal 1999 FoodCode or 105 CMR 590000. Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4'" Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date T pf O eration s Type of Inspection Ra /S�l Lo,9 rG�R �d Food Service ❑ Routine Address Risk I ❑ Retail ®inspection Telephone LevSL4 [I Residential Kitchen Previous Inspection 7Y-ra 2Dl /'"r ❑ Mobile Date: Owner e &-vA[Lw HACCP YM ❑❑ CatererTemporary ElPre-operation ❑ Suspect Illness Person in Charge(PIC) 574o4tr Time ❑ Bed& Breakfast ❑ General Complaint In: [I HACCP Inspector 04 V/0 GRArSY1-1fWM Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT' _.. ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties EMPLOYEE HEALTH El 13. Handwash Facilities ` - PROTECTION FROM CHEMICALS - ❑ 2. Reporting of Diseases by Food Employee and PIC E] 3. Personnel with Infections Restricted/Excluded El 14. Approved Food or Color Additives ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source ;TIMErrEMPERATURE.CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATION "" ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ;..REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)_ [110. Proper Adequate Handwashing [:121. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices =-CONSUMER.ADVISORY ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR ofC each. 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 cited in this report may result in suspension or revocation of (Fc-a)(sso.00s) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (Fc-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (Fc-7)(590.008) 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: 5:5001nsp dFom -14do - Inspector's SignatI Print: PIC's Signature: 1 J/� OC �� Print: J SQ yJ 9 Page / of Pages Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT H Cross-contamination 1 590.003(A) Assignment of Responsibility* 3-302.1 I(A)(1.) Raw Animal Fools Separated From 590.003(B) Demonstration of Knowledge' Cori and RTE Foods"' 2-103.11 Person in charge-duties Contamination from Haw Ingredients 3-302-11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Contamination 2 590.003(0) Responsibility of the person in charge to Confamrnation lrom the Environment require tepor-Ling by'food employees and 3-302.1HAI Food Pi(dection* applicants" 3-302.15 Washing Fruits and Vegetables 590.003(2) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person InI CJtensits* Chat*e'" Contamination from the Consumer 590.003(G) 3-306.14(A)(B) Returned Food and Reservice of Fes: 3 590.003(1)) Exclusions and Restrictions* Disposition ofAduiterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioninghnsafe FOOD FROM APPROVED SOURCEFood" 4 Food and Water From Regulated Sources g Food Contact Surfaces 590.004(A-B) Ca�liancc with Food Law'" 4-501.11 1. Manual Warewashing-Hot Water 3-20L12 Food in a Hermetically Sealed Container* Sanitization Tempej atures* 3 201 13 Fluid Milk and Milk Products' 4-501.112 Mechanical Warewashing-Hot Water 3-202.13Sheth E� s* Sanitization Tem erasures* 3-202.1.4 I.; as and Milk Products.Pasteurized* 4-507.114 Chemical Sanitization-temp., pR, 3-202.16 ice Made From Potable Drinkine Water* concentration and hardness ' 5-101.11 Drinking-Water from an Approved Svstemr 4-601.t1(A) Equipment Food Contact Surfaces and Utensils Che,IV 590.006(A) Bottled Drinking Water* 4.602.11 Cleaning Frequency of Equipment Fcxul- 590.006(B) Water Meets Standards in 310 CMR 220' Contact Surfacrs and Utensik* Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitwition of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of E ui mem* 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 3. ti 3011 m Clean Condition--Hands and Ars* 3-202-1$ Shellstock Identification Present* 2307.12 Cileaitinn Pttxedure* 590-004(C) Wild Mushrooms* 2-301.14 When to Wash" 3-201.17 Game Ammals* 1.I Good Hygienic Practices $ Receiving/Condition 2-401.11 Eating, Drinking or Using Tobacco, 3 202.11 PI Received at Proper Temperatures* 2-401.12 Discharges'From the Eyes.Nose and 3-202.15 Package Imee� W Mouth* 3-101.11 Food Safe and Unadulterated" 3-301.12 Preveri Contamination When Tastinr* 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 fomes* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11. Parasite De.shatction' Conveniently Located and Accessible 5-402.12 Records.Creation and Retention* 5. 03.11 Numbers and Ca -cities* 590.004(1) Labeling of Ingredients' 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance fHACCP Plans Supplied wdh Soap and Hand Drying 3-502.11 S ecialized Processin=Methods* Devices 3-502.12 Reduced oxygen packaging,criteria- 6-301.11 liandwashiniz Cleanser.Availabilitv 8-103.12 Conformance with A xovcd Pmceduress` 6-301.12 Hand Diving Prohrislon *Denotes critical item in the federal 1999 Food Code or 105 CNIR 590.000. i CITY OF SALEM BOARD OF HEALTH Establishment Name: 19 IM"I O r# F Lcyl-rill'-d-R Date: 19Page: of 2 Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference A—Red Item Verified PLEASE PRINT CLEARLY /c a0 Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fin poi tedollars or suC /revocation of ❑ Embargo ❑ Emergency Closure your food permit. Z) Voluntary Disposal ElOther: 3-501.14(C:) PHF,Received at Temperatures Violations Related to Foodborne fitness interventions and Risk According to Law Cooled to Factors(items 1.22) (Cont.) 41'F1451F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Coolin,Methods for PHFs 19 14 v Food or Color Additives PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PFIFs Maintained at or below 590.004(F) 41145' F* 3-302.14 Protection from na roved Additives* 3-501.16(A) Iiot PHFs Maintained at or above I S Poisonous or Toxic Substances 4o'F. � 7-101.11 Identifying Information-Oria nal 3-501.16(A) Roasts Held at or above 130'F. Containers"` 7-102.11 Common Name-Working Eentainers* 20 Time as a Public Health Control 7-201.11 Separation aration-Stora e* 3-501.19 Time as a Public Realth Control* 7-202.7.1 Kestriction-Presence and Use* 590.004(H Variance Rt uirement 7-202.12 Conditions of Use, 7-203.1.1 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11. Sanitizers,Criteria-Chemicals^` POPULATIONS(HS P 7-204.12 Chemicals for Washmr;Produce,Criteria" 21 3-80L I I(A) Unpasteurized Pre-packaged Juices and 7-204.14 Dr 'in sots.Criteria* Beverages evera�es with Warning Ias* bei 7-205.11 Incidental Food Contact.Lulnicants* 3-801.11(B) C_se of Pasteurized h egs* 7-206.1 L Restricted lise Pesticides.Criteria* 3-801A 1(D) Raw or Partially Cooked Animal Food and 7-206.12 Rodent Bait Stations* Raw Seed Sprouts Not Served. 7-206.13 Tracking Powders,Pest Control and 3-801.11 tC} Uno erred Food Package Not Re-served. CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods Mar are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate 3401.1IA(1)(2) Eggs- 155°F 15 Sec. Pathogens.*`Nre Pll*maooi E jes-humedra[e Service L45°F15sec* 3-302.13 Pasteurized Eggs Substin to for Raw Shell 3-001.11(,)(2) Comminuted Fish,Meats Fz Omne Eggs* Animals-155'17 15 sec. * 3-401.1l(B)(1)(2) Pork and Beef Roast-130'F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. * catering, mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Came, StuffedPHFs, residential kitchen operations should be Stuffing Containing Fish, Meat, debited under the appropriate sections Poultry or Ratites-165'P 15 sec. * above if related to foodborne illness 3-401.11(C(3) Whole-muscle,Intact Hart Steaks interventions and risk factors. Other 145°F+: 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under§29- Microwave 165`F* Special Requirements, 3-401.1l(A)(1)(b) All Other PHFs-- '145'F15sec . * 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165"F 15 sec. * (ltene;23-30) 3-403.11(B) Microwave-165'F 2 Minute Standing Critical mrd non-critical violations, which do not relate to the Time* foodborne iilnes.s interventions and risk factors listed above, can be 3-403.1 1(C) Commercially Processed RTE Food- found in the foltownrg sections of the Food Code and 105 CMR 140'F* 590.000. 3-403.11(F) Remaining Unsliced Portions of Beef Item Good Retail Practices FC 590.000 Roasts Personnel _ FC-2 .003 * 23. Management and P 1g Proper Cooling of PHFs 24. Food and Food Protection _---- _ FC-3 _004 _25 _ _Equi mens and Utensils FC 4 ,005 3-50'1.14(A) Cooling Cooked PHFs from 140cF to 26 Water,Plain and Waste FC 5 .006___ 70'F Within 2 Hours and From 70'F 27. Physical Facility______ FC-6 .007 to 4t'F145'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(8) Cooling PHFs Made From Ambient 29- S ectal Re uiremonts _ 009 Temperature Ingredients to 41'F145''F 30 _-- Other _ Within 4 Hours'F cs m,r�c,.na-z,mc Dents critical item in the federal 1999 Food Code or 105 CNtR 590,000, al Washington Street,4'"Massachusetts Department of Public ,Health Salem Board of Health. Floor Division of Ft od and Drugs S Salem MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel.°(978) 741-1800 Fax(978) 745-0343 Name Date T e of Operation(s) e of inspection 13- 11-014 Food Service outine Address Risk Retail 0 Re-inspection Telephone Level El Residential Kitchen Previous Inspection 1k ) E] Mobile Date: 9-3-0� �� _ WOwner HACCP YM El Temporary ElPre-operation -, �«/a ILII,-4F-1Caterer El Suspect Illness Person in dhafge(PIC) Time ❑ Bed&Breakfast E] General Complaint Q_ In: ❑ HACCP Inspector 7 � fir A,/< 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 Re'- to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention Of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties El"' - m -•�•: 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 `.: m •_ ❑ ` r ❑ 4. Food and Water from Approved Source -TIMENEMPERATURE CONTROLS(Potentially Hazardous Foods) ' El 5. Receiving/Condition ❑ 16. Cooking Temperatures _. ❑ 6. Tags'/,Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Confolrmance 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 g REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) El 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices CONSUMER ADVISORY 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�Cl 2L 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 26. Water, Plumbing and Waste (Fc-5)(sso.00s> the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address Ep29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: s:ssoinspecrFomw-ra.eoo Inspector's Signature: , Print: _7 PIC's Signature: - - Print: p „ d�L Page of UPages t 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'F 3-- 2.1I(A)(1) Raw Animal Foods Separated from 590.003(B) _Demonstration of Knowledge* Cooked and RTE Foods* 2-103.1 I Person in chacge-duties. Contamination from Raw ingredients 3-302.11(A)(2) Raw Annual 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 font employees and 3-302.11(A) Food Protection* applicants* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Foal Contact with Equipment and Applicant To Report To The Person In Utensils* Char>e* Contamination from the Consumer 590.003(G) Re ortina b Person fi Charge 3-306.14(A)(B) Returned Food and Reservice of Food* 3 1 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Remova of Exclasions and Res actions Food 3-701-11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces _T90 004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot boater 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures' 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashm Hot Water 3-202.13Sanitization Tem erahues* Shell Ea s* 3-202.14 Eggs and Milk Products,Pasteurized'* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinkinn Water* concentration and ha dnocs. 'k 4-601.1 1A 5-101.11 Drinkin Water from an Approved System- ( ) Equipment Food Contact Surfaces and Ltensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590D06(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 E ui menti Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chenecal" Some a* 11 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301.1 1 Clean Condition-Hands and Arms* Regatta to uthority 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* I1 Good Hygienic Practices 5 Receiving/Condition 2-401_I1 hating,Drinking or Usitt Tobacco' 3-202.11. P111s Received at Proper Temperatures* 2-401.12 Discharges From the Eyes, Nose and 3-202.15 Paeka e Inte its* Mouth' 3-101.11. Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 TagsfReccrds:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590904(Ej Preventing Contarrrinatimt from 3-203.12 Shellstock Identification Maintained* Em to ees* TagsiRecords: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* 590.0040) Labeling of Ingredients' 5-204.11 Location and Placement* ( 7 9 7 Conformance with Approved Procedures 5-205.11 Aeoessibility.O eratfon and lvlaintenance lHACCP Plans Supplied with Soap and Nand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced oxygen racka 'ne, criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with At roved Procedures" 6-301,12 Hand Dryin�Provision Denotes critical item in the federal 1999 Fond Code or 10CLLR 590.000. I/ CITY OF SALEM t BOARD OF HEALTH Establishment Name: 17ee„�4 ,51 4 /aI3s7-CA2 Date: Page: of Item Code c-Critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date -' No. Reference R—Red Item. - Verified PLEASE PRINT CLEARLY � u . n seece i�✓ 3- 3—o is !��7/ 7,1 4 rP7- / d 4 l F i. Y �e i s 'e :Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes ❑ voluntary Compliance ❑ I have read this report, have had the opportunity to ask questions and agree to correct all 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 o twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure } your food permit. /p ❑ Voluntary Disposal ❑ Other: 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk Accordim-to Law Cooled to Factors(Items I-ZZ) (Cont.) 4 1'F145T W'iflun 4 Hours PROTECTION FROM CHEMICALS oofing Methods for PlIFs f-14 Food or Color Additives E19 PHF Hot and Cold Holding 3-501.16(13) Cold PIfFLs Marruaincil at or below 3-20112 Additives' 590.004(lc) 41°/450 F* 3-302.14 Protection troan Una roved fkddifives - 3-fi0l.16(A) Hot PHFs Maintained at or above 1-5 Poisonous or Toxic Substances 7-101.11 Idiartifying Information-Original J-- 140"F. Y I ',-501.16(A) Roasts Held at or above 130'F. Containers" 7-102.11 Couinton Naineolitainers* 20 as a Public Health Control Containers" 1 7-204.11 Separation-Storage` 3-501 19 Time as a Public Health Control* ValanceRecuirement 7-202_71 Restriction-Presence and Use, 990.004(H) 7-202.12 Conditions of Use' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 toxic Containers-Prohibitions* POPUL IONS(HSP) 7-204.11 Sanitizeis.Critejia -Chemicals* 7-204.12 Chemicals for\Vashjng Prodi 21 3-801.11(A) Unpa,eurized Pre-packaged Juices and 7-204.14 Dryiru,Agents Beverages with Warning Criteria* Isjbels* 7-205.11 Incidental Food Contact, lubricants* Bet-eta --1,(13) -211se of Pa"ell,�17ed Laos* .I I(D) Raw or Partially Cooked Animal Food and ----icstnoted Use 7-206.1 1 Pesticides,Coterie' Raw Seed Sprouts Not Served. 7-206.11 Rodent Bait Stations 3-3U7.11(D) ' '( -, 7-206.13 Tracking Powders, Pest Control and MonitoringTM CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Proper Cooking Temperatures for Animal (ands That are Raw, Undercooked or 1,6 PHFs Not Otherwise Processed to Eliminate 3-40 1.11 A(l)(2) Eggs- 195°F 15 Sec. Polio 3-302.13 pasteurized Eggs Substitute for Raw Shell F.'s* 3-401.1. (A)(2) Conindraved Fish.Meats&Gaure Animals- 1-55'F 15 sec. * - SPECIAL REQUIREMENTS 3-401.11('13)(1)(2) Pork and Beef Roast- 130'F 121 inin)l 590t009(A)-(D) Violations of Section 590,009(A)-(D) in 3-401.11(A)(2) Ratites, Injected Meats- 15-5'F 15 sec, * catering, niobj te food, temporary and 3-401.11(A)(3) Poultry,Wild Game.Stuffed PHFs, residential kitchen operations should be Staffing,Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sec. above if related to foodborne illness 3-401.1 I(C)(3) Whole-muscle, Intact Beef steaks interventions and risk factors. Other 145°F 1 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave Micro"ave 165'F* Special Requirements. 3-40 1.11(A)(1)(b) All Other PHFs-- 145'F 15 sec. 17 --Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PFlFs 165'F 15 sec. * - (Items 23-30) 3-403.11(B) Microwave- 165'F 2 Minute StandingCritical and non-crefical violations, which do not relate to the Tinte'it foodhortic illness interventions and risk factors listed above, can be 3-4C0.1,1(C) Commercially Processed RTE Food- found in the following sections of the Food(,ode and 105(-,'AIR .590.000. 3-403.11(E) Remainine.Unsliced Portions of Beef Item Good Retail Practices FC 590.000 Roasts* ' �-U- Management and Personn�vl FC-2 7003 Proper Cooling of PHFs 24. Food and Food Protection FC-3 004 LLO- 25�__Eitiap Mont and Utensils FC-4 005 -- -------- 3--S0IA4(A) Cooling Cooked PHFs front 140'F to l, 26. Water, Plurribinqand Waste i FC-5 '006 70'F Within 2 Hours and From 70'F rv-- Ph sical Facility r---- FC-6 007 to 41'F'145°F Within 4 Hear,. [2F Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient .009 Temperature Ingredients to 41'F/45'F 1-20 Other J Within 4 Hours* 1 Sfh Deane,critical item in the federal 1999 Food Cork,or 105 CMR 590.0011. 4 ` Massachusetts Department of Public Health Salem Board SHealth M. 120 Washington Street,0 Floor Division of Food and Drugs Salem,MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978)741-1800 Fax(978)745-0343 Name Daybo T e o_yp of O eratioTyob of Inspection 2 /rf - ElFoodSerns)vice 0 Routine Address Risk ❑ Retail ❑ Re-inspection Leve 71 Residential Kitchen Previous Inspection Telephone /'V1 ❑ Mobile Date:9./- d 9 2 d6 ❑ Temporary ❑ Pre-operation Owner HACCP YIN ❑ Caterer ❑Suspect illness f dfiv Person in Charge{PIC) S Time ❑ Bed&Breakfast ❑General Complaint In: [IHACCP Inspector rrXk/s Out; Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT, _ .. . ❑ 12. vention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties 13. Handwash Facilities 60 EMPLOYEE HEALTH PROTECTION FROM CHEMICALS - ❑ 2. Reporting of Diseases by Food Employee and PIC [114.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE ` .. - TIMEITEMPERATURE CONTROLS(Potentially Hazaidous Foods) ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition C116.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 ®. ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report, when signed below C 'N ' by a Board of Health member or its agent constitutes an 3. Management and Personnel (FC-2)(990.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this capon may result in suspension or revocation of 2`5. Equipment and Utensils (Fc-4)(590.005) the food establishment permit and cessation of food 2 . Water, Plumbing and Waste (FC-5)(590.006) establishment operations. if aggrieved by this order, you 27. Physical Facility (FC-6)(590A07) 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 thisforder. 30. Other DATE OF RE-INSPECTION: �j/j1 la,tt S:S801nspedro,ma-t4.tloc J s o ' gnat Print: } Pic');Sighatute: Print: 1 e l i / �, l L Page` of Pages ;k is u A R Violations Related to Foodborne illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 590.003( 1, Assignment afRespomtbilrt}' 3-302.11(A)(1) Raw Animal Foals Separated from 590.003(_$) Demanstralron of Knouledgc° Cooked and RPE Foods* _ 2-103.11 Person in charge--dutres Contamination from Raw Ingredients 3-302.1 I(A)(2) Raw Aminal Foods Separated from Each EMPLOYEE HEALTH Other' 2 590.003tO Responsibility of the person in charge to Contamination from the Environment require reporun¢by food employees and 3-30111(A) Food Protection" a nlicants° 3-3011.5 %Vashin g Fruits and Vegetables 590.003(F) Responsibility Of A Fund Employee Or An 3-304.11 Food Contact wi th Equipment and Applicant To Reporl'Fo The Person In Utensils* Charge' - Contamination from the Consumer 590.003(0) Re tort na b Person in Charge* 3-306.14W(B) Returned Food and Reservice of Fred* 'I 590.003(D) Exclusions and Restrictions*" Disposition otAdutterated or Contaminated 590.003(E) Removal of ions and Restrictions Food 3-70111 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.0(A(A-B) Ctrmptiance with Food L1w`r 4-501_11 I. Manual Warewashine-Hot.Water 3-201.12 Pool in a Hermeti Sanitization Cem)eraturey* 3-201.13 Fluid Milkand Milk Produets* 4-501.112 Mechanical Warewashing-1-lotWater 3-202.13 ShellEas" SanitizationTemperatures* 3-?.02.14 Eu=s and Milk Products.Pas en zed's 501 114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water- 4-601 and hardness. 5-101.1.1 Drinkin Water tram an A. roved S stem* 4-6011I(A) Equipment Food Contact Sm-faces and Utensils Clean* 590.006(A) Bottled Drinking Water' 4602.11 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 E ui ment* Shellfish' 4-703.1.1 Methods of Sanitization-Hot Water and 3-201.'15 Afolluscan Shellfish from NSSP Listed Chemical* Soirees* fp Proper,Adequate Handwashing Game and N11Id Mushrooms Approved by RegulatoryAuthori2301.11. Clean Condition-Hands and Alms"` t 3-202.18 ShelklockIdentification Pmsent* 2-301.-12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301-14 When to Wash- 3-201.17 Game Animals* ll Good Hygienic Practices 5 Receiving/Condition 2-401.11 Eating,Ddnklna or Using Tobacco* Discharges From the Eyes, Bose and 3-202.11 PHFs Received at Prer Tem atares* 2-401.12 3-202.15 Paclu e Lite rit y* Mouth* ro er 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock L12 Prevention of Contamination from Hands 3-202.18 Shellstoek Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintaineef' Em lovees's Handwash Facilities Tags/Records: Fish Products 13 Conveniently Located and Accessible 3-402.:11 Parasite Destruction* 3-402.12 Records, Creation and Retention* 5-203.11 Numbers and Capacities* 590,004(.1) Labeling of Ingredients' 5-204.11 Location aril Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility.Operation and Maiing Ice /HACCP Plans Supplied with Soap and Hand Drying' 3-502.11S ecialized Processing Methods* Devices 3-.502.1.2 Reduced ox vaea packa>hla.criteria* 6301.11 Hanchvashin Cleanser,Availabilit 8-103.12 Conformance with Approved Procedures'" 6-301.12 Hand Drying Provision "Denotes critical item in the t'ederal 1999 Foal Code or 105(:,IR 590.000- 1 x CITY OF SALEM "t BOARD OF HEALTH f Establishment Name: 3ZA- '% `/s/i V `or35yeA-' Date: G, a Pager of 2- yA Item Code C-Critical Item - DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red item )) Verified f^r{ $!C PLEASE PRINT CLEARLY b 27 - au Gve/R 3 J/,/-/ t 2 — Cu v e R'io o e4 Azds,'� Pe4l ll'q 'idl,-11 w-, ew _ *3 �f-�«lr��Qshir� � 0'e_ A/eprIs OPdU SC U��/� 9 27 — Ce 44A /N fiOGGuct,(o hQS /1 .SeaL s IVAIvPDifs rel 10r ti/;3 C' c�iG . /J . 7` !/�- of/S, �e Aic,oP,P �P�S� I,� rs�C G - Citi 74- ,v Sea.{'d s / r/e S �cf = /K'eSr/a°�� e e /etcc . v 2S G - /✓u� �a��P� o� f- s�iS�ri�flz/a, aGo�iGm at acc% ar�.e/< s fr,� m2 14ka,v h�T Nee��s zad�fin9. /vac/ /%s+ e //L,AIVZ ar X J4'2mi.uar� - /3/ ruvN�rt Pam(V Ff F —(-14110 4-,O -,0 r14-*,SSUe T4 isiL. 7rse4 f1G1 v/S0�`tf'" aN r"ir��l Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction/ I have read this report, have had the opportunity to ask questions and agree to correct all 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. 4' t �, � ❑ Voluntary Disposal ❑ Other: 3-KI.14(C) PHFs Received et Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(Hems 1-22) (Cont.) 41°Fl45°T_Within 4 Hours,e PROTECTION FROM CHEMICALS 3-501.15 CoolingMethods for PHFs 19 PHF Hot and Cold Holding 14 Food or Color Additives 3-501.16(13) Cold PHFs Maintained at or below 3-202.12 Addiuses^ 590.004(F) 41°i45'F* 3-302.I<1 Protection front Una coved Addvtncs* 3-501.16(,A) Hot PHFs Maintained at or above 1,5 Poisonous or Toxic Substances 140'F. 7-10 L I 1 Identifying Information-Original 3-501.16(A) Roasts Held at or above 1.30°F. Containers* 7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control 7-20L]I Separation-Stora e* 3-501.19 Time as a Public Health Control' 7-202.11 Restriction-Presence and Use* _ 59Q004(H) VLw ince,Requirement 7-202.12 Conditions of Use, 7-203-11 '1oxicContainers-Prohibitions, REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-2()4.11 Saninzc is Criteria Chemicals* POPULATIONS(HSP) 7-204.12 Chemicals for Wai Ing Pralm.e.Criteria' 21. 3-SOl.l l(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drying Agents.Criteria* Beverages with W tunny Labels* r-2f�)511 Incidental Food Contact,Lubricants* 3-801.1'1 tB} Use of Pasteurized E-s- 7-206.t I. Restricted Use Pesticides.Criteria* 3-8t}I. Rau at Partially Cooked Animal Food and Rau'Seed S grouts Not Served. 7-206.12 1 Rodent Bait Stations" � IJno cued Food Packa>e Not Re-served. '�` 7-206.13 Tracking Powders, Pest Control and 3-801.11(1) Monitorine* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Andmal Foals That are Raw. Undercooked or PHFs Not Otherwise Processed to Eliminate Pathogens Fs-Immedr rte Service 14i"F 1.$su= 3-401.11A(1)(2) Fees- m15 Sec 3-302.1, is saeu °"�'s rried E Substitute for Raw Shell ed 3-401.1 1(A)(2) Comminuted Fish.Meats&Game Ev '* Animals- I i5"F 15 sec. * 3-401.11(B)(1)(2) Pork and Beef Roast- '130'F 121 turn" 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 3-401.1'1(A)(3) Poultry,Wild Game.Stuffed PHFs, residential kitchen operations should be Stuffine Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sec. * above if related to foodborne illness 3-401.1 t(C)(3) Whole-muscle,Intact Beet 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- Miaowave 165'F* Special Requirements. 3-401,I I W(1)(b) All Other PHFs - 145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.1.1(A)&(D) PHFs 165'F 15 sec. * (Items 23-30) 3-403.11(B) Microwave-165°F 2 Minute Standing Critical and non-critical violations, which do not relate to the Time* foodborne illness interventiorts and risk factors listed above, ccnr be 3-903.11(C) Commercially Processed RTE Food- _found in the following sections of the Food Code and 105 CMI( 1.10'F* 590.000. 3-403.1I(E} RemainingUnsticedPortionsoPBeeP Item 1 Good Retail Practices _ FC 590.000 Roasts(' 23 Management and Personnel FC-2 .003 pg Proper Cooling of PHFs ( 24 Food and Foal Protection FC-3 004 0 _ . 05 3-501.14(A) Cooling Co keK9PHFtifrom 140`Fto 25 Egupme 1andUtensils FG-4 26. NJater,Runibinq and Waste FC-5 006 70''F Within 2 Hours and From 70'F 27, Ph sisal Facility FC-6 007 to 41°5145°F Within 4 Hours. " 28 1 Poisonous or Toxic Materials FC-7 .008 , 3-501.14111) Colum PHFs Made From Ambient �29, Special Requirements 009 Temperature Ingredients to 41'F145°F i 30, Other -------- - ------ Within 4 Hours* I *Denotes critical itern 1n the Pedeml 1999 Food Code of l0i CNIR 890.000. r ` 4 CITY OF SALEM, MASSACHUSETTS v�,�cormlr . BOARD OF HEALTH 120 WASHINGTON STREET. 4TH FLOOR � I L SALEil1. MA 01970 'tg TEL. 978-74 I -1 800 BGM NE FAx 978-745-0343 STANLEY USOVICZ. JR. JOANNE SCOTT. MPH. RS. CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94 , Section 305A and Chapter III , Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to : Owner ' s Name : Derby Fish & Lobster Corp . Name of Establishment : Derby Fish & Lobster Address of Establishment : 215 Derby Street Type of Establishment : RETAIL FOOD Application Date : 01/02/2003 Restrictions : Permit for Food Establishment 208-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2003 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Boar.✓d�_ofHealth./ HEALTH AGENT ' CITY OF SALEM, MASSACHUSETTS 0 BOARD OF HEALTH Yj p i 120 WASHINGTON STREET, 4TH FLOOR CEO ` O LJ4f SALEM, MA 01970 TEL. 978-741-1800 V) I 1 -_J i' vr-ii.Gilr'j FAX 978-745-0343 BOARD OF HEALTH STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2003 APPLICATION -FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT IJL F//S' /1 L/Cd/� S��TP.✓L TEL# ) ADDRESS OF ESTABLISHMENT 0?/ MAILING ADDRESS (if different) OWNER'S NAMEJ-)egN d" 7"8,'-C O&R-A TEL# 97 --X6 -aa('r ADDRESS I aaAV5S — Ci rceh STATE -2!2 _ ZIp .0/ _ CERTIFIED FOOD MANAGER'S NAME(S) ?7lSeeA` 04/LOp,/,4i 'CERTIFICATE#(s)3/S,2o3 (required in an establishment where potentially hazardous food is prepared.) p EMERGENCY RESPONSE PERSON t&t-e4lli-BlgAC, HOME TEL#97F-70;--131,k HOURS OF OPERATION: Mon.�7_ Tue. Wed.�Thu.9q Fri.�Sat.�Sun� 7 TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YE NO O less than 25 seats =$100 25-99 seats =$150c/ more than 99 seats =$200 BED/BREAKFAST YES NOS $100 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVE YES $5 TOBACCO VENDOR YES � $50 ALL NON-PROFIT(such as church kitchens) YES 00 $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. P rsuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my b t kn nd belief, a filed a I s to returns and paid all tate taxes required under the law. S' nature Date Social IS or Federal Identification Number — ----- ----------------------------------------------------- Revised 11/25/02 FOODAP2.adm Check#8 Date ^..r-"..`^"'^^`rls..+iy.,!^A...:..rih✓r.+.'�IWr�Mu"+'Wq.R/'r-�'"'fr..KA"�w+M..a�ns�`^w."�rvrn..1'��a'c"''w.�^-4+^.�w+,Ln..�-.�-+.v-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 ` Date Type of Operation(s) Ivpe of Inspection f' / Food Service Routine Address - S.� Jam__. Risk ❑ Retail ❑ Re-inspection Level El Residential Kitchen Previous Inspection Telephone 9�C'� 7/ -7� r ❑ Mobile Date: Owner HACCP Y/N ❑ Temporary ❑ Pre-operation , , �/_�- v C=} C, ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) M� Time ❑ Bed&Breakfast ❑ General Complaint Inspector O El HACCP Out: Permit No. El Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/ Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH El2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS El3. Personnel with Infections Restricted/ Excluded El 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE El 4. Food and Water from Approved Source TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 16. Cooking Temperatures El 5. Receiving/Condition El 17. Reheating El6. Tags/ Records/Accuracy of Ingredient Statements El7. Conformance with Approved Procedures/HACCP Plans El 18. Cooling El 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20. Time as a Public Health Control ❑ 8. Separation/Segregation/ Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 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: Print_ - I PIC's Signatur: Print Page/of?,Pages FORM 734A HOBBS&WARREN -BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION `8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 1 590.003(A) Assi nment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11 Person in Charge-Duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2'. 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) Food Protection* require reporting by Food Employees and 3-302.15 Washing Fruits and Vegetables Applicants 3.304.11 Food Contact with Equipment and 590.003(F) Responsibility of a Food Employee or an - Utensils* Applicant to Report to the Person in Charge* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated ,3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE g 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-temp.,pH, 3-202.14 Eggs and Milk Products,Pasteurized* 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* L Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* 11: Good Hygienic Practices 3-201.17 Game Animals* 2-401.11 Eating,Drinking or Using Tobacco* 5 Receiving/Condition 2-401.12 Discharges From the Eyes, Nose and 3-202.11 PHFs Received at Proper Temperatures* Mouth* 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-101.11 Food Safe and Unadulterated* `'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* F13" Handwash Facilities Tags/Records: Fish Products Conveniently Located and Accessible 3-402.11 Parasite Destruction* 5-203.11 Numbers and Capacities* 3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement* 590.004(J) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance 2 Conformance with Approved Procedures Supplied with Soap and Hand Drying /HACCP Plans Devices 3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability 3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision 8-103.12 Conformance with Approved Procedures* •Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH �Y Establishment Name: \ �� Date: / 3 Page: of Z Item Code C-critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified i PLEASE PRINT CLEARLY - L l �J < i ✓SOI �� 1 Z--f�v'�� V✓1 tC�c� �'"� r 't � L — IA Irl }[1 l 0 p Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes -1 have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance El Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion ' P Ll Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure { your food permit. 1 ❑ Voluntary Disposal 0 Other: r 3-501,14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to I.w Cooled to Factors(items 1-22) (Cont.) _ 41`F145'F Within 4 Hours.* PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods'for PHFs ------ 19 Food or Color Additives PHF Hot and Cold Holding jq ------- 3-501.16(73) Cold PI•TFv „Maintained tit or below 3-202,12 Additives* 590.004(F) 41`(45°F* 3-302,14 Protection from Una awed Additives* 3-501.16(A) Hot PHFs Maintained at or above S Poisonous or Toxic Substances 40`7. * 7-70111 Itltntifying lrrfonnation-Origincd 3-501.16(A) Roasts Held at or above 130'F. r * Containe '' 20 Time as a Public Health Control 7-102.1CommonName-Working�Containers" 7=201.11 Separation-Storr¢e* 3-501,1.9 Tune as a Public Health Controp 7-202.11 Restriction-Presence and Use'k 590.004(H) Variance Requirement 7-202.12 Conditions of Use* 7-203.11 Toxic Container-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204,11 Sanitizers. Criteria-Chemicals* POPULATIONS HSP 7-204.12 Chemicals for Washing Produce.Criteria* 21 3-80Ll I(A) Unpasteurized Prepackaged Juices and 7-204.14 Diving Agents.Criteria* Beverages with Warnim;Labels* 7-205.11 htcidental Food Contact,laibricams* 3-801.11(B) Use of Pasteurtaed Eve* 7-206.11 Restricted Use Pesticides,Criteria* 3-801.1,1(D) Raw,or Partially Coked Animal Food and Raw Seed S routs Not Served. * 7-206.12 Rodent But Stations" 3-801.t 1(C) Uno.ened Food Packa ge Not Re-served. 7-206.13 Tracking Powders,Pest Control and Morutorine* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3 603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw, Undercooked or PHFs Not Otherwise Processed to Eliminate fi o:7 3-4(11.11A(1)(2) Eggs- 155^F IS Sec. Padlogeris 1 '?00i Eggs-Immediate Service 145°1715sec* 3-302.13 Pastemin,d Fags Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game Eats* Animals- 155'F 15 sec. * 3-401.11(B)(t)(2) Pork and;Beef Roast-130'F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats- 155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in catering, mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Game. Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat- debited under the appropriate sections Poultry or Ratites-165'F 15 see. * above if related to foodborne illness 3-40111(C)(3) Whole-muscle,Intact Beef Steals interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Annual Fcxxls 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 3-403.11(A)&(D) PHFs 165'F 15 sec. * (Items 23-30) 3-403.11(B) Microwave- 165'F 2 Minute Standing Critical and non-critical violations, which do not relate to the 9'ime* foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found tit the folloudng sections of the Food Code and 105 CMR 14017* 590.000. 3-403.11(E) Remataing Undiced Portions of Beef Item Good Refai7 Practices FC _390_000 Roasts': 'f 23. Management and Personnel FC-2 .003 I 24 Food and Food Protection FC-3 004 18 p Cooling Cooling - 25 Water, an q and IW Waste 5 006 _1 3-301.14(A) ProperCooked PHFs 140`F to .- 70 F Within 2 Homs and From 70'F 27. Physical Facilit FC-6007 to 41'Pl45'F Within 4 Hours. * 28_ Poisonous or Toxic Materials 1 FC-7 ,008 3-501.14(B) Cooling PHFs Made From Ambient 1 29. �ecia_l Requirements Temperature fngredicntsto41°FA5'F 30- J her Within 4 Hours's `Denotes critical item in the federal 1999 Food Cede or 105 CMR 590,900. .... ..................✓-...,..., v.�.;w.....-.�..M.�•-.-.,._:...�.._y._.-�:�,wa.•nsp�w+-��::SKF.�.,.✓�:-.w++.�.F"�M"�.-M+u..�.�.^a---�-' :.+-...�.......,,,,•._.aww�w�•--,w.-... .. -HE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 120 Washington Street, 4th Floor BOARD OF HEALTH Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION RE ORTI Tel: (978) 741-1800 Fax: (978)745-0343 Name /\ �/ Date Tvoe of Operation(s) Type of Inspection - v3 Food Service Routine Address Risk EJRetail Re-inspection / Level /n/1 ❑ Residential Kitchen Previous Inspection Telephone (7 C 6/ /" ( ❑ Mobile Date: Owner a J 6� 9 HACCP Y/N ❑ Temporary ❑ Pre-operation `/ {� /G ❑ caterer ❑ Suspect Illness Person in Charge(PIC) Time El Bed&Breakfast El General Complaint In: ❑ HACCP Inspector L-/- �C Out: Permit No. ElOther Each violation checked requires anexplanationon the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/ Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 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 TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source [116. Cooking Temperatures El 5. Receiving/Condition El 17. Reheating El6. Tags/ Records/Accuracy of Ingredient Statements El7. Conformance with Approved Procedures/ HACCP Plans El 18. Cooling ❑ 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20. Time as a Public Health Control ❑ 8. Separation/Segregation/ Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ El10. Proper Adequate Handwashing 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related Items) Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. • 590.000/Federal Food Code.This report, when signed below c N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: Inspector's Signature: Print: Print n 3 PIC's Signature- / ) Print Page of Pages v FORM 734A HOBBS&WARREN - BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 1 590.003(A) Assignment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11 Person in Charge-Duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) Food Protection* require reporting by Food Employees and 3-302.15 Washing Fruits and Vegetables Applicants 3.304.11 Food Contact with Equipment and 590.003(F) Responsibility of a Food Employee or an Utensils* Applicant to Report to the Person in Charge* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated 1,3"1 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE g Food Contact Surfaces `)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-temp.,pH, 3-202.14 Eggs and Milk Products,Pasteurized* 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 Utensil,* 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 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* 11 Good Hygienic Practices 3-201.17 Came 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* F-13 Handwash Facilities Tags/Records: Fish Products Conveniently Located and Accessible 3-402.11 Parasite Destruction* 5-203.11 Numbers and Capacities* 3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement* 590.004(J) Labeling of Ingredients* 5-205.1 I Accessibility,Operation and Maintenance 7 Conformance with Approved Procedures Supplied with Soap and Hand Drying HACCP Plans Devices 3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability 3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision 8-103.12Conformance with Approved Procedures* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. v CITY OF SALEM BOARD OF HEALTH ? Establishment Name: �G S Date: y 2 /�� Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item _ Verified -- - PLEASE PRINT CLEARLY Cale G' S 'f z t f9vC i --7 gIS-7-7Z 7e �5 fiaC �nZ� (� i ,Y 20 Y t 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 Ll Re-inspection Scheduled ❑ Emergency Suspension i 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 s your food permit. t ❑ Voluntary Disposal ❑ Other: 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 Hours, PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs I4 v Food or Color Additives I9 PHF Hot and Cold Holding 3-202.12Ad l rives* 3-501.16(B) Cold PIT'S Maintained at or below 590.004(F) 41°/45 F* 3-362.14 Protection from thin. roved eldditivcs'k 3-501.16(A) IlatPHFs Maintainedat or above 19 Poisonous or Toxic Substances 7-IOL11 klemityinglnformation-Original Containers* 3-501.16(A) Roasts Held at or above 130`F. 7-102.11 Common Name-Working Containers' 20 Time as a Public Health Control 7-?01.11 Se.aration-Stora e" 3-501.19 Time as a Public Health Control* 7-20111 Restriction-Presence and Ilse' 596.0011(4) Variance Ree unement 7-202.12 Conditions of Use, 7-203.11 TbxicContainers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11. Sanitizers.Criteria-Chemicals* POPULATIONS(HSP) 7-204.1.2 Chemicals for Washln Produce. Criteria* 21 3-801.11(A) Unpasteuri red Pre-packaged Juices and Beverages with Warning Labels* 7-20414 Drying Agents.Criteria* 3-801.11(B) Use of Pasteurizul Egos* 7-20i.1.1 Incidental Food Correct,Lubricants" 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Secd S routs Not Served. 7-206,12 Rodent Bait ens, 3-801.i I(C) Uno.ened Food package Not Re-served, 7-206.13 Tracking Powders,Pee st Control and Mori Lorin>" CONSUMER ADVISORY TIMEITEMPERATU_RE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Sb Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or PHFs Not Otlnentidsa Processed i'o Eliminate Pathoners Legs-Immediate Service 745"F15sc:c* - 3-401.11A(1)(2) Ekes mFISSec. 3-30213 PastemtrudEggsSubstituteforRawShell 3-401.1 1(A)(2) Comminuted Fish.Meats&Game pg s* Animals- 155°F 15 sec. * 3-40111(B)(1)(2) Pork and Beef Roast-1.30°F 121 min" SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sea * catering, mobile&wd,temporary and 3-401.11(A)(3) Poultry,Wild Game.Stuffed PHhs, residential kitchen operations should be Stuffing Containing Fish,Meat- debited under the appropriate sections Poultry or Ratites-1(,5°F 15 sec. * above if related to foodborne illness 3401.'1l(C)(3) Whole-muscle,Intact Beef Steals interventions and risk factors. Other 145"F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foals Cooked in a practices should be debited under 4129- Microwave 165cF* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs--145°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403,11(A)&(D) PlIFs 165'.F 15 sec. #_ (Items 23-30) 1-403.11(B) Microwave-165°F 2,Minute St'.mding Critical and non-critical violations, which da not relate to the Time* foodborne ilbress interventions and risk facmr-s listed above, eon be 3-40111(C) Commercially Processed RTE Faxl- ,found in the following sv(tionsof the Food Code and 105 CMR 1400F'` 590.000. 3403.11(E) Remaining Unsliced Portions of Beef Item Good Retail Practices IFC 580.000 Roasts"' 23. _ Management and Personnel FC-2 .003 Ig Proper Cooling of PHFs 24 Food and Food Protection FC--3 .004 25 Ecluipment and 3-501.14(A) Cooling Cooked PRFs from 140°F to Plumb! st-_ _-.. 4 1{ c 27. h sc Fsiity Waste FC ..-_ -.-....-I _ 5 006 70°F Within 2 [-fours and From 70`F � -6 .007 I to 41"F/45'F Within 4 Hours * 28. Poisonous or Toxic Materials FG-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Re uq iremenis Temperature Ingredients to 41°FL15°F 30. _( Other Within 4 Hours* *Denotes crlticat item in the federal 1999 Food Code of 106 CMR 590.000. THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 120 Washington Street, 4th Floor BOARD OF HEALTH Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 745-0343 Name Date 7 f r i n Tyne of Inspection Food Service Routine Address 1 C� C ' Risk ❑ Retail oB Re-inspection cJ Level El Residential Kitchen Previous Inspection Telephone ! C ❑ Mobile Date: Owner HACCP Y/N ❑ Temporary ❑ Pre-operation ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) N Time ❑ Bed&Breakfast ❑ General Complaint In: ❑ HACCP Inspector\ c 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 L. 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 TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) El 4. Food and Water from Approved Source [:116. Cooking Temperatures El 5. Receiving/Condition El 17. Reheating El6. Tags/ Records/Accuracy of Ingredient Statements El7. Conformance with Approved Procedures/HACCP Plans El 18. Cooling ' PROTECTION FROM CONTAMINATION A11,9. Hot and Cold Holding EJ 20. ,Time as a Public Health Control ❑ 8. Separation/Segregation/ Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9. Food Contact Surfaces Cleaning and Sanitizing El 21. Food and Food Preparation for HSP El 10. Proper Adequate Handwashing 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 b a Board of Health member or its agent constitutes an y 9 23. Management and Personnel FC-2 590.003 9 ( )( ) 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.Og6) 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: r Inspector's Signature: Print PIC's Signal re: Print: v \ Page/of 24ages L. FORM 734A H/BBS&WARREN - BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION '8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from I'l 590.003(A) Assi nment of Res onsibilit * Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11 Person in Charge-Duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) Food Protection* require reporting by Food Employees and 3-302.15 Washing Fruits and Vegetables Applicants 3.304.11 Food Contact with Equipment and 590.003(F) Responsibility of a Food Employee or an Utensils* Applicant to Report to the Person in Charge* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated a3,` 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 F 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* 4-501.1 l4 Chemical Sanitization-temp.,pH, 3-202.14 Eggs and Milk Products,Pasteurized* Concentration and Hardness* 3-202.16 Ice Made from Potable Drinking Water* 4-601.1 l(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* 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* 11 Good Hygienic Practices 3-201.17 Game Animals* 2-401.11 Eating,Drinking or Using Tobacco* "5 Receiving/Condition 2-401.12 Discharges From the Eyes,Nose and 3-202.11 PHFs Received at Proper Temperatures* Mouth* 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-101.11 Food Safe and Unadulterated" (12" Prevention of Contamination from Hands G 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 1 Location and Placement* 590.004(1) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance 7 Conformance with Approved Procedures Supplied with Soap and Hand Drying HACCP Plans Devices 3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability 3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision 8-103.12 Conformance with Approved Procedures* •Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: �� b Page: of Item Code C-Critical item DESCRIPTIONOF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified 7 PLEASE PRINT CLEARLY CA � O t vw\ — i 6- V74 ILAC 2. LA - - - a A5 `d - - � L - Discussion With Person in Charge:GJ� �� 4�Li�SLP_Y _ Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion ' violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension F 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. ' r t� LI Voluntary Disposal LJ Other: i' r 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/4-5'F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202,12 Additives* 3-501.76(8) Cold PIIFs Maintained at or below 590.004(F) 41'145'F" 3-302.1.4 Protection from Unapproved Addittcee'r 3-501.16(A) Hot PHFs Maintained at or above IS Poisonous or Toxic Substances 140'F 7-101.11 Steno ging Information-Original 3_501.16(A) Roasts Held at or above 1"30'F. Containers;, 7-10211 Conunon Name-Working Containers* 20 Time as a Public Health Control 7-201.1.1 1 Separation-Storaxes` 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use 590.004(H) Variance Ree uirement 7-202.12 Conditions of Ilse* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers, Criteria-Chemicals* POPULATIONS(HSP) 7-20412 Chemicals for Washing Produce.Criteria* 21 3-801.11(A) I Unpasteurized Pre.-packaged Juices and 7-204.14 Drying Aoeuts,Criteria* Beverages with Warning Labels`- 7-205.11 Incidental Food Contact, Lubricant s* 3-801.11(P) Use of Pasteuuzui Hn�s* 7-206.11 Restricted Use Pesticides,Criteria* 3-801.'I I(D) Raw of Partially Cooked Animal Food and Raw Seed Sprouts Not Served. 7-30512 Relent Bait Stations* 3-801.11(C) Unopened Foa9Packa>e Not Re-sen�ed. 7-20fi.13 Trackm�Powders, Pest Control and Monikoriat CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foals That nre Raw, Undercooked ca 16 Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate 3-401.17A(1)(2) Ex1s 175°F15Sec. pathogens.* 1 ts Immediate Service 14501715sec* 3-30113 Pasteurized Fg9s Substitute for Raw Shelf 3-401,11(A)(2) Comminuted ash.Meats&Game Fad,s* .,Vnmals-155'F 15 sec. If SPECIAL REQUIREMENTS 3-401.11(B)(1)(2) Pork and Beef Roast- 1.30'F 121 min* 3-401.11(A)(2) Ratites, Injected Meats-155'F 15 590.009(A)-(U1 Violations of Seaton 590.009(A)-(I))in see_* caiering,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 Pouln y or Ratites-165'F 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions anti risk factors. Other - 145"17 It 590.009 violations relating to good retail. 3-401.12 Raw Animal Fsxxh 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 3-40311(A)&(D) P1IFs 165-F 15 sec. " (Items 23-30) 3-403.11(13) Microwave-165°F 2 Minute Standing Critical and iron-critical violations, rrhich do not relate to the ]'title* foodborne illness interventions and riskjaclors listed above, can be 3-403.11(C) Commercially Processed RTF Fend- found in the following section.sof rhe Food Code and 105 CMR 14047* 590.000. __ 3-403,11(E) Remaining Unsliced Portions of Beef Item t Good Retail Practices FC 590.000 Roasts" •_23. __._.,_Management and Personnel FC- 2 .003 18 Proper Cooling of PHFs 124 Food and Food Protection FC 3 7R___4 25 I Equipment and Utensils --------- C 4 .005 3-501.14(A) Cowling Cooked PHFs from 140'F to 26 Water.Plumbin and Waste 1 FC_5 .006 70'F Within 2 Hours and From 70"F 27. Ph slag!Faoilit IFC-6 .007 -' to 4I'FJ45'F Within 4 Hours. It 28 Poisonous or Toxic Materials FC-7 008 3-501.14(B) Cooling PHFs Made From Ambient 29 , SPecial Requirernents _009 Temperature Ingredients to 4PF745'E 30 ( Other j Within 4 Hours* ' ' -6.2,' - *Denote,critical item in the red2ml 1999 Food Code or I Oi CMR 390.000. 0215 DERBY STREET Derby Fish & Lobster City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION _745-2064 Handwash Facilities FAIL ❑0 RED Owner: comment: Back handwash sink not dispensing soap. Owner to provide soap and repair dispenser. Joe Carnevale - Violations Related to Good Retail Practices (Blue Items) PIC: Equipment and Utensils FAIL BLUE Joe Carnevale Inspector: moment:All refrigerated units behind counter require general cleaning. John Gehan alO rket Forge unit requires general cleaning. Date Inspected:Correct By: 9/25/2006 C Market forge unit holding alcohol inside. Unit to be in working order or discarded. Rlsk Level: Utensils stored incorrectly on cookline. Tongs to be stored in proper designated area. coop stored incorrectly. Scoop to be stored so that handle isexposed or in a designated labeled container. Permit Number: BHP-2006-0085 cMicmwave on front line requires thorough cleaning. Status: Micro a by monitor requires general cleaning. Open #Of CfItICaI VIOIatIODS: a of ice machine requires thorough cleaning. 1 Vent above cookline requires thorough cleaning. Owner to fax over contract and invoice of new cleaner to BOH. Time IN: Time OUT: No sanitizing log available at time of inspection Log to be maintained daily. Urgency Description(s): BLUE: GENERAL COMMENTS: Violations Related to Good 849:Observed in office were two full ashtrays of cigarette butts and pack of cigarettes. Owner was explained to at Retail Practices (Critical last inspection that smoking is not allowed in any establishment under Massachusetts Geneeral Law. Owner will violations must be corrected be fined for failure to comply. Fine may start at $100.00 based on conversation with Health Agent. 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 GeoTMSO 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 25,2006 ) Page 2 of