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Commonwealth of Massachusetts
c City of Salem
Board of Health Kimberley Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 01/06/2011
ESTABLISHMENT NAME: Dube's Restaurant
File Number:BHF-2004-000170 317 Jefferson Avenue
Salem MA 01970
LOCATED AT: 0317 JEFFERSON AVENUE
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions!Notes
FOOD SERVICE BHP-2011-0244 Jan 1,2011 Dec 31,2011 $280.00
ESTABLISHMENT
Total Fees: $280.00
PERMIT EXPIRES IDecember3l, 2011
Board of Health V
40
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted
in a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any revocations,improvements,or equipment changes are made,
all plans for such must be submitted to and approved by the Salem Board of Health. Page 1
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET,4."FLOOR
TEL. (978) 741-1800
KIMBERLEY DRISCOLL FAX(978) 745-0343
MAYOR DGIZV ENBAwM&ALEM COM
DAVID GREENBAU➢t,RS
ACTING HEALTH AGENT
2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT_ UAL) TEL# 17VYq-0 (
ADDRESS OF ESTARLISHMFNT z, I'1 )✓&- FAX#
MAILING ADDRESS(if different)
EMAIL- Business': Website:
OWNER'S NAME iMeq P�j�eK —TEL# ZeIA 2-2Y63
ADDRESS_I uwsS� kt) lhQ96VAW614 J4VAY
BEET AP-ST ,e/,/1„h ex,@QIT f STATE ZIP
CERTIFIED FOOD MANAGER'S NAMES OAF g 7hU)N lw Ph CERTIFICATE# S 3 b yk 3
(Required in an establishment where potentially hazardous food is prepared) Zb364vv6
EMERGENCY RESPONSE PERSON_ j��{P�l l"�C(��/f� HOMETEL#�X)-I�,�ylky3
_DAYSOFOPERATION . , rs
day,': z, Frdy I , 'Saturclay. ;; '•',_fSunday`, :_
HOURS OF OPERATION 90,
Please write in time of day.
For example 1lam-11 �M j �'-lO i
TYPE OF ESTABLISHMENT FEE (check only)
RETAIL STORE YES NO less than 1000sq.ft. =$ 70
1000-10,000sq.ft. =$280
more than 10,000sq.ft. =$420
--- ---------------------------------------- ------ -------------------------------------------------------- ----------- ----------------------------
RESTAURANT YE � NO less than 25 seats -$140
(Outdoor Stationary Food Cart$210) 25-99 seats =$280
more than 99 seats
---- ------- --- --- ----- ---- -
BED/BREAKFAST/ YES NO $100
CHILDCARE SERVICESMURSING HOME
-
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25
TOBACCO VENDOR YES NO $135
ALL NON-PROFIT(such as church kitchens) YES NO $25
"Please pay total with one check payable to the City of Salem.
This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location
in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for
such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax
return ai state to as required under the law.
�/ �C -17-b 6y/22 671
Si atuie Date Social Security or Federal Identification Number
Revised 10/9/11 FOODAP2011.adm Check#&Date I l —�`/0 ^------------
Commonwealth of Massachusetts
s r City of Salem
Board of Health Kimberley Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 12/14/2011
ESTABLISHMENT NAME: Dube's Restaurant
File Number:BHF-2004-000170 317 Jefferson Avenue
Salem MA 01970
LOCATED AT: 0317 JEFFERSON AVENUE
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
FOOD SERVICE BHP-2D12-0036 Jan 1,2012 Dec 31,2012 $280.00
ESTABLISHMENT
Total Fees: $280.00
PERMIT EXPIRES ecember 31, 2412
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 most be submitted to and approved by the Salem Board of Health. Page 1
• CITY OF SALEM, MASSACHUSE M'S
BOAP,D OF HEAL.FH
120 WASHINGTON STREET,4"'FLOOR
TEL. (978) 741-1800
KINIBERL.EY DRISCOLL FAX (978) 745-0343
MAYOR Irainln(i@sileni.com
LARRY RAMI)IN,RS/IU:I IS,CI 10,(:P-FS
I i;%i xIi A(;IiNT
201_APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT U S _— _TEL#_ �3
ADDRESS OF ESTABLISHMENT 7177h-;�(O& lqUIi FAX#
MAILING ADDRESS(if different)
EMAIL-Business': Website:
OWNER'S NAMETEL#
ADDRESS � G(A
STR ET / CITY/ /� S��� ' STAT E„�ZD3G�yjf/- ZIP
CERTIFIED FOOD MANAGER'S NAME(S)1J d/iL G�/1/�if/[c //1(I/?9 l/, /S� CERTIFICATE##(S) Z �� f7 X�� 36gyy 3
(Required in an establishment where potentially hazardous foodisprepare ) -
EMERGENCY RESPONSE PERSON &,4. y //'�n( r??y HOME TEL#
DAYS OF OPERATION � 1, Mond - '` Tuesday j - Wednesda -- =,'--ThursdayFrida . SatuMa Sunda
HOURS OF OPERATION
Please write iJ time d day.
Forexample Ilam-11 pm
_TYPE OF ESTABLISHMENT FEE check only)
RETAIL STORE YES less than 1000sq.ft. =$70
1000-10,000sq.ft. =$280
more than 10,000sq.ft. =$420
��----- ---------------------------------------------' --------------------
RESTAURANT NO less than 25 seats =$140
(Outdoor Stationary Food Cart$2YES 25-99 seats =$280
more than 99 seats =$420
BED/B-REA- A --------------------YE-S----- O)------------------------------------------------------------------------------$-1-0-0--
------
CHILDCARE SERVICES/NURSING HOME
ADDITIONAL PERMITS ------------------------------------
MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE YES $25
TOBACCO VENDOR YES $135
ALL NON-PROFIT(such as church kitchens) YES N $25
*Please pay total with one check payable to the City of Salem.
This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location
in the Establishment.
In accordance with the State SanitaryCode before any renovations improvements,orequipment than es are
made, all plans for
such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax
returns andpaid all tate tax9s required under the law.
ZZ-Zal( ��/r27�7f
Si ature Date Social Security or Federal Identification.Number
Updated 523/11 FOODAP201 Laden Check#&Date AQ 11
f
.;�r''Yi
✓r. r - .-f1fr.. f +'rl •4�'> 4._,..n�.�r�.`.rd: �s
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,4th Floor
Division of Food and Drugs Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT t', Tel. (978) 741-1800 Fax (978) 745-0343
Name Date Tvoe of Ooeration(s) Tvoe,of Inspection
O'(loutine
Addressn Risk E] Retail El Re-inspection
Q w��0^ C 2 Level ❑ Residential Kitchen Previous Inspection
Telephone '� ;4 5� / El Mobile Date: to-t (0-0
❑ Temporary ❑ Pre-operation
Owner 1 i V 0 A 2 HACCP YM ElCaterer ❑ Suspect Illness
Person in Charge(PIC) Y Time ElBed&Breakfast ElGeneral Complaint
I � � Qll In:�(?��" ❑ HACCP
Inspector �1 dbb i L a Out: Permit No. ❑Other
Each violation checked req ita_res 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) Q 590.009(F) ❑�
action as determined by the Board of Health.
("FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
❑ 13. Handwash Facilities
EMPLOYEE HfALTW 77 " � f �
3 PROTECTION FROM CHEINICALS
❑ 2. Reporting of Diseases by Food Employee and PIC _�4 �4�k • L�.m
El 14.Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded
❑ 15.Toxic Chemicals
S'FOOD FROM APPROVED SOURCE
PTIME/FEMPERATURECQNTROIs(PotentlallyHazardousFoods) a
❑ 4. Food and Water from Approved Source tti: I j �m ti , � i"A
❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling
PROTECTION FROM CONTAMINATION" " "" `1 El19. Hot and Cold Holding
20.Time As a Public Health Control
El~8. Separation/Segregation/Protection ❑
El 9. Food Contact Surfaces Cleaning and Sanitizing L�:REgU1REtENTS FOR HIGHLYSUSCEPIII3LE POPULATIONS(HSP)
❑ 21. Food and Food Preparation for HSP
❑ 10. Proper Adequate Handwashing
❑ 11. Good Hygienic Practices
CON$UMERAUVISOyY�^ .'�
❑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 nspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code. This report, when signed below
C by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2)(590.003) 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:(',
S:seoinspectFy�6�a"`"V C- \'C'/V V -L \Q1
j"�h^`C✓
Inspector's Signature: ` l � - c.f� � Print: .Uo�j�ji CO� �
PIC's Signature: / / /i'� Print: 6 N� Y� � Page`of Wages
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT F 8 Gross-contamination
I 590.003(A) Assignment of Responsibility" 3-302.11(A)0) Raw Animal Foods Separated from
590.003(B) Demonstration of Knowledge* Cooked and RTE Foods*
2-103.11. Person in charge-duties _ Contamination from Raw ingredients
3-302.11(A)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Other*
2 590.003(C) Responsibility of the person in charge to Contamination from the Environment
require reporting by food employees and 3-302.11(A) Food Protection*
applicants* 3-302.15 Washin Fruits and Vey*etables
590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and
Applicant To Report To The Person In Utensils*
Charge* Contamination from the Consumer
590.003(6) Reporting by Person in 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) Removal of Exclusions and Restrictions Food
3-701.11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE ! Food*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water;
3-201.12 Food in a Hermetically Sealed Container* Sanitization Tem erattres*
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water
3-202.13 Shell Eggs* Sanitization Temperatures*
3-202.14 Eggs and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,PH,
3-202.16 Ice Made From Potable Drinking Water* concentration and hardness."
5-101.1.1 Drinking Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and
Utensils Clean*
590.006(A) Bottled Drinking Water*
590.006('B) Water Meets Standards in 310 CMR 22.0"' 4602.11 Cleaning Frequency of Equipment Food-
Shellfish and Fish From an Approved Source
- Contact Surfaces and Utensils*
4-702.1 t Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of E ui ment*
Shellfish* 4-70311 Methods ofSatntization-Hot Water and
3-201.15 Molluscan Shellfish from NSSP lasted ChemicaPK
Sources* 10 Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Re ulato Authont 2-301.11 Clean Condition-Hands and Arms*
3-20118 Shellstock Identification Present* 2-301-1.2 Cleaning Procedure*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201.17 Game Animals* 11 Good Hygienic Practices
Receiving/Condition 2-40111 Eating,Drinking or Using Tobacco*
3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes, Nose and
3-202.15 Package Integrity* Mouth*
3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting*
TagslRecords:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shelistock Identification* 590.004(E) Preventing Contamination from
3-203.12 'Shellstock Identification Maintained* Em 10 ecs*
Tags/Records:Fish Products 13 Handwash Facilities
3402.11 Parasite Destruction* Conveniently Located and Accessible
- 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities*
Labeling of Ingredients* S-2(4.1.1 Location and Placement*
590.004('1) 9 g 5-205.11 Accessibilit Operation and Maintenance
? Conformance with Approved Procedures
/HACCP Pians Supplied with Soap and Hand Drying
3-502.11. Specialized Processing Methods* Devices
3-502.12 Reduced ox '
en acka ng,criteria* 6-301.1 t Handwashin Cleanser,Availability
8-1(Y.i.i2 Conformance with Approved Procedures* 6-301.12 Hand Dry ig Provision
''Denotes crine:d item in the federal 1999 Foal Cale or 105 CNiR 590.000.
I
I
CITY OF SALEM
I BOARD OF HEALTH
{ ���Y)� .tom n Date:
} Establishment Name:IN.JJ O d n - �� ' 1(� Page: c�. of
' Item Code C-Critical Item +^ Dete
No. Reference R-Red Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION
PLEASE PRINT CLEARLY 1..0/V`✓�.A^Y.�i i VBrMIBd <
V�!A iYlta � AIL 2P;HP
ISIII`` .�_4�pp �J�t�� T1 ,h.,�iZFtw PP QPa Y,� -AJ-4, x
, �
%r7n-yCn a i\il�, C' ,Pn Ar,l a,,,eY..V>� _Iao 20
_
I/—A l0 � �i13)AP-,t -,0/l/v1 fn.vt _t-�' _z) — ar1 -bNE) )r, 3K �
N"A..(1 AA/I 77 v
t \r
\� r T'k�nn/D I /n.a i - nn�K.. �.(! I/V h'�PA �7AA I..O!/. _ t'Ib r OA ? +rl 1-P V1 I-A
i n `
n� �, Jn rQa+ tJ t <1 I�b� ro;AA YIXX,--11 I ��u SCA '4pi
11)a,t/A�OA II),1JA \
.J—r-Al 'A Y\ Cf1 D r :Cl �n� '- �✓i n.'l�P..�'��! �,,..n ( /J n.-C'� �,it .,,, ,-P-i,,
rJ—
Discussion With Person in Charge: Corrective Action Required: ❑ No $b .' Yee
I have read this report, have had the opportunity to ask questions and agree to correct all
4,—Voluntary Compliance ❑ Employee Restriction/
violations before the next inspection, to observe all conditions as described, and to p coon the ule 0 Exclusion
P ❑ Re-inspection Scheduled) ❑ Emergency Suspension
d comply with all mandates of the Mass/Federal Food Code. I understand that
s noncompliance may result in daily fines of twe ty-fi e dollars orsuspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. �/ / /
(/ ❑ Voluntary Disposal ❑ Other:
/ A -
r
r -
3-5f)1.14(Cl PHFi,Received at Tem(cratures
Violations Related to Foodborne itiness Interventions and Risk Aax)rding to law Cooled to -"
Factors(Iterrrs 1-22) (Cont) 11`F/45'F Within 4 Haws.
PROTECTION FROM CHEMICALS 3-501.15 Covlin,Methods for PHFs�
14 Food or Color Additives 19 PHF Hot and Cold Holding
3-501.16(B) Cold PHF,Wlamtmned at err below
3-202.12 Additives* --- 590.0(4(F) 4C145"1
3-302.14 Protection from Unapproved Adddives* I
IS Poisonous or Toxic Substances --{ 1 16(A) Hat PHPs 4latntamed at or above
7-[()1.11 Identifying info;mafion-Ori"inai i 140'F`"
_ 3 Sia l hr AI Rvast6 Held a or above ][30'1_
r 102.11 (o m on Name Ft 4i Time as a Public Health Cantron
_ t
_ ? i(i' 1 ° r to . t as Public Health C ontrol'
7-201.1 1 hSepa a,ra n Son 1 I ----� —
11
2(T2.1.1 �1ta+t ,vitro -Pr,a..nu msd L z -j o0_t#t)•7(H). _.._ _�� ir:e 2iyui
7-2202.12 Condi IuN v1UsL REOUiREMENTS FOR HIGHLY SUSCEPTIBLE
�7 ?03.t Iaxte(roti imei Poli bd-lr�;,
'04.11 Sann!rezti C rite i;, E lune in POPULATIONS(HSP) _
�° .04.7 ('Pr.uu�tis t<tr tgachii z Prod ; e i;il;nF; rewlaices wid
1 ; H�4 c a e. vith 1v�t mn labelti`
f7 104�14 Dnijtg S.t este cru ;i 801 1413) U, of Ps to i wd
(15,11 —
( 206.ti Rs;n ; ilaPrr di . (utu;r` iS ii;l)1 Yr zrPutiul C; oAnimal [u said
1
7-206.11 Rmlcn B-rt S1 i(um (.._. Rt tie a xe tit 1 Suvea [
_ — a a;N" P it�r tie R Se tit.11. "
i 206.13 1ra,kilt ;':?acde }:....:.'ontr.3 a:;d �_�
tittmitorimz'
------- CONSUMER ADVISORY
2< - 3 4,0 3 1 t"v, i r St.t iw,% Poq d Iitr C im:.tw;?tion of
TIliEREfi9PERATURE CONTROLS
that mt lva linderux>6cU t.
ik
Proper CookingTem er aures fo + !
PHS r
P -_ ' i i to; oft r SGPnxcsS � n :`tit zirut.
r-101.13A(l;( ! i ;Szcl Sc
3-40l.a(1a1�; j +mar ;it+ted e icn tifea=c a Gi mle
_ ih ; s 'i7 i vc
01.t"ti't I 2) 1 na t ; i li i Ri st i) i I t t:it _ SPECIAL RE rtt n ?hMENTS
-+ - - �:- I 9 u;i1'}{,t1- P) ( Vioizrtt ,� 0; Se,ac ;
, �1n.11(A} .; � katathd;e .t. tarts- ! 5 I , . � ;
s ( �tr`ran 1 ot�i �i x)c to-ui r to ,SatrI i
'i-401-1 lzAi:}) P u�trk Wild Co it 4 Stu'itt PHPS, 1 rt tiit, n ;[ [ttc.hc t c+} t .F:an. hv�tnd lx
� ( C nf} t�i.o tt ni m 1 itii` tw.,, � � t c,).bit U tlndCi 1[ic ?iii=ny�[t.Rc -ri;jgns
i. i ,. _ 1, f,<�:.� r ; �i C' t P tat CS':)re (tht l
I
:
VIOLA ONS RELATED 1 0 GOOD RETAIL PRA Ci!CES
(items 23-30t
� + tc iiil 11r ,
d03.11(B 1 St to )c 16Y,F "Minwe S;;ndin,: cn zr3nr i Mit t.Ri 1r< t __ xruF 4v,.o; < err ,s
—it ml li ri ndr rIi r?}na n r; rent ; i nz_r:)r tad t od.,IJ 1115 r,I"R be
n--1:)3.l n;L.j � E an nnteia h t1o<r� cd 2[f 1_xv' � i '.. i, N
1
4G1 r �0�riiz
_._.�
_-463.31(L) 1 Ri t wi!"undue:: P{x,w s n! L+n.; =_�f€em ` Goa[Beta Retail r FC 59R.00u !
1 hzaan'r 1 ' ManI P PertidPpr ann .__ rG 2 0� i
K $ +Proper Cooling of PHFs — c5 t Y4 tnr �l irrt, ig_uie +!z fa _ F{' 3 003
f'— t dr (tx)o ii7 axi P:oi<r Fh 1
FC- 4 0 _
i Sol! J4(A 71vFi14 C.x)}, d PHI e fow 171)TF ti, c - 5 �Vb
r chin r ifoutc and Front ,:} z' �T FhGsra,Ft 2tq_ X01
: 1il r- s r )is or pct r,r ;:y C- 606 i
f i 501 [4a13i C r c in 4 PiiF Tv[ de Fnxn lmhivat %_
T ms i tawre In r.d;cnts a 41 f 1+`t 3 rJtaar _
i
to;t tin-1 ldaw;r a ;
q +-e+r��rv«-aw:+ns.✓»,tl�r<+/}M°4''1..+.'Tap.l+.._.,". > ar-.. .R
,. J/,j +'t/wi�rS'If, .r.y.i�6t1 �WSra '-r O,..F'u:✓xr-.,..f'-.�' M„ry,"j q�.
Massachusetts Department of Public Health Salem Board of Health
120 Washinon Street,
Division of Food and Drugs Salem, MA 019 0-35230 Floor
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343
Name Date �} T e of Operation(s) Type of Inspection
�� pz:: 'C� 2� _l/ Food Service Routine
Address _
e � isk Retail Re-inspection
Level ❑ Residential Kitchen Previous Inspection
Telephone S/ F) � El Mobile Date:..- '�
Owner ( ZS HACCP YIN El Temporary ElPre-operation
� _017 oil ❑ Caterer ❑ Suspect Illness
Person in Charge(PIC /��J Time ❑ Bed&Breakfast ❑❑ General HACCP Complaint
( 7 OurO
Inspector o a u : Permit No. ❑ Other
Each violation checked requires ani\ejpl�l' nation 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) lam- 590.009(F)Z
action as determined by the Board of Health.
FOOD PROTECTION MANAGEMENT�;,„ ` ,.¢ ."= ❑ 12. Prevention Of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
❑ 13. Handwash Facilities
EMPLOYEE HEALTH
_ ,._®,. "PROTECTION FROM CHEMICALS ' ' r r-` 1
❑ 2. Reporting of Diseases by Food�Employee and PIC � , # ...5 "a�."` .
❑ 14.Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded
❑ 15 Toxic Chemicals
FOOD FROM APPROVED SOURCE"®"c x „
❑ 4. Food and Water from Approved Source _m T TIMEtTEMPERATURE CONTROLS(Potemralty 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 1,, '" 19. Hot and Cold Holding
8. Separation/Segregation/Protection ❑20.Time As a Public Health Control
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS HSP
E] 9. Food Contact Surfaces Cleaning and Sanitizing ME ( )
❑21. Food and Food Preparation for HSP
❑ 10. Proper Adequate Handwashing
IM
El 11.Good Hygienic Practices
- CONSUMER ADVISORY; x ,,-,
❑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 l
immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22):
of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code. This report, when signed below
C by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations
24. Food and Food Protection (Fc-3)(sso.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 OAF /RE-INSPECTION: �
S.5001ns tFor 14.dw (V (�/U'„{/1.41J 1..bz Vim"- `�"'
✓ v ,
Inspector's Signator : t1 l Print: rl U
IC' i nat e: c Pring fl,rJ I? Y fi/ -1 i. / ;` Page of_2ages
r • 1
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT S Cross-contamination ,
1 590.003(A) Assignment of Responsibility* 3-302.11(A)(]) Raw Animal Foals Separated from
590.003(B) Demonstration of Knowledge* Cooked and RTE Foods*
2-]03.1't Person in charge-duties Contamination from Raw ingredients
3-302.1.1(A)(2) Raw Animal Fails Separated from Each
EMPLOYEE HEALTH Other*
2 590.003(C) Responsibility of the person in charge to Contamination from the Environment
require reporting by food employees and 3-302.11(A) I Food Protection*
a livams* 3-302.i5 Washing Fruits and Vegetables
590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and
Applicant To Report To The Person In Utensils*
Charge* Contamination from the Consumer
590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Fund-
31 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated
590.003(E) Removal of Exclusions and Restr ctions Food
3-701.1.1 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Food*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces
590A04(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water
3-201.12 Food in a Hermetically Sealed Container* Sanitization Tent eratures`
3-20'1.13 Fluid Milk and Milk Product's* 4-501.112 Mechanical Warewashing-Hot Water
3-202.13 Shell hg s* Sanitization Temperatures*
3-202.14 Eggs and Milk Products.Pasteurized* 4501.11.4 Chemical Sanitization-temp.,pH,-
3-202.16 Ice Made From Potable Drinking Water* concentration and hardness.*
5-101,11 Drinking Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and
590.006(A) Bottled Drinking Water* Utensils Clean*
590.006(B) Water Meets Standards in 310 CMR 22.04` 4-602.11 Cleaning Frequency of Equipment Fatd-
Sheltltsh and Fish Froman Approved Source Surfaces and Utensils*
e 4-702.11. Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-HotWaterand
3-201.15 Molluscan Shellfish from NSSP Listed Chemical*
Sources*
Game and Wild Mushrooms Approved by 111 Proper,Adequate Handwashing
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms*
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Proccdme*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201.17 Game Animals* LL Good Hygienic Practices
Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco*
3-202.11 PHFs Received at Proper Temperatures* 2401.12 Discharges From the Eyes, Nose and
3-202.15 Package Integrity* Mouth*
3-101.11 rood Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting*
6 Tags/Records;Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from
3-203.1.2 Shellstock Identification Maintained* Em to gees*
Tags/Records:Fish Products 13 Handwash Facilities
3402.11 Parasite Destruction* Conveniently Located and Accessible
5-203.11 Nturibers and Ca acities*
- 3-402.12 Records,Creation and Retention" 5-204.11 Location and Placement*
590.004(J) Labeling of Ingredients'
7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance
/HACCP Plans Supplied with Soap and Hand Drying
Devices
3-502.11 Sec alized Processing Methods* 6-301.11 Handwashin Cleanser,Availabilit
3-502.1.2 Reduced ox en acka 'ng,criteria*
8-103.12 Conformance with A roved Procedures* 6-301.12 Hand Drying Provision
s Denol'es critical item in the federal 1999 Foal Cale or 105 CNIR 590D00.
CITY OF SALEM
c BOARD OF HEALTH
t Establishment Name:'.,\ 1 .:.Q.z` 5 Pi, `n?,� 1 Cin"- Date: -1 Page: of
{F Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF C RRECTION Date,
No. Reference R-Red Item Verified'
S PLEASE PRINT CLEARLY �_/VVl✓7
t
nn� )) n� ��Ir 1..
JJa
f 1��4^ -4 - i,N, f D.�� 1 V �. _� p�" f,C _M
A b `, C
r� i ��� A ��.I�J� Y d�/t��//1,1 �/1J
01
/
"W t- (I oL, 1/ ') 4,o \i— 1r1_U2_g I
k "'� l�� (/� �1. V\ r.r t� /i; n , i �„e.al �1 v VP ,Li,ry. AM iii
�CJA An. a t 3, P 0"
0 n,n, ,ADLP_e - .tn ZIA,...Q
r ,tom Ot P �i �C/l O-'CJ _ �� OYw.
VU _�
Discussion With Person in Charge: Corrective Action Required: ❑ No d—ye's
I have read this report, have had the opportunity to ask questions and agree to correct all voluntary Compliance ❑ E cploye Restriction
S 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 underst d that
3 noncompliance may result in daily fines of t e ty-five Alars or spension/revocation of ❑ Embargo ❑ Emergency Closure
j your food permit.
❑ Voluntary Disposal L3Other:
r t ,
- a 5tH 14(C) PRFs Received at Temperatures
Violations palated to Foodborne fitness Interventions and Risk According to Law Cooled to
Factors(Items 1.22) (Cont) 41`F/45`F Within 4 How's.
PROTECTION FROM CHEMICALS 3-501.15 Cwhog Methods for PHFs
-- 19 PHF Hot and Gold Holding
3-2(72.i2 A(dtv
1q Food iv es"Color Additives3-5111.16m) Cold PHFs Maintained at or below
590AX)3(F) 41'/45°F*
3-302.14 Protection from Unapproved Additives, -50i.16(A) }fot PHf s baintained at to above
15 I Poisonous or Toxic Substances 140
_'F z
'-IOL11 ldenut3mglnfr, mnrzm On ioal
3-50H 16rA} �Routs Held at or above 130°F. *
Contauter, — -- - —
� r 102 1 I ' C_ommnrt Naw 'A o Ian,,C far tin r,` i-2b -.�- _ _ Time as a Public Hsatth Control j
..�. ---� ,{}1 (9 Lm.as a PublinI:iealdl Control' —(
7301Jl Via,utur -euuage - �r1Qi 1{) — i t nancX \c to cement --�
'202.11 12eat!tct an-Pr,st FICC and 11c,`
7-202-12 Cbndition:.ofUsc* --
---- REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
F-7 7-'03-11 Toxic SanitiClltlariie Prohemivif POPULATIONS HSP)
�U4.11 Sannvels Cdtcrin Cholic h
F7204.12� Chtm +lstoltilaaht� I <xi uc C n_u7at` 21 1-SO' ' (A) F! es, withW.I4 Drl7 At rote.C nt� t t -- So 1 11113 t t t705,11 huldcmal ) xx,ICuWim L.ubt1 antsy -
# ' 801 �1{1tt i -,w,SrFittiali Cc tte<IAatn:tlCu;,dand
'.'tt7fi.!( Rrssi t t 1,a: I r ntc-ie._C.'1 icwt� 1 tt_�
SL.d `ill,Rlls 1`rvf`Crwit '
l
7-206.12 1 Rtxkn B ttscltiot, ---� �- -- { - -
06 -- - 1,— !'(C t tr. d Fig
t,<
2xl °acC ;Yate Rr crvc:l ....
1 ; Jo ( t � !Yn ,t 1k� «.rde „I. Cicmi tr and.
CONe'U;0117i ADVISORY
_ ! MEMEMPERATURE CONTROLS lar c+isna r tti t x t m amps an a
aper Cooking Temperature tot ..-� nt a 1 ) rca1 11ha c K w . C'ndesx„nked t.1
' 1 e
_-_ 153 T I > '.
, d tt Sur 'Ct 5 F _ a 1 1 F 1a , Egg;S . _ il�l rlShe11
1-401A I(A)('- I E mwmwed FINh, 14c.,n a
ta3ltLBtIS- Ill ' ? &cc, "
— SPECIAL.REGUIREMENTS
44L1lAul,c>! _ t ul- adUetKu ';4 t `71 t2lnvn i;c.tJu.t1<i `)f}.(kiU)in �.
.li O4)9Gii- i) ,
• :Mob: � prrt 3e
I:1 #
401I1(A) : 1 ' c t,:i.,f :.Sw !u t , '... 1E
, Sal r 11f {r 7 i .etc t
3
1 lP,.u, B, ,C .. .,.5 P'`:... , ,. {'±Si ,,.. .,. uti(ht Ot1,,-r '
i
,..:-'. � a , 'tFi 4. .•;k.. .. ! . ..,_ ,.,.v?:; rte. _ .�:' -.
. _. 'c:.�____._____.�� (Ifents23-30)
' 1.7 1 rReitea mit for Hot Holding 1 VIOLA T t,�llf.S RFLAT ill LCI GOOD RFTAk PRA trTICES--
' 05.11 1)f,Di FHt tc "i 1
E< -__
(13.IIm) � � I4uxswa Ir 5'F 2 Mim Sr trding
1 ( Ct , r art , u.z ' t t .r s ur rr! la. vv t o -;Nr
l isle, _ f F dlit ni it n a r rtt o r nt r, Z irxlort Ic ucf t ol,. (an lir
3-.103.1it(') Cmllemal} P1o,z.-,3 €tI€ L.,;,xi ko m fbi fo,161 ;tsc .ior c,�.J.�Food Codea+ 'L`)= CAIR
_ 340',1.1!(F) } Ruluniug L-�srced
h,asst PxasF _ FC 590 000
2 0033
�A E.Y7q and XXt P Ottar'tiort
iS yv_ Proper Cooling of PHFs _ - QFC 3 s 004_
----k---- ?� 1 Cgc. rr en and wt ns1 s ! F� 4 t16h
-5W A. I(.AJ C tnd nt Cook d PHF s Lr lrn 17f 1,r, "' - -- -
- dr Lv-tter P act a .t d rJa to I FG 5 J016
7WP Within 2 H<w . :nd t n m aivl' L97 Phys Fa c FC 007
to 41 1/47°F Within 41. h t _ :_23 also rt I )Xic b et tis , FC-7 008
3-501.idtTti--- C-oolu HiFk 5i do hom Aira1Pnt
R rn rat tre !agreiiwm, i :,45=}� ! I_ C Oihe
Flanm4 Hiw "
'Pc�.i=�cnuc elrcr n..br!, Ct,i :10� Aitt t'i0i}fi.
Massachusetts Department of Public Health,"
Salem Board of_Health
120 Washington Street,4th Floor
Division of Food and Drugs '. Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343
Name p Date Type of Operationtsl Type of Inspection
Ann A. t ® Food Service LZ Routine
Address I - 0 iQ �S� �� Risk Retail
�Re-inspection
�, Level ❑ Residential Kitchen Previous Inspection
Telephone � ElMobile Date:
Owner ^ n � HACCP YM [_1Temporary ElPre-operation
NLA A,,I ll 0-,bjA ❑ Caterer ❑ Suspect Illness
Person in Charge`(P1C),- Time ❑ Bed&Breakfast ❑ General Complaint
_ I 1 t AAM ❑ HACCP
Inspector x.° (� Out, a// Permit No. ❑Other
Each violation checked require"& an explanation on the narrative page() and a citation of specific provision(s) violated.
UNon-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)'p-1,
action as determined by the Board of Health.
"-FODDPROTECTION MANAGEMENT El12. Prevention of Contamination from Hands
1. PIC Assigned/Knowledgeable/Duties
EMPLOYEE HEALTH '��'"'.``°' El13. Handwash Facilities
r�� PROTECTION FROM CHEMICALS i��
r n ii
❑ 2. Reporting of Diseases by Food Employee and PIC -�_ • d= -� K ror ,ti =
_ -. -
El 14.Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded f
I � ❑ 15 Toxic Chemicals
q
FOOD FROM APPROVED SOURCE:_=-am�„„®,•„�„
`❑ 4. Food and WaterfrorrrApprovedSource� t *- +TIMErrEMPERATURECONTROLS(PotemiallyHazardousFoo�) x't
1 i
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements E] 17. Reheating
❑ 7 Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling
r)
q PROTECTION FROM CONTAMINATION"'-" ' "`" 4 Ia,19. Hot and Cold Holding
E] 8. Separation/Segregation/Protection El20.Time As a Public Health Control
?"REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS HSP `?
' 9. Food Contact Surfaces Cleaning and Sanitizing ( )-1
21. Food and Food Preparation for HSP
/:
�J 10. Proper Adequate Handwashing El❑ 11. Good Hygienic Practices ).CONSUMER
❑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 2
immediate) or within 10 days as determined b the Board J
Y Y Y 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
H G 23. Management and Personnel (FC-2)(590.0 by a Board of Health member or its agent constitutes an
24. Food and Food Protection (FC-3)(5&0.0044)) order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of
25, Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food
26. Water, Plumbing and Waste (FC-5)(&&0.00&) 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
PR28. Poisonous or Toxic Materials (FC-7)(190.00s) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION:
Inspector's Signature: 1 1 n Print:�� �.� ��. edlo ie
PIC's Signature: YA r 1 int' �j FI PF610 ( ( J �1 Pagel of-5Pages
R;
Violations Related to Foadborne Illness "
Interventions and Risk Factors(Items 1-22)
PROTECTION FROM CONTAMINATION_
FOOD PROTECTION MANAGEMENT F 8 Crass-contamination
1 590.003(A) I Assignment of Responsibility* 3-302.1.1(A)(1) Raw Animal Foods Separated from
590.003(B) Demonstration of Knowledge" Cooked and RTE Foods*
2-103.11 Person to charge-duties Contamination from Raw Ingredients
3-302.1I(A)(2) Raw Animal Foods Separated frern Each
EMPLOYEE HEALTH Other'
2 590.003(0) Responsibility of the person in charge to Contamination from the Environment
require reporting by food employees and 3-302.11(A) Paxl Protection*
applicants* 3-302.15 Washin Fmits and Vegetables
590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and
Applicant To Report'to The Person In Utensils*
Charge* Contamination from the Consumer
590-003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and ResmTice of Food'
3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated
590.003(E) Removal of Exclusions and Restrictions Food
-
3-701,11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Food*
4 1Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004 A-B) Compliance with Food Law* 4-501.111 Manual Warewashmit-Hot Water
3-201.12 Fo xl in a Hermetically Sealed Container* Sanitization Temperatares*
3-20113 Fluid Milk and Milk Products* 4-501.112 Mechanical W'arewashing-Hot Water
3-202.13 Shell Eggs* Sanitization Temperatures*
3-202.W Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitiv2tion-temp.,pH,
3-20116 Ice Made From Potable Drinking Water" concentration and hardness. *
5-101,11 Drinkin Water from an Approve d System- 4-601.11(A) Equipment Food Contact Surfaces and
590.006(A) Bottled DrinkingWater* Utensils Clean*
590.006(,9) Water Meets Standards in 310 CMR 22.0* 4602.11 Cleaning Frequency of Equipment Food-
Shetiflsh and Fish From an Approved Source
Contact Surfaces and Utensils*
4-702.17. 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* Ip Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
F?22ulatory Authority 2-301.11 Clean Condition-Hands and Awns*
3-202.18 Shellstock Identification Present* 2-301_12 Cleaning Procedure*
590.004(0) Wild Mushrooms* 2-301.14 When to Wash*
3-201.17 Game Animals* f1 Good Hygienic Practices
g Receiving/Condition 2-401.11 Eating.Drinking or Using Tobacco*
3-202.11, PHFs Received at Proper Temperatures* 2-`101.12 Discharges From the Eyes,Nose and
3-202.15 Package Integrity* Mouth'
3-101.11. Food Safe and Unadulterated* 3-301..12 Preventing Contamination When Tasting*
fi Tags/Records:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* 590.004(E) Preventing Contanunation from
3-20312 Shellstock Identification Maintained* Em to ees*
Tags/Records:Fish Products 13 Handwash Facilities
3-402.11. Parasite Destruction* Conveniently Located and Accessible
3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities*
590.004(1) Labeling of Ingredients' 5-204.11 Location and Placement*
7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance
/HACCP Plans Supplied with Soap and Nand Drying
3-502.11 Specialized Processing Methods* Devices
3-502.12 Reduced ox en racka ho;criteria* 6-301.11 Handwashing Cleanser, Availability
8-103.12 Conformance with A. roved Procedures" 6-301.1.2 Hand D n Provision
"Denotes-cridail item in the federal 1999 Forxi Code or 105 CMR 590.000.
UCC'\C)JTruz_'
CITY OF SALEM
BOARD OF HEALTH I-_ UwA
Establishment NamqjLD4,i oko-Ic- Date: L4-- Page:___ e:��' of
Item Code C-Critical Item '# -DESCRIPTION OF VIOLATION/PLAN Ole CORRECTION Date
F, Verified
O
No. � Reference R-Red Item
e;APLEASE PRINT CLEARLY
14 Ar Q
61 A fA' fO
I I1C PA 0 1 A
VAI
o
-7)
A �7
V/ I ,
U
A I A /.411 A 4/4
ky re I A i_�'4 Ae— Y-)
#A
V11 VA/"/I V- - -'\A 11� A nn Lam-
A
0'A I k
/ ,A00_ `� ' )i i,,( f�A .7.M,,,, - ... lA o. ,t)> `� V,/1.Q 6V� .�/
'�(S AA 4Ae_'_X
ff.AA r-
o-A c, -V A4 N'0 "t C4\U N 6,3PA A X CI-A-4-A I
- __r e4z
2 VA�4 4 �1 WVA _j4b —��7)QkA OA 7�11 .41 At
—7 V 'X, SL -1 _ \A'// I A,0_
/1 F� "�A O��
Iv) - ti)o qk;rt V2 A
Discussion With Person in Charge: Corrective Action Required: u No gp,iYes
I have read this report, have had the opportunity to ask questions and agree to correct all G,,,'voluntary Compliance 0 Employee Restriction
Exclusion
violations before0e next inspection, to observe all conditions as described, and to W/ Re-inspection Scheduled Lj Emergency Suspension
comply with all mandates of the Mass/Federal Food Code I understand that
a U_x�
_J, dollars pspension/revocation of 0 Em.bargo Ll Emergency closure
noncompliance may result in daily fines of twe, Ry I e o ars ov_
your food permit.
C] Voluntary Disposal 0 Other:
Violations Related to Foodborne illness Interventions and Risk tuordin to I<aw Cooled to
Factors(Imim;1-22) {Cont)
4 PF/45-'F Wilbin,!Hours.
PROTECTION FROM CHEMICALS -
k FT Cyoling Methods for PRFsr, E 14 Food or Color Additives 19 PHF Hot and Cold Holding
Cold PRFsmairallifled at or below
3-202,12 Atkinivas,* 90,0(l4(f-) 41°145°F-
3-302,14 Protection front lLa,jyroved ��dditivcsl
_ _ 3-j01.16(Aj 1-bit PHF�, lklairtained at or above
15 Poisonous or Toxic Substances
140'F
Identifying Infonnation Onginal, 561,J 6(A) Roasts Hold at or above 130,T.
contqjner�;,
L20 Time as a Public Health Control
7-102,11 Common Name-- Workim,Cj(
anairers* 01 —clontiol,
- ,19 Time as a Public 11
s90.019(H) V�riaecc
7-20111 Restrict.on-Pre�cinx and L se*
of T!,W
12 REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203,11 Tor;0ximineu,-Probihvioui* POPULA I N HSP
7 -204.11 sanai7ers,(rite is-cbeoticAk" -
21
" I I I(Al Unpaocjriz�,d Ne-joul.,iforl Juices and
12 hT,11-1 ca I—sf of i'71
r-_- Reverrees, with Warniq aWIsl
ia,
7 404 14 _DjLyjv nuai�-raer
S-80111(B). Uw of Parteunred i',
Incidental Fx)d Cvnla—,t.Eib, iLgE�--
3-801�i I 1�iw or PaiUAIN Cmik�d Animal and
206.11 ReAricled Use Pe ficides,Criterin' Raw Sted',prouui NO.Served. *
� Rodent fi�a SUWOTIS�7-4&E2 t3-8Paoplalrl NO Re served
70606 Tracking Powders..71,7,E control and
Nloftnoflru,!
CONSUMER ADVISORY
cd
TIMEITEMPERATURE CONTROLS l F
22 34�03A! �ong& ownull ion of
nm �Ws Rai arc Raw,� Underc�,oko;
Proper Cooking Temperatures for wim Advkoiv Powd for C 171,11,07,
16
PHFs
3 401A IA(l i(.-) Fgg,,- lWF 15
T- r hnmedi tic ""2.13 Fzsite t)-nzCd4 Fgti��SL.bsnane fol RAW Shell
Servict, 145'F]5.soc�
1) coffloannied Fish,Meats& G11)w
sec..
_;401.11(8)17;(2) Poo kayal Beet Roast- 130'F 121 nein*
SPECIAL REQUIREMENTS
pp -(D)
3 590.009 Loa 0.(X)9fA)
-401.11(A)Q) KI 1 01 Injeclai klcdt�- 155�F 15 1 catering_mobil,� trx)(j,, temporary I and
(A)-�D) violinion"oi scet
sec.
3-46-111(A)0) Poultr),;Wild Ga tie StuTtcl i'Wr7s, r"identilai kitchen operationsslionld be
S'niffing cortHining Fish, Mein, debited Linder the appropriate sections
Poultry or Ranter-1 65"1 15 se c. alxwc if related to torAft-K)rne j1hicss
3-x0).11(()(}) Wholeaqussle-hwict Buf Steaks intetvcnteons and -isk factors Otber
145"F* ---- 590.009 violations relating logoori retail
3.40 1 12 Rita Animal Foods Cooked is a piacties ihould be debited under#24.-
!!
Nliclowaw 105,F*, Special kequirernonts.
3-4011 I(Al(l)lb) All Othei PlIf's -- 145'T 15-see-*—
17 Reheating for Hot Holding VIOLAVONS RELATED TO GOOD RETAIL PRACTICES
(hems 23-30)
34031]fA)&i1)) PHF, 16-s-,T i5 se,
Crioced and vioLdwirr, which do nor relatew Me
403.11(9) wnwaw- )tis'F Minnie Standing
Time, ,foodborne d1ness uno vendors and r iA jactars lived above, can be
3-403.11(C) 'CommematIv frlocsled iFT-Floj— foarldin:Dae Johne serfidnx qf the Food Code anal 105
140T'x J90.060,
F ; MOW
Rorcunin,
Roast,* 23,__ _M 1 FC -2 1 W3
3E Proper Cooling of PHFs— 1 24, Food and Food Proleetio, FC 3
FC-4 i 001
cwhnl�Cooked PHR from 1 to 26 a Equipmentand Ulensila------ ��-=
aer.Plwnbio�and Waste i FC-5 .006
7V17 Winuit 2 Hear,,and From 7W V 27 =_F
IZ--- ------T
to 4 1'F/45'F'iVithin 4 Hours. 2ij:TPorsonous or T1x-1C1v-1a-t&-;a15-- '008
Conhug PHP Made Front Ambient recof R�qwrernenls
Other Temperature lninvdients to 41°1`/45`F Sp -----------------
Within 4 lhxrrs"
1j)ej),jesc,eerj)leen iij ih;fdeTal 199)Food CMM or 105 CINTR590000
CITY OF SALEM
BOARD OF HEALTH
Date: Page: e��> of 7;?,
Establishment Nam
DESCRIPTION OF VIOLATION/PLAN OFFORRECTION
ltem,� Code C-Critical Item g� Date
Reference R-Red ltern�, 'y verified
No.
C� 4 -1 PLEASE PRINT CLEARLY
C-M A 0 OZ
A&U9- Q 0 0- VJA An V-/ A b A A n000 0
)Q C11, 1A �aQ OA 6 -PIA r �2
OA-A-Z 0)-)0"_4T'!PMA iyp Fl�0, AJ� 0-11) (A, (Z' -k
4e C - \Y I/ -
i� )bs"14 P 0)U P4 LA min J-P/Q f7U(Af\J -A A 0)A
All) C)
0
J)' ( ho 0P' A,1APjJ () AID 00��A[,V� /V�A CA) �A
N ' -14— - C)26 A
(dDonllo 1� 1-1
0
P 9A P t+hAk�
it
CU A f
-,I A A-7)
q, A \7' V Jp_ P
-,'A J,_0A OZ (DeoQ
A, �Z 0-01 U'l
AA
/,I
It F
N
Discussion With Person in Charge: Corrective Action Required: 0 v�7 1 zo Yes
I have read this report, have had the opportunity to ask questions and agree to correct all Epi/dV�oluntary Compliance a Employee Restriction
Exclusion
violations before the next inspection, to observe all conditions as described, and to Re-inspection Scheduled Li Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncom pliance.may result in daily fines of twedty-f ive dollars or suspension/revocation of C] Embargo Ll Emergency Closure
your food permit. J
U Voluntary VoluntaDisposal 0 Other:
Violations Related to Foodborne Illness Interventions and Risk According to Lavy Cooled to
Factors liitems 1-22) (Coot) 4 1 F/45'F Within ' Homo,
Coolfin,44 hal for PHPs
PROTECTION FROM CHEMICALS 51,1 15
t4Food or Color Additives 1 19 PHF Hart and Wit Holding
I—sollb(Bt
1)2 12 Addili%e� Cold PHI-s Nlaijlt,kined at(w below— �Li 0
LS114 Lf 11 41-145"F
3-302,14 1Pr�)Wc
3-50 1�I 6W) Flirt PHFz Maintained at -'rabow
L - Poisonous or T aide Substances
I I Identifyinl;Intbi ni�non -Original
r' Z-5(H.W.A) koai;ts Held at or above i Off t
Cont LineW
Time as a uic eafth C
nieL-�!20`- TPblHto,
102,11 0amaort NA'auni, Ltorkirn
3-�01,19 TIM,-,as a Public Health Corarrw
7-201.3 I Svpavation-St
I tntcnient
—Sor
Si
1-20111 Re�,tricluon-Pr once anU
d <c*
7-'02.12 Conditiorrsof IUS
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
72303,11 Toxii;Container,--Prohibinous* I
-- -- - POPULATIONS(HS
7
204 1! Saint i7efs,criteria-chturicolO
21 Juices and
2 ttoe,(.,Awiia� I
te-
±2th_ - 't"�
7-2(9,14 DrviaiL. A'etw.crfteria� _ SeI
L,ra" , IvqL-
1-80 1.11 4 Y4
1-801'11(D) Rawor Panualiv CIA*cd Animal Food and
In',adcunil
I T6.I I Rogriced["se pequides, crneml�'
j_
Raw St,nJ Sproulz,Na)t Served,
7-206J2 Rcidina Bon Statii)n,�
7206 13 Fracking Powder,, fi-,,st Control and
CONSUMER ADVISORY
TIMEITEMPERATURE CONTROLS 22 TT-�)OTI i (-'ooiaoner!urisivv ptmcd for(Annumption of
Anulail I Umlezcxlkcd of
Proper Cooking Temperatures for
PHFs Not Orlierivise Prac:,�,ssed to Idif"Illate
—346 1 iik(l)(2) 1 A6 155 r 15 Sc.
145"1-15sn, hlqeuri/"d 1 ggs Substitute fol Raw Shell
Comminuted fish. Meat,&Gane
Ponwals -
401.11(5)(1)(27 PoA and Ilvel R(tioa 110"F121 rin0* SPECIAL REOGIREMENTS
� 401 2) ItaEus Itjui dh9e<ttd 155 F 15590. . , '009lAt-kfii Violannn�of Section 590.(X)9(A)-(D) in
st caterint' niolmic fixxInalapa-al vand
3]TOT.I I—(v 1 re"moli,ritial kitchcri opeiationsshould be
sillfbatz Containing Fiii'll,Mena, debited and the appropriate S"Lion's
Poultry(it,Radwc-165"1 15 scc. aWve if rchned to
intcrverrtion�and risk ldclor� Other
-T401 JDC)f3) fide rialsde, unnLt Def Steaks
1459; 590.(0) violations relating to coral retail
3-401.i2 kaw lifflitt FVIKk Cnrrkcad III I practices hould be debited under#29 -
Iii towave
Mictowave 165'F spot nal Re lttirc£tte Its_
I!Othet l'If Fs- I 5'F 15.cc.
F77 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
TW3,1-1{ ),',(0) PfIV, 1650F 1�sup, (Itents,23-30)
3-4403—.1I(6) Nfioowave- 165'P�2 Minute Standirl', Claical and non-,rinwl Ivinch do an relate io Me
Ture, favelbortle flbwsr rate?V01nomiTand hykjmrors Ilivied abeive con be,
3-403A 1(C) corainei OWN proccisod i�T-6 found in iheP:iV0u,wg, ceciiinis of the Food Cod(,w,d RC) CMR
140"F' 590.000,
5S0 000
3 40�31(F) Remaining Unsliced Portions of],feel FC
23 i Mlanaval-eilt and Per on ref 1 FC 2
DE Proper Cooling of PHFs Food.�nd Food Pron�tw
----------- ......
ant and Ufen,38i; i FC-4 005
501 H(A) C4'w'li(IgCook rdPHFs from 1401"to 26 W
701T Within 2 ffrw-and From 791, 1 FG-5 006
--- ----------------
io 41 F145 F Within 4 How s� 26 Poisonous orTomc Materials F 008
i
I Coolua;Pffii Witt Final Ambient
2") ,5-peva!R'-Qtirom '009
Temp ralure liucredients to 41`1145`F
I r5o I I -TINIVithin 4 Hours
critical itetit iii III,,Wem! 1499 Foam I("Ale r,r 105("'AR 591)fy)(),
Commonwealth of Massachusetts
City of Salem
Board of Health IGmberiey Driscoll
pe 120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 12/30/2008
ESTABLISHMENT NAME: Dube's Restaurant
File Number:BHF-2004-000170 317 Jefferson Avenue
Salem MA 01970
LOCATED AT: 0317 JEFFERSON AVENUE
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
FOOD SERVICE BHP-2009-0301 Dec 30,2008 Dec 31,2009 $280.00
ESTABLISHMENT
Total Fees: $280.00
PERMIT EXPIRES IDecember3l, 2009
Board of Health
AA -
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all
plans for such must be submitted to and approved by the Salem Board of Health. Page 1
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET,4"-�FLOOR
TEL. (978) 741-1800
KINTBERLEY DRISCOLL FAx(978) 745-0343 e
MAYOR IDIONNE&.ALEM.COM N0V 2 0 2008
JANET DIONNE, cit P OF SALEM
ACTING HEALTH AGENT BOARD OF HEATM
2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME
NAME OF ESTABLISHMENT V b TEL#
ADDRESS OF ESTABLISHMENT 317 FAX#
MAILING ADDRESS(if different)
EMAIL-Business': G Website:
OWNER'S NAME � TEL# �D
ADDRESS UN y
EET� MW///i �r r��� CIT STA E ZIP
�7 "` �( ��inJ� I �Iw f Hif i, 3353,693
CERTIFIED FOOD MANAGER'S NAME(S) eA14 A14DIU6 �O7�N CERTIFICATE#(S) 4ciW_U� 76�e61�p
(Required in an establishment where potentially hazardousfood�isl,prepared)�ed)
EMERGENCY RESPONSE PERSON `'My� sHOME TEL#:ZX-B, %' C( ✓
DAYS OF OPERATION Monday °", 1:-1-'Tuesday Wednesda Thursday!} 1 Fdda Saturda Sund
HOURS OF OPERATION I
(lease write in time of day,
! 1 I- '
For example 11 am-11 m I
TYPE OF ESTABLISHMENT FEE (check only)
RETAIL STORE YES NO less than 1000sq.ft. =$70
1000-10,000sq.ft. =$280
more than 10,000sq.ft. =$420
-------------------------- --YEE� NO less than 25 seats =$140
(Outdoor Stationary Food Cart$210) 25-99 seats =$280 •--
more than 99 seats =$420
-------------------- " ......YES NO $100
CHILDCARE SERVICES -
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25
TOBACCO VENDOR YES NO $135
ALL NON-PROFIT(such as church kitchens) YES NO $25
*Please pay total with one check payable to the City of Salem.
This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location
in the Establishment.
In accordance with the State Sanitary Code, before any renovations,improvements,or equipment changes are made,all plans for
such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax
returns d Wall t fe-tbes requirey under the law.
60-
Si a Dale Social Security or Federal Identification Number
Revised 424/07 F001 k#&Date tqlsl 11115101 $ /)
0317 JEFFERSON AVENUE Dube's Restaurant
City of Salem
FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection
HACCP: ❑
Item Status Violation Critical Urgency
+Telephone: PROTECTION FROM CONTAMINATION
1744-9531 Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑d RED
Owner: Comment:Sanitizer bottle in kitchen is still too strong. Provide sanitizer of proper concentration(200ppm)at all times.
Mary Pelletier
iPIC:
John Farinelli
g Inspector:
j Elizabeth Salandrea
Date Inspected:Correct By:
11/10/2008
=Risk Level:
"Permit Number:
2 BHP-2008-0299 ,.
i Status:
'SIGNED OFF
I#of Critical Violations:
41
'Time IN: Time OUT:
Urgency Description(s):
BLUE: All other violations noted in the 11/3/08 inspection report have been corrected.
Violations Related to Good
Retail Practices (Critical
violations must be corrected
immediately or within 10
days)(Non-critical violations
must be corrected immediately
or within 90 days)
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 17,2008 ) Page 1 oft
Y-•
Item Status Violation Critical Urgency
RED:
Violations Related to .
Foodborne Illness Interventions
and Risk Factors (Require
immediate corrective action)
:f
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 17,2008 ) Page 2 oft
l*
01
` 0317 JEFFERSON AVENUE Dube's Restaurant
City of Salem
FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection
HACCP: ❑
Item Status Violation Critical Urgency
Telephone: PROTECTION FROM CONTAMINATION
744-9531 Separation/ gregation/Protection FAIL Critical ❑� RED
Owner: mment; Continental deli unit has bacon stored above ready to eat items like potatoes and fruit.Organize fridge to properly
Mary Pelletier separate PHFs from RTE items.
PIC: - Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑d RED
John Farinelle Co ent: Sanitizer bottle in kitchen too strong.Provide sanitizer of proper concentration(200ppm)at all times.
Inspector: utting boards in kitchen stained and scored.Resurface or replace cutting boards.
Elizabeth Salandrea
Date Inspected:Correct By: r did not have sanitizer available; PIC stated the bar uses a bottle of cleaner that was stored in the kitchen and did not have an
EPA registration.Provide the bar with a bleach sanitizer bottle or a cleaner with an EPA reg.number,and ensure it is stored at the
11/3/2008 bar for use.
Risk Level: Violations Related to Good Retail Practices (Blue Items) U
Food and F d Protection v/ FAIL Critical BLUE
Permit Number: omment:There is some uncovered food in the kitchen walk-in and the 2 d or beverage air fridge.Cover all food in storage to4
prevent contamination.
BHP-2008-0299 P
Status: 42 oyee drink found in prep area near steam table.Store employee items separately to prevent cross contamination.
VIOLATION
•#Of Critical Violations: sanitized
in flour container in the back room was laying in the flour.Store scoop in flour with handle extending out,or in a clean,
sanitized container designated for the scoop only.
! 3 � �
Time IN: Time OUT: MContinental deli unit holding at 45°F.Turn fridge down to ensure temperature is 41°F or lower.
Equipment d Utensils - FAIL Non-Critical BLUE
Urgency Description(s): 7ment: Back walk-in needs general cleaning of the floor.
BLUE: t � �
Violations Related to Good6Cig t fixtures in kitchen have an accumulation of dust and grime on them.Thoroughly clean light fixtures.
Retail Practices (Critical
violations must be corrected i urboair fridge needs general cleaning on the bottom.
:immediately or within 10 Veft oven needs general cleaning. -
days)(Non-critical violations
must be corrected immediately Reinspection in one week, all violations to be corrected.
or within 90 days)
j
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 04,2008 ) Page 1 oj2
,r
Item Status Violation Critical Urgency
Violations Related to I
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 2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 04,2008 ) Page 2 oft
A
IMPORTANT MESSAGE
FOR IZ
DATE TIME :U 'I .M.
M
i
OF 6 03 1�7 y �p 2 �+
PHONE ! 1� �o 8913
AREA CODE NUMBER EXTENSION
❑ FAX
❑ MOBILE
AREA CODE NUMBER TIME TO CALL
TELEPHONED el PLEASE CALL
CAME TO SEE YOU WILL CALL AGAIN
WANTS TO SEE YOU RUSH
If RETURNED YOUR CALL WILL FAX TO YOU
{ MESSAGE.._ S:
R
On Ser Uc :Sq.pp— �
I
SIGNED
FORM 4009
gqbps MADE IN LLS.A.
NOTES
i
I
i
» Salem Board of Health
Massachusetts Department of Publicl hHealth ,„
Division of-Food and Drugs Sal Washington Street,4 Floor
9 Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343
Name r Date Tvpe of Ooeration(s) yp of Inspection
gra /J.O/ (�FoodService ❑ Routine
Address } I YQ Ri>#k ❑ Retail R-Re-inspection
A Level ❑ Residential Kitchen Previous Inspection
Telephone ❑ Mobile Date:4 4H,)s)
OwnerHACCP YM ElTemporary El Pre-operation
r v I tf-f-reQ ❑ Caterer ❑ Suspect Illness
Person in Charge(PIC) Time ❑ Bed&Breakfast ❑General Complaint
In:q�-3 ❑ HACCP
Inspector�j ouO. A p 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.
m FOOD PROTECTION MANAGEMENT:=77=71M=7 ❑ 12. Prevention of Contamination from Hands
❑ 1 PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities
r EMPLOYEE HEALTH '�. ,��`my x
' _,..,._».� a,� 1" „aLlvt.-,a,.a� ,k '=PROTECTION FROM CHEMICALS � i
❑ 2. Reporting of Diseases by Food Employee and PIC -»=- amu== •w�m _ a +���� _ '• -- �-1� �=�I
❑ 14.Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded
❑ 15 Toxic Chemicals
FOOD FROM APPROVED SOURCE�,�,,,,.;r,+,s I a „ .,
'hmE1tEMPERATURE CQNTROLs(Potem�ally Hazardous Foods) ,
E] 4. Food and Water from Approved Source €� �oy p r (
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling
T'PROTECTION FROM CONTI(MINATION- ' ''l`tl'" 19. Hot and Cold Holding
-ate>1 p,
❑ 8 Separation/Segregation/Protection ❑20.Time As a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing u,REQUIREMENTSFORHfGHLYsdstiiPTIBt eOopULATIONS(HSP)=
y El 21. Food and Food Preparation for HSP
❑ 10. Proper Adequate Handwashing _
{L�..a. spa%:-.
El 11.Good Hygienic Practices , CONSUMER ADVISORYr_p c
+
;/ ❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices Number of Violated Provisions Related ❑ x
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°rr 1�I:i
23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an
24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations
-25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of
the food establishment permit and cessation of food
26. Water, Plumbing and Waste (FC-0)(000.000) establishment operations. If aggrieved by this order, you
27. Physical Facility (FC-6)(590.067) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION: -
s:50,n�,Fo�.14.�
Inspector's Signature: Print: (^
PIC's Signature: / Print: - Page/ OIL Pages
r
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT 8 Cross-cantamtnation
1 590.003(A) I Assignment of Responsibility* 3-302.1.](A)(]) .Raw Animal Foods Separated from
590.003(B) Demonstration of Knowledge* Cooked and RTE Foods*
103.11. Person in charge-duties Contamination from Raw ingredients
3-302.11(A)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Other*
2 590.003(C) Responsibility of the person in charge to Contamination from the Environment
require reporting,by food employees and 3302.11(A) Food Protection*
a tlicants* - 3-302.15 Washing Fruits and Ve etables
590.003(F) Responsibility Of A Fuld Employee Or An 3-304.11. Food Contact with Equipment and
Applicant To Report To The Person In Utensils*
Charge' Contamination from the Consumer
590.003(03) Re orti ng by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food*
31 590.003(3) Exclusions and Restrictions* Disposition of Adulterated or Contaminated
590.003(E) Removal of Exclusions and Restrictions Food
3-701.11 Discarding or Reconditioning Unsafe.
FOOD FROM APPROVED SOURCE Foods
4 Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing.=Hot Water
3-207.12 Food in a HennetioallYSealed Container*
Sanitization Tem eratures*
3-201.13 Fluid Milk and Milk Products* 4-501.112. Mechanical Warewashinb Hot Water
3-202.13 Shell Eggs* Sanitization Tem eratures*
3-202.14 E<,>s and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH,
3-202.16 Iee Made From Potable Drinking Water* concentration and hardness.
5-101.t 1 Drinkin Water from an A roved S stem' 4-60111(A) Equipment Food Contact Surfaces and
Utensils Clean-
590.006(A) Bottled Drinking Water* -
590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food-
Contact Surfaces and Utensils*
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* 44:1:0:1:.11 Methods of Sanitization-Hot Water and
3-20115 Molluscan Shellfish from NSSP I fisted Chemical*
Sources* Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Regulatoty Authority 2-301.11 Clean Condition-Hands and Arms*
3-202.18 Shellstock Identification Present* 2-301..12 Cleaning Procedure*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201..17 Game Animals* 1.1 Good Hygienic Practices
$ Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco*
3-202.11, PHFs Received at Pro er Temperatures* 2401.12 Discharges From the Eyes,Nose and
3-202.15 Package Integrity* Mouth*
3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting*
6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from
3-203.12 Shellstock Identification Maintained" Em lovees*
Tags/Records:Fish Products 13 Handwash Facilities
3.402.11 Parasite Destruction* Conveniently Located and Accessible
- 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities*
590.004(J) Labeling of ingredients* 5-204.11 Location and Placement*
ry Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance
/HACCP Plans - Supplied with Soap and Hand Drying
3-502.11 Specialized Processing Methods*
Devices
3-502.1.2 Reduced oxygen rreka 'nom.criteria* 6-301.11 Handwashing Cleanser,Availability
8-103.12 Conformance with A roved Procedures* 6-301.12 Hand Drying Provision
°Denotes critical item in the Federal 1999 Fax]Code or 105 CMR 590.000.
CITY OF SALEM
BOARD OF HEALTH /
Establishment Name: w 5 \ CSS �a J��n { Date: C A Page: of
:Rem. Code ,C-Critical Rem xs� DESCRIPTION OF VIOLATION/PLAN OF CORRECTION "'r '' Date - �
No-."y'* Reference„ R=Red Rem
�'l 3'' z 3e i`�'^e' a"',""wv? .� €Y`F a5,. , w, ,c r _e�„.+���:wP� p,. `','.;w Y,u11 z'''`i Jam,` , *rT.,�..,.,j a Verified$,
// fti. PLEASE PRINT CLEARLY
JA a 1^ S 1.1110
n l /
Iwiw Y cOA � �. C YCNK.. An PJf O L of _-�... —1A0 ✓ ) r <c .rr= -VYIu-�-- ✓rl
/ d r r
�.fin i t� � 4. I tl � r 'Y h J--�C cl../. j r=
i
x
t
r
z Discussion With Person in Charge: Corrective Action Required: ❑ No 14Yes
t� I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
violations before the next inspection, to observe all conditions as described, and to Exclusion
p ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
` noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
I J your food permit. ❑ Voluntary Disposal ❑ Other:
I
atures
Violations Related to Foodborne fitness Interventions and Risk According to Law Cooled to
Factors(hems 1-22) fCont) 41�IV45,F Within 4 Hams-
coolim-Mathritis for PHIFt,
PROTECTION FROM CHEMICALS PHF Hat and Cold Holding
T
fee P'-
L14Food or Color Additives
12
2bl- 3 sol,[()(B) Cold PHFs Maintained at or beli,w
,
es,
3-:50 1,1 fi(A) Ilot PHI's N.1ainfained at or above
fencer
4 Poisonous or Toxic s Subs
14017
Containers, -5
int 16,(A) koroos field at or above 13V
Time as a Public Health Control
()I,I I C'amnil int liners*_ EEO
e wire
3-i(l) 19 T'nnc as a publo�Health controV
7-201 11
# u
— vs
7-20111 1 Reot,icnon-Pr acnes acrd L'Ne* viriancef;
7-202.E-
7-2d,1 I Toxic Contamel" - Proliiboion",� REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS(HS
1-204.11, sallboreri,Criteria.-chernien!s
21 3-801_1I(A) L rpaqloultzed No-pacraged Atictsaid
Bovera"es will, War in.1,abolr�
204 clitraial )
7 204,14 Diving Aaejjtc.C teria"
of paqeIllized Fe"s*
3-801.14111
i-205.11 1m;iusnial FAxl Contact,tailnerrrti�OC).(I Rei aulyd Lae Ye trades C nteirt . 3-Rist7i-i-J)-)
RaW 1W Pall[Mtk C(X)kdAWITIAJ Food dad
Raw Si urs Not scryed.
1 7-<06.12 1 Roileat Bait Stations'
3-RC1 1_UCL jLv eraeSl -,x!sPaLk,t r Not Re-served.
i 7-306,1 ]racking Powders.floq Cuntrol and
CONSUMER ADVISORY
22 Conguorcr Aa�isoiv fr(^,td for CornumptAon of
TIMEITEMPERATURE CONTROLS hronod F�a,,ds 11lat ary Raw, tindeior
16 Proper Cooking Temperatures for Not OthClWiSe PNCaSS'ed 1 0 FlinoWle
PHFs -, I I`o
3-d01. I
_ -11 A(I)(12) Fg&s- 155'Fl_5Soc'. !!_I �f!_—I
-
N.�
13 teorucl Fggs SAwnnme for Raw Shell
71
Annnak
SPECIAL REQUIREMENTS
J violurion"oi Section �90,()( (D) in
c,Inorine mobil o food,ten aporay and
;_[.11_(A)(3)
ounrN,Wild(;u1ne,stuffe rcmdcirldl kitchen be
Sloffilig CoulAillim"Piste, Rte t debit under the approprianesecuons
Pcrtiltrt or Ratitos-155°F If abuve if related to Rx)dhr,f no nlovss
7_401_11(co) NVIe'l, intelVondons and risk bfotovq� Other
1451� 590.009 virdatiroig relating to goal retail
-5 40i.1^
Raw Anintai KNxis CkKiked in a i pi acticet;'hoold be debited under#29 -
M ict owal o Wsl'* Special Requiremenvs.
' T46TIl(A)(I)tb) kil Other PHFy-- 14TT 15 sec
L7 Reheating for Hot Holding VIOLATIONS fiE_LATE& RETAIL PRACTICES
i-iF3_iT(_A)&Ti7)) 15_wc, (Items 23-30)
microwavc. 165,F 2 Minute standing C)inralaced non-critical a io rriort.T, rvieic*ria real ,elute to die
rce,' fi(N)dhortu,ilhoos nifervennomv ond riskfactors livo�d above, uatr
3403.I_F(--)— Processed FTF Ftxxd- forint!in lhel6flon log�ef 1011V of the Food Code card 105 CMR
140T��
j—
_403A l(El ifsaiii An;ictiwea I FC
Rernainim, Unsiwed Prvtion�of Beef' —------
I !_!Fl! l %,I Yicril and Personnel 1 FC -2 003
RoasW _ L1RET ------ j__ L 1-- —is -
! Fond and Food Proiectio, FG 3 004
Proper Cooling of PHFs ------ .......
25, 1-Equ, rnent and utrnlils FO-4 1
3-501.J4(A) CorilingCoolo.,dPHI-'s Gam 14W17n)
t7ryk
7 0°[7 27. P ralfaciiity
Within 2 1 foura wid From 7TIL _]2wlter,Pfurnbm�,iric;Waste QFC-5
_�000nous or Toxic klalerkiis 7 li X8
3P ta!R___qU ermlne`
Coolim,111IFs Niade Front Ambient _a_- J_San — M_ UC9 .r
Temperance
Within 4 lhxlr,
sIR 590 rw"
t/tA
` Commonwealth of Massachusetts
j City of Salem
Board of Health lGmberley Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED:. . 01104/2010
ESTABLISHMENT NAME: Dube's Restaurant
File Number:BHF-2004-000170 317 Jefferson Avenue
Salem MA 01970
LOCATED AT: 0317 JEFFERSON AVENUE
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
FOOD SERVICE BHP-2010-0062 Jan 4,2010 Dec 31,2010 $280.00
ESTABLISHMENT
Total Fees: $280.00
PERMIT EXPIRES [December 31, 2010
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all
plans for such must be submitted to and approved by the Salem Board of Health. Page 1
1
CITY OF SALEM, MASSACHUSETTS
• - BOARD OF HEALTH .1�N
120 WASHINGTON STREET,4'FLOOR i"
TEL. (978) 741-1800
KIMBERLEY DRISCOLL FAx(978) 745-0343
MAYOR DGREENBAUM(!)SALEM.CONI
yv ^s Z�Q9
DAVID GREENBAum,
ACTING HEALTH AGENT Ooh. :FIj
�Iy
2010 APPLI ATION F PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT S TEL#_/
ADDRESS OF ESTABLISHMENT 3,17 _JF - C[) U ci FAX#
MAI LING ADDRESS(if different)
EMAIL-Business': Website: �?
OWNER'S NAME IM& C�I,'� D�( // TEL
ADDRESS 4!2/ySli�`M/ulN/I� � /WK d/i7�
STREET —r CITY STATE ZIP
CERTIFIED FOOD MANAGER'S NAMES) kl IG�I L�C�/ '����/P CERTIFICATE#(S) '\�Z��b yzl6
(Required in an establishment where potentially hazrdous food is repared) Tl#f. �A�/ LL[ xG`Z0�(��/�/3
EMERGENCY RESPONSE PERSON HOME TEL# y3
,DAY$:QFOPERATIQN � ;� Monda �,�', ?ues'day%� We'_dnesday���'°�Thursday'^ "rt-�„ Fnda� ,;Iu';°,Saturday�:� �Sugtlay;;- ,+
HOURS OF OPERATION _
Please write in time of day / j
For example I1am-11pm
TYPE OF ESTABLISHMENT FEE (check only)
RETAIL STORE YES NO less than 1000sq.ft. =$70
1000-10,000sq.ft. =$280
more than 10,000sq.ft. =$420
------------------------------------------------- ------- ------------------------------------------------------------------------------------------------------
RESTAURANT YES NO less than 25 seats =$140
(Outdoor Stationary Food Cart$21 25-99 seats <'
more than 99 seats =$420
BED/BREAKFAST/ YES /�10 $100
CHILDCARESERVICES/NURSING HOM
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25
TOBACCO VENDOR YES $135
ALL NON-PROFIT(such as church kitchens) YES 0 $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 hapter 62C,Section 49A, 1 certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax
returns and II tat xe required under the law.
/ L)
Signa ure Date Social Security or Federal Identification Number
Revised 424/07 FOODAP2008.adm Check#&Date
r
t �
,t
a 4.
Massachusetts,.Departmeht of* Public Health Salem Board of Health
P., - v 120 Washington Street,4'" Floor f=1
Division of Food and Drugs Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343, N
Name (� / / Dai? Type of ODerationfs) T e of Ins ection
QA V Ii K o �lCUru�l 4 L)' Food Service Lk outine
Address t Risk (Retail ❑ Re-inspection
s P Level ❑ Residential Kitchen Previous Inspection
Telephone v ❑ Mobile Date:�{p(r+t'
'711--4- S S 3 7!
❑
Owner HACCP YM Temporary ❑ Pre-operation
Z l Le ),, z ❑ Caterer ❑ Suspect Illness M
Person in Charge(PIC) / Time ❑ Bed&Breakfast ❑ General Complaint
In:7. E] HACCP
Inspector J �n 20.^4� 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 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.
t.
F60D PROTECTION MANAGEMENT :',` . M �'` -
` ";;� ��„;� ��r ❑ 12. Prevention of Contamination from Hands -
❑ 1. PIC Assigned/ /Duties
[113. Handwash Facilities
EMPLOYEE HEALTH w„
.`.,,..,u m.met�s� s PROTECTION FROM CHEMICALS r w� 2 "`-
El 2. Reporting of Diseases by Food Employee and PIC ����' - t,� ��« ®` •� =m� 1 a� y
❑ 14.Approved Food or Color Additives r
❑ 3. Personnel with Infections Restricted/Excluded
� � a
El 15.Toxic Chemicals
FOOD FROM APPROVED SOURCE ;_,„,�� ,„, ,„:;;;,„,-�,�;= aG � �,
❑ 4. Food and Water from Approved Source �TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Reheating
f
El7. Conformance with Approved Procedures/HACCP Plans 19 18.Cooling
PROTECTION FROM CONTAMINATION ` „ g ' '� '�' Hat and Cold Holding
❑ 8. Separation/Segregation/Protection ❑20:Time As-a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing [,REQUIREMENTS FOR HIGHLY SUSCEPTIBLEPOPULATIONS(HSP),
El 21. Food and Food Preparation for HSP
❑ 10. Proper Adequate Handwashing \
E] 11. Good Hygienic Practices ,
:OONSUMER:ADVISaRY„,, „ -.U+�' a,a,..,;®
❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices Number of Violated Provisions Related
Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22):
of Health.Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. `. 590.000/federal Food Code. This report, when signed below
C a. 1V by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2) order of the Board of Health. Failure to correct violations
24. Food and Food Protection (FC-3)(5590..90.0 004))) cited in this report may result in suspension or revocation of
25. Equipment and Utensils (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)(590.067) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7)(510.008) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) .t ' within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION:
Inspector's Signature 41� --f Print:
PIC's Signature:, �' f7 '� '`n`��_---„� Print: Page of 'Pages
t _�
i
R
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT 8 Cross-contamination
1 596.003(A) Assignment of Responsibility* 3-302.1 I(A)(]) Raw Animal Foods Separated from
590.003(B) Demonstration of Knowledge* Cooked and RTE Foods*
2-103.11. Person in char e--duties Contamination from Raw Ingredients
3-302.11(A)(2) Raw Animal Foals Separated from Each
EMPLOYEE HEALTH Other"
2 590.003(C) Responsibility of the person in charge to Contamination from the Environment
require repotting by food employees and 3-302.1ILA) Food Protection*
applicants* 3-302.15 Wasting Fruits and Ve tables
590.0030 Responsibility Of A Food Employee Or An 3-304-.1 1 Food Contact with Equipment and
Applicant To Report To The Person In Utensils*
Char*e* Contamination from the Consumer
590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food*
3 590.003(D) Exclusions and Restrictions* - Disposition ofAdulterated orContaminated
590.003(E) Removal of Exclusions and Restrictions Food
3-701.11 Discarding or Reconditioning Unsafe.
FOOD FROM APPROVED SOURCE Food*
4 Food and(Nater From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Compliance with Food Law* 4-501.1)I Manual Warewashing-Hot Water
3-201.1.2 Food in a Hermetically Sealed Container* Sanitization Temperatures* -
3-20L 13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water
3-202.13 Shell Eg s* Sanitization Temperatures*
3-202.14 Eggs and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH,
concentration and hardness. 'k
3-202.16 Ice Made From Potable Drinking Water*
5-101.11 DrinkingWater from an Approved System* 4-X01-11('4) Equipment Food Contact Surfaces and
590.006(A) Bottled DrinkingWater* Utensils Clean'
590.006(B) Water Meets Standards in 310 CMR 22.04` 4 602.1 I Cleaning Frequency of Equipment Fo l-
Shellfish and Fish From an Approved Source
Contact Surfaces and Utensils*
4702.11. Frequency of Sanitization oY'Utensils and
3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of E ui ment*
Shellfish* 4-703.11 Methods ofSaninzation-Hot Water and
3-201-15 Molluscan Shellfish from NSSP Lasted Chemical*
Sources* 10 Proper,Adequate Handwashing
Genie and Wild Mushrooms Approved by
Regulatory Authodt 2-301.11 Clean Condition-Hands and Aims*
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201..1.7 Game Animals* 11 Good Hygienic Practices
5 Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco*
3-202.11, PHFs Received at Proper Temperatures* 2401-12 Discharges From the Eyes, Nose and
3-202.t5 Package Lite it-* Mouth*
3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting*
6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from
3-203.12 Shellstock Identification Maintained* Etnilo ees*
Tags/Records: Fish Products 13 Handwash Facilities
3402.11 Parasite Destruction*
Conveniently Located and Accessible
3-402.1.2 Records,Creation and Retention* 5-203.11 Numbers and Ca acities*
590.004(7) Labeling of Ingredients' 5-204.11 Location and Placement*
7 Conformance with Approved Procedures
5-20511 Accessibility,O icration and Maintenance
/HACCP Plans - Supplied with Soap and Hand Drying
3-502.11 Specialized Processing Methods* Devices
3-502.1.2 Reduced ox• en iacka 'ng.criteria* 6-301.11 Handwashing Cleanses,Availability
8-103.12 Confo mance with A roved Procedures" fi-301.(2 Randf) n*Provision
*Denotes critical item in the federal 1999 Food Code of 105 CMR 590.()00. -
CITY OF SALEM
r BOARD OF HEALTH
Establishment Name: i h Sem f4 41 - Date: ,�2y Page: of
i .Item Coda„ C-Critical item ;, s . ,� y DESCRIPTION OF VIOLATION!PLAN OF CORRECTION , '- Date
No , Reference R_Red Item ��yy 1:gt' b - F s c,.c _ 0"', Verified
�, e�' �Y' ,£2�,` r"', o'<,'. l• XD's.,. .m
''s.rr I LEA' PAINT CLEARLY / '' "�'"" `"'"'"
C,�
t
ct , ti °Y IrQ ti, /p a4 Ihl 1C,14 foL4 avp
n, .
G c-4-102 <;)10 % Jt e G2
tl t I n D 91 / r LP
G _ __
14- ,a-
ICE '-
s
i
.o , =
-� 4
0
<< Discussion With Person in Charge: Corrective Action Required: ❑ No s
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
t P Re-inspection Scheduled ❑ Emergency Suspension
�• comply with all mandates of the Mass/Federal FAood Code. I understand that
4 noncompliance may result in daily fines of twenty-five dollars or uspe slon/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. y�A C -
. '\ \ ❑ Voluntary Disposal ❑ Other:
� 3-Siit... (c, �'t`t€frs62e�ivednt"Fentlse;raturvs
Violations Related to Foodborne fitness Interventions and Risk .Accoxding tet Lave Cooled 6c
Factors(Itenfs 1-22) (Carel _ 1 41"F745`Ir rcitkin 4 Hours. m _
PROTECTION FROM CHEMICALS _J ,_401.15 — Coolie,,Methods for PHFs
--1---- cs PHPHF Hot and Gold Holding
C
14 } F000 }r Golor Additives
f- — _. �3 4{s 14(H} C rtlC s Yxsntuinec(at ox below
3-20, 12 I Additives*
1
. ---- - 590.f)041'7 41`r45`1"
3;3fY2.'14 Protection From L`nut roved Addrttvee"' _r.�.... ---4
}D ._... 'i -)l.lmA' - IlolPHF' N4uintainedatrn-abow
C1S
Poisonous or Toxic Substances � � I
�-�-- 14{7'f; r<
7-lot.if E ldenti3yin infgrmation-C)ri�mal
} * - '" C" 16(A) Riststsfield atoraboro 130"F_'
�_ Caatahl rSk
Zi7 Time as a Pubfic Heatfh Control
�-r-1 02.1 i ' Cvtnnrnon Name 1R eras,C owairai s* 9 4U1 k� - Tttree as i Pub#ie Health Conirotr .
' 7 10111 Se ar ruo t 5torakr _ "'� .. —`�'
72t}„_i l Res)uaon -Pr<sc.ncx-laid ase*! ` -------- _......t�'?_r'tnct `. ull_
end
7 202.12 Coadidons of Usti, _—....._ REGii9tRE$iEMT."a FOR HIGHLY SUSCEPTIBLE7-203_it �jlcrxt Canrtaurei ohtb+inns' POPU ATIONS(tS
r 2(74.11 T1 i5ficnicnls” --
7 304.12C,h uu s1s for h dvht t rx ue {etc- 21 3-801.11(A) pP tsteuriz d ikc pee'aged Juices will
7 704.14 Drtvt As,ent�.Cxncsrt _. � —�evenaae�with Warnrny l.ab,.lss` ...
X01 i t{S} E,c vt Pa tenn7ed} >��k
X05.11 11 tde neat NxId(e ni tci Tzdtt ieants- -- — — —
72U6_i( Rexnt� dcuPe C�hude._Cnt ut �
3-&01 t t(i3} P iw ca ll a
Poini xrk d Animal Food and
------ ..- _
Raw Sc ro
d S}tntw Not Seared._
7 2{#x.12 1 aleU.rt Sramn, 3.801 17-6 lC7 T errn
e ui Fcxl Pac -
x ' . Not Re-served.
�"'----- .
i ltcaitrrin _ — CONSUMER ADVISORY _
2 3' 00 1 I Consutnt r ii av:sor v fsKred ;or cciw rwnpttiorr of
TIME/TEMPERATURE CONTROLS
ynienrl 1xxli that me Rein. Underrilokedoi
2b ProperGoak€ng Temperatures for I Lot€atlrcrursePnx;eved,oEliminate
C __._}..P�H.Fs ._,._. _._. Pct4ao ins < ''A "", vo:.•
3+101.71 4tlt{,'.j ! F' 8s- 155' �' 15 S�ti. ---'~- —
i r-imrncd rte Serviu 1 t4 F-lSsec^ ;u"r 13 I'rsrearrr at}gds flubs trot_for Raw SIae71
746111{,l)t2t Cotnrrrinut d f ash Meaty A C,amc
AnitndS 157`F to sec SPECIAL REQUIREMENTS
740 Pau and livor d lW - 1 ,ft t 1"1 nein" F5ooO(ly(Ai (r)) Grolatt in of Section �9{},O(})tr1}-(I>} in
t.d01.i1(A}C1 � Ratrreslnjua.d ,t4cnts ItS [ t5 # '�
s e% o I calornng Mobil farce tentpurarvaad
3-401.11(A)!3) Poifln';kfldGue.Stuirll'NFs, resSduut.alki£chtnoPetationsshat:(dhe
sruffing Containing Fish Meat, debli a wader the appropri etc.sections
Y<tdir rltantes SE>5`C IS , ° aurae if wlaicd w Icr<Aborne illnoss
x-401Al(C)(3) Yhole-mnvcle.. Intact Beef.5tc is interventions and rfskfret'ors (ther
590.009 violation,rclatinr to good retail
3-e1+11.12 Rtti A mal Kl Tcxxis f ook(A in a ( practices should be dahites3 under#29-
__ lure cave 165'T" _ 'Pe
tl RePairetnents_
3-401 11(R7(1)(b) All Other PHF 145`4 15 -ec * _ _
LIT Reheat ing for Hot Holding — 1/PLIiTCIOF}fS RELATED TO GOOD RETAIL PRACTICES
3-103.1t(A)8t(T)) PIFt,165`11 Kc.T (hems2330)
3-4011 A(B) microwave 165 F2 411nuts 5taodiag Grurrcat and ra + l-ilif"m violoPrus, uP7eh do cot relate "n rhe
rate' Poeelhorne rltne is in!erveiuiona 1"0 rte$}araors$eta d a ovc. ton be
3-403.(7(C') C'!
mono" aliv Prcceseed RTF Fc__K'ct- fourra in zhe¢rtfnv7ng sr rrr�ons u'7[he Food Code mid 105 CMR
t 4U F� 590(kkr
._ ._ r . _.
3-40111(E) Remaining Lnslwed Potrions of lice' �ttem � Good Retail Pradttces i FC v ------ . 1
R�rast* 20 Naneme t aro Per cmnel_ FC d 1 .003
1gProper Cooling of PHFs 24 C Fax sod cep Prpiecil0 FC s 004 _
------- ?6 Cc utpmen attd 6 t e I a a S FFG 4 .665 �
3-5OFJ.4(A) Cexrim*Gawk dPHl'sEans l=10`f'to ' 20 Wa'er Plnrrksn�ana Nesta _5 .pU4,
to 41 F 4J F tkitiun 4 andFrom70'1' I2-7 eE. "'-ltsical Fac Iily i FC " 007
seg 00.1 or Taxrc 613+era!s ri 7 1 606
3-501-4(B) Csmlua,PHFv nvfade Front Aribiznt � r 22 �Speciai P qt it�mennt z — � -009 1
Tetnpetatare Ingredients In 41oF(45`F
Within H(Ku�*
+Denies critical)tarn bt na roland 1999 Pond Glaevc 103 CM11590 X30.
s
'CITY OF SALEM
BOARD OF HEALTH'
Establishment Name: �J i Date:--_ /L) `j Pager of t
Item Code h , C=Critical Item ., s ,DESCRIPTION OF VIOLATION/,PLAN OF_CORRECTION Date
No. Reference R-Red Item`s :; "�
E
Verified
PLEASE PRINT CLEARLY - �` e 4 w
U vary17aC' � ' �1 , p k
LJA (r
I,
r ' � '4V3-4 l. C ec, o , �-,1 v ca/I S crf
;> � . // //
' S UG ni a ✓ e r i ✓ J
(
uw 1fjj r(-t- Q/ PV /1. o�N Ir A O.
� .
S a U i a a rN✓K l
r
FDiscussion With Person in Charge: Corrective Action Required: ❑ No Yes
ve read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ i`ations before the next inspection, to observe all conditions as described, and to Exclusion
P X 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 LI Emergency Closure
t your food permit.
F "t--k
l _ ❑ Voluntary Disposal ❑ Other:
ti
PHFs ReaJved at"1' tperatures
Violations Related to Foodborna,Illness liffe"ernforts end Risk { I Acolrdin.,to I-av- Cwted to
Factors(items 1-22) (Cont)
I I I�JV45-F Within 4 Hours
1-501 1 i Ccolin l Nlahock,tnr 111IFs
PROTECTION FROM CHEMICALS
r-'14 T-Food or Color Additives L19 --PHS Notand Cold ftiding
T56T716(liT Cold P4Fs maintained at(W below
202 f2
"tivc,'* 5_x_0.00 t{F4[^,)45"F,
3--10114 Protechlai from l:n 3pPros�ed Wdilvles'
loot PIIFs Mantailled at or above
PS—
at Toxic SubstancesSubstances '
.11 4 polsomous
Idernifying Infallraltion--Oci�ginal i 40 F,?-501,16(5.l liddat orablave 130"F,
Containers,
1-_
2q Time as a Public Health C
7 10211 commonNholic - workin2, cr, -t-L—
�0111 01
2-, EE
T'i ml�as d Public I lea i , V
Ith com,ov
1-201.11 S�Pmsulln -slol apc`
Restriction-Presillico and Use* Variance R
F2�2I)2 12 Condition,of Usc`
TOX i�C X)lltaifl(o
7-103,11 REOUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS HSP
204.1 Sanitiser Ctfl(Tia-CbColiCak
7-204.12 21
ijiiLL2wacN with %kanio
7-204A CriteriO
±--- -- i i-s()1,1 I(B) I U4�of pa<tckltized E'-"
- - 7—t ,a--h 1-1 Ca k-n -7�-�77-17
?-205,11 Incidental F(X;4("'ora ii�c t-
7--206AT-- Pelricidel;,crittaizlr 3-ii0l.I Ill)! � R%iw or Paruallv FrxJ and
..... Raw StxI SpronLiNor Servvd.
7-206.12 Roilem Ban Stiqion,�'
i I I I(C"l x!Packil, Noi Re-sen lal-
P,�sl C"ontrol and
CON-SUMER ADVISORY
'17IMEITEMPERATURE CONTROLS 2 3 T-:7,-11 Torlwnlcr Xck i.wry Posted for coutnimption of
;nim tl f xxis That are Raw. Under",ked o;
16 Proper Cooking Temperatures For---]PHFs dot Odwra ise Pressed to Llinnnaw
Patho,,ms l'
101.1 1 1(1 4 Sys 15Ss F 15 skx.
13 s f1psomny"d Eggt-Sobvlitljl.,-So3 Raw Shell
Cominimiled Hsh, Meats K, Gaflnc
AmmaLs 151"F i , sec.
SPECIAL REQUIREMENTS
3 40 1A I(B)i I'i(2) v Pori;and 13,Ti Roast - 13,01-121 min' r570
11(ti)(2) Raines, Inieculd k1rals 1557FIT, -] I
I calcrin& n1ohno tool,tenipwacy and
1 t twidentialkitchen operations be3 40LIFA0� Poultr%,Wild(4ime, �njffed
stoffilig Contioning FisllMeat,
I d-blied undar the appropriate se bents
Poultry or klitites-i 65"T'llfisec. alsove if rkdaled to foollilborne diness
�)IlWelv-Intact lidaf Steaks ill risk factors. Offier
3-401 HiC)(T7 Wholc mcerventiona a
---I---,—I — 590.009 violations relating to good retail
3-401.12 R;ox Animill fillixis C,mked in t
I I pil�. tic(ls should be debited under #29 -
At la o 10"F speeial Requirements.
31,401,11(A)(I)(b) All Other PlIfs-- 145'T 15 sec.
Reheating for list Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-103.11(A)&,(D) ffIF, 165'F, (7 sc(. (Items 23-30)
7 403 11(IT; 14oalawavc- 165"F210mul,Standing Co i. r10;d non-craical Vil italilml, wh ch do lull retelp"in the
Tiarel foodborne iilbl as,enure ntiona and rol k !errors listed abm-e, can be
7� �er=ns ol lh,;Fowl Code and 10-5('114)?
(C) Commercially Pirx:eis�d Rf Efixd found al da ftillm,ing,
140"7� 590,000,
3-403,11(17) Relllailliyq,Uelleed Nxtions of 13cef '—Item--'T'Good--- 1 0-6-0-1-1
Rotrl;W P!lr,- -2
-FC
Proper Cooling of—PRFs 24, Fold and Food Pmllctjon, Fc- 3 004
gt�;p!Ltqtane tens�i� FG-4 005
Cooling PFIFF front 14ff to -------
--.006
70"F Withm2 ffours end From 701: 6 �007 1
to 4 i�F,145�F Witlon 4 Houn,. 7 606
26 �Pcdonotla at Teisc fdaka,laG i
4(b) Col iloag PIIF!z Made From Ambient -—----- 009
Ircm[wailite hnllredient�to 41 30, othe,
Within 4 flows
-Dell'at,crutical alml in m"lodtaal 1999 F(hsf1C,x!eor 105(WOY)OM
- I
Commonwealth of Massachusetts
City of Salem
s e
Board of Health Kimberley Drisooll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Foo"etail Establishment Permit
DATE PRINTED: 01/08/2008
ESTABLISHMENT NAME: Dube's Restaurant
File Number:BHF-2004-000170 317 Jefferson Avenue
Salem MA 01970
LOCATED AT: 0317 JEFFERSON AVENUE
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
FOOD SERVICE BHP-2008-0299 Jan 7,2008 Dec 31,2008 $280.00
ESTABLISHMENT
Total Fees: $280.00
PERMIT EXPIRES December 31, 2008
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all
plans for such must be submitted to and approved by the Salem Board of Health. Page 11 of 11
3 CITY OF SALEM, MASSACHUSE
>R
3 � o BOARD OF HEALTH
120 WASHINGTON STREET,4"'FLOOR
TSL.(978) 741-1800 `
KIMBERLEY DRISCOLL FAX(978) 745-0343 � �
MAYOR ISCOTT(&SALEM COM eOg 2j
?o 4V
JOANNE SCOTT, y ce
HEALTH AGENT <Ty
2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT C,. % TEL# ZLJCI-y,-
ADDRESS OF ESTABLISHMENT FAX#
MAILING ADDRESS (if different)
EMAIL-Business': M Website:
OWNER'S NAME TEL#� y�� �1 291
ADDRESS MEET � ClTr-�'shsLt STATE y ZIP
—
CERTIFIED
CERTIFIED FOOD MANAGER'S NAME(S) �W NAN J(�N (A121 Ulft 1 CERTIFICATE#(S)
(Required in an establishment where potentially hazardous food is prepared)
EMERGENCY RESPONSE PERSON HOME TEL#
DAYS OF OPERATION Monday Tuesday 1 Wednesday Thursday Friday Saturday Sunda
HOURS OF OPERATION f
Please write in lime of day. 10D n- 10 (�-ID I t�' o 1 11, ID il-ID Cw S��
Forexam le Ilam-17 m)
TYPE OF ESTABLISHMENT FEE (check only)
RETAIL STORE YES NO less than 1000sq.ft. =$70
1000-10 000sQ.ft. =$280
more than 10,000sq.ft. =$420
----------
----------------
(Outdoor
-------------
1 E NO less than is-s-e-a-ts $k49�
(Gutdoor Stationary Food Ca. $2 i0j 25-99 seats �" $280
more than 99 seats '—=$"
- - - -------------- ------146-------------------------------------------------------------------------------$"1-0--0------
BEDIBREAKFAST/ YES
CHILDCARESERVICES ------------------------------- ----------------------------------- ------------------ ...........
ITI
ADDONAL PERMITS
MAKE (not just serve)ICE CREAM,YOGURT/SOFT SERVE YES NO $25
TOBACCO VENDOR YES NO $135
ALL NON-PROFIT(such as church kitchens) YES NO $25
'Please pay total with one check payable to the City of Salem.
This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location
in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for
such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C,Section 49A,1 certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax
recur s d p ' at to es req i under the law.
Sigriature A Date .� I _g'I -_ —Social Security or Federal Identification Number
Revised 4/24/07 FOODAP2008.adm Check#&Date
a,�
�f
0317 JEFFERSON AVENUE Dube's Restaurant
City of Salem
FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection
HACCP: ❑
Item Status Violation Critical Urgency
Telephone: PROTECTION FROM CONTAMINATION
744-9531 Food Contact S ces Cleaning and Sanitizing FAIL Critical RED
Owner: ' omment: Continental unit cutting board stained and scored. Resurface or replace boards.
Mary Pelletier
PIC: I Violations Related to Good Retail Practices (Blue Items)
John Farinelle Food and Food Pr tection FAIL Critical BLUE
Inspector: mment: Personal drink being stored directly in ice in ice machine. Personal items to be stored in designated employee areas.
John Gehan �
Date Inspected:Correct By: i�"a k in unit has uncovered foods. All foods must be covered.
7/24/2007 [` tal unit has uncovered foods. All foods must be covered.
Risk Level
Beverage Air unit has uncovered foods. All foods must be covered.
Permit Number: Equipment and Ut siIs FAIL BLUE
BHP-2007-0320 j
Status: omm ack white freezer has no visible thermometer. Provide visible and accurate thermometer.
Open Mop be' g stored incorrectly. Mop to be kept so that it can air dry.
#of Critical Violations:
anitiz
2 ing log not being kept daily. Log to be maintained on a daily basis.
Time IN: Time OUT:
Urgency Description(s):
BLUE:
Violations Related to Good
Retail Practices (Critical
violations must be corrected
immediately or within 10
days)(Non-critical violations
must be corrected immediately
or within 90 days)
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jul 24,2007 ) Page I oft
3
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®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jul 24,2007 ) Page 2 oft
r
: CITY OF SALEM
BOARD OF HEALTH
Establishment Name: Date: -71411 -7 Page of
DESCRIPTION OF,VIOLATION/PLAN OF CORRECTION Date
Item Code* C-Critical Item
No Reference R-Red Item .m 9 ` N' F - �. Verified
- � %X rd < <•"=xi - �-t' +x' x '' PLEASE PRINT CLEARLY '�
i
i
tr�
t
1•
Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction
Exclusion
violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twe q-five do I s or sy pension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. /�
❑ Voluntary Disposal ❑ Other:
V
IF 77ti 1-14(J, FHFs Reccild at 1-mf
Violations Related to Foodborne Illness Interventions and Risk According to Lain Cooled it)
Factors Ilierm 1-22) (Cont,) 41°F45"1, Within,l Ht
L T5 Cooling Me1ho&for 111IFs
PROTECTION FROM CHEMICALS -- -
-- ---T—Foodor Color Additives 19 PHF Not and Card Holding
3 501.16B) Cold Pffs miontained at or litlow
320212 AdditivcO 59rr(-X)'(F)
3-31)2 14 Protection from L-1-1aELr-111—e1lt 3a 501 WA) flot NIFS NITintained ato,abovePoisonous or Toxic Substances
" Wifl Identifying Intle oration - Origiro'd
501 16(A) (Xtevs livid at or aboe 13"
7 102,11 Common NMtrae- L21) 1
Time
as a ble,Health control
as Tl%ftlie=Iealth�Contjrol-'
FIT I T,ale,
mai -�1011 �11—
1202.11 Restrictiou -po'stric
---1 e
7-2022,12 Condaitars of Oso
7 0321
— —T—oxicC-o'n'ouno,, -- Prohibitions' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULA IONS HS
7-iO4 if sanitizers,Criteria--chcmic"ils* I-Pi—
("ficnac:ik for Wmh 1,11(At Unpastcuri?cd Pre-sac.iged Juices and
'— Efc4eraeswith7-204�12
7204,14------ Dridn Avow.Crit<.ria� LA —Wan"
---- 't-80 1.11(B)
'-Ks I I Incidental r:Ix),11 contart, Lublicauts" _L�e tit Pzotcune(d EgEf
7 3-01.11(D) Rawor pallialls CookedAnimal Fosd and
'-20& Roso-naed Use Pe�ticidc�'critcna�
7-206.12 Rociera Bait Smuori,�� moats Net Sewed
7'[06.13 Tracking P�sl'Ellltarol IrIT—
CONSUMER ADVISORY
TIMEITEMPERATURE CONTROLS 223 4) isors,Nt.qted ter(Amsourption of
U Or'quok'r Ad
Proper Cooking Temperatures for— "viintal F&AK That arc Raw, UndercixAcd of
PHFs Not OflwTa is e processed to Eliminate
1",�(l)(21� Fgg� L5,5'F 15 Sc.
1, 1
3-302.13
Service 1451--15sec, 11e-stclmzci Fgg;SubsiEtat. for Raw Shell
3-401 11(A)(2
Cmurninwad Fish, Meats& Chnit.
_7Animals- 155"FI(3)(1)(2) Foil and 13cc1 Roam - 130"r, 121 nail I SPECIAL REQUIREMENTS
violafioo'�6 Section 590,009W4D)in
2)
eatering. rlrobilc"xi,temporary and
3 401
I tcsidelliial kitchen operation
A (A;
t3? S should be
sollffniti contaluing Fish, 10-at, debited under the appropriate sect lolls
ous
_Louhfyo, I�evws- 65 i s c above if related to fiNy-lborne ithicss
�3-401Whole mus-le,Intact B e44 Stooks inrcrycvliolts and risk firctom Other
-1451, 590.009 violtqicioy relating to good retai I
40L12 Raw Aniawl Foals Cooked in a praedces shouldbe debited under #29 -
Micamave Wire
'F* --- Special Requments,
-------
401
Fl All Other 1111,- I 45Ti5 sec
Reheating'for Not Holding —00-1-A Ti-ONS REI A TEL) TO GOOD RETAIL PRACTICES
3-1011 1(A)&(D) 111-IF.s 165"F I�sec I
(11stom 23-3(3)
3-403.11(8) 165"F 2 Minute Staraliq Cn6r-ai and non-erwfao vivielolosts, which this nen relate to the
----- - - f(w)dhornv olness and n4irr(tors toted above, (an bi,
-T4 3 I IT) Commercially Processed RCE I 1x1� C.44
140'F 590,000,
f
-TZ3TI(F) Remaining Unsficed Portions(if�Ccl FC 596.006 1
Roasts* 3 -y' l-miagene-n I and Pet cn rtel
Proper Cooling of PHFs 24 ( Rodand Food Protection 3
1 004
-:'-50 1,Tl(A) Cooliue Cookid PHFF front 14)'Fio 26, i VJ --i Egtisttman+and Utas sus FC 4 006-
aVil j a, FC 5
70'F Within 2 Hours and From 70'F -- ---
27, 1 Pt,:ycicaj Fa,641y FRC,-6
007
to 4 FF/45`F Wiflrin 4 Hmn,. 28. }Weser or Tiyjc kiaktnaf�, .008
(H) Cooling Pl-1Fs Made Front Ambient -29, 8
--R 009
Temperature Ingredients o,41`F/45 F _s0Other
------- ------
L -Within 4(heal*
'Dcre're,cnueal irem m the leektml 1991)K)(XIC'Xie of 105("lk 54130W
0317 JEFFERSON AVENUE Dube's Restaurant
City of Salem
FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection
HACCP: ❑
Item Status Violation Critical Urgency
Telephone: FOOD PROTECTION MANAGEMENT
744-9531 PIC Assigned/Knowledgeable/Duties PASS 0 RED
Owner:
j Non-compliance with:
Mary Pelletier PASS
Anti-Choking
PIC:
Mary Pelletier Tobacco PASS
Inspector:
John Gehan � EMPLOYEE HEALTH
Date Inspected:Correct By: Reporting of Diseases by Food Employee and PIC PASS �/❑ RED
1/22/2007 Personnel with Infections Restricted/Excluded PASS RED
Risk Level:
FOOD FROM APPROVED SOURCE
Permit Number: Food and Water from Approved Source PASS ] RED
BHP-2007_0320 Receiving/Condition PASS RED
Status:
SIGNED OFF �. Tags/Records/Accuracy of Ingredient Statements PASS RED
#Ot CfItlCai Violations: Conformance with Approved Procedures/HACCP Plans PASS RED
1 j
Time IN: Time OUT:
Urgency Description(s):
BLUE:
Violations Related to Good
Retail Practices (Critical
violations must be corrected
immediately or within 10
days)(Non-critical violations
must be corrected immediately
or within 90 days)
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 22,2007 ) Page 1 of
• ' Item Status Violation Critical Urgency
RED: PROTECTION FROM CONTAMINATION
Violations Related to Separation/Segregation/Protection PASS Q RED
Foodborne Illness Interventions
and Risk Factors (Require Food Contact Surfaces Cleaning and Sanitizing FAIL RED
immediate corrective action) Comments: Sanitizer reading too strong. Sanitizer to be reading at 50 ppm as mandated.
Proper Adequate Handwashing PASS 0 RED
Good Hygienic Practices PASS RED
Prevention of Contamination from Hands PASS 0 RED -
Handwash Facilities PASS RED
PROTECTION FROM CHEMICALS
Approved Food or Color Additives PASS Q RED
Toxic Chemicals PASS 0 RED
TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods)
Cooking Temperatures PASS ❑d RED
Reheating PASS RED
Cooling PASS RED
Hot and Cold Holding PASS RED
Time As a Public Health Control PASS 0 RED
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
Food and Food Preparation for HSP PASS Q RED
CONSUMER ADVISORY
Posting of Consumer Advisories PASS 0 RED
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 22,2007 ) Page 2 of
Item Status Violation Critical Urgency
Violations Related to Good Retail Practices (Blue Items)
Food and Food Protection FAIL BLUE
Comments: Ice scoop was stored incorrectly. Scoop to be stored in designated container or with handle exposed.
Walk in has foods that are uncovered. All foods must be covered.
Equipment and Utensils PASS BLUE
Water, Plumbing and Waste PASS BLUE
Physical Facility FAIL BLUE
Comments: Dry storage ceiling tiles have visible water stains or are damaged. Find source of leak and repair. Replace tiles.
Management and Personnel PASS BLUE
Poisonous or Toxic Materials PASS BLUE
Special Requirements PASS BLUE
Other-See Notes PASS BLUE
V
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. Jan 22,2007 ) Page 3 of
IMPORTANT M1=SSAGr
FOR
DATE '�dJd TIME A.
MC>
PHONE / 78"D�4NUgN E?lI
AREA COE R EXTENSION
❑ FAX
❑ MOBILE
AREA CODE NUMBER TIME TO CALL
TELEPHONED PLEASE ALL
CAME TO SEE YOU WILL CALL AGAIN
WANTS TO SEE YOU RUSH
RETURNED YOUR CALL WILL FAX TO YOU
MESSAGE
SIGNED
F4009
MoIN U.S.A.
NOTES
COURT DOCKET NO. CITATION NO.
SCITY
O SALEM
VIOLATION NOTICEPD 6045
NAM .(LAST,FIRST,INITIAL).
STREETADDRESg CITY/TOWN Iii STATE ZIP
LICENSE NO. LIC.EXP DATE GATE OF BIRTH
/—/lo-o
OWNER'S NAME(LAST,FIRST,INITIAL)E
. Cr , ; G
STREETADDRESS CITY/TOWN STATE ZIP
--�/9 - �esv, �r 1`14 64,*-7
REGISTRATION NO. STATE EXP.DATE MAKE/TYPE YEAR COLOR
DATE OF VIOLATION TIME DATE CITATION WRITTEN PERSONAL
❑AM NJUW
_ ❑PM ❑YES
❑NO
LOCATION OF VIOLAT.II N,.L-..TjEJF'$ -Y CS' • ENFORCING DEPT.
'ca
OFFENSE CHAP. SECT. FINES
>. A a x IUB fo o 140 7"?
OFFICER
I.D.NO. TOTAL
NE
DIUEK/
OFFICER CE^RITIFIES COPY GIVEN TO VIOLATOR
� � � IN HAND
X gV MAIL
QO-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
tti 'fhwi' hir M 4. r ITny � ��','+•; ' 1;0 +' .-� z :rt
COURTODDKETNO�1 ay} 7CR7dNXi NO=Y
NTYtOFaSALEM,! s % rc
F � - 7
AyRST INITIAL) +m ,+"'. ,w..n7 -17
P yAx' x 7
CITY/To"I:STTWE
iKENSENO. ••,� � s RTH
OWNERS NAME(LAST,FIRST.MITIAI)
STREETADDRESS ClWtTOW14 STATE ZIP
REGISTRATION NO. STATE EXP.DATE I MAKE/TYPE YEAR COLOR -
F
Q = DATE OF VIOLATION TIME DATE CITATION WRITTEN ?EnS�Nnt
LET O AM OYES
v- PM NO
LAGAT[OCt OFN Y c' E ORCI E
s 3/r� U, �4rrG v
OFFENSE CHAP. SECT. FINES
i A �1
OfFiCER i.D.NO. TOT j
� FINE
�II -y DUE
r
CERTIFIES COPY GIVEN TO VIOLATOR
o �\ ❑ IN HAND
rrI
YMAIL
P6NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY I
'ORDER OR BY CHECK MADE PAYABLE TO; �.
Z= O I CCITY ITY CLEHALRK I
W
m 93 WASHINGTON STREET
SALEM,MA 01970 i.
W Z o a - i TEL.(5D8)745.9595 X 251
QLLI o C $ r� ; I HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON
(n'otW - PAYMENT"IN CONFESS
TO THE HE Of OFFENSE CHARGED,AND ENCLOSE
Do
O m h< I $___.- CASE N
Q SIGNATURE
m FY SEE OTHER SIDE FOR FURTHER INFORMATION
ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL
i
0
Q
SW
<(r Oµ
t
�I _cam ��_ r u b�—�-_
� ' _ _ . _ _nye ,
_-- � '~
--
i
i -
ii
i
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- I
� �
r
Commonwealth of Massachusetts
City of Salem
Board of Health
120 Washington Street,4th Floor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 01/05/2007
ESTABLISHMENT NAME: Dube's Restaurant
File Number:BHF-2004-000170 317 Jefferson Avenue
Salem MA 01970
LOCATED AT: 0317 JEFFERSON AVENUE
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
FOOD SERVICE BHP-2007-0320 Jan 5,2007 Dec 31,2007 $150.00
ESTABLISHMENT
Total Fees: $150.00
PERMIT EXPIRES (December 31, 2007
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all
plans for such must be submitted to and approved by the Salem Board of Health. Page 1 of 1
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET,4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
Fax 978.745-0343
Kimberley Driscoll W7SALEM.COM
Mayor .JOANNE SCOTT, MPH, RS, CHO
HEALTH AGENT
2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT/
NAME OF ESTABLISHMENT 4 __ TEL#
ADDRESS OF ESTABLISHMENT-�:�� = �� FAX#
MAILING ADDRESS (if different)
EMAIL--Business': � _ � � � Owner's:
OWNER'S NAME I/Th "gyp (.1L( �(} { 1 ; J TTEL# y} /� /
ADDRESS ' 61�1 A �l�—��r 1/e 4t- 0 12 ... o/q�_
STREET MM ��jj //jj CITY STATE ZIP
CERTIFIED FOOD MANAGER'S NAM�(S)l IIOV UT's�
..�Y// j�t
� 164h CA91&f(a /g'�I- b93
(Required in an establishment where potentially hazardous food
fis�prep'ated)
EMERGENCY RESPONSE PERSON-�1 � U' k HOME TEL# Q"l7
DAYS Of OPERATION Monday Tuesday WeduesdaV Thursday Friday Saturday
NPtflOaeOralsR:axSawOmrFiatOleePitnEtRdaAmmfl-atOtoy1Nm0al V. ///1_`y/) /I"�(l/1 - (l/j-�l�I �^ � Sunday
IT I1- 16 //" lV
TYPE OF ESTABLISHMENT FEE (check only)
RETAIL STORE YES? NO less than 1000sq.ft. =$ 50
1000-10,000sq.ft. =$100
more than10,000sq.ft. =$250
_ ---
RESTRURANT YES NO less than 25 seats $100
25-99 seats 150
more than 99 seats 200
.._...._...... -
YES-- --- -------- -- _
NO -- ---- -- -- --- - - --
-- -- ..........$1...0_..... . ....- -- --------- ----------- --
BEDI6REAKFAST 0
__.-..--._..-_.... ... -....-.......... . .- .._ -------._.....-......_....._.................... ----- ------ ------ ----
ADDITIONAL PERMITS
MAKE(not just serve) ICE CREAM, YOGURT, SOFT SERVE YES _NO-, $5
TOBACCO VENDOR YES / $50
ALL NON-PROFIT(such as church kitchens) YES AWL} $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 M L` 1a r 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief,
)a,v,e h Ii s at tax ret and aid aB state taxes required under the law.
natur.---- ------ - --- ✓ ��ised 11/13/0G FOODAP2007.adm CheckN 8 Date __ //
k
Massafchusetts Department of Public. Health Salem Board of Health
Division of Food and Drugs t 120 Washington Street,4' Floor
9 Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343
Name Date T of Ooeration(s) Tme of Inspection
U Food Service [irRoutine
Address ( I ' S V Ris LJ Retail ❑ Re-inspection
t rc Level ❑ Residential Kitchen Previous Inspection
Telephone L1�3 ❑ Mobile Date:/0,/.0�
OwnerHACCP YM
El Temporary ❑ Pre-operation
Ur '/P�� t 4/ ❑ Caterer El Suspect Illness
Person in Charge(PIC) I Time ❑ Bed&Breakfast ❑ General Complaint
In:a; p ❑ HACCP
InspectorOut:7 Permit No. ElOther
Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco
Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑
action as determined by the Board of Health.
FOOD PROTECTION MANAGEMENT"„"„ "'"`"'�""'""" °'�"�""""��°`I V12, Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
❑ 13 Handwash Facilities
EMPLOYEE HEALTH .. T:, y„ y •,�q,
PROTECTION FROM CHEMICALS
E]�2. Reporting of Diseases by Food Employee and PIC =a - �h� "»•- •��, .....od or Color Additivesm�4 �•®m - •�
❑ El 14.Approved Fo3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals
FOOD FROM APPROVED SOURCE„�""u„"ourc', ia;=,�"i "„�w"`a TIM&EMPERATURE CONTROLS Potentiall n Ha'zardo'us Foods a k-"I
❑ 4. Food and Water from Approved Source 1 ( Y ) )
❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures
_a ❑ 6. Tags/Records/Accuracy of Ingredient Statements [117. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ;,/it
.Cooling
�s " °a9. Hot and Cold HoldinPROTECTION FROM CONTAMINATION""'" ""' Aa � 9
❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and SanitizingREOUIRtMENTS FOR NIGHLiT$USGEPiII -E POPULATIONS(NSP)s;
❑21. Food and Food Preparation for HSP
❑ 10. Proper Adequate Handwashing
❑ 11. Good Hygienic Practices _CONSUMEtTADVISORY ,r
E1.2-2. 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 n/
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 1 ' by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations
24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of
25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food
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:
S.5000sIaFor -14.Cx o
Inspector's Signature: I Print: D
PIC's Signatures �.� Print: �,J Page-4o Pages
V
Violations Related to Foodborne Illness
Interventions and Risk Factors(Items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT 8 Cross-contamination
1 590.003(A) Assignment of Responsibility* 3-302.11(A)(]) Raw Animal Foods Separated from
590.003(B) Demonstration of Knowledge* Cooked and RTE Foods*
2-103.17. Person in charge--duties - Contamination from Raw ingredients
3-302.11(A)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Offer-
590.003(.C)590.003(C) Responsibility of the person in charge to Contamination from the Environment
require reporting by food employees and 3-302.11(A) Food Protection*
applicants* 3-302.15 Washing Fruits and Ve. etables
590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and
Applicant To Report To The Person In Utensils*
Char e* Contamination from the Consumer
590.003(G) Reporting by Person in Charge 3-306.14(A)(B) Returned Food and Reservice of Food*
31 590.003(D) I Exclusions and Restrictions* Disposition of Adulterated or Contaminated
590.003(E) Removal of Exclusions and Restrictions Food
3-701.11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Food*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Compliance with Food.Law* 4-501..111 Manual Warewashing-Hot Water
3-201.1.2 Food in a Hermeticall •Sealed Container* Sanitization Temperatures?,
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical W arewashing-Hot Water
3-202.13 Shell ER s* Sanitization Tem eratures*
3-202.14 Fags and Milk Products.Pasteurized* 4-501.11.4 Chenucal.Sanitization-temp.,pH,
3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. '"
5-101..1.1 Drinking Water from an Approved System' 4-601.1[(A) Equipment Food Contact Surfaces and-
590.006(A) Bottled Drinking Water* Utensils Clean*
590.006(B) Water Meets Standards in 310 CMR 22.01` 4-602.11 Cleaning Frequency of Equipment Food-
Shellfish and Fish Froman Approved Source
Contact Surfaces and Utensils*
0.-702.1 t Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment*
Shellfish* 4-70311 Methods of Sanitization-Hot Water and
3-201.15 Molluscan Shellfish from NSSP Listed Chemical*
Sources* Ip Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms*
3-202.18 1 Present* 2-301.12---^ 'Cleaning Procedure*
590.004(C Apr' 2-301.14 When to Wash*
3-201.17 Game Animals* 11 Good Hygienic Practices
g Receiving/Condition 2-401.11 - - "Eating,Drinkin g or Using Tobacco*
3-202.11 PHFs Received at Proper Temperatures* 2401.12 Discharges From the Eyes, Nose and
3-202.15 Package line it * Mouth*
3-101.11 Food Safe and Unadulterated* 3-301.12 PreventinContamination When Tastin
6 Tags/Records:Sheilstock 12 Prevention of Contamination from Hands
3-202.18 Shellsto k Identification* 590.004(E) Preventing Contamination from
3-203.1.2 Shellstock Identification Maintained" ..Employees*
Tags/Records:Fish Products 13 Handwash Facilities
3402.11 Parasite Destruction* Conveniently Located and Accessible
3-402.12 Records,Creation and Retention*
5-203.11 Numbers and Capacities*
590.004('1) Labeling of Ingredients' S-204.11 Location and Placement*
7 Conformance with Approved Procedures
5-205.11 Accessibility,Operation and Maintenance
/HACCP Plans Supplied with Soap and Nand Drying
3-502.11 Specialized Processin Methods* Devices „
3-502.12Redaced ox• en acka ging,criteria* 6-301.11 Handwashin ,
Cleanser,Availability
8-103.12 Conformance with Approved Procedures'"
6-301.1.2 Hand Drying Provision
�Denoics critical item in the federal 1999 Food Code of 105 CNIR 590.000.
CITY 0F1 SALEM
BOARD OF HEALTH
Establishment Name: I I Dater G Page: of
Item Code c-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION 'Date
No. Reference R-Red Item p Verified
PLEASE PRINT CLEARLY _
za Al
J c`- tr'Q J• /t
i r
k
SL'
l �
f�
Discussion With Person in Charge: Corrective Action Required: ❑ No I IVYes
f I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance C3 Employee Restriction/
{ violations before the next ins ection, to observe all conditions as described, and to Exclusion
P Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
a��� /.—J ��'-- 0 Voluntary Disposal ❑ Other:
t-10 LI d(C) laffs Recowcel 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 Hours. Y
PROTECTION FROM CHEMICALS3-501 15_ Cooll"L kfcdiusk�.torPIFs
1=4 Food or-Ccior A-dditives ---- Fig PHF-Hot and Cold Holding
7_20'.12 Addjtvta,� 3-501.16(11) Cold PHFs Maintained at or below
.590.004(F) 1145'
`z-302.14 floaccuon 1-501.16(A)
LIL- Poisonous or Toxic Substances PHF�Maintained at or above
14WE
7-101,11 -1deattyinia Intormalion-Original
3-501,16(A) Roasts field at or above 130°17.Container"'
7-102.1'1 Common Name- "A'ork n�(_olltarnors" 2=0 Time as a Public health Control
7-201.11 Scjraratiorr-Stcnaac* 3-501.19 Time as a Public Health Control*
Variance R
7-20111 Reqriction-Presence and Use* 590.004t H) Variance
7-202.12 CondWoo�of Use"-ProhibitionsREQUIREMENTS FOR HIGHLY SUSCEPTIBLE
-203�11 Toxic Containers POPULATIONS(HSP)
7-204.11 Sanitizers,Criteria-Chenucals*
21 7 9,0 1 11(A) Unpasteurized Pre-packaged Juices and
7-204.12 Chemicals for Washing Produce,Criteria"`
'_204.14 Drinnts
.Crucial* Bet ages with 11arn..�g 1-abdi- ...
4U4 "I
1___--I
7-205.11 Incidental Food Ccittact,Lubricants* 3-801,11(B) liw of Pasteurized E ,s*
7-206.11 Restricted Usr Pesticides,Criteria* 3-801,11(f)) Raw or Partially Cooked Animal Food and
7206 12 Rodent Bad Stations, Raw Sced'sprouts Not Served.
7-106,1 Trackirw,Powders,Pest Control and 3-8ol'13(c)
CONSUMER ADVISORY
TIMErrEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consundition of
16 'Wnice-cls'lliat are Raw.Undercooked or
Proper Cooking Cooking Temperatures for iq I R
PHFs Not Otherwise Processed to Hdainate
3-101.1 IA(l)(2) F'Ms- Patta
155�17 15 Sec.
1-302.13 pasteurized Eggs Substitute for Rws Shell
Eggs*
3-401.11(A)(2) Comminuted Fish, Meats&Gains -
Animals- 155°F 15 sec. :� SPECIAL REQUIREMENTS
3 401.11(B)(1)(2) Pork and Beer Roast-130°F 121 nvin"
3-401.11(A)(2) Ratites,injected Meats- I 55'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
see. " catering, mobile food,temporary and
3-401.11(AaPoultry, Wild Came,Stuffed PHFs, residential kitchen operations should be
Sculling Containerv,Fish,Meat, debited under the appropriate sections
above if related to foodborne illness
-740 1A I(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
- 145'13- 590.009 violations relatingto good retail
3-401.12 Raw Animal Foods Cooked 11 11 practices should be debited under#29-
Microwave 165"F Special Requireircents,
340 1,11(A)(l)(b) All Other PHR,- 145'F 15 see.
Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
140-1.11(,A)&(I)) PHFs 165°F 15 (Iterns 23-30)
cacon
03.11(B) Microwave- 165° F 2 Minute Standing Critical and -critical violations, which do not value,to the
- Tone* foodborne illness haevanftcars and risk factors i;sied above, can be
3-403.1 Cormucrckiliv Pn)ceqs-,d RTE Food- .found at the fathoming sections(if the Food Code and 105 CNIR
14WF* 774 1 590.0_00.3-403.11(E) Remaining UnTle:ed Portions of Beef Item Good Retail 15ractims FC 590.0007
�
Roasts"' 1 23. Managanne
wandPersonnell- _FC -2 .003
Ig - Proper Cooling of PHFs 24. Ford and Food Protection FC-3 l .004
25. E ena and Utensils F& I
tluipm-_
3-501.14(A) Cooling,Cooked 111-11a,from140'17 to -26 Water, Plumon and Waste _FC-5 _006
70T Within 2 Hours and From 70'F 27. Physical Facility
to4l"F/45°F Within 4 Hours. r 5--Poisonous or Toxz Material, -7
PC .008
3-501.1403) Conlin.,PHI s Made From.runbient 24 S eeial Re uiremerts .009
Temperature logredients to 4 I'R/45'F 30,-- Other
Within 4 Hours*
Denotes critical item in the ii,deod 1999 Fired Code or 105 CMR 590 Oou
CITY OF SALEM
f BOARD OF HEALTH _
Establishment Name: !l ,J Date: 1 Pager of
Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION ate
,y No. Reference R-Red Item - verified
.�
PLEASE PRINT CLEARLY
170
+1
Kp:
Yt
W
L
t
t
Discussion With Person in Charge: Corrective Action Required: LlNo es
❑ V luntary 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 alllmandates of the Mass/Federal Food Code. I understand that
' noncompliance, may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. ❑ Voluntary Disposal ❑ Other:
•t
3-501.24(0) PHFs Received at Temperatures
Violations Related to Foodborne Illness Interventions and Risk Amording to Law Cooled to
Factors(items 1-22) (Cont.) 41°F/45°F Within 4 Hours_*
PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs
F PHF Hot and Cold Holding
14 Food or Color Additives 3-501.16(B) Cold PHFs Maintained at or below
3-202.12 Additives" 590 004(F) 41`/45° F.
3-302.14 Prot coon from Unapproved Additives* 'i-501.16(A) Hot PHFs Maintained at or above
15 Poisonous or Toxic Substances -
7-101.11 klendtyinglnnornwtion-Original 140°F. *
3-50116(A) Roasts Held at or above 130°F. "
Comners*
7-102.11 Common;Vratne Working Containers* 20 Time as a Public Health Control
7-201.11 Se oration-Stara 3-501-19 Time as a Public Health Control" .
7-202.11 Restriction-Presence and Use'k
590.004(H) Variance Re nhement
7-202.12 Condition;of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.1 Sank Containers -Chen ions" POPULATIONS(HSP)
7.2(}4.11. Sanitizeas,Criteria hemicals^'
7-204.12 Chemicals for Washing Produce,Criteria: 21 3-801.'11(A) Unpasteurized Pre-packaged Juices and
7-204.14 Dr ing Agents.Criteria* Beveiaites with WaminE I-,abels*
3-5011 I(B) Use of Pastennzed Fees*
7-205.11 Incidental Food Contact, Lubricants* 3-80111(D) Raw or Partially Cooked Animal Food and
7-206.11 Restricted Use Pesticides.Criteria`
Kau Seed S routs Not Served.
7-206.12 RodenTracking
Bait Stationse 3-801AI(C) Unn enedLoodPacka�eNotRe-served.
7-206.13 'Pro king Pgwderg,Pest Control and
Monitoring* CONSUMER ADVISORY
TIM_EITEMPERATURE CONTROLS 771
Consumer Advisory Posted for Consumption f
Anhnal Foods That are Raw.Undercooked or
q6 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate
PHFs Pathogens.": �""° 'v�"
3-401.1IA(1)(2) Figs- 155'FISSec.
F*>s-hvmediate Service 145°Fl Ssec*
3-302.13 Pasteurized Fggs Substitute for Raw Shell
3-401.11(A)(2) Counmarred Fish,Meats&Game 5 gar
Animals- 155°F 15 sec. *
3-401.1 I(B)(1)(2) Pork and Beef Roust-I40'F 121 min* SPECIAL REQUIREMENTS -
3-401.11(A)(2) Ratites,Injected iVieat's 155'F 15 590-009(A)-(D) Violations of Section 590.009(A)-(D)in
sec.* catering, mobile food,tempora y 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-165'17 15 sec. * above if related to foodborne illness
3=401.1 i(C)(:3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
1450E* 590.009 violations relating to good retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited under 1129-
Microwave 165"F* Special.Requirements.
3-401.I'I(A)(1)(b) All Other PHFs-145'F 15 sec.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-303.11(A)&(D) PHFs 165'F 15 sec. * (Items 23-30)
3 403.11(B) Microwave- 165'F 2 Minute Standing Civic al and non-critical vioianons, which do not relate to the
Time* 'foodborne illness interventions and risk factors listed above., can be
3-403.1.1(C) Commercially Processed RTE Food- found in the following sec'tirms of the Food Code and 305 CMR
140'17" .590.000.
3-403.1.1(5) Remaining Unsliced Portions of Beef item Good Retail Practices FC 590.000
---
Roasts* _ Personnel _ F� .003
23. Management and Person, _
1g Proper Cooling of PHFs24.-- Food and Food Protection FC -3 .004
-- -- --------
__ _
3-501.i4(A) Cooling Cooked PHFs from 140°F to 25.__ E ui mentand Utensils FC-4 .00526. Water,Plumbin and Wasie FC-5 006
70017 Within 2 Hours and From 70°17 27. Ph sical Facility FC--6 .007
to 41°F/45nF Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008
3-501.14(B) Cooling PHFs Made From.Ambient 29. S eeiai Re virements .009
Temperature Ingredients to 41'r/,15°17
Within 4 Hours:' rr. nxte-z.a„
+Denotes critical item in the faieral 1999 Food Code or 105 CMu 590.000.
i
Northshore
ro\eSa e Marko l
9 BOURBON STREET
PEABODY, MA 01960
(978) 536-2600
® FAX (978)$35-4242
Complete Line of Foodservice
Equipment,Supplies&Design
INVOICE
I
I
S S
DUBE'S RESTAURANT H DUBE'S RESTAURANT
D 317 JEFFERSON AVENUE P 317 JEFFERSON AVENUE
T SALEM, MA 01970 T SALEM MA 01970
' Q MARY Q '
f978) 7tt-9531
CUSTOMER REF.NO. SALESMAN TRUCK NO. ORDER DATE INVOICE DATE TERMS' INVOICE NO.
I
DUBE 00 09/06/06 09/06/06 C. O.D. 92885
QUANTITY P - BILLING UNIT '
UNE ITEM NO. . UOM ✓ DESCRIPTION 'EXTENSION',
ORDERED DELIVERED s',., _ UNITS .n PRICE.=
1 499499 1 1 . EACH _ JACKSON 200 DIGITAL THERMOMETER W/ 1 249.00 249.00*
ENTER PROBES BOARD
2 1 i EACH HIPPING/FREIGHT CHARGE 1 -0.00 NIC
0 BE ADDED x.
x** SALES TAX @ 5.000% *** 12.45
These ar T)qf' invoices:
Inv. Da ed
`Tu Int Due
08/29/ 77 x}$88. 75 .s i
m � a 50.00
08/30/ �
09/06 53. 34
TOTAL 2.09
1r,
4L1
a4_
NUMBER 2 INVOICE 2Cili 45
OF PIECES _ _ a D C.O.D. CHARGE TOTAL
Customers agree that a SERVICE CHARGE of 11/2%PER MONTH(18%PER YEAR)will be added to PRODUCT RECEIVED IN GOOD CONDITION
any balance due over 30 days,and that a reasonable attorney's fee will be charged should litigation
become necessary.Purchase of the above described merchandise in accordance with Terms and
Conditions of this agreement between Seller and Buyer and receipt of a copy of this Invoice are hereby CUSTOMERS �/
acknowledged.All claims for shortage or damaged goods must be made at time of delivery. - SIGNATURE A
1
Massachusetts Department,Of public Health Salem Board of Health
120 Washington Sreet,
Division of Food and Drugs Salem, MA 01970-t35234 th
190-35234" Floor
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343
Name Date I T of Operations) Type of Inspection
(�\ C1 a (] Food Service ❑ Routine
Address j - c Ris ❑ Retail E,Re-inspection
Level ❑ Residential Kitchen Previous Ins9action
Telephone
El Date: S /0c
El Temporary 11Pre-operationOwner 9 o HACCP YM ❑ Caterer ❑ Suspect Illness
Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint
In; ElHACCP
I� J
Inspector "-"- Out: Permit No. El Other
Each violation checked r quires 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
,L
"'FOOD PROTECTION MANAGEMENT_,j :r o- ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties J,
y ❑ 13 Handwash Facilities
� EMPLOYEE HEALTH _` . .
aw `PROTECTION FROM CHEMICALS T. =:
El2. Reporting of Diseases by Food Employee and PIC r ,,,N '�� - _ _ _ �i �� ».�r.a _! f
❑ 14.Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals
"FOODFROM APPROVED SOURCE;;�,-,,. . _ e1.„„„»JA,. ,0U
❑ 4. Food and Water from Approved Source �,nmEtrEMPERATORE CONTROLS(PCtendally Hazardous F66ds)7
❑ 5. Receiving/Condition ❑ 164 Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling
I PROTECTION FROM CONTAMINATION'"``� „= T , `" ❑ 19. Hot and Cold Holding
i„'r. . 13..�,.•. � ,.�,. A .�a. ':q�,� a'.u;,r-u =cti i;�r"a 1�Esw
❑ 8 Separation/Segregation/Protection ❑20.Time As a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing ° REQUIREMENTS FOR HIGH ILY,SUSCEPTIBLE POPULATIONS(HSP)7,
❑21. Food and Food Preparation for HSP
❑ 10. Proper Adequate Handwashing
❑ 11. Good Hygienic Practices
f CONSUMER ADVISORY e,ff i. m. ,„ i&m i
❑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 a 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an
24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations
25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of
the food establishment permit and cessation of food
26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you
27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7)(590.006) 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:
55901nspeclFarmbl4 tlx
Inspector's Signature: Print: Q
PIC's Signature•. Print: /�t Pageof_Pages
c
G'`
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22)
PROTECTION FROM CONTAMINATION
_ FOOD PROTECTION MANAGEMENT - 8 Cross-contamination
1 I 590.003(A) Assignment of Responsibility*-_� 3-302.11(A)(]) Raw Animal Foods Separated from
590.003(B) Demonstration of Knowledge* Cooked and RTE Foods*
2-103.1'1 Person in charge-duties Contamination from Raw ingredients
3-302.11(A)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Other*
2 590.(X)3(C) Responsibility of the person in charge to Contamination from the Environment
require reporting,by food employees and 3-302.11(A) Food Protection*
applicants* 3-302.15) Washing Fruits and Vegetables
590.003(F) Responsibility Of A Fad Employee Or An 3-304.11 Food Contact with Equipment and
Applicant To Report To The Person In Utensils*
Char e* Contamination from the Consumer
590.003(G) Reportina by Person in Charge* 3306.14(A)(B) Returned Food and Reservice of Food*
3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated
590.003(E) Removal of Exclusions and Restrictions Food
3-701.11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Food*
Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004('A-B) Compliance with Food Law* 4501.111 Manual Warewashing-Hot Water
3-201.12 Focal in a Hermetically Sealed Container* Sanitization Temperatures* - -
3-20113 ,Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water
3-202.13 Shell Eggs* Sanitization Temperatures*
3-202.14 E sand Milk Products.Pasteurized*
4301.11.4 Chemical Sanitization-temp.,pH,
3-25))2.16 Ice Made From Potable Dunkin Water"
concentration and hardness. 'k
5-101..1.1 Drinking Water from an Approved System*tem* 4-601.11(A) Equipment Food Contact Surfaces and
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*
Sheltlish 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 u5) memt
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and
3-201.15 Molluscan Shellfish from NSSP Listed Chemical*
Sources* 10 Proper,Adequate Handwashing
Regulatory Authori
Game and uMushrooms Approved by 2-301.11 - Clean Condition-Hands and Arms*
3-202.18 Shellstock Identification Present* 2-301..1.2 Cleaning Procedure*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201..17 Game Animals* ll Good Hygienic Practices
Receiving/Condition 2-401..11 Eating,Drinking or Using Tobacco*
3-202.1.1. PHFs Received at Proper Temperatures* 2-401.1.2 Discharges.From the Eyes,Nose and
3-202,15 Package Integrity* Mouth*
3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting*
6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* 590.004(B) Preventing Contamination from
3-203.12 Shelistock Identification Maintained* Em ilo yeas*
Tags/Records;Fish Products 13 Handwash Facilities
3-402.11 Parasite Destruction* _ Conveniently Located and Accessible
- 3-402.12 Records.Creation and Retention" 5-203.11 Numbers and Capacifies*
590.004(7) Labeling of Ingredients' 5-204.11 Location and Placement*
7 Conformance with Approved Procedures 5-205.11 Accessibility,O reration and Maintenance
/HACCP Pians Supplied with Soap and Hand Drying
3-502.11. Specialized Processing_Methods* Devices
3-502.12 Reduced ox en ackx 'nom.criteria* 6-3011.l l HHandD.Drying Provision Cleanser,Availability
- 6-30 .12
8-103.12 Conformance with A roved Procedures*
Denotes critical item in the federal 1999 Food Code or 105 CIMR 590.000.
S
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,4th Floor
Division of Food and Drugs Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343
NameDrat / Tvoe of 0 eration(s) Type of Inspection
Food Service ❑ Routine
Address i f (� isl{/ Retail 12 Re-inspection
1_ Level ❑ Residential Kitchen Previous nsppction
Telephone -i 5 ❑ Mobile Date: "di
Owner 7 HACCP YM ❑'Temporary ❑ Pre p�r�at�K
- 5 ��r ❑ Caterer ❑ Suspect Illness
Person in Charge(PIC) / I Time ❑ Bed&Breakfast ❑ General Complaint
In: ❑ HACCP
Inspector Dai? 3a 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 Anti-Choking Tobacco
Violations marketl may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑
action as determined by the Board of Health. -
PObD PROTECTION MANAt3EMENT» re „l,a ❑ 12. Prevention of Contamination from Hands
❑ 1 PIC Assigned/Knowledgeable%Duties
aElt n ,MNy mr, 13 Handwash Facilities
EMPLOYEE HEALTW
El 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 F�,,mss,may y ', m- „, =a: S, TIMElTEMPERA7URE CONTROLS(Potentially Hazardous Foods
E] 4. Food and Water from Approved Source f Y )' 4
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑1118. Cooling
, 1 `"�O
PROTECTION FROM CONTAMINATION:"' x f � ^" _ 1�19. Hot and Cold Holding
v
..�,+..,.. --..»v.....«.».,...s..a.:...r:Aa.e„-
El 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing f REOUIREMENTSFOR HIGHLY SUSCEPTIBLE
POPULATIONS
❑21. Food and Food Preparation for HSP
❑ 10. Proper Adequate Handwashing
❑ 11. Good Hygienic Practices '_CONSUMER ADVISORY„" �a,�..,, n s"' ,�,,, _r- ' 1, " ;µa r,-
❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices Number of Violated Provisions Related
Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22):
of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code. This report, when signed below
C ` by a Board of Health member or its agent constitutes an
24. Food and Food Protection (FC-3)(590.0
23. Management and Personnel (FC-2)(sso.0 4)) order of the Board of Health. Failure to correct violations
cited in this report may result in suspension or revocation of
25. Equipment and Utensils (Fc-a)(sso.o0 )s) the food establishment permit and cessation of food
26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you
27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7)(59o.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: \ �7
s:5901os IFo m 14.eac - 1 � A vU C_
Inspector's Signature: Print:
PIC's Signature: ,� �� Print: _ /c-� page-Fpage-F of Pages
Violations Related to Foodborne Illness
Interventions and Risk Factors(Items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT $ Cross-contamination .
1 590.003(A) Assignment of Responsibility* 3-302.11(A)(1.) Raw Animal Foods Separated from
590.003(B) Demonstration of Knowledge* Cooked and RTE Foods*
2-103.11 Person in charge-duties Contamination from Raw ingredients
3-302.11(A)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Other*
2 590.003(C) Responsibility of the person in charge to Contamination from the Environment
require repotting by food employees and 3-302.11(A) Food Protection*
applicants* 3-302.15 ..Washing Fruits and Vegetables
590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and
Applicant To Report To The Person In Utensils*
Charge* Contamination from the Consumer
590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food*
3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated
590.003(F.) Removal of Exclusions and Restrictions Food
3-701.1.1 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Food*
4 Food and Water From Regulated Sources F 9 Food Contact Surfaces -
590A04(A-B) Compliance with Food law* 4-501.111 Manual Warewashing-Hot Water
3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures*
3-20113 Fluid Milk and Milk Products* 4-501.112 MechanicalWarewashina Hot Water
3-202.13 Shell Eggs* Sanitization Tem eratures*
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitisation-temp.,pH,
3-202.16 Tee Made From Potable DrinkingWater* concentration and hardness. *
5-101.11 DrinkingWater from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and
590.006(A) Bottled DrinkingWater* Utensils Clean* -
590.006(B) Water Meets Standards in 310 CMR 22.0"' 4-602.11 Cleaning Frequency of Equipment Food-
Shellfish and Fish From an Approved Source
Contact Surfaces and Utensils*
4-702.11 Frequency of Sanitization of Utensils and
3-201.14 Fish and Reerearionally Caught Molluscan Food Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-HotWaterand
3-201.15 Molluscan Shellfish from NSSP Listed Chemical*
Sources* 10 Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Re ulato Authority2-301.11 Clean Condition-Hands and Arms*
3-202.18 Shellstock Identification Present" 2-301.12 Clearing Procedure*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201..17 Game Animals* 11 Good Hygienic Practices
Receiving/Condition 2-401.11 Eating,Drinking or Using Tobaccos'
3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and
3-202.15 Package Ince it y* Mouth*
3-101.11 Food Safe and Unadulterated* 3-30'1,12 PreventingContamination When Tasting*
6 Tags/Records;Shellstock 12 - Prevention of Contamination from Hands
3-202.18 Shellstock Identification* -T90 004(F) Preventing Contamination from
3-203.1.2 Shellstock Identification Maintained* Employees*
TagsfRecerds.Fish Products 13 Handwash Facilities
3-402.11 Parasite Destruction' Conveniently Located and Accessible
3-402.12 Records,Creation and Retention*
5-203.11 Numbers and Capacifies*
590.004(.T) Labeling of Ingredients' - 5-204.11 Location and Placement*
q Conformance with Approved Procedures 5-205.11 -Accessibility,Operation and Maintenance
IHACCP Plans Supplied with Soap and Hand Drying
3-502.11. S ecialized Processin Methods* Devices
3-502.12 Reduced oxygen packaging,criteria* 6-301.11 - Handwashi ng Cleanser, Availability
8-103.12 Conformance with A. roved Procedures* 6-301.12 Hand Drying Provision
*Denotes critical item in the federal 1999 Food Cade or 105 CMR 590.040.
CITY OF SALEM
j� BOARD OF HEALTH
< Establishment Name: Date: q/4r,q/4Page:_. of
Item Code C-Critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
5 No. Reference R-Red Item Verified
PLEASE PRINT CLEARLY
S. ( ta jj J40 q--5
J O aCAI
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u e a O 6
GtDu-
Co ti 1
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4
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4
Discussion With Person in Charge: Corrective Action Required: ❑ No Yes
y 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
t comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of wenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
,t your food permit.
❑ Voluntary Disposal ❑ Other:
r.
k
a77-
r
a'-50i.14(C) PR Fs Received vt Temperatures
Violations Related to Foodborne fitness Interventions and Risk According to taw Cooled to
Factors(items 1.22) (Cont.) 41`FJ45°'F Within 4 Hours.
PROTECTION FROM CHEMICALS 3-501.15 Cooliun Methods for PHFs
I9
14 Food or Color Additives - PHF Hot and Cold Holding
3-202.12 Additives*
3-501.1(0) Cold PITS Mainlo
Maintained at or below
590.004(F) 41'145°F-
3-30114 Protection from Una i roved Additives* 1-501.16(A) Mot PHFs Maintained at or above
15 Poisonous or Toxic Sutrstances '
140'F. *
7-101.11 Identifying information-(h'iginal 3-501,t6(A)� Roasts Held at or above 130°F.
Containers*
7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control
7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control*
7-202.11 Restriction-Presence and Use'
k 590.004(H) Variance Re uirement
7-202.12 Conditions of Use*
7-203.11 Tomo Containers-Prohibitions" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.1'1 Satnuzers,Criteria-Chemicals* POPULATIONS(HSP)
7-204.12 Chemicals for W ashime Produce,Criteria's 21 3-80L1 t(A) Unpasteurized Pre-packaged Juices and
Beverages with Winning Labels"
7-204.14 Dain*. ents,Criteria�* -- --
7-205.11 Incidental Food Contact.Lubricants*
3-801.1i(B) Use of Pasteurized Eggs*
7-206.1 1. Restricted Use Pesticides.Criteria* 3-801.11(D) Raw or Pin tially Caked Animal Food and
Raw Seed S Mouts Not Seived. .e
7-206.12 Rodent Bait SCations* 3-8{g.11(C)
Unopened Food Packa,e Not Re-served.
7-206.13 Tracking Powders,Pest Control and
MonitorinP*
CONSUMER ADVISORY
TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
16 Proper Cooking Temperatures for
Animal Foods'l-hat are Raw.Undercooked or
PHFs Not Otherwise Processed to Eliminate
r
3-401.11A(1)(2) EggPathos*ens*Fray*„ lvzoor
- 155'F15Seo. '
E gqs-hmnediate Service 145=F15see* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
3-401.11(A)(2) Comminuted Fish,Meats &Game
E es*
Animals- 155°F 15 sec. .
3 401.11(13)(1)(2) Pork and Beef Roast- 130°F 121 ruin* SPECIAL REQUIREMENTS
3-401.1l(A)(2) Ratites, tnjected Meat's-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
Stuffine Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-165°F 15 sec. u' above if related to foodborne illness
3-401.11(,C)(3) Whole-muscle,Intact'Beef Steaks Interventions and risk factors. Other
1450F* 590.009 violations relating to good retail
3401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165"F* Special Requirements.
3401.11(A)(f(b) All Other PHFs- 145°F 15 sec.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-103.11(A)Rt(D) PHFs 165°F 15 sec. * (Items 23-30)
3-403.11(B) Microwave-165°F 2 Minute Standing Critical and non-critical vio&+tions, nirich do not relate to the
Tune" foodborne illness interventions and risk fn(tors listed nbove, can be
3-403.11(C) Commercially Processed RTE Foal- found inthe foHowbrg se:etions of the Food Code and 105 CMR
140°F` 590.000.
3-403.11(G) Remaining Unsliced Portions of Beef Item Good Retail Practices FC 590.000
Romts* 23. Management and Personnel FC 2 .003
1g Proper Cooling of PRFs 24 Food and Food Protection FC 3 1 .004
3-501 14(A) Calutg Cooked PHFs from 74-0°F to -2-5.-- Egmpment and Utensils FC 4_;_ .005
26 Mater,Plumbina and Waste FC 5 1_.006
70°F Within 2 Flours and From 70'F 27. Ph sical Facility_----_._ FC-6 .007
to 41.°Fl45"F Within 4 Hours. 23. Poisonous or Toxic Materials FC-7 008
*
S ecial Re: uirements .
350114(8) Cooling PHFs Made From Ambient 291 .009
Temperature Ingredients to 41"F745°F 30 Other
Within 4 Flours* ssaoa,m,nxcez:w�
*Denotes critical itean in the federal 1991.)Pooh Code or 105 CMR 590.000.
--- - Cita ofSalem, Massachusetts
r+
"ire Department
8L $neat 1 {
SaLm, Mw4 acAusetu 01970-3695 fire Prevennon
''pu vu(jv..Curly Tel 978-744-1235 Bureau
CA f FaX 978-745-4646 978.745-7777
9"S�7444990
d�ody(('Xlalem cam
Dubie's Restaurant
317Je£ferson Avenue
SAlem,MA 01970
ATTN: Owner/ Manager
MAINTENANCE.CLEANING.AND TESTING OF FIXED FIRE EXTINGUISHING SYSTEMS,
MAINTENANCE.CLEANING OF HOOD AND DUCT SYSTEMS WHERE COOKING GREASE
IS GENERATED.............
....
The Salem Fre Prevention Bureau requires that all hood and duct systems are to be cleaned
from the cooking area (hooM in the kitchen, all the way fo the extreme end of the duct. THIS
CLEANING WILL OCCUR ON A 9MMERLY BASIS.
A certificate showing the name of the compeny,the person,and the date of the cleaning shall be
posted near the hood area. The rartlficate will indicate what work was performed, and will also
-indicate areas not cleaned.
ALL FIXED FIRE EXTINOU13HING SYSTEMS ARE TO BE TESTED AND CHECKED SEM11-
Af NUALLY. THIS TEST WALL ALSO INCLUDE A TEST OF THE INTERIOR FIRE ALARM
SYSTEM.
The cleaning company and the fixed extinguishing service company shall file within(5)five days
after the work is performed, a report with the Salem Fire Prevention Bureau of all their activities
relative to the above listed systems. The report shaft also list any and all deficiences of the
systems and the remedial action to be taken. Failure to adhere to this public safety requirement
will result W the shut down of the systems. Prior to resuming operations an inspection will be
conducted by this office.
Per Order.
IJAugust 29, 2006
Lt..Erin rifAn t Date of Conveyance
Fire Marshal
FORM 81R(4/05)
CC: —file Health Licensing Building
I
V0 39Cd HO1tldSI(l 32113 W3-VS Z0V6SVLSL6 Zb.80 900Z/6Z/80
rf _
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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 Dae Type of Ooeration(s) Type of Inspection
_ I� rJ Food Service ❑ Routine
Address r / Rik ` Lj Retail Re-inspection
Telephone Level ❑ Residential Kitchen Previous Inspection
❑ Mobile Date 06
Owner HACCP Y/N El Temporary E] Pre-op ration
/ I (� / ❑ Caterer ❑ Suspect Illness
Person in Charge( IC) Time ❑ Bed& Breakfast ❑ General Complaint
Inspector In:10.'r0 permit No. _] HACCP
Out;j
Other
Each violation checked require 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
El 1. PIC Assigned Knowledgeable Duties ❑ 12. Prevention of Contamination from Hands
/ /
EMPLOYEE HEALTH - " " • ° -- El13. Handwash Facilities
CTION FROM
� �OjgEAPP oved Food oMCoIAorAdditives
El 2. Reporting off D Diseases by Food'
Employee and PIC - - _ -
El 3. Personnel with Infections Restricted/Excluded
FOOD FROM APPROVED SOURCE_ "" --- _ El 15.Toxic Chemicals
TIMEITEMPERATURE CONTROLS(Potentially )
❑ 4. Food and Water from Approved Source ( otentiall 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)
El 10. Proper Adequate Handwashing EI21. Food and Food Preparation for HSP
El11. Good Hygienic Practices ,:CONSUMER ADVISORY'
1 ❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices 4 Number of Violated Provisions Related
Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions
immediately or,within 10 days as determined by the Board and Risk'Factors(Items 1-22):
of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code. This report, when signed below
23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an
24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations
5. 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)(590.0681) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION:
S.590M,dFmm 14,do
Inspector's Signature: ` Print:
PIC's Signature: Print: G I(� , t'Al t l L/ I Page.of-Z-Pages
i --
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT_ 8 Cross-contamrnarion
1 590.003(A) Assignment ofResponsibility- 3-302.11(A)(]) Raw Animal Foods Separated from
590.003(B) Demonstration of Knowledge* Cooked and RTE Foods*
2-103.11. Person in char e-duties Contamination from Raw ingredients
3-302.1.1(A)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Other*
2 590.003(C) Responsibility of the person in charge to Contamination from the Environment
require reporting by food entploycos and 3-302.11(A) Food Protection*
a licants" 3-302.15 Washln Prints and Veaetables
590.003(F) Responsibility Of A Food Employee Or Flu 3-304.1 t Food Contact with Equipment and
Applicant To Reportto The Person In Utensils*
Charge* Contamination from the Consumer
590.003((7} Re tarCin b Persrm in Charge* 3-306.14(A)(B) Returned Food and Rescivicc of Food*
3 590.003(D) Exclusions and Restrictions^ Disposition of Adulterated or Contaminated
590.003(E) Removal of Exclusions and Restrictions Food
3-701.11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Food*
4 Food and Water From Regulated Sources ) Food Contact Surfaces
590.004(A-B) Compliance with Food Law" 4-501.111 Manual Warewashing-Hot Water
3-201.12 Food in a Hernielically Sealed Container* San[iration'rem)eratures*
3-20'1.13 Fluid Milk and Milk Products* 4-501.11.2 Mechanical Warewashing-Hot Water
3SheE*�s* Sanitization Temperatures"
3-202.14 Milk Products.Pasteurized* 4-501..114 Chemical Sanidiation-temp.,pH,
3-202.16 Ice Made From Potable Drinkin*Water'" concentration and hardness..,
5-1.01.1.1 Drinkin Waterfi�om an A moved S stem° 4-601A I(A) Equipment Foad Contact Surfaces and
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 Seurce ?02.11. Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreational ly Caught Mol lusatn Food Contact Surfaces of ui ment*
Shellfish" 4-703.11 Methods of Sanidaation-Hot Water and
3-201.15 Molluscan Shellfish from NSSP Listed Chemical*
Sources* tp Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Regulatory Authority 2-301.11 Clean Condition-Hands and Alms*
3-202.18 Shellstock Identification Present.` 2-301..12 Cleanin;Procedure*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201.17 Garm, Animals," 1.1 Good Hygienic Practices
Receiving/Condition 2-401.11. Eatiniz.Drinkin,or Usines Tobacco"
3-202.11 PRFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and
3-202.15 Packa e htte rit " Mouth*
3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When 1'ast9n "
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 loyees*
Tags/Records:Fish Products 13 Handwash Facilities
Conveniently Located and Accessible
3-402.11 Parasite DestrnC6011-
3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities*mn
590.0040) Labeling of Ingredients' S-204.11. Location and Placement*
ry Conformance with Approved Procedures
5-205.11 AccessibllSt•, ptexationandMaintenanee
/HACCP Plans Supplied with Soap and Nand Drying
3-502.11 Specialized Processing Methods* Devices
3-502.12 Reduced oxygen >acka='n,,.criteria* 6-301.11. Handwashing Cleanser, Availability
5-103.12 Conformance with A roved Procedures* 6-301.12 Nand Dryim*Provision
I
i 5 4
*Uenolts critical itcot in the Ccderal llJ)Foal Code or(c_C?IR.vJ09Y3.
CITY OF SALEM
I_ BOARD OF HEALTH
Establishment Name: 6 S Date:n7 Pager of
e nem Code C—critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R—Red Item - ' - Verified
A' � PLEASE PRIM CLEARLY-
400
tt1 O 91 i
Q)j ICS� (vjc'' 1 v[t P /moi /
( 1
i
{
Discussion With Person in Charge: - Corrective Action Required:" ❑ NoFJ
Yes
I have read this report, have had the opportunity to ask questions and agree to correct all11—Voluntary Compliance L) Employee Restriction/
inspection, to observe all conditions as described, and to Exclusion
violations before the next ins
P ' ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty
--five d tars or suspension/revocation of 1 ❑ Embargo ❑ Emergency Closure
yourfood permit ! / v \
lY• . I ❑ Voluntary Disposal ❑ Other:
3-50 L 14((-) PHFs 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 Conlin,,Methods for PHFtt
19
14 Food or Color Additives PHF Hot and Cold Holding
3-50116(8) Cold PHFi,Maintained at or below
3-262.12 Additie * 590.004(F) 41 V45°F*
3-302.14 Protection from Unapproved Additives
3-501.16(A) trot PHFs Maintained at orabove
15 Poisonous or Toxic Substances
140'F
7-101.11 ldentifyittg Information-Original 3.501 16(A) Roasts Held at or above 13WE.
Containers`
7-102.11 Common Name-Working*Containers* 26 Time as a Public Health Control
7-201.11 Separation-Stte*
3-561.,9 TimeasaPublic RealthControl*
7-262.11 Restriction-Presence and Use* 5)0.004(H) Variance Re uirement
7-202.12 Conditions of Use*
7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-264.11 smtitizers,Criteria-Chemicals* POPULATION
3501S HSP) _
7-204.12 Chemicals for Washing Produce,Criteria" 21 - .11(A} l;npasteurized Pre-packaged Juices and
7-201.14 D =. ents,Criteria*
El Beverages wide n tH' nsLabels*
7-26511 Incidental Food Contact.Lubricants* -801-I1{B) Use of Fasteurized L L es`
7-206-'11. Restricted t?se PeaCrcides. Criteria* 3-801,11(D) Raw or Partially Cooked Animal Food and
Raw Seed Sprouts Not Served.'r
7-206.12 1 Rodent Bait Stations* 3-801.1](C) Uno�ened Fax1 Packag=e Not'Re-served.
7-266.13 Tracking Powders,Pest Control and
Monrtorina*
CONSUMER ADVISORY
TIMErrEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
16 Proper Cooking Temperatures for tUiunal Fattl That are Raw, Undercooked or
PRFs Not Otherwise Processed to Eliminate
e ;o0,
3-101.1f . " :
Eggs- Immediate Service 145`1715sec* 3-302.13 Pasteurized tgls Substitute for Raw Shell
3-401.11(A)(2) Comminuted Fish,Meats&Game -- Begs*
Animals- 155'F 15 sec.
3-401.1 l(B)(1)(2) Pork and Beet Roast-13WF 121 min* SPECIAL REQUIREMENTS_
3-401.11(A)(2) Ratites,Injected Meats 155'F 1.5 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
sec, * catering, mobile food, temporary and
3-401.1l(A)(3) Poultry,Wild Game, Stuffed PCF" residential kitchen operations should be
Stuffing Containing Fish,Meat, debited ander the appropriate sections
Poultr�l65"F 15 sec. * above if related to Foodborne illness
3-401.11(C)(3) Whole-mnscle, Intact Beet Steaks interventions and risk factors, Other
t45°F* 590.009 violations relating to good retail
3-461.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165'F* Special Requirements.
3401.11(A)(1)(b) All Other PHFs- 145'F 15 sec.
17 Reheating for Hoo Holding
VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-403.11(A)Rt(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 alter centiam and risk factors listed above, can be
3-403.11(C) Commercially Processed RTE Fail- fznrnd in the follow rrg seetians of the Food Cade and 105 CMR
'140'F* 590.000-
3-403.11(E) Remaining Unsiiced Portions of Beef Rem Good Retail Practices FC 580 000
Roasts* 23. management and Personnel FC-2 .003
18 Proper Cooling o4 PHFs 24. Food and Food ProtectionFC
2-5 ___ E ui ment and Utensils _ FC 4 .005_
3-501..14(A) Cooling Cooked PHFs from 140`17 to 26. Water, Plumbin and Waste FC 5 .006
--- - -
70°'FWithin 2 Hours and From 70°F 27. Physical Facilitt, .007
to 41`F/45'F Within 4 Heals. * 28. Poisonous or Toxic.materials FC-7 4 .008
3-501.14(B) Cooling PHFs Made From Ambient 29. S ectal Re utrements
Temperature hieredients to 41"T/45'F _ 30 _Other__
Within 4lours* S "r ""`6-2d,°
Denote"critical item in the federal 1999 Food Code or 105 CMP.594,000.
-•'+LET _ f .YJ+:fry vt^4A R•...Wr.+n../YM1. r
SR'•r n • r'rnM r M :.a.... r..-a,, r - , ('. ,'i+.^.,a'
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 I Date Tvpe of Operation(s) Type of Inspection
Address ,O Food Service (❑,Routine
Ris ❑ Retail /❑ Re-inspection
Telephone Level El Residential Kitchen Previous Inspection
3 I ❑ Mobile Date: Jp f a.2 ( xs--
OwnerHACCP YM El Temporary ElPre-operation
Q Irl IIP f/ ❑ Caterer ❑ Suspect Illness
J Person in Charge tFIC)i Time ❑ Bed& Breakfast ❑ General Complaint
In: (�,- co ElHACCP
Inspector cr G A Out: L Permit No. El
Each violation checked requires an explanation on the narrative p'age(s)and a citation of specific provision(;) 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
i 1 ❑ 13. Handwash Facilities
EMPLOYEE HEALTH}
PROTECTION FROM CHEMICALS
❑ 2. Reporting of Diseases by Food Employee and PIC E3 jq Approved Food or Color Additives
[:] 3. Personnel with Infections Restricted/Excluded
FOOD FROM APPROVED SOURCE El 15.Toxic Chemicals] '•,
❑ 4. Food and Water from Approved Source -TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) .r
❑ 5. Receiving/Condition [116. Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance.with Approved Procedures/HACCP Plans ❑ 18.Cooling
PROTECTION FROM CONTAMINATION L ❑ 19. Hot and Cold Holding
t
❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control
E 9 Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
E3 10. Proper Adequate Handwashing ❑ 21. Food and Food Preparation for HSP
1.
❑ 11. Good Hygienic Practices f , "CONSUMER ADVISORY „"" -
❑22. Posg 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
ofCHealNth. 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
4. 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) the food cited in this report mastablishment permit and y:.result in suspension or revocation of
e
26. Water, Plumbing and Waste (Fc-5)(590.006) establishment operations. If aggrieved cessation of food
ed 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: 7
S:sso�nw�'rFomrt 14 Mo 7� �j��Y 10
Inspector's Signature: \ Print:
PIC's Signature:/ Print: / Pagef 2Pages
Violations Related to Foodborne Illness
interventions and Risk Factors(items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT $ Gross-contamination
I 590.003(A) Assignment of Resp 3-302A 3-30211(A)(]) Rau Animal foods Separated from
,,
590.003(B) Demonstration of Knouledg� Cooked and RTE Foods*
2-103.11 ) Person in aArerge-duties Contamination from Haw Ingredients
3-302.11(A)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Other*
2 590.003(C-) Responsibility of the person in charge to Contamination from the Environment
require reporting by food employees and 3-302.11(.) Food Protection-
a tlicants*_ _ 3-302.1.5 Wash(neFruits and Vegetables
590.003(F) Responsibility Of A Food Employee Or An 3-304.11. Food Contact with Equipment and
Applicant To Report To The Person In Utensils*
Chatbe" Contamination from the Consumer
590.003(6) Reporting by Perso�* 3 306.14(A)(B) Returned Food and Reset-vice of Food*
3 590.003(D) Exclusions andRcstrictions* Disposition of Adulterated or Contaminated
590.003(E) Removal of Exclusions and Restrictions Food
3-701.11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Ftp*
4 Food and Water From Regulated Sources 9 Food Contact-Surfaces .
590.004(A-B) Compliance with Food Law'" 4-501.111 Manual Waretirashing-Hot Water
3-201.12 Food in a Hermetically Scaled Container* Saunization leu eranues'
3-201,13 Fluid Milk and Milk Products* 4-501.112 Mechanical W arewashing Hot Water
3-202.13 Shelf Eaas*
Sanitization Temperatures*,
3-202.14 E re and Milk Products,Pasteurized* 4-501'114 Chemical Sanitization-temp" pH,
3-202.16 Ice Made From Potable Drinkinn Water" concentration and hardness:* -
4-601.11(A) Equipment Food Contact Surfaces and
5-101.1.1 DrinkingWater from an A roved Svstetn* Utensils Clean* "5
596006(.) Bottled Drinking Water* 47602.11 Cleaning Frequency ol'EquipmemFood-
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils'"
11
Shellfish and Fish From an Approved Source
4-702.11 Frequency of Sanitizaffon of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan ntcnt*Foal Contact Surfaces of E ui
Shellfish* 4-70111 Methods of Sanitization-Hot Water and
Sourcel*
3-201.75 MorShellfish front NSSP Listed Chemical*
ces* of Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Ra Mato Avfhorrt 2-301.11 Clean_Condition-Hands and Arms
3-20218 Shellstock Identification Present* 2-301.12 Cleaning, Procedure*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* -
3-201.17 Game Animals' - 1.1 Good Hygienic Practices
5 Receiving/Condition t` 2-401..17 Eatitt ,Drinking or Usrn�Tobacco°`
3-202.17. PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes, Nose and
3-202.1.5 Package Lug it: - Mouth*
3-101.11. Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting"
6 Tags/Records: Shellstock 12 Prevention of Contamination from Hands
3-202.18 ShellstockIdentification * 590.004(E) Preventing Contamination from
3-203.12 Shellstock Identification Maintained* Eirlevees*
TagsiRecords:Fish Products 13 Handwash Facilities
3-40211 Parasite Destruction* ConvenientlyLocated andAccessible
3-402.12 Records.Creation and Retention* 5-203 it _ Numbers and Ca acnies*
590.0040) Labeling of Ingredients' - 5-204.11 Location and Placement*
g Conformance with Approved Procedures
5-205-11- -Accessibility.Operation and Maintenance "(
/HACCP Plans Suppiied with Soap and Nand Drying
Devices
3-53-502.11SPee i;ilizec7 Processing Methods* Dev �
. 3-502.12 Reduced oxygen tacky ins*.enteria* 6-301.11 Handwashiniz Cleanser, Availability
8-103.12 Conformance with A. roved Procedures* 6-301.12 Hand Drying Provision
*Denotes critical iter in the federal 1999 Food Code at 105 f1b112 590004
1
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: !JJ1S Date: Page's of
`t Item Code C-Critical Item DESCRIPTION OF VIOLATION hPLAN OF CORRECTION Date
No. Reference R-Red Item - -` - - - Verified
PLEASE PRINT C ARLV �,
I may-
n
i
-fit C Q 46- n,
_ 7 �-
s
h0A4 -je-- c7 IGe
•r
L
r ,
✓ r, r
a
Discussion With Person in C K a ge: 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
-+ violations before the next inspection, to observe all conditions as described, and to Emersion
P � Re-inspection Scheduled El Emergency Suspension
comply with all mandates of the Mass/Federal ood Code. I understand Pat
noncompliance may result imclaily fines of tw ty-five ollars or usp slon/revocation'of ❑ Embargo ❑ Emergency Closure
your food permit. ❑ Voluntary Disposal ❑ Other:
a
3-501.14(C} PHFs Received at Temperatures
Violations Related to Foodborne Illness Interventions and Risk According to Iaw Cooled to
Factors(Items 1.22) (Cont.) 4l'F/45'F Within 4 Hours."
PROTECTION FROM CHEMICALS 3-501.15 Coohn"Methods for IWs
1=414 _ Food or Color Additives 19 PHF Hot and Cold Holding
3-202.12 Additives"
3-501.16(B) Cold PPIFs Maintained at or below 3-302.14 Protection for Toxic
a t rovc Substances ed Additives* 590.004(F) 41'145 F*
Poisonous or Toxi3-501.16(A) Hot PHFs Maintained at or above
IS
40'F. *
7-101.11 Identifying Information-Orio nal 3-501.16(.4) Roasts Held at or above 130'F.
Containers"
7-10211 Common Name-Working Containers` 20 Time as a Public Health Control
7-201.1 1 Separation aration-Stora e* 3-501.19 Time as a Public Health Control*
7-202,11 Restriction-Presence and Use*
590.004(H) Variance Re uirement
7-202.12 Conditions of Use*
7-203.11 Toxic Containers-Prohibitions"` REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11. Sanitizeas,Criteria-Chennicais!' r POPULATIONS HSP
7-204-12 Chemicals forWashineProdo c. Criteria* `I- -901.-fitA) UnpisteurizedPre-packagedJuices and
•- Beverages with Warning Labels*
7-204-14 Drvina cots,Criteria*
7-205.11 Incidental Food Contact.Lubricants* 3-S01.11(P) Use of Pasteurized Eees*
7-206.1 t Restricted Use Pesticides.Criteria" 3-801.1.1(D) Raw or Partially Cooked Animal Food and
Raw Seed Sprouts Not Served. *
7-206.12 Rodent Bail Saitions"` 3-801.11(C) Uno enedFoodPacka>oNot$e-served. "
7-206.13 Tracking Powders,,Pest Control and
Monitoring*
CONSUMER ADVISORY
TIME/TEMPERATURE CONTROLS 22 3-603-11 Consumer Advisory Posted for Consumption of
Animal Foods That are Raw.Undercooked or
15 Proper Cooking Temperatures for
PHFs Not Otherwise Processed to Eliminate
Pathogens-' Ertve 4
eadv2Jet
3-107.LIA(1)(2) F gs- 155'F 15 Sec.
Eggs- hornediate Service 145'F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
3 401.11(A)(2) Comminuted Fish,Meat,&Game E vs r
Animals- 155'F 15 sec.
3-401.11(B)(1)(2) Pork and Boef Rorast - 13VT 121 min*, SPECIAL REQUIREMENTS
3-401.1 1(A)(2) Rntites,Injected Meats 155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
sec, ` catering,mobile food, temporary and
3-401..11(A)(3) Poultry,Wild Game,Shifted PHFs, residential kitchen operations.should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultr or Ratites-165"F 15 sec. * above if related to foodborne illness
3-401.11(C)(3) Whole-muscle,Intact Beef Steaks- interventions and risk factors, Other
145'17* 590.009 violations relating to good retail
3-401.12 Raw Arnaud Foods Cooked in a practices should be debited under#29-
Microwave. 165°F* Special Requirements.
3-40LlI(A)(1)(b) All Other PHFs-145'F'15sec- *
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-403.11(A)&(D) PHFs 165'F 15 sec.* (Item,;23-30)
3-403.11(B) Microwave-165'F 2 Minute Standing Criocal and non-erifical violations, which do not relate to file
Time" foodborne illness rater venrions and risk fiu tors listed above., can he
3-403.1.1(C) Commercially Processed RTF Food- found in the following sections of the Food Code and 105 CAIR
t41)°F* 590-0(10.
3-403.1.1(E) Remaining Unsliced Portions of Beef -!tem Good Retail Practices FC 530 000
Roasts* 23. Management and Personnel_ FC-2 .003
18 Proper Cooling of PHFs 24 Food and Food Protection FC-3 .004
25, E uq argent and Utensils FC-4-_4_ .006
3-501.14(A) Cooling Cooked PHFs from 140'F to 26 Water,Plumbin and Waste FC _ .006
70'F Within 2 Hours and From 70'F 27. Physical Facility FC-6 .007
to 41'F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 1 008
3-501.14(13) CoolingPHFs Made From Ambient 29 S ectal Re ulrements 1 009
Temperature Ingredients to 41"17/45'F 30.- Other
Within 4 Flours*
v Denotes critical item hrlhe federal 1999 Food Code or 105 CMR 590.000-
C
c'�
..b.. „n � 2ir,,'hP f'.^}.a�*v' ,r. .,.c'"r m 'rain. � y,•eer�a: ,+.. r-+a.,+.
Commonwealth of Massachusetts
City of Salem
Board of Health
120 Washington Street,4th Floor
s e SALEM,MA 01970
y Food/Retail Establishment Permit
DATE PRINTED: 01/02/2006
WHO'S PLACE OF BUSINESS IS: Dube's Restaurant
File Number:BHF-2004-0170 317 Jefferson Avenue
Salem MA 01970
LOCATED AT: 0317 JEFFERSON AVENUE
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
FOOD SERVICE BHP-2006-0059 Jan 2,2006 Dec 31,2006 $150.00
ESTABLISHMENT
Total Fees: $150.00
PERMIT EXPIRES December 31, 2006
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any revonations, improvements,or equipment changes are made,all
plans for such must be submitted to and approved by the Salem Board of Health. Page 26 of 26
.y
,i
CITY OF SALEM, MASSACHUSETTS
s BOARD OF HEALTH
I = 120 WASHINGTON STREET, 4TH FLOOR -
.�.... SALEM, MA 01970
Q
STANLEY J.US; Z JR. FAx 978-745-0343 e C/ oFc ®Z ,�
MAYOR ' WWW.SALEM.COM Og9O op O�✓
JOANNE SCOTT, MPH, RS, CHO (7F����
HEALTH AGENT �C„ ALJ
��ti
2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT 1 A)tE i 1-
� TEL# �71V yU31
,k T
ADDRESS OF ESTABLiSHMEN-, �) A tti
MAILING ADDRESS (if different)
OWNER'S NAMEn�l4�
ADDRESSS�J"(Af
CITY, STATEcnifl ZIP fb 19Ns6 OL2S(
CERTIFIED FOOD AGE 'S NAME(S) Mb NAND 1V& CERTIFICATE#(s)
Dt. int .(zhl tJ w�uL1 rh a t 1 v 1c Z_ 35 �
(required in an establishment where potentially hazardous food is prepared.) /02613 i
EMERGENCY RESPONSE PERSON MA-y6 ����IL HOME TEL# ��I ✓;SSI ZS��
HOURS OF OPERATION: Mon.1 I' IUTue. I E- Wed.11-10 Thu.11.0 Fri.(h�_Sat. 11-11 Sun.
TYPE OF ESTABLISHMENT FEE (check only)
RETAIL STORE YES NO less than 1000sq.ft. =$ 50
1000-10,000sq.ft. =$100
more than I0,000sq.ft. =$250
- ---N-- -
O
------------------------------- -----------...-..ss.---t--han.....5...s.ea....ts $1-------... -$-
---0
------------------RESTAURANT YES le2
25-99 seats 150
/ C/ more than 99 seats
VES'
. E-------------------- -
' $
----- ---------------------------------------------------------------------'1"0"-0-------------
BED/BREAKFAST S NO $ 0
- - ---------------------........-------.........--------.........---------.-........------......------------------------------
ADDITIONAL PERMITS
MAKE (not just sense) ICE CREAM, YOGURT, SOFT SERVE YES $5
TOBACCO VENDOR YES $50
ALL NON-PROFIT(such as church kitchens) YES O $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
know edg n ell f, ha file all state tax returns and paid all state taxes required under the law-
L __ I7 -1-0� N- IZgi_S71
Sig6ature Da e Social Security or Federal Identification Number
------------------------------------------________________--------__----------
_________J------------------------------------------
Revised
_______________ ______________Revised 11/03/05 FOODAP2.adm Check#&Date
l
' y
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,4th Floor
Division of Food and Drugs Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978),.7,45-0343
Name Date T e of O eration s Tvpe of Inspection
Food Service ❑ Routine
Address r7 f-7 Risk ❑ Retail 5K.Re-inspection
J T Level El Residential Kitchen Previous Inspection
Telephone /r, ❑ Mobile Date:
Owner HACCP YIN El Temporary ElPre-operation
(,( I ❑ Caterer ❑ Suspect Illness
Person in Charge(PIC) Time ❑ Bed& Breakfast ❑ General Complaint
Inspector Ou:4 -, 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) [_1 590.009(F) ❑
action as determined by the Board of Health.
,.FOOD PROTECTION MANAGEMENT " ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
EI- - 13. Handwash Facilities
EMPLOYEE HEALTH
PROTECTION FROM CHEMICALS "
❑ 2. Reporting of Diseases by Food Employee and PIC '-
E] 14. Approved Food or Color Additives
El3. Personnel with Infections Restricted/Excluded
❑ 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)
E] 21. Food and Food Preparation for HSP
❑ 10. Proper Adequate Handwashing��
r CONSUMER ADVISORY -
❑ 11. Good Hygienic Practices `
J ❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices Number of Violated Provisions Related
Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22):
of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board
of Health. today, the items checked indicate violations of 105 CMR
�r, N-, 590.000/federal Food Code. This report, when signed below
23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an
4. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations
25. Equipment and Utensils (FC-a)(Sso.005) cited in this report may result in suspension or revocation of
25. Water, Plumbing and Waste (FC-4)(590.000) 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)(59o.om) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION:
s: 14.ea 4�-k
_ ��
Inspector's Signature: Print:
PIC's Signature: Print: S6 ;� ; s. ( 7 Page o,�_L Pages
i�
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22)
PROTECTION FROM CONTAMINATION_
FOOD PROTECTION MANAGEMENT K Cross-contamination
1 590.003(A) Assignment of Responsibility* 3-302.11(A)(]) flaw Animal Foods Separated front
590.003(B) Demonstration of Knouledoe* Cooked and RTE Foods*
r2-103.11 Person in charge-duties Contamination from Raw Ingredients
3-302.1.,1(A)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH EE3-306.14(A)(B)
Other"
590.00 3(C.) Rity of the person in charge to Contamination from the Environment
reitintg by foot(employees and 3-302.11(A) Food Protection*ap3-302.15 Washin Fr590.003(F) Rlity Of A Faxl Employee Or An 3-304.11 Food Contact with Equipment and.Ao Report To The Person In Utensils*
CContamination from the Consumer
590.003(03} K -Person in Chrn'ea* 3-306.14(A)(B) Returned Food and Reservice of Food*
3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated
590.003(13) Removal of Exclusions and Restrictions Food
3-701.11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Food*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewasbing-Hot Water
3-201.12 Food in a Herm_eticaliy Scaled Container* Sanitization Temperatures*
3-201.13 Fluid Milk and MilkProdncts' 4-501.112 MechanicalWarewashina HotWater
3-202.13 Shell Egns* m Sanitization Teeratures*
3-202.1.4 Eggs and Mill:Products.Pasteurized* 4-5(11.114 Chemical Sarutization-temp., pH,
3-202.16 lee Made From Potable Drinking Water* concentration and hardness.'"
5-101.11 DrinkingWater from an Approved System" =1'601.11{A} Equipment Pool Contact Surfaces and
Utensils Clean*
590.006(A) Bottled Drinking Wads 4-602.1 t CleaningFrequency of Ec ui pment Food-
540.006(B} Water Meets Stand in CMR 22.0" Contact Surtaces and UtensiLO
Food-
Shellfish and Fish fromm an Approved
oved Source4-702.11 Frequency of Sanitization of Utensils and
3-20].14 Fish Mixt Recreationally Caught Molluscau 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
Re Matoorit -
Game and Au Mushrooms Approved by 2-301.1 I. Clean Condition-Hands and Arrns*
'
Wil
3-202.15 Shellstoc4:.Identiflcatiou Present* 2-301.12 Cleaning Procedure*
..
590.004(C) Wild Mushrooms* 2-301.14 When to Wash"`
3-201.17 Game Animals* - 11 Good Hygienic Practices
Receiving/Condition -"2-401.11 Eatin ,Drinking or Using Tobacw"`
3-202.11. PHFs Received at Pro per Tem eratures* 2-401.12 Discharges From the Eyes, Nose and
3-202.15 Package ante it y* Mouth*
3-101.11 Food Safe and Unadulterated* 3-301.12 Preventin Contamination Win n'Pastuig"'
6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands
3-202.1$ Shelistock Identification* 590.0(4(E) Preventing Contamination from
3-203.12 Sliellstock Identification Maintained'" Em plovees*
Tags/Records:Fish Products 13 Handwash facilities
Conveniently Located and Accessible
3-402.11 Parasite Destruction*
3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities*
590.0040) Labeling of Ingredients' S-204.11 Location and Placement*
q Conformance with Approved Procedures 5-205.11 Accessibility.Operation and Maintenance
IHACCP Pians Supplied with Soap and Hand Drying
3-502.11 Specialized Processing Methods* Devices
3-502.12 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser,Availability
9-103.12 Confonnartce with Approved Procedures" 6-301.12 Hand Drying Provision
"Denotes critical item in the federal 1999 Fo,xl Code or 105 CtIR 590.000.
CITY OF SALEM
z
BOARD OF HEALTH
�a���--
Establishment Name: 3 Date: C� Page: of
� _
Item Code C-Critical Item , DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
i No. Reference R—Red Item
Verified
rN PLEASE PRINT CLEARLY
- O
FY
Y
f
I
z
T
1
I
t Discussion With Person in Charge: Corrective Action Required: ❑ NoYes
R. I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance Ll Employee Restriction/
: violations before the next inspection, to observe all conditions as described, and to Exclusion
I
P LI Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food CoAe. I understand that
r noncompliance may result in daily fines of twe t -five lets or suspension/revocation of ❑ Embargo El Emergency Closure
your food permit. � 1 ?
❑ Voluntary Disposal ❑ Other:
c �
�� r _
M
3-501.14(0) PHFs Received in Temperatures
Violations Related to Foodborne illness interventions and Risk According to Law Cooled to
Factors(Items 1-22) (Cont.) 41°F/45°F 1yithin 4 Hours.
PROTECTION FROM CHEMICALS Coolinu.Methodi for PF[Fs
PHF Hot and Cold Holding
14 Food or Color Additives r,-9-
3-202.12 Additives" 3-501.16(B) Cold PlIFs Maintained at or below
3-302.14 Protection troll] 590.004(F) 41°/45°F"
L i5- Poisonous or Toxic Substances 3-501.16(A) ]-lot PHFs Maintained at or above
140-'F. *
7-101.11 Identifying information-Original 3-501.16(A) Roasts Held at or above DWR
Containers-
7-102,11 Common Name-Workin.,Containers' 20 Ti s a Public Health,Control
7-201.1 Z
"me as
Control,
- 3-50IA9 Time as a Public Health Control*
I -�S�2mgc* P
7-20111 Restriction-Presence and Use* rin"nualt
3-501-19 Time
Ummumn
519;00(1)014eW)j �"oms
7-202.12 Conditions of Use*
7-20311 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11 Sanitizefs,Criteria-Chemicals"'
POPULATIONS(HSP)
21 3-801 IRA) Unpasteurized Pre-packaged Juices and
7-204,12 Chemicals for Wushing Produce,Criteria''' hleverageswith Warning I abels-
7-204.14 Dr'in ents,Criteria'
7-205.11 Incidental Food Contact. Lubricants' 3-801,11(B) Use of Pasteurized fe,us*
3-80 1.11(D) Raw or Parbaliv Cooked Animal Food and
7-206.11 Restricted Ilse Pesticides.Criteria="
Raw Seed S rronts Noe Served. 'a
7-206.12 Rodent Bail Stations' 3-801.11(C)
7-206.13 Tracking Powders,Pest Control and
CONSUMER ADVISORY
TIMEITEMPERATURE CONTROLS 22 3-603,11 Consumer Advisory Posted for Consumption of
16 Proper Cooking Temperatures for Annual Fosicls'lliat are Raw, Undercooked or
PHFs Not Otherwise Processed to Eliminate
3-401.1 JA(l)(2) Eggs- 155`F'15 Sec. -- Patlhm'csrs.
Eels-Inimechate Service 145'IFI fisec* 3-30213 Pasteurized Eggs Substitute for Raw Shell
3-401.11(A)(2) Comminuted Fish, Mean;&Game
Animals- 155°F 15 sec. *
3-401.1 I(B)(1)(2) Pork.and Beef Roast - l30`F 121 min* SPECIAL REQUIREMENTS
3-401.11(A)(2) Rataci, Injected Meats-- 155°F 15 590,009(A)-(D) Violirions of'Section 590,009(A)-(D)in
see. * entering, mobile food, temporary and
3-401_11(A)(3) Poultry,Wild Game,Stuffed PtIFs, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
P2H!!KLor Ratites-165`F 15 see. abcr-if related to foodborne illness
3-401A 1(C)(3) Wbole muscle, intact Beef Steaks ;1 .rventions and risk factors. Other
145°F* . 1. - - )0.009-violations relatin.-, to good retail
3-401.12 Raw Amaral Foods Cooked in a practices should be debited under#29 -
Microwave 165'F* Special Requirements.
3-40 1.11(A)(1)(b) All Other PHFs 145°F 15 see.
F17 Reheating for-Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3403.11(A)&(I)) PHFs; 165'F 15 sec. * (Steins 23-30)
3-403.11(B) Microwave- 165°F 2 Minute Standing Critical and non-rrifical violations, islach do not relate to the
Time* foodborne illness interventions and risk listed above, can be
;-403.11(C) Commercially Processed RIF Food- finowl in the following,sections of the Food Code and 105 CMR
140'F* 590,000.
3-403.11(F) Remaining Unsliced Perilous ol'Beef item Good Retatll Practices FC 590.000
Roasts::, 23. Mane I FC-2 .003
Proper Cooling of PHFs 24. Food and Food Protection 1--FC-3 .004
ZT--
v
3-501.14(A) Curling Cooked 111IFs from 140'F It) _RC-4 005
26. Water,Plumbi land aste FC-5 006
70°F Within 2 Hours and From 70°F 27 Physical Fadlty_ Tc��,607
to 4 I'F/4.5"F Within 4 Hours. 28. Poisonous or Toxic Materials FC-7 1 .008
3-501.14(B) Coofin.,PI-IFs Made From Ambient 29: Seoial Re wrements 1 .009
Temperature Ingredients to 41 OF145"IF 30 -Other
Within 4 Hours*
Denotes critical item in ihc%licsteral 1999 Food Code or I05('MR 590.000.
��,.r.:a:..-�✓a+ . ..av,..`.`v:i .�:c�+.r.t.Mti.:Y: 4 J-' ,'ri,�.,a;.ww.,e'M":..+N nN.+i�M1*,. �.a�fijr�,�'Y*..`#.�r+^-.,.n,. �,.x..ar.^ ....'�T ..
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 r Date T of 0 eration(s) Type of Inspection
Address i^ l Food Service El Routine
Risk ❑ Retail Re-inspection
Level El Residential Kitchen Previous Inspection
Telephone
_ ❑ Mobile Date:la/Zhu
OwnerI HACCP Y/N El Temporary ElPre-operation
Eb ❑ Caterer ❑ Suspect Illness
Person in Charge(PIC) I Time ❑ Bed&Breakfast ❑ General Complaint
In: /�_ p g,ID ❑ HACCP
Inspector I D Out: j Permit No. ❑Other
Each violation checked Oequires 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
❑ 13. Handwash Facilities
EMPLOYEE HEALTH
'
❑ 2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS
❑
El 3. Personnel with Infections Restricted/Excluded 14. Approved Food or Color Additives
FOOD FROM APPROVED SOURCE El 15.Toxic Chemicals
_
❑ 4. Food and Water from Approved Source - f TIMEITEMPERATURE.CONTROLS(Potentially Hazardous Foods) "
❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling
PROTECTION FROM CONTAMINATION - --- ❑ 19. Hot and Cold Holding
❑ 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control
Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 21. Food and Food Preparation for HSP
❑ 10. Proper Adequate Handwashin`g'
❑ 11. Good Hygienic Practices f '�� "F t 'C CONSUMER ADVISORY _
Y ❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices Number of Violated Provisions Related
Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 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 e W 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
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:
f ,
Inspector's Signature: Print: t,
PIC'sSignature: Print: \ +)J �^AA it-)_GC./ Page_of-`Pages
4
i r+
r
Violations Related to Foodborne Illness
interventions and Risk Factors(Items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT I Cross-contamination
1 790.603(A} Dmemonstration
ibilitys` 3-302.11(A)(1) Raw Animal Goods Separated from
790.003(B) ledge* Cooked and Rib Foods,
2103 11 s Contamination from Raw ingredients
3-30211(A)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Other'
2 590.003(0) Responsibility of the person in charge to Contarnination from the Environment
require reporting by food employees and 3-302A 1(A) Foal Protection*
a licams* 3-302.15 Washmm Fruits and Uevetables
- 590.003(F) Responsibility Of A Food Employee Or An 3-34.11 Food Contact with Equipment and
Applicant To Report'To The Person Lt Utensils*
Chat'se* Contamination from the Consumer
590.(103((3) Re ortind be Person in Cha3-306.14(A)(B) Returned Food and Resenrice of Food*
31 590.003(D) Exclusions and Restrictions' Disposition of Adulterated or Contaminated
5)0.003(E) Re,oval of Exclu ions and Restrictions Food
3-701.11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCEFood*
4
- Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B} Com h mcc with Ftmd Law* 4-501.111. Manual Warewashing-Ho[Water
Sanitization Temperatures
201.12. Food ma Hermetically Seated Container* 4-501_112 Mechanical w arewashing-t-Ior Water
3-201.13 Fluid Milk and Milk Products"
3-202.13 Shell Eggs* Sanitization Temperature'*
3-202.14 13 s rmd Milk Products.Pasteurized' -Z-501-114 Chemical Sanitization-temp.,pH;
3?02.16 fee Made From Potable Drinking,Water'"
conecntration and hardness. ll
5-101.11 Drinking Water from an A revved System' 4-661..11(A) Equipment Food Contact Surfaces and
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'
FishShellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and
3-201.14 Shel and Recreationally Caught Molluscan Fail Contact Surfaces of E-ui tlnenF*
Shellfish* 4-703.1 t Methods of Sanitization -Hot Water and
3-201.15 Molluscan Shellfish front NSSP Listed Chemical*
Sources" L0 Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Re ulato Authofi 2301.11 Clean Condition--Hands and Arms"`
*Procedure"
3-20215 Shel7stock Identification PreseItt* � - -2-301.12 Cleauin--s'�--- - ---
590.004(C) Wild Mushrorans* 2-301.14 R9ten to Wash*
3-201.17 (lame Animals* i 11 Good Hygienic Practices
,5 Receiving/Condition 2-401.11 Sating,Drinking or UsinS Tobacco*
3-202-11 PRFs Received at Pro ler Tem ieiatures* 2-401.12 Discharges From the Eves,Nose and
3-202.15 Package hiteerit * Mouth*
3-101.11 Foal Safe and Unadulterated,x 3-301.12 Preventing Contamination When Tastinms'
6Tags/Records:Shelistock 12 Prevention of Contamination from Hands
3-202.18 ShellsCock Identification* 590.004(E) Preventing Contamination from
3-203.12 Shelbaock Identification Maintained* Em lovees*
Tags/Records:Fish Products 13 Handwash Facilities
Conveniently Located and Accessible
3-402.11 Parasite Destruction*
5-203.11 Numbers
3-402.12 Records.Creation and Retentions` d a aerosis*
590,0040) Labeling of Ingredients' 5-264.11 Location and Placement,
7 Conformance with Approved Procedures 5-205.11 Accessibility,0 station and Maintenmtce
(HACCP Plans Supplied with Soap and Hand Drying
3-502.11 S ecitilizcd Prtxessin=Methods*
Devices
3-502.12 Reduced oxygen packaging,eriteiia* 6-301.11 Handwashing ovisAvailabiiit-
8-103.12 Conformance with A xoved Pr'a;ednress` 6-301.12 Hand Drvin Provision
'0enote€critical item in the fuleral 1999 Food Code or 105 CMR 596.000.
CITY OF SALEM
BOARD OF HEALTH
I
Establishment Name: s Date: ! Page:_ of
Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION DateVerified
} No. Reference R-Red Item
e PLEASE PRINT CLEARLY
Sb
1 - " �-
�✓ � I�
i
S 0..�' 'k', SP .-
- -
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C Lc i LJ CQ
o4j. f ,Lf /!
c C7 r✓l c�
c
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r
t
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e
-i
' F
+= Discussion With Person in Charge: r Corrective Action Required: LlNo es
u_
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
_ P Re-inspection Scheduled Ll Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twe fiv Ilars or spension/revocation of Embargo ❑ Emergency Closure
your food permit.
❑ Voluntary Disposal ❑ Other:
, ,1
o
14(0) PHFs I2rceived'if Tc=to
Violations Related to Foodborne Illness Interventions and Risk 4 cording trr.(aw CoFactors(items 1.22) (Cont) 41'F145 F Within 4
PROTECTIONFROM CHEMICALS 3-507.15 Ccwtina Methods for PHFs
14 Food or Color Additives 19 PHF Hat and Cold Holding
3-202.12 Additives'
r 3-501.16(B) Cold PHFs Maintained at or below
590 004(F) 31`145°F„
3-302.10. Protec,ti<»i from Un...........
i moved Additives" 3-501.16(A) Hut PHFs Maintained xt or above
l5 Poisonous or Toxic Substances 14W
7-101.11 Identitying Information-Original 3_g07.t6(A) Roasts Held at or above 130`F.
Containers*
7-1.02.11 Common Name-Working*Containers* 20 Time as a Public Health Control
7-201.11 Se.aration-Storaeet, 3-501.19 Time as aPublic Heald
hContn>)*
7-202.11 Restriction-Presence artd Uso*
590.004(1-1) Variance Re uirement
7-202.12 Conditions of Use"
7-203.11 Toxic Containers-Prohibitions* REOUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11 Sanidzers,Criteria-Chemicals* POPULATIONS(HSP)
7-204.12 Chemicals for Washine Produce,Criteria" 21 3-801.11(A) Unpasteurized Pre-packaged Juices and
_ Beverases with Warnine Labets*
7-204.14 Drvind A entws,Criteria* --
3-501-11(B) Use of Pasteurized Ee,e's*
7-205-11 Incidental Food Pesticidtact,es,
Lubri,Criteria* 3-901.11(D) Raw or Partial] Cooked Aninnal Food and
7-206.11 Restricted Use Pesticides.Criteria" y
7-206.12 Rodent Bait Stations*
3-$01.11(0)
Raw Seed S moots Not Served.'t
7-?06.13 Tracking Powders,Pest Control and
Uno eued rood Packa e Hot Reserved
Monrtorin<T"
CONSUMER ADVISORY
TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
Aninnal Foods'fliat arc Raw-Undercooked or
16 Proper Cooking Temperatures for
PHFs Not Otherwise Processed to Eliminate
3-401.11A(1)(2) E,,gs- 155°F 1.5 Sec.
PathtlR�nY Cveceee ,iWt
Eggs-Immediate Service 145'Fl5sec- 3-302.13 Pasteurized Fggs Substitute for Raw Shell
3-401.11.(A)(2) Comminuted Fish,Meats&Game 6 es*
Anirntis- 155°F 15 sec.
3-401.11(B)(1)(2) Pork'.and Beef Roast- 130'F 121 min* SPECIAL REOUIREMENTS _
3-401.11(A)(2) Ratites, Injected Meats-155°F 15 590 009(A) (D) Violations of Section 590.009(A)-(D)in
sec, w catering,mobile food, temporary mud
3-401-1 1(A)(3) Poultry, Wild Game,Stuffed PHFs, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited wider the appropriate sections
Poultry or Ratites-165"'F 15 sec. * -- ^- &bove'if related to foodborne illness
3-401.1 t((')(3) Whore-muscle,Intact Beef Steaks interventions and risk factors. Other
115°F* 590.009 violations relating to good retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited under 1#29-
Microwave 165F* Special Requirements.
3-401.1 i(A)(1)(b) All Other PHFs - 145'F 15 sec.
11 Reheating for Hot Holding VIOLATIONS RELATE?TO GOOD RETAIL PRACTICES
3403.11(A)&(D) PHFs 165'F 15 sec. T` (Sterns 23-30)
3-403.11(B) Microwave- 165°F 2 Minute Standing Critical and non-critical violations. which do not relate to the
Tlmc* loodborne illness interventions and risk factors listed above„ can be-
3-403.11(C) Commercially Processed RTE Food- .found itt the following sections glthe Food Code and 105 CMR
1400F"- 590.000,
3-403.1.1(E) Remaining Unsliced Portions of Beef item Good Retail Practices_ FC 530.000
Roasts* 1 23. Management and Personnel FC-2 .008
IS Proper Cooling of PHFs 24. Food and Food Protection ----_FC-3 .004
25 E ui>meni and Utensils FC 4 005
3-501.14(A) Cooling Cooked PHFs from 140°F to 26 Water Plumbing and Waste FC S 006
70`F Within 2 FIours and From 70°F 2T. Ph iron Facilit _ FC-6 , .007
to 41°F/45°F Within 4 Hours. '" --T8- Poisonous or Toxic_Materials FC-7 1 .008
3-501.14(B) Cooling PHFs Made From Ambient 29 Sectal Re wrements -_ 009
Temperature Ingredients to 4I'F145'F 30._ Other
Within 4llours" -
*Denotes critical item in they federal 1999 Food Code or 105 CKIR 590.000.
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Massachusetts Department of Public Health Salem Board S Health
M 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 I Date Tyne of Oceration(s) Type of Inspection
® Food Service ❑ Routine
Address Riski Retail E3 Re-inspection
f Level ❑ Residential Kitchen Previous Inspection
Telephone ❑ Mobile Date:
Owner {(- HACCP YIN ❑ Temporary ❑ Pre-operation
❑ Caterer [I Suspect Illness
Person in Charge(PIC) Time ❑ Bed&Breakfast ❑General Complaint
In: ( )'AD [] HACCP
: -
Inspector / p OutO, 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 ❑ 13. Handwash Facilities
EMPLOYEE HEALTH - PROTECTION FROM CHEMICALS
❑ 2. Reporting of Diseases by Food Employee and PIC 0 14, Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals
FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑ 4. Food and Water,from Approved Source
❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling
PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding
''_❑�. .88. Separation/Segregation/Protection ❑20.Time As a Public Health Control
[ . Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR.HIGHLY.SUSCEPTIBLE POPULATIONS(HSP)
!- ❑21. Food and Food Preparation for HSP
[110. Proper Adequate Handwashing
e CONSUMER ADVISORY
❑ 11. Good Hygienic Practices tt �Oq ❑22. Posting of Consumer Advisories
_ 1
Violations Related to Good Retail Practices Number of Violated Provisions Related
Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22):
of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code.This report, when signed below
c N by a Board of Health member or its agent constitutes an
23. Management and Personnel ei (FC-2)590.0 4)) 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:
i
5:5901n5peclFO/m614.tloc ^
Inspector's Signature: Print: Oq
PIC'sSignature: �� s �; )�7- page-
Print: of Pages
l
Violations Related to Foodborne illness
Interventions and Risk factors(items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT 8 Cross-contamination
1 590,003tA) Ansi mment of Res ionsibility"` 3-302.11(x1)(1) Raw Animal Foods Separated from
590.003(B) I Demonstration of Knowledge* Cooked and RTE Foods'
2-103.1.1 Person in charge-duties Contamination from Raw Ingredients
3-30111(A)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Others'
2 590.003(0 Responsibi lily of the person in charge to Contamination from the Environment
require repoiling by food employees and 3-3021ItA) Food Protection*
a li,eants' 3-30115 WaShil1g Fruits and Ve«stables
590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and
Applicant To Report To The Person In Utensils*
Char�e* Contamination from the Consumer
590.003(0) Reporting by Person in Charge" 3-306.14(A)UH Returned Food and Reserviceof Food*
3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated
590.003(h) Removat of Exclusions and Restrictions Food
3-70t.i 1 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Food"
4 Food and.Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Com lmj i mcg with Fa:d Law* 4S01.111 Manual Warewashing- EIot Water
3-201_12 Food in a tlermetical,ly Sealed Container* - Sanitization Temperatures*
3-201.13 Fluid Milk and Milk Products* 4-501_112 Mechanical Warewashina Hot Water
3-20213 Shell Eg,,s" Sanitization Tem aeratures*
3-202.14 6gKs and Milk Products,PasteutizedM 4-501.114 Chemical Sanitization-temp.,PI 1,
concentration and hardness.
3-202 16 ice Made From Potable Drinking Water*
5-101.11 Drinking Water from an A iroved Svstem* 4-ti01.1l(A) 'Equipment Food Contact 5urfaoes and
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 220* Contact Surfaces attd Utensils*
ShefNish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreatiana(ly Caught Molluscan Food Contact Surfaces of Is ui menY*
Shellfish* 4-703.11 Methods of Sanitization--Hint Water and
3-201.15 Molluscan Shellfish front NSSP Listed Chemical*
Sources" 10 Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Re ulatoAuthority 2-301.1 L Clean ConditionHandsand Arms*
3-202.18 SheLlstock Identification Present* 2-30 1.12 Cleaninn Procedure`
'
590.004(0) Wild Mushrnmms* . 2-301.14 When to Wash*,.
3-201.17 Oame Animals* t
11 Good Hygienic Practices
E ReceivinglCondition2-401.11 Eating,Drinkim r or Using Tobacco*
3 202.11 PHFs Received at Proper Tem>eratures's 2-401.12 Discharges From the Eyes-Nose and
3-20211 Package Lite it * Mouth^
3-101.1.1 Food Safe and Unadulterated 3-301.13 Preventing Contamination Nfien Tasthn *
6 Tags/Records:Sheilstock 12 Prevention of Contamination from Hands
n90.004(E) Preventim,Conta.minationfrom
3-202.18 Shelkiock Identification*
3-203.12 Shellstock Identification Maintained* Em loveas*
Tags(Records:Fish Products 13 Handwash Facilities
3-402.11 Parasite Destruction* Conveniently Located and Accessible
3402.12 Records. Creation and Retention* 5-203.7.1 Numbers and Capacities*
590.0040) Labeling of Ingredients* 5-204.11 Location and Placement*
7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance
/HACCP Plans Supplied with Soap and Hand Drying
3-502.11 Devices
3 30212 Reduced oxy>en ackaain ,criteria* 6-301.11 Htandwashvt Cleanser.Availability
8-103.12 Conformance with Approved Procedures* 6-301.12 ]-land Drvin�Provision
''Denote,critical item it)[lie federal 1999 Food Code.or 105 CMR 590.000.
CITY OF SALEM �=
BOARD OF HEALTH
' Establishment Name: D i h o S Date: Page: z�k of
Item Code C=Critical nem DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date
No. Reference R Red Item ._ - _ Verified
PLEASE PRINT CLEARLY
-
C Ai
QCT O l /
ti ,4 A jiai,, ukLA -
72E-f
ry
t
Lil c
/
rL; _6A r4t L
U v, 7
Discussion With Person in Charge: Corrective Action Required: ❑ No �es
1 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 L3Emergency Suspension
comply with all mandates of the Mass/Federal Food Codeunderstand that
.
noncompliance may result in daily fines of twenr five dol ar or pension/revocation of :3Embargo ❑ Emergency Closure
your food permit.
❑ Voluntary Disposal 0 Other:
i
7_50-11 '(C') PHFs Received-at'lemperatures
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 Coaling Metluxis for PHFs
14 Food or Color Additives 19 PHF Hot and Cold Holding
3-202.12 Additives* 3-50 L I6(B) Cold PHFs Maintained at or betow
590.004(F) 411145°F"
3-302.14 Protection front Unapproved Additives* ¢-507.16(A) Hot PHFs Maintained at or above
IS Poisonous or Toxic Substances
40"F. *
7-101.11 Identifying Information-Chigina 3-501.16(A) Roasts Held at or above DOT
Containers*
7-102.11 Common Name-Workino Containers* F 20
Time as a Public Health Control
7-201.11 Separation-Storage" 3-501.19 Time as a Public Health Control*
7-20211 Restriction-Presence and Use's
590.004(H) Variance Re nlremeII
7-202.12 Conditions op Use'"
7-20311 "toxic Conudners-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11 Sanitizers,Criteria-Chemicals* POPULATIONS(HSP)
7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and
Beverages with Warning labels*
7-204.14 Dt vino Agents.Criteria` -
3-80111(Bj Use ofPastenuzedEe*s^
7-205.11 Incidental Food Contact,Lubricants' 3-801.11(D) Raw or Partially Cooked Animal Food and
7-206.1 L Restricted Use Pesticides.Criteria* Kaw Seed S trouts Not Served.
7-206.12 Rodent Bait Sanious* 3-801.11(C) Unopened Food Package Not Re-served. -`
7-206.13 Tracking Powders,Pest Control and
Monitoring*
CONSUMER ADVISORY
TIME/TEMPERATURE CONTROLS 22 3 603.11 Consumer Advisory Posted fru Consumption of
15 Proper Cooking Temperatures for Animrd Foods That are Raw, Undercooked or
PHFs Not Otherwise Processed to Elitninate
3-40 1.1 Eggs- 15S°F 'tSSec.
Pathogens.*
Ergs-Lnmedrute Service 145'F15sec' 3-302.13 Pasteurized Eggs Substitute for Raw Shell
3-401.11(A)(2) Comminuted Fish,Meats&Game Eggs*
Animals- 155'F 15 sec. '"
3-401.11(B)(1)(2) Pork'and Beef Roast-130'F 121 min* SPECIAL REQUIREMENTS
3-401.11(AU 2) Ratites, Injected Meats-155'F 1.5 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
sec. * catering. mobile food,temporary and
3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, residential kitchen operations should be
Stuffing Containing Fish, Meat, debited under the appropriate sections
Poultry or Ratites-165'17 15 sec. * above if related to foodborne illness
340111W)(3) Whale-muscle,Intact Beef Steaks interventions and risk factors. Other
145'F* 590.009 violations relating to good retail
3.401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Mun owave 1650F* Special Requirements.
3-40 I_I1(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) 11E117s 165'F 15 sec. '= ([tents 23-30)
3-403.11tB) Microwave- 165°F 2 Minute Standing Critical and non-critical violations, which do not relate to the
Time' foodborne illness interventions and riskfactors listed above, can be
_T_403 1 I(C) Commercially Processed RTE Food- .found in the follow-ing sections of the Food Code and 165 CUR
140`'b-* 590.000.
3-403.11(E) Remaining Unsliced Portions of Bee Item Good Retail Practices FC 598000
Roasts* 23. Maria sment and Personnel FC -2 .003
18 Proper Cooling of PHFs 24 Food and Food Protection _ _ FC-3 .004
25 ui E merit and Utensils FC 4 .005
3-501.141 Cooling Cooked PHFs from 140'F to - r-
26. Water, Piumbin and Waste FC-5 i .006
70°P Within 2 Hours and From 70°F 27. Physical FacilitesFC-6 I .007 _
to 41'F145'F Within 4 Hours. 28. Poisonous or Toxic Materials
_ ____ FC-7 ! .00II
3-501.14(B) Caroling PHFs Made From Ambient 29 S eciai Requirements .009
Temperature Ingredients to 41"17145°F 30 .Other
Within 4 I-lours'x
Denotes critical item ut ihz federal 1999 Food Code or 105 CMR 590.060.
_ .. .r .-_.r%+.;.�+A-t� ...x� . a ,yes•-,4.-,.. ,•ter. ..retia.. .v..,r*"r+w.m.�.nZ:r.wnu�y-.ti m^'. y,,.:a .
Massacbusetts Department of Public Health Salem Board of Health
120 Washington Street,4'h Floor
Division of Food and Drugs Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343
Name Date Type of Operations) Type of Inspection
s O /o Food Service Routine
Address ' �" (S Risk ' Retail LRe-inspection
Telephone _ Level ❑ Residential Kitchen Previous I spe tion
El Mobile Date: a711Os�
Owner HACCP Y/N ElTemporary ❑ Pre-operation
&Y, I -Q ❑ Caterer ❑ Suspect Illness
Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint
El HACCP
Inspector In.(� 15 Permit No. ❑ Other
Out:( �Z�a
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 1 ',' ❑ 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 r� ,
i El14.Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded
- 15.Toxic Chemicals
i FOOD FROM APPROVED SOURCE, El;
❑ 4. Food and Water from Approved Source ''TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑ 8. 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)
{,
V _ ❑21. Food and Food Preparation for HSP
El 10. Proper Adequate Handwashing t
El 11. Good Hygienic Practices ' [:122.
QONSUMER'.ADVISORY
❑ 22. Posting of Consumer Advisories
r
Violations Related to Good Retail Practices Number of Violated Provisions Related
Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions n
immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): G�
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.
"C 7Na 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-4)(590.005) the food establishment permit and cessation of food
,26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you
27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION:
Inspector's Signature: Print:
PIC's Signature: Print: I Page of Pages
Violations Related to Foodborne Illness
Interventions and Risk Factors(Items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT 8 Cross-contamination
1 790 003tA) Assignment of Responsibility* :r302.i 1(A)(1} Raw Animal Foods Separated from
590.003(B) I Demonstration of Knarledge* Cooked and RTE Foods*
2-103.11Personmcharge--duties Contamination from RawIngredients
3-302.11(A)(2) Raw Anima]Fads Separated from Each
EMPLOYEE HEALTH Other*
2 590.003(C) Responsibility of the person in charge to Contamination from the Environment
require reporting by food employees and 3-302.11(A) Food Protection*
aunts* 3-302.15 Washing Ftnits and Ve,,etables
590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and
Applicant To Report To The Person Ta Utensils*
Charge* Contamination from the Consumer
590.003(G) Reporting by Person in Charge*, 3-306.14(A)(B) Returned Food and Reservice of Food*
31 590.003(1)) 1 Exclusions and Restrictions* Disposition of Adulterated or Contaminated
590.003(E) Removal of Exclusions and Restrictions Food
3-701.11 Discarding or Reconditioning unsafe
FOOD FROM APPROVED SOURCE Food*
q Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004 Aa B) Cum Bance with Fapd Law* 4-501.111. Nlanoal Warewashing-Hot Water
�..,..
3-201.12 Puodin u HenneticaAy Sealed Container* Sanitisation Tem ecautres*
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-HotWater
3-202.13 Shell Eras Sanitization Temperatures*
3-202.14 Eggs and Milk Products.Pasteurizl*'. 4-501.114 Chemical Sanitization-temp.,pH,
3-202.16 Ica Made Front Potable Drinking Rater" concentration and hardness.
5-101,11 Drinkin* Water from an Approved Systeme 4-601.11(A) Equipment Food Contact Surfaces and
Utensils Clean*
590.006(A) Bottled Drinking Water* 4-60?11 Cleaning Frequency of Equipment Food-
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensik*
ShefNish and Fish From an Approved Source 4-702.11 Frequency afSanitization of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of E-ui pment*
Shellfish's 4-703,1,1 Methods of Sanitization-Hot Water and
3-201.15 Molluscan Shellfish frontNSSP Listed Chemical*
Sources* 10 Proper,Adequate Handwashing
Came and Wild Mushrooms Approved by 2-301,11 Clean Condition-- Hands and Anus*
Re Mato Authorit
3-202.18 Shellstock Identification PrescriO 2-301.12 C(caninv Procedure*
590.004(0) Wild Muslunoms* f 2-301-1,4 Gotten to Wash*
3-201.17 Game Animals"` t 11 Good Hygienic Practices
g Receiving/Condition 1 2.401.1 l Latin ,Drinkin or Using Tobacap*
3-202.1 1 PHFs Received at Pro er Tenn eramres* '2-401.12 Discharges From the Eyes.Nose and
3-202.15 Package Into it.* Mouth*
3-101.11 Food Safe and Unadulterated'k 3-301.12 Preventing Contamination When Tasting*
6 Tags/Records:Shelistock 12 Prevention of Contamination from Hands
3-202.13 Shellstock Identification* 590.004{E) Preventing Contamination from
3-203.12 Shelhiock identification Maintained* Em kpvees*
Tags/Records:Fish Products 13 Hantlwash Facilities
3-402.11 Parasite Destruction* Convenientty Located and Accessible
3-403.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities",.
540.004(1) Labeling of Ingredients`
5-204.11. Location and Placement*
7 Conformance with Approved Procedures 5-205.11 Accessibility,O oration and Maintenance
IHACCP Plans Supplied willi Soap and Hand Drying
3-502.11 S ecialiudProcessin�Methods* Devices
3-502.12 Reduced oxygen packagin ,criteria* b-301.11 H.andwashing Cleanser.Availabilit
8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drvin Provision
*Denote,Critical item fn dtc federal 1999 Fapd Code or 105 CMR 590.000.
l .
CITY OF SALEM
k. BOARD OF HEALTH
r-
ti Establishment Name: 1 / � ,,r C Date: c� , Pager
1 of
{ Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF C90RECTION Date
.+ No. Reference A-Red Item , Verified
PLEASE PriINT CLEARLYI -
f c c r trr ✓-� rn
c
In u5c A20, P(o n I s e u co
.(
1
"k •25- -SPI. i I C JA I AarOlkrtzf
5e2utC ill v
u
Z
s r y r —
/c
y (40 Df— v. (? 2O t.�
4� n U.5
n
Sfi c S "s." 0 o
eG
1 7
lir ✓ y u A - 4 ZZ(
Discussion With Person in Charge: Corrective Action Required: ❑ No Yes
❑ Voluntary Compliance ❑ Employee Restriction/
f have read this report, have had the opportunity to ask questions and agree to Correct all Exclusion
i ;potations before the next inspection, to observe all con�itio�i s as described, and to Re-inspection Scheduled ❑ Emergency Suspension
•' comply with all mandates of the Mass/Federal Food/1- o r
ode. I understand that
noncompliance may result in daily fines of twe fie ds or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. f ❑ Voluntary Disposal ❑ Other:
;r
F.
3-501-14(C)_ PHFs Received at'fenrperatures
Violations Related to Foodborne Illness Interventions and Risk According to Law Cowled to
Factors(items 1-22) (Cont.) _ 41`FP45°F Within 4 Hours.
PROTECTION FROM CHEMICALS 3-501.15 Coolins Methods for PRFs
Fig 14 Food or Color Additives PHF Hot and Cold Holding
3-202.12 Additfves'k
7501.16(B) Cold PHFs Maintained at of below 3-302.14 Protection fro59(L004(F) 41"145°'F-
m Una t roved Additives* 3-501.4(F) Hot PHFs Maintained at or above
15 Poisonous or Toxic Substances 140'F
7-101.il Identityinglnfonnation-Oziginai 3-50116(A) Roasts;Held at or above 130°F. *
Containers"
02.11 Common Name-Workin°Comainers' 20 -Tifne'asa Public Health Control
01.
7-201.11 Separation-Stora*e' 3-519 Time as a Public Health Control*
7-202.11 Restriction-Presence and(lse'r
590.004(H) Variance Re uirement
7-202.12 Conditions of Use*
7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11 Saninzers,Criteria-Chemical~' POPULATIONS(HSP
7-204.1.2 Chemicals for Washing Produce,Criteria' 21 3-801 11(A) I Unpasteurized Pre-packaged Juices and
1(D) Raw oBeverages with W arai ne Labels*
In
7-204.14 in inn A eats,Criteria* 3-801.11(6) Use of Pasteurized Eeus*
7-205.11 incidental Food Contact. Lubricants* 1 r Partially Cooked Animal Food and
7-206.11 Restricted Use Pesticides.Criteria* 3.801
Raw Seed Sprouts Not Served. *
7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.
7-206.13 Tracking Powders,Pest Control and , .
Monitoring*
CONSUMER ADVISORY
TIME!TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
16 Proper Cooking Temperatures for q.
Aniutal Foods That are Raw-Undercooked or
PHFs Not Otherwise Processed to Eliminate_3-401.tIA(1)(2) Eggs L55`F1.5Sec.
Pathogens.* n,k°e "agar
_ L s_s-hnmedtate Service 145`F15sec� 3-302.1' Pasteurized Fggs Substitute for Raw Shell.
3-401.11(A)(2) Comminuted F-isb,Meats&Game $ gs
Animals- 155°F 15 sea
3-401.11.(B)(1)(2) Pork and Beef Roast- 130°F 121 nun* SPECIAL REQUIREMENTS
590.009(A)-(D)' Violations of Section 590.009(A)-(D)in
3-401.11(A)(2) Rntitcs, Injected Meats-155°F 15 .�
sec. * f�.) catering, mobile food, temporary and
3-401.11(A)(3) Poultry, Wild Game,Stuffed PHFs, t' residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultr g or 12aritee-165°F 15 sec. * alcove if related to foodborne illness
3-401.11(C)(3) Whole-musete'Intact Beef Steaks interventions and risk factors. Other
145°F 590.009 violations relating to good retail
3-401.1.2 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165"1- * Special Requirements.
31101.11(A)(I)(h) All Other PHI-,. 145°F'15 sec.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-401.11(A)&(D) PHFs 165°F 15 sec- * (Items 23-30)
3403A I(B) Microwave- 165°F 2 Minute Standing Critical and non-critical violations, n°hich do not relate.to the
Time* ,foodborne illness interventions and risb-factars listed above can be
3-403.11(C) Couunercially Processed RTE Food- found in the falloudag sections of the Food Cade and 105 CMR
140°F* 590.900.
3-401 1.1(F5) Remaining Unsliced Portions of Beef item Good Retail Practices FC 580.W0
Roasts* 23. MantTpement and Personnel_____ _FC-2 .603
ig Proper Cooling of PRFs 24. Food and Food Protection- ____ FG-_3 .004
25 _Equipment and Utensils FC-4 .005
3-501.14(A) Cooling Cooked PHFs from'140°F to 26 Water,Plumbin and Waste FC-5 006_
70°F Within 2 Hour and From 70°F 27. Physical Facility FC-6 .007
to 41'1-/45°F Within 4 Hours. * 28. Poisonous or Toxic Materials_ _ FC-700'
3-501.14(B) Cooling PHFs Made Fronnilaribient 29. S eoial R uiremants _ .009
Temperature b>,eredients to 41'1'/,15'F 30 1-
Within 4 Hours*
-"Denotes raitic v item in the Federal 1999 Ford Code or 105 CNIR 590000. :3
f
r
Y CITY OF SALEM I
BOARD OF HEALTH
Establishment Name: 1/. X1"5 Date: l S Page: of
Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R—Red Item L Verified
/'' �'J, ,,,� - PLEASE PRINT CLEAR Y �_.,/ J
_ p C IY1r l ��.. t3 / ��. 4 'V�Vf' fJ• USI? �J O V
i Q i� SS
�- _ � c o ✓� leo !J
r nJ Q 71 n
'•� �n Irl r+e �'"� c � ZP/ N
F
4
t
1
n}
_E A
}
r
? t
Discussion With Person in Charge: J Corrective Action Required: ❑ No Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Vol ntary Compliance ❑ Employee Restriction/
Violations before the next inspection, to observe all conditions as described, and to Emersion
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 twe y iv doll ' r suspension/revocation of El Embargo ❑ Emergency Closure
your food permit. LI Voluntary Disposal ❑ Other:
' l
s v
� t
3-501.14(0) PHFs Ret, cd at Temperatures
Violations Related to Foodborne Illness Interventions and Risk According to Iaw Cooled to
Factors(items 1-22) (Cont.) _ 41'F145 F Within 4 Hours.
PROTECTION FROM CHEMICALS _7501 15 Cooling Methods for PHFs
14 Food or Color Additives 14 PHF Hot and Cold Holding
3-561.16(8) Cold P1IFs Maintained at or below
3-202.12 Additives'[ 590,004(F) 41'145F*
3-302.14 Protection from Una roved Additives* 3-SOI.tfi(A) Hot PHFs Maintained at or above
15 Poisonous or Toxic Substances
140°F. *
7-101.11 Identifying Informat'ion-Original 3-501.16(A) Roasts Held at or above 130'F.
containers-
7 10-2 11
ontainers*7-102.11 Common Name-Working Containers" 20 Time as a Public Health Control
7-201.1] -Separation-Storage" 3-501.19 Time as a Public Health Controls
7-202.11 Restriction-PresenceatidUse''
590.004(H) Variance Re ui Lnem
7-202AT Conditions of UP-
7-203.11 Toxic Containers-Prohibitions3' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-2041 11, Sannizers.Criteria-Chemicals"' POPULATIONS(HSP)
1
7-204. 2 Chemicals for Washing Produce,Criteria* 2'1 3-801.1 I(A) Unpasteurized Pre-packaged Juices and
Beverages will,Ilar-nin labels,
7-204.14 Drvin t =eats,Criteria* 3-801.11(B) Use of Pasteurized Et, *
7-205.11 Incidental Foal Contact,Lubricants* 3-80L l I(D) Raw or Partially Cooked Animal Food and
7-206.1 I Restricted tine Pesticides. Criteria* Raw SeYd S zones Nuc Served. '"
7-206.12 Rodent Baitu 3-801.1](C) Dno.ened Food Package Not Re-served.
7-206.13 Tracking Powderders,,Pest Control and
Monitorin-*
CONSUMER ADVISORY
TIME/TEMPERATURE CONTROLS 22 3 603.11 Consumer Advisory Posted for Consumption of
Animal Fable"That are Raw,Undercooked or
16 Proper Conking Temperatures for
PHFs Not Otherwise Processed to Eliminate
Pathogens.^"
3-401.11A(1)(2) Eggs 155`F 15 Sec.
ErrWey,=;:azoo
E ss-Immediate Service 145°P15sec" 3-302.13 Pasteurized Eggs Substitute for Raw Shell
3-401.11(A)(2) Comminuted Fish,Meats&Game
Animals- 155'F 15 sec.'"
3-401AI(B)(1)(2) Pork'.and Beef Roast- 130'F 1.21 min"' SPECIAL REQUIREMENTS
3-401.11(,,)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in ,I
sec. * catering, mobile food, temporary and
3-401.1.1(,,)(3) Poultry,Wild Game,Stuffed i'I-fFs, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited tinder the appropriate sections
Poultry or Ratites-1650F'15 sec. "` above if related to foodborne illness
3-401.11(C)(3) Whole-muscle,Intact BeefSteaks interventions and risk'factors. Other
1450F" 590.009 violations relating to good retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited under 7129-
Microwave 165`F* Special Requirements,
34017 J(A)(I)tb) All Othar 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 see.a- (Items 23-30)
3-403.11(6) Microwave- 165°F 2 Minute Standing Ci i ical and non-critical violations,iihich do not relate to the
Timet' foodborne illness order venlions and risk factors listed above, can be,
3-403.1 I(C) Commercially Processed RTE Food- found inthe fotGmmeg sections of the Food Code"rut 105 CMR
'14WF* - 5.90.000.
------
3-40111(G) Remaining Unsliced Portions of Beef ' Item Good Retail Practices FC 530.000
Roasts* 23. Managemsni and Personnel FC--2 .003
----------------
1g Proper Cooling of PRFs 24. Food and Food Protection _ FC-3 .004
25. _Equipment and Utensils _ FC 4 1.,005
3-501.14(A) Cooling Cooked PHK from 140`F to 26. Water. Plumbing and Write FC-5 i 006
70''F Within 2 Hours and From 70"F 27, Ph steal Facile___.._ FC-6 007
to 41'F145'F Within 4 Hours. * 26. Poisonous or Toxic Materials FC-7 .008
3-501.14(6) Coling PIIFs Made Fron,Ambient 29_ 5 ectal Re uirements .008
Temperature Ingredients ro 41'F145`17 40 Other
Within 4 Hours:' ssnurome.«tcam�
*Denotes critical ileo in the federal 1999 Foot)Code or 105 Cb1R 590.(00.
Massachusetts Department of Public Health Salem Board SHealth
p 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 DateOperations-1
Rout Ins a tion
1 2 7 p f eJ Food Service ijfj�Rputine
Address Risk ❑ Retail [IRe-inspection
.7/7 J f F oN �fi! Level� E] Residential Kitchen Previous Inspection
Telephone yt� S 3 f"l ❑ Mobile Date:
❑ Temporary ElPre-operation
Owner HACCP YiN
�� El Caterer [I Suspect Illness
Person in Charge(PIC) Tlme ❑ Bed&Breakfast ❑ General Complaint
In: ❑ HACOP
Inspector r Out: Permit No. ElOther
Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco
Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑
action as determined by the Board of Health.
FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS -
El 2. Reporting of Diseases by Food Employee and PIC ❑ 14,Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded ❑ 15,Toxic Chemicals
FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) '
❑ 4. Food and Water from Approved Source
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling
PROTECTION FROM CONTAMINATION - ❑ 19,Hot and Cold Holding
❑ 88. Separation/Segregation/Protection ❑20,Time As a Public Health Control
G?9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP). .I
❑21, Food and Food Preparation for HSP
❑ 10. Proper Adequate Handwashing
CONSUMER ADVISORY -
❑ 11. Good Hygienic Practices [122, Posting of Consumer Advisories
Violations Related to Good Retail Practices Number of Violated Provisions Related
Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions f
immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): 1
of Health. Non-critical (N)violations must be corrected Official Order for Correction- Based on an inspection
immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code.This report, when signed below
by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations
24. Food and Food Protection"- (Fca)(sso.00a) cited in this report may result in suspension or revocation of
25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food
26.Water, Plumbing and Waste (FC-5)(590.006) establishment operations. if aggrieved by this order, you
27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
T30.
Other DATE OF RE-INSPECTION:
S SWM, IFom 14 d.c
Inspector's Siguatur Prints ?
PIC's Signature: / Print: Jx/ z! c� � [Pagol_of Pages
{
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT R Cross contamination
1 I 590,003(A) Assignment of Responsibility* 3-302.11(;1)(1) Raw Aoimal Foods Separated from
590.003(B) Demonstration of Knowledge* Cooked and RTF.F Foods"
2-103,11 Person in charge--duties - Contamination from Raw Ingredients
3-302A RA)(2-) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Other*
2 590.003(0 Responsibility of the person in charge to Contamination from the Environment
require reporting by food employees and 3-302.1.I(A) Food Protection*
applicants* 3-30215 Washing Fruits and Vegetables
590-003(17) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and
Applicant To Report To The Person ht Utensils*
Charee* Contamination front the Consumer
590.003(G) Re orting b Pelson in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food*
3 590.003(1)) Exclusions and Restrictions* Disposition of Adulterated or Contaminated
L590 003(f-,) Removal of Exclusions and Restrictiitns Food
3-701.11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE I Food*
4 Food and Water From Regulated Sources FFood Contact Surfaces
590.004(A-B) Compliance with Fond Law* 4-501.111 Manual Warewashing-Hot Water
3-201..12 Fond ma Hermetically Sealed Container* i Sanitization"Fem eratures*
3-201-13 Fluid Milk and Milk Products* 4-501..1.12 Mechanical Warewashing-riot Water
3-202-13 Shell Eggs*- Sanitization Tent>eratur'es*
3-202.1.4 Eggs and Milk Products.Pasteurized' 4-501.114 Chemical Sanitization-temp.,p17,
3-202.16 ice Made From Potable Drinkin E Water*
concentration and hardness. ",
System" 4601.11(9) Equipment Ford Contact Surfaces and
5-101.11 Drinking Water from an Approved System"
590.006(9 Bottled Drinking Water* Utensils Clean
4602.11 Cleaning Frequency ofEquipment Food-
590.006(B) Water Meets Standards in 310 CMR 22.p* Contact Surfaces and Utensils`
Shellfish and Fish From an Approved Source 4.402.1 t Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of E q ui mem*
Shellfish's 4703.11 Methods of Sanitization--Hot Water and
3-201.15 Molluscan Shellfish from NSSP Listed Chemical^
Sources* 10 Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Re ulato Authont 2-301.11 Clean Condition--Hands and Arms*
3-202.18 Sheilstock Identification Present* 2-301.12 Cieatt=n*Pt(xedure*
590.004(C) Wild Mushrooms' 2-301.1.4 When to Wash*
3-201.17 Game Animals" it Good Hygienic Practices
5 Receiving/Condition 2-401.11 Icon-,,Drinking or Using;Tobacco*
_3 202-11 PIiFs Received at Proper Tem)eratures" 2-401.12 Discharges From the Eyes.Nose and
3-202.15 Packaee htte grit, Month*
3-101.11 Food Safe and Unadulterated * 3-301.12 1 Preventing Contamination When Tastln g*
6 Tags/Records:Sheilstock 12 Prevention of Contamination from Hands
3-202.18 Sheilstock identification* 590.004(E) Preventing Contamination from
3-203.12 Shel'lstock Identification Maintained" Ent to ees'
TagstRecords:Fish Products 13 Handwash Facilities
3-002.11 Parasite Destruction* Conveniently Located and Accessible
3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities*
590.004(7) Labeling of Ingredients` 5-204.11 Location and PlacemcuO
7 Conformance with Approved Procedures 5-205.11 Accecsibllity,O exa6on and Maintenance.
lHACCP Plans Supplied with Soap and Hand Drying
3-502.11 Specialized Processing Methods* Devices
3-502.12Reduced oxygen packagin ,criteria* 6-301.11 Ilandwashin Cleanser.Availability
8-103.12 Conformance with Approved Procedures* 6-307.12 Hand Drying Provision
9
'a Denote,cutleaf item it)the fcdaral ll)9 Food Code or 105 CR1R 590.01)0.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: Oi A&E S Date: 2/!i1c1- Page: 2 of 2
Item Code C-Critical Item. DESCRIPTION OF VIOLATION/PLAN OF CORRECTION "Date
.. No. Reference R—Red item - - "" " Verified
// PLEASE PRINT CLEARLY
">
2 Ark rN 443 -r64-15 trcW eK VVa <06W G '8 el f O
L r�
s
f n/
S 2� C v+ fir; #0V1 rlor.-s[, 1"o! jS S o !jaCeCZJr-r oL r:*-tf•rrurG /Vet✓
t N /!<t3P t .ry S .r,z.i✓� rawnar✓ e.r 44111t-Y .#-&441 us
tl1a�CK rT/�= T�irlt 7 �NG Ta�✓iEeJ(✓ /�' t 3 .
c
i q !
tY N d
rs.�. rc�r
r
Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes
t. ❑ 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
j/ ❑ Volunta Dis osal ❑ Other:
75 d I'I(C) PHFs Received at Temperatures
Violations Related to Foodborne Illness Interventions and Risk According to Log Cooled to
Factors(items.1-22) (Cont.) 41°Ft45°F Within 4 Hours.
PROTECTION FROM CHEMICALS
3-501,15 Co lin=, Me hods for PHFs
14 Food or Color Additives 19 PHF Hot and Cold Holding
3-501.16(B) Cold PIIFs Maintained at or below
3-202.12 Additives'" 590.004(17) 41J45°t,-
3-302 14 Protection from Unapproved Additives* 3-501.16(A) Hi)t PHFs Maintained at or above
15 Poisonous or Toxic Substances
40`F. *
7-101.11 IdentifyingJnfonnation-Original 3-501A(t(A) Roasts Held at or above 130°F.
Caamainers'°
7-10111 Common Name-Working Containers* 20 Time as a Public Health Control
3-501.19 Time as a Public Health Control*
7-201. R11 ration-Sterane" 590,004(H) Variance Re uirement
7-202.1 l Restriction-Presence and User
7-2012 Conditions of Use-
7-20111 FOR HIGHLY SUSCEPTIBLE
7-203111 'FoxicContaiuers-I'rohbitions* POPULATIONS(HSP)
7-204.]1 Sanitizers.Criteria-Chemicals*
7-204.12 Chemicals for Washing Produce. Criteria* 21 3-80'1.11(A) Unpasteurized Pre-packaged Juices and
Beverages with RarmngLabels*
7-204.14 Drvin*, eats.Criteria-
7-205.11 Incidental Incidental Food Contact. Lubricants* 3-801,11(B) Use of Pasteurized Eggs*
7-206.11 Restricted Use Pesticides, Criteria* 3-80L11(D) Raw or Partially Cooked Anunal Foal and
Raw Seed S rmnts Not Sewed. .,
7-206.12 Rodent Bait densPe Pe3-g0 L 11 Uno)cited Faxi Packa rc Not Re-served.
7-206.13 'tracking Powders, st Control and
Monitoring*
CONSUMER ADVISORY
TIMEtTEMPERATURE CONTROLS 22 3-603,11 Consumer Advisory Posted for Consumption of
16 Proper Cooking Temperatures for
Anunal Foods Mat are Raw. Undercooked or
PHFs Net Otherwise Processed to Eliminate
3-401.11A(1)(2) F,;gs- 155'F 1.5 Sec.
Path?rens rrn, - .uer
Ergs-Itmredrate Service 145°P15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
E£ s`
3-401.11.(A)(2) Comminuted Fish, Meats&Game
Animals- 155°F 15 sec.*
3-401.11(13)(1)(2) Pork and Beef Roast- 130"F Ll 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 ford,temporary and
3-401 1 I(A)(3) Poultry, Wild Game,Stuffed PHFs, residential kitchen operations should be
Smiting Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-165`la 15 sec. " above if related to foodborne illness
3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
145`17* 590.009 violations relating to good retail
3-401.12 Raw Animal Foods Cooked in a pi'actiees should be debited under#29-
Microwave 165°F* Special Requirements.
3-401.11(A)(11)tb) All Other PHFs-l45°F'15 see. *
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-403.11(A)&(D) PHFs 165'F 15 sec. * (.[tems 23-30)
3-403.11(8) Microwave-165`F 2 Minute Standing Critical and non-critical violations, which do not refute to the
Time* foodborne illness interventions and risk fa-tons listed above., can be
3-403.11(C) Commercially Processed RTE Fond- foarnd fn the,falhoning sections of the Food Code and JOS CMR
140°F* 590.000.
3-403.11(E) Remaining Unslieed Portions of Beef Item Good Retail Practices FC boo.000
Roasts* 23. Mona ement and PersonnelFC-2 003
18 Proper Cooling of PHFs 24. Food and Food Protection _.. FC--3 .004
25 _ _ Equipment and Utecsils FC 4 __ .005_
3-501.14(A) Cooling Cooked PHFs from 140`17 to 26 Water,aier, Plumbin and Waste FC 5 1 .006
_
70`F Within 2 1fours and From 70°F 27. Physical Facility FC-6 .007
to 41`F145°F Within 4 Hours. ,* 26. Poisonous or Toxic Materials .008
3-501.14(B) Cooling PHFs Made From Ambient 29. S ectal R uirements _ _ 908
Temperature Ingredients to 41"F/45°F
Within 4 Aours* sasnr„a.,aa-za,�
"Denotes orincal item In the Federal 1999 Food Code or 105 CMR 590.000.
4-4
"3&m4&
'K 'h 'dt- , ':e .� ....-.-+:N:.-•-- a...w. .. .ro.. � } '� to �- rr
CITY OF SAL:EM9 MASSACHUSETTS
BOARD OF HEALTH
Y d
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: FOOD SERVICE
Name of Establishment: Dube's Restaurant
Address of Establishment: 317 Jefferson Avenue
Owner's Name: Mary Pelletier
Restrictions:
Application Date: 11/18/04
Permit for Food Establishment 23-05
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. �f
(/HEALTH AGENT
y CITY OF SALEM9 MASSACHUSET F(C1?II V 4Q
BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR
g SALEM, MA 01970 NOV 17 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 FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENTS h --TEL
#_JeA��Z /
ADDRESS OF ESTABLISHMENT f7 �C<� DLJ QU
MAILING ADDRESS (if different) �J / / 6�
OWNER'S NAME-1 A I /Y-ZGLCni'y��/[// \ TEL# S)-6 Z���
ADDRESSLON 1 R 6
CITY STATE zip OMT
CERTIFIED OD MANAGER'S NAME(S) /V4)Q 1L/10/J& CERTIFICATE#(s)
(required in an establishment where potentially
yhazardous
``food is prepared.)MA-ft V1ZL-
EMERGENCY RESPONSE PERSON�jry ISN �L L �� HOME TEL# I�3
HOURS OF OPERATION: Mon.
Tue. Wed. Thu.��Fri. /)-I' Sat. k1-11 Sun._`L2 '
TYPE OF ESTABLISHMENT FEE check only
RETAIL STORE YES NO less than 1000sq.ft. 1 =$ 50
1000-10,000sq.ft. =$100
more than I0,000sq.ft. =$250
RESTAURANT YES NO less than 25 seats 100
25-99 seats =$150
more than 99 seats =$200
BED/BREAKFAST YES NO $100
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5
TOBACCO VENDOR YES NO $50
ALL NON-PROFIT(such as church RchersI ES NO $' 51
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 M pter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my
best ede and Tf, h iled all state tarLr turns and paid all st t t quired under the law.
Sigr Date Social S uri y or Federal Identification Number
----- - - ----- ---p - ------ -------------------
- - - - ------------------------------------
Re sed 1/03/03 FOODAP2.adm Check#8 Date �`
t
r CITY OF SALEM9 MASSACHUSETTS
BOARD OF HEALTH
- � -
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter 94,
Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food
Establishment in the City of Salem is hereby granted to:
Type of Establishment: FOOD SERVICE
Name of Establishment: Dube's Restaurant
Address of Establishment: 317 Jefferson Avenue
Owner's Name: Mary Pelletier
Restrictions:
Application Date: 12/2/2003
Permit for Food Establishment 85-04
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 ""
u CITY OF SALEM, MASSACHUSETT ` T? ly
BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR �I p ray3
• .�. SALEM, MA 01970 NOV 1 ry 8 200
TEL. 978-741-1800
FAx 978-745-0343 �� •r �,JI- S;SLLuj
STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO BOARS;? OF HEALTH
MAYOR _ HEALTH AGENT
. 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT �� L TELA# -7
ADDRESS OF ESTABLISHMENT
MAILING ADDRESS (if different)
'
OWNER'S NAME� TEL#
ADDRESS
CITY�}���'ft ST TE ZIP 33j3�fS3
CER-tt iFED rllVU' lV 4 Ski 14*4E(S' , . CE3'�Ti
� miula)-t- �)Trultl' y9��vs
(required in an establishment Lvhere potentiallyhazardousfood is prepared.)
EMERGENCY RESPONSE PERSON /1�(/ �� � HOME TEL#
HOURS OF OPERATION: Mon.�a TJo lE
ue. Wed ��Thu. lD Fri. (
Sat. l
Snr �
TYPE OF ESTABLISHMENT FEE check only
RETAIL STORE YES NO less than 1000sq.ft. =$50
1000-10,000sq.ft. =$100
more than 10,000sq.ft. =$250
RESTAURANT YES NO less than 25 seats =$100
25-99 seats =$150
more than 99 seats =$200
BED/BREAKFAST YES NO $100
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5
TOBACCO VENDOR YES NO $50
ALL NON-PROFIT(such as church kitchens) YES NO $25
Please pay total with one check
payable to the City of Salem
This Permit is not transferable and must be reissued upon change of ownership. The Permit must
be posted in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements,or equipment
changes are made, all plans for such must be submitted to and approved by the Salem Board of
Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my
best k dge;a f, h ve d all state tax returns and paid all st to s required under the law.
i
Si gA 6� Date Social Security or Federal Identification Number
F
Revised 11/03/03 FOODAP2.adm Check#&Date >L%qf 9
• '� u �_ '-fie "� 'ri+
r I
Massachusetts Department of Public Health Salem Board of Health j
120 Washington Street,4th Floor l
Division of Food and Prugs Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343
Name p Date T of O eration s Ty a of Inspection
v8 f l` .SP-AvAP4N` O Food Se vice p outiFt ne
Address ?/7 J���� r�� ^ Risk ❑ Retail ❑ Re-inspection
Leve) , ❑ Residential Kitchen Previous Inspection
Telephone
7Y - 94-4/ ;1 ❑ Mobile Date:
Owner HACCP Y/N El Temporary ElPre-operation
AAA L`F 4C4 /g/L ❑ Caterer ❑ Suspect Illness
Person in Charge(PIC) Time ❑ Bed& Breakfast ❑ General Complaint
n In: [_1HACCP
Inspector0,61Z,12 Cl 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 I ❑ 12 Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties 13. Handwash Facilities
EMPLOYEE HEALTH v _-
PROTECTION FROM CHEMICALS
❑ 2. Reporting of Diseases by Food Employee and PIC _
❑
El 3. Personnel with Infections Restricted/Excluded 14.Approved Food or Color Additives
❑ 15.Toxic Chemicals
FOOD FROM APPROVED SOURCE
❑ 4. Food and Water from Approved Source TIMENEMPERATURE 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
ysr
❑ 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
V,
❑ 11. Good Hygienic Practices CONSUMER ADVISORY - ,
❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices Number of Violated Provisions Related
Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22):
of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code. This report, when signed below
by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations
2 : Food and Food Protection (FC-3)(590.0044)) cited in this report may result in suspension or revocation of
5. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food
26. Water, Plumbing-and Waste (FC-5)(590.0,06) establishment operations. If aggrieved by this order, you
27. Physical Facility I (FC-6)(590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7)(590.00s) and submitted to the Board of Health at the above address
29. Special Requirements - (590.009) within 10 days of receipt of this order.
30. Other ".".6A - DATE OF RE-INSPECTION:
S:50MVc rFown 14.doc yt '+ •.
k r
Inspector's Signature: PrinE
R YONeJ
PIC's Signature: �� e, Print: Pagel-of -Pages
Violations Related to Foodborne illness „
Interventions and Risk Factors(items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT g Cross-contamination
I 590.003(A) Assignment of Responsibility* 3-302.11(A,)(1) Raw Animal Foods Separated Prom
590.003(B) Demonstration of Knowledge* Cooked and RIF goods*
2-103.1.1. Person in charge--duties Contamination from Raw Ingredients
3-302-11(e1)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Other*
2 590.003(C)� Responsibility of the person in charge to Contamination from the Environment
require reporting by food employees and 3-302.11(X) Food Protection*
applicants* 3-302.15 Washing Fruits and Vegetables
590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and
Applicant To Report To The Person hi Utensils*
Charge" Contamination from the Consumer
590.003(G) Reporting by Person in Charge* 3-306.1=4(.h)(&) Returned Food and Reservice of Fax(*
3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated
590.003(F.) Removal of Exclusions and Restrictions Food _
3-701.11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Food*
Food and Water From Regulated Sources 4 Food Contact Surfaces
-""' '- 4-501.111 Manual K'arewashin* Hot Water
590.004(A-B) Compliance with Food Law' g"
Sanitization'Fcni eramres*
201..12 Food in a Henneticall Sealed Container*
3-201.1.3 Fluid'Milk and Milk Products* 4-5Ot.112 Mechanical Warcavashina-Hot Water
3-202.13 Shell Egna Sanitization Temperatures"
3-202.14 Eggs and Milk Products.Pasteurized" 4-501.114 Chemical Sanitization-temp.. pH,
:;'_02.16 Ice Made From Potable Drinkinc Water'"
concentration and hardness.
5-101-11 Drinkim7 Water from an Approved System* 4-601.'(l(A) Equipment Fexid Contact Surfaces and
Ptensik Clem*
19O.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*
ShefBish and Fish From an Approved Sourco 4-70211 I^regnency of Saniti nation of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equip ment*
Shellfish`" 4-703.11 Methods of Saniwittion-Hot Water and
3-201.15 Molluscan Shellfish from NSSP Listed Chemical"
Sources* to Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by 2-301.11 Clean Condition- Hands and Anus"
Re Mato Authorit
3-202.18 Shellstock Identification Present*: 2-301.12 Cleaning Procedure*
590.004(C) Wild Mushrooms* r
2-301.14 When to wash*
3-201.17 Game Animals" 11 Good Hygienic Practices
S Receiving/Condition 2=101.11 _ Fining,Drink'in T *
or Using obacco
3-202.1 1 Miles Received at Pro ger Tem teratures'" 2-401.12 Discharges From the Eyes,Nose and
3-202.15 Package Ince i t•* M01th4
3-101.11 Ford Safe and unadulterated* 3-301.12 Preventing Contamination When Tastin,*
6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shcl(sux:k identification* 590.004(E) Preventing Contamination from
3-203.12 Shellstock Identification Maintained* Em rk>vees'"
TagstRecords:Fish Products 13 Handwash Facilities
3-402.11 PaasitaDeshuctan* Conveniently Located and Accessible
3-402.12 Records.Creation and Retention' 5-203.11 Numbers and Ca acities="
590.004(1) Labeling of Ingredients' 5-204.11 Location and Placement"
7 Conformance with Approved Procedures 5-205-1,1 -Nccessibilh O erasion and Maintenanec
IHACCP Plans Supplied with Soap and Hand Drying
3-502.11 S ecializedProcessin>Methods" Devices
3-502.12 ,Reduced oxygen ackaain ,criteria* 6-301.1.1 1 landwaqhing Cleanser.Availabilit
A-103.12 1 Conformance with Approved Procedures* 6-301.12 Hand Drvin r Provision
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.f100.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: OU1?6fir i@tlRl4rrr- Date: 7/rt-l0y Page: ez— of 2
Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R—Red Item Verified
PLEASE PRINT CLEARLY
urJLJVSf''60 b ot�0
N T 0 cJlr' F es
C. tN 14140 u GcKw Il IIJ JP`Ufr*'drL wr/ F
covtg MdG .
G eSL N V-Q&J -r N
►-�JC-
ovg qWit
6d�r oop)
O
�zy /
Discidssion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
inspection, to observe all conditions as described, and to Exclusion
violations before the next ins
p ❑ Re-inspection Scheduled ❑ Emergency Suspension ;
comply with all mandates of the Ma s/Fe5Nral
Food Code. I understand that
noncompliance may result in d sWJ LV enty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
� ❑ Voluntary Disposal ❑ Other:
r
i -
3-501.14(0) PHFs Reeeiveil at Te0iperatures
Violations Related to Foodborne Illness Interventions and Risk Accordim,to I nw Cooled to
Factors(items 1-22) (Cont) _ 4'1'17145'F Within 4 Homs.
PROTECTION FROM CHEMICALS 3-501-U Cooling Methods for PHFs
14 Food or Color Additives 19 PHF Not and Cold Holding
3-202.12 Add rives'" 3-501.16(B) Cold PHFs Maintained it of below
590.004(F) 41.'145'F*
3-302.14 Protection from 17na moved Addiffvcs* 3-501.16(9) Her PHFs Maintained at of above
15 Poisonous or Toxic Substances
140,F.
7-101.11 Identifying Intorntation-Original 3-501.16(A) Roasts Held at or above 130°F.
Qvttainers* -
7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control
7-201.11 Se araban-Storage* 3-501.19 Time as a Public Health Control*
7-20271 Restriction-Presence and Use* 590.004(14) Variance Recuirer mt
7-202.12 Conditions of Use*
7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11 Sanitize rs.Criteria-Chemicals' POPULATIONS(HSP}
7-204.12 Chemicals for Washing Produce,Criteria' 3-801.11(A) Unpasteurized Pre-packaged Juices and
21.
7-204.14 Drying Agents,Criteria* BeveraLes with Wariong Labels*
3-801.11(5) Use of Pasteurized L-�* s
7-205.1.1 ReIncstricted
Food Contact, ,CriLubrteria* 3-801 17(D) Raw or Partially Cooked Animal Food and
7-20(1.11 Restricted Llse Pesticides,Criteria*
Raw Seed S trouts Not Served
7-206.1, Rodent Bait Bait, 3-801.11(C) iJno ened Forx1 Packa>e Not Re-served. "'
7-206.13 Tracking Powders,Pest Control and
Monitoring" CONSUMER ADVISORY
TIME/TEMPERATURE CONTROLSConsumer Advisory Pasted for Consumption of
Animal Foods, I'tiat are Raw. Undercooked or
PHFs
(( Proper Cooking Temperatures for Not Othem ise Processed to Eliminate
r rvva r von
3-401.1 IA(1)(2) FIs 22 3-603.11 155'F 10 Sec. Pathogens.*
L_ s Immedtatc Scrvicc 145°FlBsec* 3-302 SS Pasteurized Eogs Substitute for Raw Shell
3-4pt11(A)(2) Comminuted Fish.Meats&Game
.Animals- 155'F 15 sec. " -
SPECIAL REQUIREMENTS
3-401.11(B)(1)(?) Pot and Beef Roast-130°F 121.mut* -
3-401.11(A)(2) Ratites, Injected Meats-155'F 15 590.009(.4)-(D) Violations of Section 590.009(A)-(D)in
sec * catering, mobile food, temporary and
3-401.11(A)(3) Poultry,Wild Game.SmtTed PHFs, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-165'F 15 sec. " above if related to foodborne illness
3-401.11(C)(3) Whole-muscle- Intact Beef Steaks interventions and risk factors. Other
145-F„ 590.009 violations relating to good retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited under#129-
Microwave 165'F* Special Requirements.
3-401.11.(A)(I)(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 see. * (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 internentions and risk factor-s listed abort, can be
3-403-'11(C) Commercially Processed RTE Food- found it; rhe following se(tiona of the Food Code mrd 105 CIlIR
140'F* 590.000.
3-403,11(F) Remaining Unsliced Portions of Beef 1 Item 1 Good Retail Practices FC 599.000
Roasts* 23 Manac,nmont and Personnel IFC-2 .003
--
if 1g Proper Cooling of PHFs 24 Food and Food Protection _ FC_3 .004
25. .Equipment and U_tensils _ FC 4 005
3-501.14(A) C:oohng Cooked PHfr
Fs om 140"F to 26. Water. Plumbin and Waste FC 5 .006
7(FF Within 2 Hours and Front 70'F 27cilit. Ph sisal FaFTC--& .007 --
to 41'F145"F Within 4 Hon rs.* S Poisonous or Toxic Materials i FC-7 ,OOS
3-501.14(B) Cooling PHFs blade From Ambient 29. Sema Reg_wrements 000
Temperature fngredients to 41'FJ45`F 30. Other 1 1
titiifhin 4 Hours*
S r yo'24-
*I.)enotes Critical item in the edeml 1999 food Code or 105 CMR 590900,
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
3J a 120 WASHINGTON STREET. 4TH FLOOR
t M.M. SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
STANLEY USOVICZ, JR. JOANNE SCOTT. MPH. RS, CHO
MAYOR HEALTH AGENT
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter
94 , Section 305A and Chapter III , Section 5 of the General Laws, to operate
a Food Establishment in the City of Salem is hereby granted to :
Owner' s Name : Mary Pelletier
Name of Establishment : Dube ' s Restaurant
Address of Establishment : 317 Jefferson Avenue
Type of Establishment : FOOD SERVICE
Application Date : 12/10/2002
Restrictions :
Permit for Food Establishment 39-03
Frozen Desserts/Ice Cream
Permit for the Sale of Tobacco Products
These Permits Expire December 31, 2003
This permit is not transferable and must be reissued upon change of
ownership or location. The permit must be posted in a prominent location
in the Establishment.
In accordance with the State Sanitary Code, before any renovations,
improvements, or equipment changes are made, all plans for such must be
submitted to and approved by the Salem Board of Health.
/HEALTH AGENT
'"`.e;:14`�. r x.." ';.'"I' a �;` i v"• ''` �' .Ah +t. °'
> r c!R
CITY OF SALEM, MASSACHUSETTS
BOARD OF HLA LTH
120 WASHINGTON STREET, 47H PLOOE
SALEM. MA 0 1 970 DEC 9 * 2002
TEL. 978-741-1800
FAx 978-745-0343 1 1 6ALEIVI
STANLEY USOVICZ. JR, JOANNE SCOTT, MOH, RS, CHO BOARD OF HEALTH
MAYOR HEALTH AGrN I
2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
I
NAME OF ESTABLISHMENTbjjl��..TEL#- qq-�
ADDRESS OF ESTABLISHMENT-3 A
MAILING ADDRESS (if different)
OWNER'S NAME rho" TEL
,,—
ADDRESS I
C!TY—in,jQ STATE 114 ZIP
CERTIFIED FO(0D'MANTkGERS NAME(S) A9.41JA CERTIFICA E#(s
119
Ct7 11-W
J�
(required in an establishment where pote ally hazardous food is prbpared.)'t
/ - 6 �' 67P
EMERGENCY RESPONSE PERSON HOME TEL# g`J3
HOURS OF OPERATION: Mon. Tue]1"d Wed.I fo Thu. I I'/0 Fri. ( I'l I Sat. I Sun.
TYPE OF ESTABLISHMENT FEE check only
RETAIL STORE YES NO less than 1000sq.ft. =$ 50
1000-10,000sqft =$100
more than 10,000sq.ft. =$250
RESTAURANTCNO less than 25 seats =$100!9 25-99 seats =$1_50 ..
more than 99 seats =$200
BED/BREAKFAST YES NO $100
ADDITIONAL PERMITS
MAKE ICE CREAM, YOGURT, SOFT SERVE YES VOr� $5
TOBACCO VENDOR YES Ne $50
ALL NON-PROFIT(such as church kitchens) YES f $25
Please pay total with one check
payable to the City of Salem
This Permit is not transferable and must be reissued upon change of ownership. The Permit must
be posted in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment
changes are made, all plans for such must be submitted to and approved by the Salem Board of
Health.
Pursuant to MGL-Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that 1, to my
be k led fie ave filed all state tax returns and paid all state taxes required under the law,
-77' an 1 l9-�11)21 IV-12171 .7
Signature U Date Social Security or Federal Identification Number
----------------------------------------- ------------------ --- ---------------------------------------- ---
—
-T
Revised 11/25/02 FOODAP2.adm Check#&Date 156 -/'Z�L ez
ri"r^v'r^r+^^'"`+"r'�-,1+r,.�y'hf,.,ol:<+w"rf'{,F•»3"•.Y'.-'*^"'Yi.v�Fe'^F�G'ai..^"p'i°^-^.. . 'ArL.J--"Ar...i.Ffv,ciaa.rs*�+we,+^e^vow=.,.....-..•.*+.....
THEL'OMMONWEALTH OF MASSACHUSETTS
[4frjr}r CITY OF SALEM
BOARD OF HEALTH Address: 120 Washington Street, 4th Floor
Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT_ Tel: (978) 741-1800 Fax: (978) 745-0343
Name -- %J r �f Date Type of Operations) Tyne of Inspection
G S r�- G �(�'(/f-+ // eo ❑ Food Service ❑ Routine
Address - -�_.. /psi - Risk ❑ Retail ❑ Re-inspection
GX`t`ClL Levelin ❑ Residential Kitchen Previous Inspection
Telephone ' _ /� _ / /rl
El Mobile Date:
OwnerHACCP Y/N El Temporary ❑ Pre-operation
t ❑ Caterer ❑ Suspect Illness
Person In Charge(PIC) _ •t M , Time ElBed&Breakfast ElGeneral Complaint
L1 In: ❑ HACCP
Inspector (-2!^ 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
❑ 3. Personnel with Infections Restricted/ Excluded ❑ 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE
El 4. Food and Water from Approved Source TIMEJEMPERATURE CONTROLS(Potentially Hazardous Foods)
El 16. Cooking Temperatures
El 5. Receiving/Condition
El6. Tags/ Records/Accuracy of Ingredient Statements El 17. Reheating
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
El 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 10. Proper Adequate Handwashing ❑ 21. Food and Food Preparation for HSP
CONSUMER ADVISORY
❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories
Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related
Items) Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22):
of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/Federal Food Code.This report, when signed below
C N by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations
24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of
25. Equipment and Utensils (Fc-4)(590.005) the food establishment permit and cessation of food
26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you
27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing
28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION:
Inspector's Signature: Print
PIC's Signature: _ n Print: v ' Pageyof__?_I�Iges
v i
FORM 734A HOBPS&WARREN - BOSTON
Violations Related to Foodborne Illness
Interventions and Risk Factors (Red Items 1-22) _ PROTECTION FROM CONTAMINATIO
'8 Cross-contamination 1
FOOD PROTECTION MANAGEMENT 3-302.11(A)(]) 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
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 9 Food Contact Surfaces'4`: Food and Water From Regulated Sources 4-501.111 Manual Warewashing-Hot Water
590.004(A-B) Compliance with Food Law* Sanitization Temperatures*
3-201.12 Food in a Hermetically Sealed Container* 4-501.112 Mechanical Warewashing-Hot Water
3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures*
3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-tem H,
3-202.14 Eggs and Milk Products,Pasteurized* p,P
gg Concentration and Hardness
3-202.16 Ice Made from Potable Drinking Water* 4-601.1 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*
10J` 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 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
"6Tags/Records:Shellstock 590.004(E) Preventing Contamination from
3-202.18 Shellstock Identification* Employees*
3-203.12 Shellstock Identification Maintained* 13 Handwash Facilities
Tags/Records: Fish Products Conveniently Located and Accessible
3-402.11 Parasite Destruction* 5-203.11 Numbers and Capacities*
3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement*
590.004(J) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance
7 Conformance with Approved Procedures Supplied with Soap and Hand Drying
HACCP Plans Devices
3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability
3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision
8-103.12 Conformance with Approved Procedures*
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
CITY OF SALEM
l / BOARD OF HEALTH
Establishment Name: r�� S ��S/�lA�/ Date: Page: Z of Z
't Item Code C-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R-Red Item - Verified
PLEASE PRINT CLEARLY
_ -
t �r
f7 i7
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
ru)ncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
i yu?r?food permit. ❑ Voluntary Disposal ❑ Other:
3-501.14(0) PHFs Received itTemperatures
Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled m
Factors(items 1.22) (Cont.) 41`F145`F Within 4 Hours.
PROTECTION FROM CHEMICALS 3-501.15 Coolina:Methods for PHFs
14 Food or Color Additives 19 PHF Hot and Cold Holding
3-501.16(13) Cold PHFs Maintained at or below
3-202.12 Additives`" 590.004(F) 41'145'F*
3-302.14 Protection trorn Una i awed :kidrtives* 3-50t.16(A) Hot PHFs Maintained at or above
15 Poisonous or Toxic Substances
40°F.
7-101.11 7dentit),ng Information-Original 3-50t.16(A) Roasts Held at or above 130'F.
Containers'
7-102.11 Common Name-Working Containers" 20 Time as a Public Health Control
7.201.11 Separation-Stora e* 3-501.19 Time as a Public Health Control'"
7-202.11 Restriction-Presence and Ilse* 590.004(14) Variance Rer airetnem
7-202.12 Conditions of Ilse*
7-203.'11 'toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS(HSP) _
7-204.12 Chemicals for Washm g Produce.Criteria* 21 3-801.1I(A) Unpasteurized Pre-packaged Juices and
7-204.14 Dr ting Agents,Criteria*
Beverages with Warning Labels*
7-205.11 Incidental Food Contact,Lubricants* 3-801.11(B) Use of Pastemazed LUS*
7-206Al. Restricted Use Pesticides,Criteria* 3-80}1-1l(D) Raw or Partially Cooked Arial Food and
Raw Seed Sprouts Not Served
7-206.1.2 Rodent Bait Stations* 3-801.11(C) Unopened Foal Packs e Not Re-served.
7-206.13 Tracking Powders, Pest Control and
Monitoring` CONSUMER ADVISORY
TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
16 s Proper Cooking Temperatures for Animal Fuods That are Raw.Undercooked of
PRFs Not Otherwise Processed to Eliminate
3-401.11A(1)(2) Eggs 155'F 15 Sec. Pathogens.*''r ,ve, •e,
Eggs-Immediate Service IWF15seccl 3-302.13 Pasteurized EggS Substitute foi Raw Shell
3-401.1 I(A)(2) Comminuted Fish.Meats&Game Eo- s
Animals-155`F 15 sec. "`
3-401.1 1(Il)(1)(2) Pork and Beet'Roast- 1.30°F 121 min*
SPECIAL REQUIREMENTS
3-40 Ll I(A)(2) Ratites, Injected Meats- 1550F 15 590M09(A)-(D) Violations of Section 590.009(A)-{D)in
Sec catering, mobile food, temporary and
3-401.11(A)(3) Poultry,Wild Game.Stuffed PHFs, residential kitchen operations should be
JtutIln,Containing Fish,Meat, dei tire
r r-
Poultry or Ratites-165'F 15 sec. * above if related to foodborne illness
3-401.11(C)(3) Whole-muscle. Intact Beef Steaks interventions and risk factors. Other
135'F* 590.009 violations relating to good retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Miciowave 165'14* Special Requirements,
3-401.11(A)(1)(b) All Other PHFs - 145'F 15 see. *
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-403.11(A)&(D) PHFs 165'F 15 see. " (Items 23-30)
3-4011 l(B) Microwave- 165° F2 Minute Standing Critical and non-critical violations, which do not relate to the
Time* foodborne ilhtess interventions and riskfactors listed"hove, can be
3-403,1.1(C) Commercially Processed RTE Find- found in rhe following sect;no of the Food Code and 105 CMR
140'F* 590.000.
3-403.11(E) Remaining Unsliced Portions of Beet' Item j Good Retail Practices FC 590.000 1
Roasts* 4,23,- Management and Personnel_ FC-2 .003
1g Proper Conlin of PHFs 24. _Food and Food Protection FC,3 .004
Cooling k25 t Equipment and Utensi s ___ FC 4 .005 ___
3-501.14(A) Cooling Cooked YllFsfrom ]40Fto , 26. � Water,Plambingand Waste � FC-5 .006
70'F Within 2 Hours and From 70'F 27. 1 Physical Facilit FC-6 .007
to 41.°Fl45'F Within 4 Hours. * 1 28. I Poisonous or Toxic Materials FC-7 .008
3-501.14(13) Cooling PHFs Made From Ambient 29. Special Requirements
Temperature Ingredients to 4PF/45`F 30. other
Within 4 Hours* s.=xi;Unussaanti
"Denote,;Critical item in the tederal 1499 Food Cale m 105 CMR 590.000.
..r'^..-.-.....,.�-.�py�..n ..k..ia....-'NMAvj,.)wa.Yn,. ..imJw:..�--'i.r.+-.f'..e s-i4'i`h iA...a"if+1+T'^-".:s:Pi.w-v+'MWS•?!^'n��'+..+VgT-��.w.•Awa.-----wm.wu-�.....r.T.-....a,w
4
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 Da /22/(Q
T . fOperation(s) T f Inspection
!_-2 Z Food Service Routine
Address Risk ❑ Retail Re-inspection�/ s
9LZLevel ❑ Residential Kitchen Previous Inspection
Telephone „ 7111 - /
El Mobile Date:
Owner HACCP Y/N L1Temporary ElPro-operation
❑ Caterer ❑ Suspect Illness
Person In Charge(PIC) 1 _ Time El Bed&Breakfast ❑ General Complaint
✓� In: ❑ HACCP
Inspector Out: Permit No. ❑ Other
Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)
violated. Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti-Choking Tobacco
Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑
action as determined by the Board of Health. Local Law ❑
FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/ Knowledgeable/ Duties
❑ 13. Handwash Facilities
EMPLOYEE HEALTH
PROTECTION FROM CHEMICALS
❑ 2. Reporting of Diseases by Food Employee and PIC
❑ 14. Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/ Excluded-.
❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE
TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods)
F-1 4. Food and Water from Approved Source
El 16. Cooking Temperatures
El 5. Receiving/Condition
El 17. Reheating
El6. Tags/ Records/Accuracy of Ingredient Statements
❑ 7. 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)
X9. Food Contact Surfaces Cleaning and Sanitizing
❑ 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 (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 Signatur� / t� Print: QA \ / � J
PIC's Signature://///( �` ° ✓ Print: Page/ofL Pages
FORM 734A HOBBS&WARREN -BOSTON
r
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
P:. 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 WashingFruits and Vegetables
.ye Applicants* g
3.304.11 Food Contact with Equipment and
590.003(F) Responsibility of a Food Employee or an Utensils*
Applicant to Report to the Person in Contamination from the Consumer
Charge*
3-306.14(A)(B) Returned Food and Reservice of Food*
590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated
''3' 590.003(D) Exclusions and Restrictions* Food
590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe
Food*
FOOD FROM APPROVED SOURCE g Food Contact Surfaces
Food and Water From Regulated Sources 4-501.111 Manual Warewashing-Hot Water
590.004(A-B) Compliance with Food Law* Sanitization Temperatures*
3-201.12 Food in a Hermetically Sealed Container* 4-501.112 Mechanical Warewashing-Hot Water
3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures*
3-202.13 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*
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*
3-201.17 Game Animals* 11 Good Hygienic Practices
2-401.11 Eating,Drinking or Using Tobacco*
5 Receiving/Condition 2-401.12 Discharges From the Eyes,Nose and
3-202.11 PHFs Received at Proper Temperatures* Mouth*
3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting*
3-101.11 Food Safe and Unadulterated* ,12°::` Prevention of Contamination from Hands
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from
3-202.18 Shellstock Identification* Employees*
3-203.12 Shellstock Identification Maintained* 13 Handwash Facilities
Tags/Records: Fish Products
3-402.11 Parasite Destruction* Conveniently Located and Accessible
5-203.11 Numbers and Capacities*
3-402.12 Records,Creation and Retention* 5-204.11 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*
•Dentes critical item in the federal 1999 Food Code or 105 CMR 590.000. "
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: U(�� /L r�. �/ aD te: / Page: of
Nottern Coda
Date
Reference %Ra�CriticalRed ltemem, DESCRIPTION OF,VpOLATIIOASE �N CLEARLY Verified
OF CORRECTION � �', � � ver fled`
5
ct- 5 l��L_ fel ' \Y1
C7
v
v
ze
- S CZsIJ -
I `7 T_
� L, rv-i s 2 2 l
G
"_
}
Discussion With Person in Charge: Corrective Action Required: '.' ❑ No ❑Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance O Employee Restriction/
violations before the next inspection, to observe all conditions as described, and to comply Exclusion
❑ Re-inspection Scheduled L) Emergency Suspension
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 your food permit. ❑ Embargo ❑ Emergency Closure
r
? ❑ Voluntary Disposal ❑ Other
FORM 73413 HOBBS &WARREN - BOSTON
Violations Related to Foodborne Illness Interventions and Risk 3-501.14(C) PHFs Received at Temperatures
Factors(Red Items 1.22) (Cont.) According to Law Cooled to '
4I'F/45*F Within 4 Hours.*
PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs
+14'S Food or Color Additives 1119 PHF Hot and Cold Holding
3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below
3-202.14 Protection from Unapproved Additives* 590.004(F) 41'F/450F*
,15:Ii Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above
7-101.11 Identifying Information-Original 140°E*
Containers* 3-501.16(A) Roasts Held at or above 130°E*
7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control .
7-201.1 I Separation-Storage* 3-501.19 Time as a Public Health Control*
7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement
7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Containers-Prohibitions* POPULATIONS(HSP)
7-204.11 Sanitizers,Criteria-Chemicals* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and
7-204.12 Chemicals for Washing Produce,Criteria* Beverages with Warning Labels*
7-204.14 Drying Agents,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
7-205.11 Incidental Food Contact,Lubricants* 3-801.1 l(D) Raw or Partially Cooked Animal Food and
7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.*
7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.*
7-206.13 Tracking Powders,Pest Control and
Monitoring* CONSUMER ADVISORY
22' 3-603.11 Consumer Advisory Posted for Consumption of
TIME/TEMPERATURE CONTROLS Animal Foods that are Raw, Undercooked or
16 Proper Cooking Temperatures for not Otherwise Processed to Eliminate
PHFs Pathogens.* EllecWe 11112001
3-401.11A(1)(2) Eggs- 155*F 15 Sec. 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs*
Eggs-Immediate Service 145"F 15 Sec.*
3-401.11(A)(2) Comminuted Fish,Meats&Game SPECIAL REQUIREMENTS
Animals- 155*F Sec.* 590.009(A)-(D) Violations of Section 590.009(A)-(D) in
3-401.11(B)(1)(2) Pork and Beef Roast- 1307 121 Min.* catering,mobile food,temporary and
3-401.11(A)(2) Ratites,Injected Meats- 155*F 15 Sec.* residential kitchen operations should be
3-401.11(A)(3) Poultry,Wild Game, Stuffed PHFs, debited under the appropriate sections
Stuffing Containing Fish,Meat, above if related to foodborne illness
Poultry or Ratites- 165'F 15 Sec.* interventions and risk factors. Other
3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 590.009 violations relating to good retail
145°F* practices should be debited under#29-
3-401.12 Raw Animal Foods Cooked in a Special Requirements.
Microwave 165°F*
3-401.11(A)(1)(b) All Other PHFs- 145'F 15 Sec.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
17 Reheating for Hot Holding (Blue Items 23-30)
3-403.11(A)&(D) PHFs 165'F 15 Sec.* Critical and non-critical violations, which do not relate to the
3-403.11(B) Microwave- 165'F 2 Minute Standing foodborne illness interventions and risk factors listed above, can be
Time* found in rhe following sections of the Food Code and 105 CMR
3-403.11(C) Commercially Processed RTE Food- 590.00.
140°F* Item Good Retail Practices FC 590.00
3-403.11(E) Remaining Unsticed Portions of Beef 23. Management and Personnel FC-2 .003
Roasts* 24. Food and Food Protection FC-3 .004
Proper Cooling of PHFs 25. Equipment and Utensils FC-4 .005
3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Water, Plumbing and Waste FC-5 .006
70'F Within 2 Hours and from 70'F 27. Physical Facility FC-6 .007
to 41*F/450F Within 4 Hours.* 28, Poisonous or Toxic Materials FC-7 .008
3-501.14(B) Cooling PHFs Made From Ambient 29. S ecial Requirements .009
Temperature Ingredients to 41*F/45'F 30. Other
Within 4 Hours*
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
N T6
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
Nam Date Type 'Operation(s) T Ins ion
ood Service outine
AddressRisk LJRetail ❑.Re-inspection
Level ❑ Residential Kitchen Previous Inspection
Telephone ❑ Mobile Date:
OwnerHACCP YM ElTemporary ❑ Pre-operation
❑ Caterer ❑Suspect Illness
Person in Charge(PI Tim ❑ Bed&Breakfast ❑General Complaint
In; ElHACCP
Inspector r Out: Permit No. ❑Other
Each violation-checked requires an expl f
nation on the narrative page(s)and a citation of specific provisions)violated.
Non-compliance with: �y
Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco l!�
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 MANAGEMENT12. Prevention of Contamination from Hands {
❑ 1 PIC Assigned/Knowledgeable/Duties
El13. Handwash Facilities
.EMPLOYEE HEALTH _
[12. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS
❑ 14.Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded
❑ 15.Toxic Chemicals
FOOD FROM APPROVED SOURCE
El 4 Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazard_oue Fooda)
❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements [:117. Reheating
❑ 7. Conformance with Approved Procedures/HAC,CP Plans ❑ 18.Cooling
PROTECTION FROM CONTAMINATION r. _.. ❑ 19. Hot and Cold Holding
❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing - REQUIREMENTS FOR_HIGHLY SUSCEPTIBLE POPULATIONS(HSP),
El21. Food and Food Preparation for HSP
El 10. Proper Adequate Handwashing
❑ 11.Good Hygienic Practices .CONSUMER.ADVISORY-" - =====, _
[122. Posting of Consumer Advisories
Violations Related to Good Retail Practices Number of Violated Provisions Related
Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors(items 1-22):
of Health. Non-critical (N)violations.must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code. This report,when signed below
C-, x by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2) order of the Board of Health. Failure to correct violations
24. Food and Food Protection (FC-3)(5590.90,0 0044))) cited in this report may result in suspension or revocation of
25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food
26. Water,Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you
27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7)(590.006) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) A within 10 days of receipt of this order.
30. Other -a DATE OF RE-INSPECTION:
59J
S: �re FDm 14.o
n
Inspector's Signature: Print:
PIC's Signature: Print: Page-of Pages
lit ..... h •... :..�w .-r..w. at �` _ _. :- -r - a... ln. Y . ...p -
/a`.. ^Fn.��.0 +F .. rte✓' •aw .- �-�.. f� < -a [-..,n/7'4r'.awv'a[..� .a ruYYa- ' 4
f ,
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT S Cross-contamination
1 590A03(A) Assn men[of Res nsibilit * 3-302.11(A)(t.) Raw Animal Foals Separated from
Cooked and RTE Foals*
590.003(B) Demonstration of Knowled e* Contamination from Raw Ingredients
2-103.11 Person in charge-duties 3-302.11(A)(2) Raw Animal Foals 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 Fool Employee Or An
Applicant To Report To The Person In _ _ _ Utensils*
_ Contamination from the Consumer
Charge* 3-306.14(A)(B) Returned Food and Reservice of Food*.
590.003(G)' Reporting by Person in Charge*
3 590.003(D) Exclusions and Restrictions* _ Disposition of Adulterated or Contaminated
Food
590.003(E) Removal of Exclusions and Restrictions 3-701.11Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE howl*
4 - 1 1 Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water
3-201.1.2 Foal in a Hermetically Scaled Container* Sanitization Temperatures*
3-201.13 Fluid Milk and Milk Products* - 4-501.112 Mechanical Warewashing-Hot Water
3-202.33 Shell Eggs* Sanitization Temperatures*.
Eggs E =s and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH;
3-202.16 Ice Made From Potable Drinking Water*
concentration and hardness.*
-5-101:11 DrinkingWater from an Approved S .te"* 4-601..1[(A) Equipment Food Contact Surfaces and-
590.006(A) Bottled Drinking Water* Utensils Clean*
590.(H6(B) Water Meets Standards in 31.0 CMR 22.0* 4-602.11 Cleaning Frequency of.Equipment Food-
Shellfish and Fish From an Approved Comact,Surfaces and Utensils*Source . -�
4-702.11. Frequency of Sanitization of Utensils-and
3-201.14 Fish and Recreationally Caught Molluscan - Fax!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
Author' 2-301.11 Clean Condition-Hands and Arms*
Re diato
3-202.18 Shellstoxak Identification Present* 2-301.12 Cleaning Procedure*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201.17 Game Animals* 11 Good Hygienic Practices< .
5. Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco*
'3-202.11 PRFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and
3-202.15 Package Integrity* Mouth* - - -
3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting*
6 • . Tags/Records:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* 590:004(F) Preventing Contamination from
3-203.1.2 -Shellstock Identification Maintained* -
Tags/Records:Fish Products 13 Handwash Facilities
3402.11 Parasite Destruction*
Conveniently Located and Accessible
3402.12 Records.Creation and Retention*
5-203.11. Numbers and Capacities*
590.004(J) Labeling of Ingredients' - 5-204.11- Location and Placement*
� Conformance with Approved Procedures
5-205.11 Accessibilit Operation and Maintenance'
/HACCP Plans - Supplied with Soap and Hand Drying
3-502.11. Specialized Processing Methods* Devices
3-502.12 Reduced ox en PackaLing,criteria*
6-301.11 Haralwashing Cleanser,Availability
8-103.12 Conformance with A. roved Procedures* 6-301.12 Hand-Drying Provision
'Denotes critical item in the federal 1999 Food Cale or 105 CMR 590.000. -
AAI O
- � f 1. m' 1. . lm li�_
—__�►�i�.�4- -�� .- •rte- .ew'
Milli
ARM
•1 MUM� W. /
± 3-501.14(C) PHFs Received at Temperatures -
y Violations Related to Foodborne Illness Interventions and Risk According to taw Cooled to
Factors(Items 1-22) (Cont.) 41'F/45'F Within 4 Hoam
1
PROTECTION FROM CHEMICALS 3-501.25 Cooliae Methods for PHFs
F-14 Food or Color Additives 19 CHF Not and Cord Hording
' 3-501,16($) Cold P1TPs Maintained at or below
3-202.12 Additives* 590.004(F) 41'145'F*
3-302.14 Protection from Unapproved Additives," 3-501.16(A) Hot PHFs Maintained at or above
55 Poisonous or Toxic Substances
1 140`F,
7-101,11 Identifying Information-Original
3501.16(A) Roasts Heid at or above 130°F.
Containers*
Tuns as a Public Health Control
7-102.11. Common Name-WorkingContainers* 20
* 3-501:14 Time ac a Public Hent Cantron*
7?01.11 Separation-Stora
7-202.11 .Restriction-Presenceand Use* 590.004(H) VarianceR usremeM
7-202.12 Conditions of Use' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 'Toxic Containers-Prohibitions* POPULATIONS HSP
7-204.11 Sanitizers.Criteria-Chemicals*
21 3-$01.11(A) Unpasteurized Pre-packaged Juices and
7-204.1.2 Chemicals fru Washin Produce,Criteria*
7-204.14 Drying Agents.Criteria* Bevcra res with Warninglabels*
7-205.11 Incidental Food Contact,Lubricants* 3-501.11(B) Use of Pasteurized E *s*
.1
7-206.11 -Restricted Use Pesticides,Criteria* - 3-$01 I(D} Raw or Partially Cooked Animal Food and
Raw Seed Sprouts Not Served.*
7-206.12 - Rodent Bait Stations* 3-$01.11 C Uno sed Food Parka Not Re-served.
7-206.13 Tracking Powders, Pest Control and
Monitoring* CONSUMER ADVISORY
TiMEtI EMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Postel for Consumption of
16 Proper Cooking Temperatures far Animal Foods That are Raw,Undercooked or
PHFs Na OtherwiseProcessedto Eliminate
iPathogens.'
3.401,11A(1)(2) Eggs- 155`F 15 Sec.
E, -Immediate Service 145°F15sec* 3-302.13. Pasteurized Eggs Substitute for Raw Shell
3 4i11.i1(Aj(2) Comminuted Fish.Meats&Creme E
Animals-155'P 15 sec.
3.401.11(11)(1)(2) Pork and Beef Roast- 130OF'121 min* SPECIAL REQUIREMENTS
f Sects
590.009(A)-(D) Violations of Section 590.009{A}-(D)in
'
3401.11(A)(2) Ratites, Injected Meats-155`F 15 catering,mobile food,
sec.* g, temporary and
3-401.1 t(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-165'F 15 sec, * above if related to foodborne illness
3401.11((2)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
145°F* 590.009 violations relating to good retail
3-401.12 Raw Animal Foals Cooked in a practices should be debited under#29-
Microwave 165°F* Special Requirements.
340LI I(A)(1)(b) All Other PHFs- 145'F 15 sec.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3403AI(A)&(D) PHFs 1657 15 sec.* (Items 23-30)
3-403.11(B) Microwave 1W F 2 Minute Standing Critical and non-critical violations,which do not relate to the
Time* foodborne illness interventiaru and risk factors listed above, can he
3403.11(C) Commercially Processed RTE Foal- found in the folloning sections of the Food Code and 105 CMR
140°F* 590.000.
3-4W.11(E) Remaining Unsiiced Portions of Beef item ! Good Retail Practices 1 ,FC 580.000
l Roasts* 1 23. 1M naoement and Personnel - FC-2 .003
24. Food and Food Protection FC-3 .004
18 Proper Cooling of PHFs 25. Equipment and Utensils i FC-4 .005
3-501.14(A) Cooling Ccroked PHFs front 140`F to 26, rWater.Piumbine and Waste FC-5 .006 I
700F Within 2 Hours and From 70'F 27. 1 Phvsical Facifity FC-6 I .007
to 41`F/45'F Within 4 Hours.* t 26. ' Poisonous or Toric Materials ' FC " 7 006
3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements _009
Temperature Ingredients to 41°F/456F 30 i Other
Within 4 Hours*
Denotes crifical m1m in the L-dderal 1999 Food Cade o'105 C-MR 590.000.
t
CITY OF SALEM
BOARD OF HEALTH
Establishment Nam.0\D D " "'t— Date: R"_1�±3 Pager Of _
Rem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date-
No. Reference R-Red Item Verified
PLEASE PRINT CLEARLY
r
" .
Discussion With Person in Charge: Corrects a Action Required: ❑ No Yes
I have read this report, have had the opportunity to ask questions and agree to correct all :'/_ Re-i'nsPqcfion
untary Compliance ❑ Employee Restriction/
violations before the next inspection, to observe all conditions as described, and toExclusion
P Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that oxtme,
r noncompliance may result in daily fines of twe -five liars or su pension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. ❑ Voluntary Disposal ❑ Other:
i
h - 3-501.14(C) PHFs Received at Temperatures
Violations Related to Foodborne IBness.lnterventions and Risk According to Law Cooled to
Factors(@erns 1-22) (Cont.) 41'F/45`F Within 4 Hours. ,
PROTECTION FROM CHEMICALS 3-501.15 Coolin Methods for PHFs
t 14 Food or Calor Additives 19 PHP Hot and Cold Holding
3-501.16(B) Cold PRFs Maintained at or below
3-202.12 Additives*
590.0;1{F)
3-302.14 Protection from Un roved Additives* 3-501. Hot P °F*
15 Poisonous or Toxic Substances 16(A} H140`F.Hot P. * Maintained of or above
*
7-101,11 identifying Information-Original
i3.501.16(A) Roasts Geld of or above 130'F.
Containers' '
7-102.11. Common Name-WorkingContainers* 2® Tame ea a Public Health Control
7?01.11 Separation-Stoma * 3-501A9 Time as a Public Health Control*
7-202.11 .Restriction-Presenceand Use* 590.004(H) Variance Requirement
7-20112 Conditions of Use*
7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
a
P U HSP
3-801.it(A}
7-204.11 Sanitizets.Criteria-Chemicals* 1(A) tUnpasteurized Pre-packaged Juices and
7-204.12 Chemicals fru WashingProduce,Criteria*
21
7-204.14 Drying Agents.Criteria* .Beverages with WarningLabels* -
3-801.1 I(B) Use of Pasteurized Eggs*
7-205.11 Incidental Food Contact,Lubricants* 3-801..11(D) Raw or Partially Cooked Animal Food and
7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served,
7-206.12 Rodent:Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.
7-206.13 Tracking Powders, Pest Control and
Monitoring* CONSUMER ADVISORY
TIMET i EMPERATURE CONTROLS 22 3-603.11 1 Consumer Advisory Posted for Consumption of
HFs
16 PAnimal Foods That are Raw.Undercooked or
Proper Cooking Temperatures for F6 PProp - Not Otherwise Processed to Eliminate
3-401.11A(ix2) Eggs- 155F 15 See. Patho *
Eggs-Immediate Service 145'FlSsec* 3-302.13. 1 Pasteurized Eggs Substitute for Raw She11
3-401.11(A)(2) Comminuted Fish.Meats&Game Eggs*
Animals-155'F 15 sec.
3401.I1(B)(1)(2) Port:and Beef Roast-130'F 121 min* SPECIAL REQUIREMENTS
3-401.71(A)(2) Ratites,Injected Meats-155`F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
sec.* catering, mobile food,temporary and
3-401.1.1(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites465'F 15 sec. ' above if related to foodborne illness
340I.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
145*F* 590.009 violations relating to good retail
1 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165'F* Special Requirements.
3-401a(A)(1)(b) All Other PHFs--145'F 15 sec.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-403.11(.A)&(D) PHFs 165-F 15 sec. * (Items 23-30)
3403.11(B) Microwave-165'F 2 Minute Standing Crilical,and non-critical violations,which do not relate to the
Time* i - ,foodborne illness interventions and risk factors listed above, can be
3403,11(C) Commercially Processed RTE Food- ,found in the following sections of the Food Code and 105 CMR
140*F* 590.000.
3403.11(E) Remaining Unsliced Portiaas of Beef j item i Goad Retail Practices FC 59O.tlt7o i
! Roasts* j 23. i Management and Personnel FC-2 .003
! i 24.. 1 Food and Food Protection FC-3 .044 i
18 Proper Cooling of PHFs
1 25. 1 Equipment and Utensils _ 1FG-4 .005 1
3-501.14(A) Cooling Cooked PRFs from 140`F to + 264 Water.Plumbing and Waste ^i PC-5 .006
70°F Within 2 Hours and From 70°F 27. Physical Facility IFC-6 - .0107
to 41°F/45'F Within 4 Hours. * �28. i Poisonous or Toxic Materials 1 FC-7 .008
3-501.14(.6) Cooling PHFs Made From Ambient2� 9. Special Requirements
Temperature Ingredients to 41°F/45°F ! 30. i Other ! .-
Within 4 Htxux* """""�""''*'`
3 Denotes critical item in the federal 1999 Feud Cale ur 105 CMR 590,000.