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DUNKIN DONUTS - ESTABLISHMENTS Dun�Inl Donvts � (�1 �� h�hy�� ftNIVERSAL® UNV-12110 MADE IN USA SUSTAINABLE MW RECYCLED ll PMT-0TIATCONTENT 10% . ESIVE NE C.Med Rber Sa.Wnp PTtm%w .aw e0pmgmm arq SI nIfA Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978)741-1800 Fax(978) 745-0343 Named� (Aate TyW of Ooeration(s) Tv of Inspection ti Jt a� inn t, \ )inn , ly I _ r I i� Food Service Routine Address l , A �GiLE a vv, t7M !Y` Risk Retail Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone (,� (�44 1 nc-( El Mobile Date: Owner ,- ) HACCP YM ❑ Temporary' ❑ Pre-operation t 9n � 0a ,ja /l t ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) l I Time ❑ Bed 8 Breakfast ❑ General Complaint Inspector f' - In Permit No. El HACCP n R P I ou: j � El Other Each violation checked requirds an explanation on the narrative page(;;) and a citation of specific provision(s) violated. v 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 ,, - -� J ❑ 12. Prevention of Contamination from Hands 0 1. PIC Assigned/Knowledgeable/Duties E] 13. Handwash ❑ I I Facilities r 0Y_ L �LH PROTECTION O 2. Reporting Food Employee and PIC El1 .ApproedFoodor Color Additives M u� ❑ 3. Personnel with Infections Restricted/Excluded El15.Toxic Chemicals L FOOD FROM APPROVED SOURCE i" "' { ❑ 4. Food and Water from Approved Source f TIME/TEMPERATURE CONTROLS(Potentlally Hazardous Fooda) ❑ 5. Receiling/Condition E:116. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans [118. Cooling I 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 [REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS_(HSP)' A 0 El 21. Food and Food Preparation for HSP C] 10. Proper Adequate Handwashing \ /❑ (�, k ) - - y 11. Good Hygienic Practices ICONSUMERADVISORY/// ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)$olations marked must be corrected To Foodborne Illnesses Interventions immediately or7within 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) 4order of the Board of Health. Failure to correct violations 24. Food and Food Protection (Fc-s)(590.0oa)so.ocited 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 1 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order,you Q�. 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: (ji _ O Inspector's Signature: /�� 1J. __ Print: �'D b l/� '7 PIC's Signature: /�/ /j /•v�_ rut�� Print: �nIJ�1w / ja/ -c_ _ I Page of des r Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION S Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 1 590.003(A) Assignment of Responsibility* Cooked and RTE Foods* J 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11 Person in charge -duties 3-302.11(A)(2) Raw Anirruil Fouls Separated from Each Other EMPLOYEE HEALTH I Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-30111(A) Food Protection* require reporting by fuud employees and � 3-102.15 Washing Fruits and Vegetables applicants* 590.003(F) Responsibility Of A Food Employee Or An 13-304.11 Food Contact with Equipment and Utensils Applicant To Report To The Person In Contamination from the Consumer Charge* 590.003(G) Reporting by Person in Charge* i i 3-305.I4tA)i B 1 Returned Food and Rted or C nt Food* 3 590.003(D) Exclusions and Restrictions* Food Disposition of Adulterated or Contaminated 590.003(F) Removal of Exclusions and Restrictions 13-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 41 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 ma Hermetically Scaled Container* Sanitization Tenweratures* 3-201.13 Fluid Milk and Milk Products* ( 4-501.112I Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* ! Sanitization Temperatures* 3-202.14 I Eggs and Milk Products.Pasteurized* 4-501.114I Chemical Sam tization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water` concentration and hardness. 5-101.11 Drinking Water from an Approved System' 4-b01.t 1(A) Equipment Food Contac Surfaces and Utensils Clean* J 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards m 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 I Food Contact Surfaces of Equipment* Shellfish" I 14-703.11 I Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP listed I Chemical* Sources* Game and Wild Mushrooms Approved bV 10 Proper,Adequate Handwashing RegulatoryAuthority ( 2-301.11 1 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* 51 3-201.17 Game Animals* 11 Good Hygienic Practices Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 1 3-202.11 PHFs Received at Proper Temperatures* 12-'401.12 Discharges From the Eyes,Nose and 3-202.15 Package Integrity* Mout 3-101.11_ Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 TagstRecords:Shellstock I ( 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* ( 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained'" Employees* Tags/Records;Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records.Creation and Retention` 5-203.11 Numbers and Capacities* 590.004(7) Labeling of Ingredients* +�+ 5-204.11 Location and Placement* 7 Conformance with Approved Procedures i 5-205.11 Accessibility,Operation and Maintenance i Sp CCP, Processing Methods* D Plans I ( Supplied ices with Soap and Hand Drying 3-502,11 3-502.12 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser, Availability 8-103.12 Conformance with Approved Procedures" 6-301.12 ( Hand Drying Provision *Denotes critiad item in the Weral 1999 Fund Cate or illi CMR 590.000. BOARD OF HEALTH Establishment Name:C)4.P AA A� I/1- -T) Date: �l r� 1</ Page: of QL- Item Code C-Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date ,r No. Reference R-Red Item �( � �) PLEASE PRINT CLEARLY Verified p �":.Pn� ,I^J/� f I � (_On-i P 0,,�/_ n 1'0 YO'S�P_ (0' /�1D/V�1A-)S(I, F—n e .� . D F I ,I I V K� � -tom_ ; ISO -��' / _) Vnl7 /1/�i1 A7�/1/t � 1 � �/AA41�� lU a I I �l `t 01-1 0�x �QS r}/1 �Y1 1,V/1 S 0/)A ,o_��Yf/�1� l r�("a ' .mac �k � I IN�itys� ( SIA 11GA A (DA tT,tv,J A A A 0 # SII IWI 4 (✓ � rn'oAnQ IInn rx�nA �Te� // I1/// `k�] �I'nS_tar�0- kI.-,tA �,rA-1 /inA$ rpc, n,nt,'-fQL-LrA�U-(Q)o (nn( �i v,AQ�t ,. •I 1 IL Y YSl�! li' Grp J . /"'7t 4'F./R/1IA,tl -W [n.<-.J1 7r� 11 /1 (,1' A 0 rd NVIU-1( //- , \Luok A11 vv\ 1 AA-P" 1 0- Cc/AA (��n./ .\ 71l rA r n_ Q.LO i 1Lf�ct� Qpm_ _ Ay> �Ipp ff �/,/l I l fni i1'�T p�it,/.,1^t '�� D `I.vy��/IA IYn -1 A A E�, , �k/,7�1'� - n/YAf/I AIL] �O I IhP_ � A,7w .1 P�AX/..l'P. ! .t/A" `I�n_ � �J'1'1 C ✓7 �i�l"1 n_� �- Discussion With Person in Charge: /1 Corrective Action Required: I LINo IIdYes /l1L1 /X/ Ei Voluntary Compliance LIEmployee RestrictionPA(6 / f i`enh Exclusion �7 Re-inspectioq Scheduled ❑ Emergency Suspension w ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other FORM 7348 (REV. 7/2000) HOBBS & WARREN, - BOSTON This Form Approved by the Department of Public Health 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 41°F/45°F Within 4 Hours.* PROTECTION FRO N CHEMICALS 3-501.15 Cooling Methods for PHFs 14 I Food or Color Additives 19 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 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original 140°F.* Containers* 3-501.16(A) Roasts Held at or above 7-102.11 Common Name-Working Containers* 4 20 I Time as a Public Health Control 7-201.11 Separation-Storage* 13-501.19 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* 121 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* Beverages with Waning Labels* 7-204.14 Drying Agents,Criteria* 3-801.11(B) Use of Pasteurized ERRS* 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 22 3-603.11 Consumer Advisory Posted for Consumption of TIME/TEMPER ITURE CONTROLS Animal Foods that are Raw,Undercooked or 16 Proper Cooking Temperatures for not Otherwise Processed to Eliminate PHFs Pathogens.* E*olb i1112001 3-401.11 A(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(8)(1)(2) Pork and Beef Roast-130°F 121 Min.* catering,mobile food,temporary and 3-401.11(A)(2) Ratites,Injected Meats- 155°F 15 Sec.*1 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 the 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 Unsliced Portions of Beef 23. Management and Personnel FC-2 .003 Roasts* 24. Food and Food Protection FC-3 .004 18 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/45°F Within 4 Hours.* 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special 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. •Pb.d.+l•.+"firs= 5�Y^'. !�°rrt'j�{J-.Yl..+`„FR. ,. � v..�°.';n,Q�. t'wr•.-w.. � ..�.- rw.%..-«.lh:�.n:yy<f ti�'°. .°.. .� 4. .,•. Mcitsachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4th Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 7,45-0343 Name j� Da e- Type of Ooeration(s), Tyree of Insoection I/, ,(\� i A �, T5 � 5 1)05 1 jjr Food Service ❑ Routine Address c� Ri k ' [] Retail � Re-inspection y N-A ��eCh 'A � `�� !;� Level ❑ Residential Kitchen Previous i spection Telephone �� -4 F ' I ❑ Mobile Date: C��,� d j Owner � �T ❑ Temporary ❑ Pre-operation `� I �^ I 71 I•/ -s - 5 M HACCP Y/N I ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) )h Time ❑ Bed&Breakfast El General 0 HACCP Complaint In: inspector \ 1 '� t{ p Out � Jt Permit No. ElOther Each violation cTiecked 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 ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded El„_, T, m _ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE , ❑ 4. Food and Water from Approved Source . TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 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 ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices "CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-z)(590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.0044)) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility t (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 5901nspectFomM-10 Ca Inspector's Signature: , // (//Jj'V � , Print: PIC'sSignature: '� � Print: Av��r ?�6iYf i/� - ` I Page_(of_�Pages Violations Related to Foodborne Illness Interventions and Risk Factors(Items 9-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 18 ( Cross-contamination 1 590.0u3(A) Assignment of Responsibility' j 3-302.1 l(A)(1) Raw Anunal Foods Separated from 590.003(B) Demonstration of Knowledge' Cooked and RTE Fcads* ( 2-103.11 Person in charge-duties I Contamination from Raw ingredients 3-302.1 BA)0) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other' 2 590.003,C) Responsibility of the person in charge it, I Coniammadon from the Environment - require reporting by food employees and 3-302.1 I(A) Food Protection'" applicants" j 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 13-3(A.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge' Contamination from the Consumer 590.()()3(G) Reporting by Person in C'h.rr-e* i 3-306.1.4(A)(B) I Returned Food and Resen ice of Food 3 590.003(D) Exclusions and Restrictions* I Disposition of Adulterated or Contaminated 590,003(F.) Removal of Exclusions and Restrictions I I Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food*, 1 dFood ano Water From Regulated Sources ( i 9 Food Contact Surfaces I j 590.o(A(A-B) I Compliance with Food Law* 4-501.1 11 Manual yVarewashmg-Hut Water 13-201.12 I Food in a Hermetically Seated Container* ( Sanitivation Temperatures ( 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-I lot Water I I 13-'02.13 ) Shell Eggs* ' Sanitization Temperatures* 3-202.14_ _ F,-,,s and Milk Products.Pasteurized'' I i 4-501.114 Chemical Sanitization-temp.,pH, concentration and hardness. 3-202.16 Ice Made From Potable Drinking Water* j 14-60L1 I(A) Etitupment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved System" j 1 Utensils Clean` 590.006(A) Bottled Drinking Water* 4-602.11 1590 006(1B) Water Meets Stwulards in 310 CMR 22.0* j 1 Cleaning Frequency of Equipment Food- Shellfish and Fish Froman Approved Source 1 Contact Surfaces and Utensils' ' 4-7u2.t i Frequency of Sani tizannn of Utensils and 401.14 Fish and Recreationally Caught Molluscan I Food Contact Surfaces of Equipment* Shellfish` 14-703.11 Methods of Sanitization-Hut Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources" I to Proper,Adequate Handwashing Game and Wild Mushrooms Approved by i Requlafory Authority 12-361.11 Clean Condition-Hands and Arius" 3-202.18 Shellitock Identification Present* j 12-301.12 Cleaning Procedure* 590.004(C) j Wild Mushrooms* I 12-301.14 When to Rash"' 3-201.17 j Gama Animals* j I ]1 I 1 Good Hygienic Practices 5 j Receiving/Condition I 12-401 11 Eatine. Dunking or Using Tobacco' 3-20111 PHFs Received at Proper Temperatures" I 12401.12 Discharge,From the Eyes, Nose and ian3?02 15 Package andMouth'" 3-101.11 Food Safe d Unadulterated Integrity- * 3-30t.12 j Preventing Contamination When Tasting* 6 TagslRecords:Sheiistock j 112 ( Prevention of Contamination from Hands 3-202.18 Shell stock Identification* ( 590.XWE) Preventing Contamination from 3-203.12 Sheilstock Identification Maintained" I Emphwecs* 13 Tags/Re-cords:Fish Products 1Handwash Facilities Conveniently Located and Accessible j 3-402.11 Parasite Destruction' I 13-402.12 Records.Creation and Retention* j 5-203.11 Numbers and Capacities* j 590.0040) j Labeling of Ingredients' j i 204.11 Location and Placement* Conformance with Approved Procedures 15-205.11 Accessibility,Operation and Maintenance I /HACCP Plans ( I Supplied with Soap and Nand Drying 13-502.11 Specialized Processing Methods* I Devices - - 6-301.I1 Handw•ashing Cleanser.Availability j 3-502.12 Reduced oxygen packaging,criteria' I - 18-103.12 Confornarce with Approved Procedures* I ( 6-301.12 Hand Dry np Provision j 'Denotes critical new in the federal 1099 Fax]Cafe o, 105 Cbl l2 590.000. Massachusetts .Department of Public Health Salem Board of Health Division of Food and Drugs S Salem, MA 01970-3523 120 Washington Street,4'"Floor FOOD ESTABLISHMENT INSPECTION REPORT t rfe Tel. (978) 741-1800 Fax (978) 745-0343 Name D'�to T e of 0 eration s Tyge of Insoection I/- I/�l4r,/1 (/, (1 J 1 Y Dcf I Food Service --Routine AddressI. f 1 � Risk Retail [IRe-inspectionc51 wG✓I n i✓I. Level ❑ Residential Kitchen Previous Inspection Telephone :714 A ✓ El Mobile Date: V 1 / ,/ [I Temporary ElPre-operation t I Owner i�jh�l .� /�t/1TN-. 'I r_.r�5,9'� HACCP YM I ❑ Caterer El Suspect Illness Person in Charge(PIC) - Time ❑ Bed&Breakfast ❑❑ HGeneral ACCP Complaint Inspector Ioxz � n Out: Permit No. El Other Each violation checkerequires 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 ,:- . -f .11 ..1 Dg'12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties '' . EMPLOYEE HEALTH' _ - ❑ 13. Handwash Facilities . . , PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded El15.Toxic Chemicals FOOD FROM APPROVED SOURCE ,, ,: , .,- ;, . . _ . 4. Food and Water from Approved Source IIME/TEMPERATURE CONTROLS(p6L-kialiy Hazaido6s Foods)"- ❑ ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans 1❑ 118• Cooling .], PROTECTION FROM CONTAMINATION" - -FL'CJ 19. Hot and Q21.d Holding M1'" ❑ 8. Separation/Segregation/Prot11 ection ❑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 ❑ 10. Proper Adequate Handwashing Y El11. 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 C _ x by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-P) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(5590.0090.003)4) 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 5901ns IFOm 14 dw Inspector's Signature/ �� Print: PIC's Signature: Print: Page ofPages / 6-1vCrD T Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Cross-contamination I 590.003(A) Assignment of Responsibility* 3-30211(AM) Raw-Animal Foods Separated from 590.003(B) Demonstration of Knowledge* I ( Cooked and RTE Fwtds* 2-103.11 Person in charge-duties ( ( Contamination from Raw Ingredients 3-302.11tA)(2) Raw Animal Foods Separated from Each EMPLO`EE HEALTH Other' 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment � require reporting by food employee;and 3-302.11(A) Fuai Protection. J applicants* 3-302.15 Washine Fruits and Vea-tables 590 003(F) Responsibility Of A Fund Employee Or An 13-304.!1 I Food Contact with Equipment and --- -I Applicant To Report To The Person In Utensils* Charge* I Contamination from the Consumer 590.003((1) Reporting,by Person in Charge* 3-306.i 4(A)(B) ( Returned Food and Reservice of Foods Z J 590.003(D) Exclusions and P.e,trictionsx Disposition of Adulterated or Contaminated 590,0{)3(E^^) Removal of Exclusions and Restrictions I Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food" J 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) ( Compliance with Food taw* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Scaled Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* ( 1 501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Egos* Sanitization Temperatures* 3-202.14 Eggs and Milk Product,,Pasteurized` � 14 501 11` I Chemical Sanifimhon-temp., pH, concentration and hardrtees. 3-20216 ice MadeDrinking From Potable Drinking Water- 5- ater' 4-60,L l I(A) Equipment Food Contact Surfaces and 5-1.01.11 Drinking Water from an Approved System* ( Utensils Clean- 590.006(A) Bottled Drinking Water* - �� 4-602.11 C1r-anine Frequency of F;quipment Food- 590.006(B) Water Meets StaFish From ds in Approved CMR ._.0 ( Contact Surfaces and Utensils* Shellfish and Fish Frain an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3201.11 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Eouipment' Shellfish" 4-70_,11 Methods of Sanitization-HotWaterand 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources" ( t0 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 12-301.11 Clean Condition-Hands and Anus* j Reaulatory Authority 3-202.18 Shelistock Identification Present` i ( 2-30112 Cleaning Procedure* J 590,004(0) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Came Animals* ]1 Good Hygienic Practices J c Receiving/Conditicn 2-401.11 Eating,Drinking or Using Tobacco* f 3-202.11 PH Fs Received at Proper Temperatures* 2-401 12 Discharges From the Eyes, ',Nose and 3202.15 Package Integrity" - --- -j i Mouth* l 3-101.11 Food Safe and Unadulterated' j ( 3-30 L 12 Preventing Containination Wlien Tasting' J i 6 Tags/Records:Shellstock ( 12 Prevention of Contamination from Hands J 3-202.18 Shelistock Identification' 590.0(4(E) Preventing Contamination from I 3-2.0_3.12 Shellstock Identification Maintained- Employees* l Ta s/Records: Fish Products 13 I Handwash Facilities Tags/Records: I Conveniently Located and Accessible j j 3402.11 Parasite Destruction* 5-203.11 3-402.12 Records,Creation and Retention' Numbers and Capacities= - 590.0040) Labeling of Ingredients* 5-204.11 Location and Placement* 9 I Conformance with Approved Procedures 5-205.11 Accessibility.Operation and.Maintenance /HACCP Plans ( Supplied with Soap and Hand Drying 3-502.11 Specialized ProcessingMethorls* Devices 3-502,12 Reduced oxygen packaging criteria* � � 6-301.11 Handwashing Cleanser,Availability j 5-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drying Provision *Denotes critical nem in the federal 1999 Foix?Cate ui 105 CMR 590.000. r CITY OF SALEM i� BOARD OF HEALTH Establisirl,ent Name: 1/jtw (n 17> 11 Date: PT61 10q Page: Z of g Item Coda C-Critical Item DESCRIPTI N OF VIOLATION/PLAN OF CORRECTION v Dafe No. Reference R-Red Item .Verifled PLEASE PRINT CLEARLY - i 'KL a ,n f,� � S�ro I.n) (-,v, .,v.� ..�1L2 �Pj _ - - - , tc..-,�e/l_�- , IV ��+ hov, l / n✓/ 'i- /i Oli�h vi✓,cn _c �L� 1IJ��= log✓, nPc� , >V, ND (t la �)✓a v� Fc cL.,9�1i� �.n/ -P.0 D� ��o r Q I = } � ' d c7 , � /�5� � /�IP i� .� -7�P��_ '�J-r�l Qr (_►n,�- G�_,�r��lPn� r,?n n�nfC I 6 01- 11 WH'A C 0, pg. (t it. kn TPo TII/ 1 7¢ - /i1lC�VID . / 1GO Q 1 rf" r jj ) ' IIGI ,�S�t �& �/ l�o.M GIS{/��/ ; �-1 +/! 'N, 1 c�ujq-pla� q' (c J(�,_s �-1, �� 1f 0 ��/� ten [ ~ 4-;\,44 (I"4- (le j6AIIAS �) �p G 'T _SZ�Or I jlf'I rn�noc blc 1 /l(L C) cll (lt( n1to� r> �� S�J t 1/�9� c f7or.� . iii TI"l �!/) 4o �CQ</1 �,A,/� 4-/,= ') c --p- 14- f- 14- � ,— hP l,�i- NcA ice (..4.fi -�p�v�� ✓ t I l _ 7 r Discussion With Person in Charge: Corrective Action Required: I ❑ No 'Yes I have read this report, have had the opportunity to ask questi s and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all con to s�/as -escribed, and to e-inspection Scheduled ❑ Emergency Suspension p; ,comply with all mandates of the Mass/Federal Food od I66und�&and that ! noncompliance may result in daily fines of twenty- e f�s_er s�spension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. / ❑ Voluntary Disposal ❑ Other: 3-501 )4(('.) PI?Fs Rec ived at Temperatures -� Violations Related to Foodborne Illness Interventions and Risk AccYvding to Lau Cooled to Factors(Ifents 1-22) (Cont) 4I'F/45`F Witbin 4 Hours. x PROTECTION FROM CHEMICALS I 3-501.15 Cooling Methods for PHFs i 14 I I Food or Color Additives I ( l9 PHF Hot and Eoid Holding 3 501.16(B) Cold PHFs Maintained at or below 3-202 12 I .Adcbuve." I 590 W40- -11`'14.,`f=" 3-302.14 ( PovteUum fromL'nappnned Adddncr` 1 y 115 I Poisonous or Toxic Substances t 501,16(A) Hot I FiFs Mainlained at or above i 101.11 Id ntifying-Intitrtnaunn -original ! 140'P.* P i z'±.I6tA) .� Ro,tqPHcldat,,r.tbpt'e13{1^h. '� {nntsu.era 1201 Time as a Public Health Contra€ — '-Cornmon.Nan - N.,r6'inc Cuatamcr,`--� --��-.,- '---'-----f—. ! --` t: 4 F;mw 3"'i Public I tealrh Control, rit-i'Hri -- --- 202,11 kc,v moll-- Prruncn<mJ L,r` 7-202.12 i Condnior:rfUsc" j 7-'_03 11 Toxic Cuutamcr' -Prnh;M:i,tn,' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE — 20.1.11 "anitizets.Criteria -C'hemic;ik' ! POPULATIONS111SP) — 2tIi,lr i np:.:reun�cd Pre-!lac}aced Juice%wid 7.'9-4 12 ('hrnttcal,f-n L�'a,htni'r,Wne'Le_Cnten;i' � — ---- '------ ; I Rc;'rra,,es with Waruine labait" ! 7 304.!4 D;Ong.Agem,.Cnwria"_ 7 205.11_ bnad,ntai F:+xl C-'unta..E, Ijthrt':awi- - or :ePtan:,ax:.:'Cr1k.t,r=dr lo.'nui2 arl-vF�etru.J�an ❑._d e ru ,I t'tcnCot-rt:_tScru `t,L+n(, \ut SHYe.l.! Z:O(.l< rt<;Ien: B.utt--_:� Pa'! I 10613 i ..u_`4:_mtndp.. _._—.__.___- _ �__--�_-- T_---. --_--._. __ _ —CONS UMER ADVISORY TIME(I EM PERATURE CONTROLS 1'0 11 Ce,:,un r Ac;i,or, Pnv:,i l,tri mz umppon of ; ; Ilya.:a l:niiat:cstl.rd c; Prop16 ` PHFerCook€ngTentpeeatu+esto• ! ! •)tlr,:r:,is� Pn,rs::r,,:o;: CITY OF SALEM BOARD OF HEALTH I Establishment Name: 11 ,nY n _�t ; �1 1./��n. t f Date Ig'E��.lIIPage: ___�l of Item Code C-Critical Item •DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified PLEASE PRINT CLEARLY 4 �' � YI 0.� _ 1c1.4 -1 /rI Y} J//.(A_ '01 MO/i ./. /, n-e._� n� J_ n r-, 56XlG / rC4 V r e% a( + I/114./we,{ ,L 14 /./w T'-) r �I!'ice p�� I x / — I IA I ( flr� j _�t J ().N� j vS,nq Civ f Gl SN tones 221 /I (I knn., r Y I_c, i�/O. Or+/J —tl7_ - I OLf/✓L_� r"�w.r/� 7✓i�, � 1� Cr— _� Lel� 0../' r_l•�M/1_P.i�/ I Lre Discussion With Person in Ctiarge: Corrective Action Required: I ❑ No Yes I have read this report, have had the opportunity to a st Lons and agree to correct all ❑ Voluntary Compliance ❑ Employee R striction Exclusion violations before the next inspection, to observe a cord tion as described, and to Re-inspection Scheduled ❑ Emergency Suspension f ,comply with all mandates of the Mass/Federal F lod ode. I nderstand that noncompliance may result in daily fines of twe o s o• suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit ❑ Voluntary Disposal ❑ Other: i i✓ / I j JUI.14(C) ( PtiFs Rexn'ed at Temperatures I • Violations Related to Foodborne Illness Interventions and Risk I , Au;urding m Lav, Cuuled to Factors(herr f-22) (Cont.) i I'F/45`F Within 4 Hous. PROTECTION FROM CHEMICALS 3-501.15 Conlin"Witiodt,for PHFs 19 PHF Hot and Gotd Holding 14 Food or Color Additives ?-SW.16(E) Cold PHFs A7anitainetd at or below 3-292.12 Adthtivcs" I Svc(x)-(t t 13-392.14 Protection from Unapproted Adddivec' j 41'745`F` ! 1-50 L f nI A) 1Int PHF, Maintained at or ab lw Poisonous or Toxic Substances I i l y{/ }' ' (()E.II klcntifying inthrtnannn-Orr;:ina! ( — II (2n.ate Ht.ld at orabwe IAAF " Container;' I ! 7 102.11 i_(:,tamon Sam: N'.n•k rt, t ,n,t.unar,` ! i-'-i) Time as a Public Health Control i i-201.11 Srpar.ta,; I'im'tts , Publit Heal Bt Control- -� 7-_'Q2.i 2 C'unduion.,of I f Q,C 1 7 ?o,l I I T<aic Contarnet> - Pruhibr::•,t,,,. — { REQUIREMENTS FOR HIGHLY 5USCL•P7113LE 7-204.11 Sani3i/eis,Criwria - Chvmicots^ I POPULATIONS(HSP) i v.i_}#.Ia V ( hrncnl.for , 21 -10111(A) L'opa<tcmtCdPJu,tt,and- ---a 7 ?041 14 I Dnin 1 et tt.Cataria" =.i.!i!` Val h t .: SUI I I,Ti: l.c:,i 3 7 205 11 Luiderfal F,xxl C'omac+ 1 uhnctmiv I _ :.S{i3,1101 R,'I or P:L2:.I P, f_,s,xal :kuhnal Ftxtil end 17-2U6 ti J� {{e.n mrd t`oa PraitaAe! (.trtet t.r _ 3 i , .;t Kldnl 1i::1 _ •�_'U!=_I? I ntr,•i au:i J '-----_'-=-'--- -i'�#_.. _ _----____....._'-- ----�----....J Un-pt'`+ �'r ,i Pac'r=s. "xt,f k, CONSUMER ADVISORY _ T6&SE1TEft)PERATI}nE CONTROLS Conium Ar :.o a, t,.1 i.v :ru'u(*tpA,r;;o! PhFs ' 4,1L f;;rt heli -_ __.._._�_..____ >, traun d::tie `.., - , i's e�' , � (-lii=! : +_nr,;:+I;;iL�d r':>1t, \'lc,,:> :_1,,.•,,. s nc i N Mt.gt, ,"i!F •! , t i �htdi lilt ::i;1.31' 13'il•�(ian 1�1, 'Ied it!t!<- I r�,.tliCii" ti t..Cii86 J4;Ci Jt!C4`d 'mk wldP 4ur,'?n,i;t'.tn•:faias Fish o k,i tl+,. at,i•,n•;n:,d'e i i , !, , _ t; iiche:Y!c :to: .:i 1'101. -.tt 4('_..�:r'•,q.5 i7)...^,"f:.<. t._r :r[afj,i 11(:..�1.. t�'"N C..'.:,... 1,S \;i 11 St'wF1 ::n,:,a; •q. t .:i< in'C t,r"i Comrnt:l'ia P} 11141,;.::d i'.='h,,1 It,^a:i:.i.: {,. • , >,'. P - n _ ac.Kiccs _.=r Sr",C tl:i;;• .,:imm _ :tan.^,P. - I EF ; ( Pruper Cooling of PHFs 2, -_ —:'-tr_ r'd`-�rx7 P�, ,<o_n -- ----- i is -_> tr?4_- ..i ` "-----------"--4H,I't ! :: =itGc":'not.in ---- g.i9 ~f -.h V6E . . ihi II(A) I C'txr?Utt`i'.x?lrtl PNPB i�utl= LtO�I'4, I-.,c _ _ __ __.. .. ._ ._..__ _. _. _ ._ i ..., lit _ f —_ ._ 1Vw:3a' fi,nfr.::3•ii Fn-=m;.+'t a_ P_,t., Fac'';' _FC-8 OC; 't, 11 F 1 141,111-'• 11,`LL � "'ve.'3.t!S _(il)it .` 50) 14(2ii I t nr>iir,><('ilF. AJn(ic Ft ouiAarFtt"t i ;---_, .:: :a:_R_.4t.,rar^,>>•`----- ----- -- -- -- - p(;,j- -- 9',nt{`'•on.rce B;-re+iLx,i; It a'YLt::P ; : 'C. .�. .,E 9 1 11. � ..,�1) ,., Massachusetts Department of.Public Health Salem Board of Health 120 Washinon Street, Division of Food and DrugsSalem, MA 019 0-35234'" Floor FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Namej r Date Type of Operationfsl Tyge of Insoection '`/.)ny.,. l /,W%J_) ('Mr- tnO, ® Food Service ❑ Routine AddressRisk ElRetail © Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: Owner p I HACCP YM ❑ Temporary ❑ Pre-operation ❑ Caterer ❑Suspect Illness Person in Charge(PIC) V Time ❑ Bed&Breakfast ❑ General Complaint ?o ❑ HACCP Inspector �� p f Out:11.r 1 Permit No. ❑ Other Each violation checked requ)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) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties El•,u,_ • . 13. Handwash Facilities EMPLOYEE HEALTH ; PROTECTION FROM CHEMICALS " ' "" ° "' '• ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded _ ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE, ❑ 4. Food and Water from Approved Source . 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 ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY [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 N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(s90.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.0044))) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27.,Physical Facility (FC-6)(590.00) 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 580lnspecfFor 14Ooc Inspector's Signature: Y� �V: /�\1 \I((� Print: CY_�nyn. riGO�. Qd PIC's Signatureru L�i n.. Print: /YP � 1%Ie I m QOVI I Page oft Pages 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)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge` ( Cooked and R17E Foods* 2-103.11 Person in charge-duties Contamination from Raw ingredients 3-30111(A)(2) I Raw Anconal Foods Separated front Each EMPLOYEE HEALTH Other- 2 540.003(C) Responsibility of the person to charge to Contamnation from the Environment require reporting by food employees and ! j 3-302.11(A) ( Food Protection' applicants* ( 3-302.15 Washing Fruits and Vegetables f 590.003(F) Responsibility 01'A Food Employee Or An 3-3tk1.1! Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer J 590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reserviee of Food* f 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 I FOOD FROM APPROVED SOURCE Food" J 1 4 I Food and Water From Regulated Sources ( 9 Food Contact Surfaces 540.004(A-B) Compliance with Food Law" 4-501.111 Manual Warewashing-Hot Water 3-207.12 Food in a Hermetically Sealed Container* Sanitization Temperatures" 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashint Hot Water 3-202.13 Shell Eggs* I I Sanitization Temperatures- 3-2 emperatures* 3 202.14 Eggs and Ice Made From F4-501.114 I Chemical Sanitization-temp., pH, Milk Products.Pasteurized* concentration and hardness. " 3-203.16 ( m Potable Drinking Water" ( 14-60i.11(A) I Equipment Food Contact Surfaces and 5-101.11 Drinking Water from ved System'an Appro 590.006(A) I Bottled Drinking Watery Utensils Clean" 590.0(!6(6) Water Meets Standards in 310 CMR 22.0* 4-603'(J Cleaning Frequency of Equipment Food- Contact Surfaces and Utensils* Shellfish and Fish From an Approved Sauce 4-702.11 Frequency of Sanirization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan I I Food Contact Surfaces of Equipment* __) Shellfish" ! 4-703.11 Methods of Sanitization-I-Iot Water and 3-201.15 Molluscan Shellfish from NSSP Listed I Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Reguratory Authority 2-301.11 Clean Condition-Handsand Arms- 3-202.18 Shell stock Identification Present* ( 2-301.12 Cleaning Procedure* 590,004(0) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 1/ j Good Hygienic Practices S Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* J 3-202.1 t PHFs Received at Proper Temperatures' 2401.12 I Discharges From the Eyes,Nose and 3-202,t5 Package fntegrttyr Mouth* 3-101.11 Food Safe and Unadulterated* ( 3-30 t.12 Preventing Contamination When Tasting* 6 TagsfRecords:Shellstock ( 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification i590.604(E) Preventing Contamination from 3-203.12 Shelistock Identification Maintained" Employees* � Tags/Records:Fish Products 13 I Handwash Facilities 3-402.11 Parasite Destruction* ( Conveniently Located and Accessible � 3-402.12 Records.Creation and Rcten5-203.11 Numbers and Capacities-*-. tinn" � - ----- --s-*-. .,-........� 590.004(1) Labeling of Ingredients" 5-204.11 Location and Placement* ( T Conformance with Approved Procedures 5-205.11 A=ssibility.Operationand.-Maintenance /HACCP Pians Supplied with Soap and Hand Drying 3502.11 Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packapmp ,criteria* ( ( 6-301.11 Handwashing Cleanser,Availabilitv 8-103.12 Conformance with Approved Procedures* 6301 12 Hand Drying Provision *Denotes critical item in the federal 1999 Food Code or 105 CNIR 590.006, i Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4th Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name Da� TYoe of Ooerationtal. Type of Insoection 11,Jf1 K1 v� �M i h I11 C, (Q Food Service 'Routine AddressII I_ Risk ❑ Retail ElRe-inspection I S� �i h r_�l^ rT Level ❑ Residential Kitchen Previous f Inspection Telephone El Mobile Date:�IL(-7 7A-4 G 44 HACCP YM El Temporary El Pre-operation Owner ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint Iwo;15rElHACCP Inspector n I� �r � I Out:) 4'�_ Permit No. ❑Other Each violatiocheck d `requires an explanation on the narrative'page(s)and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT _ _„_ ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties El. , , 13. Handwash Facilities EMPLOYEE HEALTH , PROTECTION FROM CHEMICALS�—- - ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE,, .. E] 4. Food and Water from Approved Source ; TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling r i PROTECTION FROM CONTAMINATION_ - 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP), ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C' "N" by a Board of Health member or its agent constitutes an 23. Management and Personnel (Fc-z)(ss0.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-4)(560.0044)) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-5)(590.006) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (Fc-s)(sso.00s> 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 REINSPECTION: _ S 59oM,OFam 14 do ",/�fj/^/'/ (�/1� \JJ,L, Inspector's Signature: � ! Print: ///�/ PIC's Signature: �w- - Print: �jy./r �'o C�`J I Page-k_,;4ages Violations Related to Foodborne Illness , Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 18 Cross-contamfiatron I 1 590.003(A) Assignment of Responsibility* ( 3-302.11(A)(1) Raw Annual Foals Separated from 590.003(B) Demonstration of Knowledge` I Cooked and RTE Fouls* 2-103.11 Person in charge--duties I Contamination from Raw ingredients 3-302.11(A)(2) Raw Animal Foals Separated liom Each EMPLOYEE HEALTH Other' 2 590.003(C) Responsibility of the person in charge to j Contamination from the Environment require reporting by fait employees and 3-302.11(A) Food Protection* applicants* 3-302.15 Washing Fru;ts and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-uA.1I Foal Contact with Equipment and Applicant To ReportTo The Person In Utensils* J Charge* Contamination from the Consumer I 590.00.3(6) Reporting by Person in Charge` I 3-306.14(A)(B) Returned Food and ReseNice of Food'* f 3 590.003(D) Exclusions and Restrictions* I Disposition ofAdulteratedorContaminated 590.003(E) Removal of Exclusions and Restrictions I Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Foal* 4 Food and Water From Regulated Sources ( 19 Food Contact Surfaces 590.004(A-B) Compliance with Food Law" v-501.1 I I Manual Warewashing-Hot Water 3-201.12 Food in a Henuetically Scaled Container" j I Sanitization Temperatures" 13-201.13 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* I i 4-501.114 Chemical Sanitization-temp.,pH, 13-202.16 I lee Made From Potable Drinking Water' concentration and hardness. " 4-601.11(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved System- I Utensils Clean' j 590.006(A) Bottled Drinking Water* 4-602.1 1 Cleaning Frequency of Equipment Fad- " 1590.006(B) Water Meets Standards in 310 CMR.._.0* Contact Surfaces and Utensils" Shellfish and Fish From an Approved Source ; 4-702.11 Frequency of Sanitization of Utensils and 3-20!.14 Fish and Recreationally Caught Molluscan Fexx1 Contact Surfaces of Equipment* _ Shellfish* 14-703.11 :Meth.ds of Sanitization-Hot Water and 3-201-15 Molluscan Shellfish from NSSP Listed I Chemical"' Sources" 110 I Proper,Adequate Handwashing Regulatory AuthorityI Game and Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Anus* 3-202.18 Shellstock Identification Present' I 12-301.12 Cleaning Prucxdurc* 590.004(C) Wild Mushrooms* 12-301.14 When to Wash* I I 3-201.17 Game Animals* I I IS Good Hygienic Practices I j g Receiving/Condition I 12-401.11 I Eating,Drinking or Using Tobacco* _ 3-202.11 PHFs Received at Proper'remperatures" j I '-40!.12 I Discharges Front the Eyes, Nose and 1 13-202.15 Package Integrity, I Mouth* 3-i 01.11 Food Safe and Unadulterated* I 3-301.12 Preventing Contamination When Tasting* j 16 Togs/Records:Sheilstock ( 12 Prevention of Contamination from Hands 3-202.18 Shelistxk Identifiruiva 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* EmplovecO I Tags/Records:Fish Products 113 Handwash Facilities 3402.11 Patasue Destruction* I Conveniently Located and Accessible 3-402.12 Recods.Creation and Retention" 15-203.11 I Numbers and Capacities* _ 590,004(1) Labeling of Ingredients' 15-204.11 I Location and Placement* _ 1 l Accessibility,ibili - . ccesst ,Operation and Maintenance 7 Conformance with Approved Procedures 5 Y I /HACCP Plans ( I Supplied with Soap and Hand Drying 3-502.11 I Specialized Processing Methods* Devices 3-502.12 1 Reduced oxygen packaging,criteria` 16-301.11 Handwashmg Cleanser,Availability 8-103.12 ( Conformance with Approved Procedures° I 16-301.12 1 Hand Drying Provision I 'x Denotes critical nem in the federal 1999 Fcxx1 Cate of 105 CblR S90p00, 4 CITY OF SALEM BOARD OF HEALTH R j� ( 1 / P Establishment Name: -)r)l-l� �1\11-4-1— 1-2�lAJi N, 5 IZin &r Date: Page:. of Item Code - C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified LL � PLEASE PRINT CLEARLY I Ing .7eI P� —1—ID CJKGt✓r�.r0� rr--l�olP ro� ' S�Jre c�✓t .X -�►� IL , It a1f2� Ir tB �-I— Cleo l ch4« to ))ejIleUA GI/C&JL'0, (� ' I( Xxko clip_ 1/1 /Ute l� C�(��t�–, / 7i�_ci 1+j VC t Jn I �r P(Z✓i c Lc SS M- n 1fL ,n I I I i 1 } i , I Discussion With Person in Charge: I Corrective Action Required: ,I ❑ .. No I-)R,—Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ voluntary Compliance, ❑ Employee Restriction/ ' violations before the next inspection, to observe all conditions as described, and to Exclusion P _ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty=five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. y Ll Voluntary Disposal 0 Other: l- lir Dn ,;.5':{.i4tt.,s � PF3t�vRr,:irtied,ti'ientperatares I Violations Retired to Foodborne rltnest Interventions said Riau j r>,er^r<tini;to 1AV, C„x,led to Facta,-s(Itans I-22} {Cont.} ! 4("F/4;'F Within.A rthur,. j } :.it}( i 5 ( Cx ,tia:t ti4cthtxl:!ar i'N}'s _ PROTECTION FROM CHEMICALS ( Ic ' PHF Hat and Laid Holding i, 7d I Food or Ca€ut Additives t ;i{)t.l5(Fif C'ois;PHF, Mwa!;uncsJ at„r b;b;x j 2.202,12 i AtRii',w," j ! roti " ! , F, i 3302.111 i Pr,a cis i'r,yotl;nuplao,t'rdAdiilicc` j j 3.`.t)t Ih,:�r ntl'tf7. #:tirtni3teclat•rrst,,tr I5 { pOi3orhous of Toxic Substances i I ( i 40'F. ici,:ttt,!'tintl?intvrin.,tiun - Oogina! j . � Z.{t;t iiir,.1 R,,.iat::McEd at or.tbova isU"F " i - Time as a Public Health Ca»Ira; 102,f 20 { 7-?C3t.ii lul"it Sri:a. ! i 't.iiii tl Ci m,;at, ,1Public ItcalthC.sdrni' ! 5`;ts.'l04t)i; 6':,riancx:kx;unrrcmes,t i j ?-2t}2.1'. kc,tr;�ttnn- Hr:v-s,ce.uld lsr, i � _._. j 7-102.i2 colid,tos1, of tit,;" i %-'U3 i t T zxic+'Amiaineo - t obibi':,tn. E REG7U9REMENTS FOR HIGHLY SUSCEPT6Bi E j -,'.�t).t,,' Sanititea.,i'nterie-tt,uniudz= POPULATIONS(HSP) i-'_t)-t,i, t'hrtilt. „I 3-Stn.{itA) l,ni;a:teuriurl Pre-}>axi::t;;cd Jxticec snd i 7-204.14 Di Ymii Airnt,.ir,t^,ia` tse+;ra^es ,uttlj liVaruirw I airdc j ?-801,. iiB; E,e,rfParteu:iredt.ce::'" i j 7 Li}5.{t 3n.irirat'tt F,,,it t_un,act. t.ubnc.tr,t�s" - . 7 ! �',.c,r. j 1 4-ti01 t ltti} i R�i.t�•rr P.uua!1'<Cex,{:::i ;laitna€ t=,x,J and 1 •'- Gti, ! kerarta,,d x n.:uiee, rst^t;:,' i I kart tic ra�trruvt±,�,q Set rid. .. )h,t: t.htt: Yor,,,, -, t'esti•out:oland "— --___ i.tvtut,x'tnn, CONSUMER ADVISORY T3RtEt1EUPERATUFtE CONTROLS ` 22 3 0)'.11 Con'anr,x t Aiino:or� Posted forolisanspiiois of i ifr I Proper Cooking tetaperatures ta: luuutri ,,,Ist'S�itruetc' data. ilmrlve, cd,;a PHFs ` r,t i}tlter...isr!n„•,;tit,-d:,t Fiit.vnate 401 31 , ht:u< tttt:t,:,l:',t•;:rr.,e. i'44•I;t;,scx• ( t. iFgt.Sx,h.tttznr}a! tLtu.Slte!7 r-401.11(A)12,, omtmilwl i] !,,h. :Miat” 1 Ci.11nr SPECIAL REQUIREMENTS d(33.5!.Ski,;�•, r;,rl, a,.r: a^ci Tru: t 114;1,' 121n:aa* cy,`l00'a t; kDl L'icdati,ua> ell Set.tit:n ;;`it},(y)=t(<11 t D) ,it 403;.1 1(A3t.', Faux., i"iccre<{li:.its 15`,-F IS mnhit.' iixtd,temp,.rary and I . rcr.idcuiiat kildicri oreTatimis',houid he ?4Ct1.i1fA,„ + 3 xtilrv,N ,!IA ia3ite. Stut'cd i -IFS, E ( I , S:aitlllz C=rt+,ihnr tti;tt. Aieai. dchmd under i L nppr,;pr.ate Y,lillf,-+a'1{glib.:'-It,S't' a,.t. ' ( jlx QFC if iclated to iC,t0l0in,: liti:dS, 3.401A I:C'ii"„ ill"to nnt?,ic, tnc+ci 3,"'f o rn}.s tntert'entirruc and risk factory Ostl',Cr "F 5,40.009 eioiallol.reSatinr to�7kxxl r Aw'! } 3=01.12 Rao. An:m..i J o Kl,z t`{xtk o n;<, rn;b.ticcs .,lichild he de ,ited:ander #29 - 14ir:o,rsvr Itt}:"1 " Sp:ctal ftuluirern nts 7-401,11 iAtil;tto IAi(l Otir:r! fOF, _ 145°t' 1'� ,ei ( 17 j ReF eating tar not iiafding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES I ;_t0i.tttais:,Ila 1 3'Ht•, ib3'F. i`.e,:. I (3temc23.30) 1 '1_403,1 is t3) ' fill,"wilv", ifs+'F Nit atne;it of tilig {.`tit;ru; u,rT ril ,'t<,i „hn:h dtl dol ."law To ir, IFlm", (rr,:r;hr.rrtr•tltiwni ;nu'+'i rrtt„rrw and rtakjiwas”licivil r;hMv, t,+n b: - ( onissiso,ivtit,lF.E.,;N . (nrd in tlhn• ,e,-r3 ,rrr,J :hu£nulini,•Nae ij fddb;G9 1 itr'y 3.40; 1itk. I Itrnt.tnusz t;nvbr•e,l P„tttott<of 33cei ' thtm Good Retail P-actices 1 FC `; 5:70.000- i 23 _ _ya2agernent ttr.c Fernor,ne! Fi:..:'. i_'x?=? _. _. 1R ! Proper Cooling at FHFs 2J. Food.Ind Fuai Protert,r r, 1 FC- ;i 001 _ s 5;31 J-4(A) 23 EQuion twit and Utenans ' =C - n Ohb W ! ( i'sts{ine E:,ntk,.d PHt's i'nin ! {d i"F ic, j"-"-'- i 2S i Wr,Sat,tit rztbinp:,nd Waste 1 Ft;-5 Otrh i Tt'FµViiian a Ileum and Front 7G'L j 27. ! Phycvai Facd_'.hLFt:-G i it,1 l`7:`45 F lr'Wnn 4 Flom!,, ' j ! 26 Po:srnt,us of r mr Materials _ I FC_; '_QOh j 3 SGS.)tint t j f;t,ol! rid PHFn M:<dv €^tont Ann+lent i '�3_LL.TSitac:a!R,�auuarneraa <,:,ttste l j Wifil&n a Ii,Aa rasa!ae,;n Th.,!?demo: 1^,'Iv;,,,,d t'We,: 10 c ti$591:t:i10 CITY-OF SALEM ` BOARD OF HEALTH 1 s Establishment Name: 1�,/ll�t n 0311 .715 - 15(9 �A�G�� 4�� SI Date: (�i �J�J Page: of -� F Item- Code C-Critical Item DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date 1 I No. Reference R-Red Item Verified I PLEASE PRINT CLEARLY Ship Id M,55,-�7 1 tz 0-� /,��i (_ Ib lV�1�.7e�1 i !pre Lc��s v ,lz Ors s �4- �-3��,tc v�n�� 00er-6 it � s c<�3,rc <,^ �� w. � �L U1 at r�e � �ic lcf c�A I - ' /c�tra� d c�eZs (e t„J 9f�" r{ : yA--_T2,e 4 iJ lin, � ��X41, 4O ra� /�-c��• /�r1✓ C�.lrVi�C�� I M I IJ DZL,� -9-- 1- L_ - 4- , Ld- 11 ILV�5,7��J'sQ MfJ 7A:J '( U CD�.S i2 (:"i'17..NMPM�I Com-- _- _ 4Nl). C7 t i r C2lqC/---j -Jo 9J e- I+-CtOcA, r �I b,' I�- /Vnt-J. S I i I�� o'S�1- I14 11)[211 n TIG �4\S-Slnq � 2< I r CALL GJ3Fth5-QL CC2QAll 4T) t+1Sfir�U01- 7L. c d P Ali Iy� '30/1-h-2_ 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 twentyAive dollars or suspension//revocation of ❑ Embargo U Emergency Closure your food permit. �� / �� Gll� l ❑ Voluntary Disposal U Other: 1 e50; ;4(0 PIR at Tevipet4orres Violations Related to Foodbarne,iffnes.,Interventions and RISA to 1��, ccI,)ilJ n) F�tars(Issems;1-22) (Cont) i I-Fi4`5`F wihaia4 Houn;. 4 15 ,)r PHF!� PROTECTION FROM CHEMICALS 19 PHF Hot and Cold Holding 14 Food or Color Additives Col'i PlIF:,S9aint.un4tt at or 14 i plmoi.b,a)Irwal UllailpruitJ Adjm�, I O�A", 11"'I plil-,i "'0aillijilled at or 2N)w Polsonotac or Toxic Substances F, 101.11 i ldmsiNmg lstlia inution Ojt,nnad 1(,(A� %,mm,I-Idd at or,,'.,pee 130%, eviltailloll; 1 20 Time as 3 Public Health Control i ; 102 U 11 Consims-lTiNalaw zoi.il I S�sui!.cikaa- ii„raga 7-202.12 REOUiREMENTS FOR HIGHLY SUSCEPTIBLE ?03,it 1 ,Xic Cljnvnrcll. prolllbrotW� POPULATIONS(HSP) (riviju Cbs-sai(mts, 1 I 21 s:�A) Unpi ztw liid Juice-,ad f,)r�N,,fljjjv J�r,djs(,v, 7-2()4 12 11 7 "#-1.1.11 Dndri,ai,tw.Criteria' ih Waruill, 7 201, 11 '.-§§41,1 Paill.,liv tl.vF iii Anitnfll NXd and st,"J Nt,rlanl� ,N,i 7 :'.176.12 l RkX[Gra bi6i St:,!wTk,,- 1, 2 'I'Tacking Powder,, P.-Si{`anti*I and X01A i,() lli,sj-rilv0 lixd Packau: Nos Ru i,mvd Moaltosrin CONSUMEP ADVISORY 2-, luti"'a W,1Sor,, lion;,! ior I'llimunpucat kit' TIMEITEMPERATURE CONTROLS P,J� .:re k;,,x Undel"A'Ked ka 16 Propel Cocking Temperatures for iir,�egse,l�o Flimmai, PmFe .... . I l,mc-iJmti: fon ka� sliell Conlmniw�,d f7i�h. Mcat,;& G kim '4()IJ T(A)i 2) All,inak I Is WC, ' 1 3-401.11(13),1 li 21 Poi}. aiid bl-o ktmsit 130`F i 21 sum, SPECIAL REQUIREMENTS i001(W1liAi its' Vk!a!s1a!,,ni Su(:n `100(99W-tD) in R,wc, fiiic�rca! Manz: - I 15 F,s,. * Mn ti. food, 'emporat l, avId, ?-40!A I tA)( ti Poohry,Wild CAasle. stufte"1111p,,) kilcht'r, be Fish. Sleet, und"I 111C lwiojl. abovo it Ill iit.m innio liet1:,leaks and rlac 1jAur5 Otiacr t45'-F 5,10,00t) oiuiutlow;relawn", so �ood retail O)sicin,C,�ihsliilj he debitcd :ruder #29 - "-.;1)1.1'2' It's w All;rial T-k d�,( ookd i 1051, I sill.,:iat Rk'(pircmClIt" .1-4kil II(Ai(14) A11001vn PIIF� - 145,F i5,t+: 1 17 Reheating for Hot Holding I VIOLATIONS RELATED TO GOOD RETAIL PRACTICES VHF; W 1: 13 zee 23-.4t) 105" 1, 2 Mmulc swnilhlg !,,odiwrif" nlkj,,t ler;!,w4aboi, (an its, 3-403 11 t Corufrm,ialh )2TY H.,d- i fi,swil ill Olt t',,ld C.,dea,,4 I'd :40'F* �1,0,mkr, Portion,;,fliod cord filltilif piactice�� FC 59atio Rou'.40 stanquflnc,ii,,rd Per-mol Fr, Wl 18 —24, l-�l�mm Fw.i P;ol�tsosi FC 3 i W4 Prager cootinq of PHFc ott,-� �nla 501 i 44 A) Ctal!iap Cfoli ft PHFc iforu 14W Fir, -26 PI;mla,n�qanu �Va�te 5 1 ow 4)"!,shithut , Hours Hud Frorn,!"J,f nhyalca; X7 L, W-alaq I ` _.4 . roi,,,os ou5 or Torr M atvi313 F0, - 501.1.4lb) Coolhw PHF, Madc Him,Asnbiw Ttasp,+raw.c to 4 s`J:`A-S lz C IMPORTA T MESSY + FOR c/'-� DATE n / l� 1� TIME e OF PHONE AREA MOE NUMBER EXTENSION ❑ FAX O MOSII F AREA CODE NUMBER TIME TO CALL { TELEPHONED ' PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN ' WANTS TO SEE YOU I RUSH ' RETURNED YOUR CALL WILL FAX TO YOU ' MESSAGE 'Le—.6..111 'Nal I 06% Y SIGNED ! FORM 4009 MADE 11 U.S.A. ( IMPORTANT MESSAGE ) FOR / A.M. DATE TIME P.M. M -IOC 'Jj w s ^A OF _>.N bpja I J utnll'.S PHONE AREA CODE NUMBER EXTENSION ❑ FAX D MOBi P AREA CODE NUMBER TIME TO CALL TELEPHONED I PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU . ""J'j RUSH RETURNED YOUR CALL I WILL FAX TO YOU MESSAGE 7G�s<'Aa;kc Adf SIGNE F M 0 409 M OE IN U.S.A. Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4'"Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name1 l I i Dat U2 �y Type of Ooerationfsl, Tvpe of Insciection J n K I, Dnr,,A + I Ry Food Service ❑ Routine AddressII_ _ 1 Risk El [3 Re-inspection <4 Level it t, a_ Level ❑ Residential Kitchen Previous . Telephone r-y/,/, ! CI�7dl ❑ Mobile Date: 7`1d+ 11 Owner HACCP YM ❑ Temporary El Pre-operation6��r � -tG ❑ Caterer El Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint Inspector OutO� -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) ❑ "' r 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 - ., . - - ... „ _. -.. 11 PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases byy Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE„' ❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potemialry 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 " `" 9. 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 ❑ 10. Proper Adequate Handwashing El11. 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 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 _1>1K26. 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)(660.006) 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 l DATE OF RE-INSPECTION: L �� er /�I-,VI(� S 501,�Fo�14� Inspector's Signature: / ' / Print: PIC's Signature: / Print: / �J Page of L.-Pag �, es r Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 590.003(A) Assignment of RespnuabiLty* 3-302.1 I(A)(1) Raw Animal Fonds Separated from II 590.003(B) Demonstration of Knowledge" Cooked and RTE Foals* 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 foal 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 ( 3-3014.11 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 Resenice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(F.) Removal of Exclusions and Restrictions ( ( Food 701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* J 4 Food and water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law" 4-:101 111 Manual Warewashing-Hot Water 3-201.12 Foal ins Hermetically Sealed Contvner* Sanitization Temperatures* J 3-201.13 Fond Milk and Milk Products" ( 4-501.112 Mechanical Warewashin Hot Water 3-20-1.13 Shell Eggs* I Sanitization Temperatures* 3-202.14 Eggs and Milk Products,Pasteurized* 4_501.114 Chemical Sanitivation-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water" concentration and hardness. 5-101.11 ( Drinking Water from an Approved System* 14-601.1 i(A) Equipment Foal Contact Surfaces and Utensils Clean* 590.006(A) Bottled Drinking Rater* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.04` ( ( Contact Surfaces and Utensisils* 1 Shellfish and Fish From an Approved Source ( 4.702.1 I Frequency of Sanitization Utensils and 3-M1.14 Fish and Recreationally Caught Molluscan Fond Contact Surfaces of Equipment* Shellfish* ( 4-703.11 Methods of Sanitization-Hix Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 ( Proper,Adequate Handwashing Game and wild Mushrooms Approved by I - -- - Regulatory Authority 2-301.11 Clean Condition-Hands and Amts'' 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure" 590.004(C) Wild Mushrooms* ( 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices g Receiving/Condition ( 2-001.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures" 2-401.12 Discharges From the Eyes,Nose and 3-20115 Package Integrity' Mvinh* 3-101.11 Food Safe and Unadulterated" 3-301.12 Preventing Contamination When Tasting_*__) 12 Prevention of Contamination from Hands 6 � Tags/Records:Shellstock � _ 3-202.18 Shellstock Identification* ( 590.0()4(F,) Preventing Contamination from 3-203.12 Shellstock Identification Maintained" Employees, Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction" Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities* 590.0040} g g 5-204.11 Location and Placement* Lobelin of Ingredients' 7 Conformance with Approved Procedures 15-205.11 Accessibility.Operation and_Maintenance /HACCP Plans Supplied with Soap and Nand Drying 3502.11 Specialized Processing Methods* Devices 6-301.11 Handwashing Cleanser, Availability 3-502.12 Reduced oxygen packaging,criteria* --- 8-10312 Conformance with Approved Procedures" 6301.12 Hand Drying Provision Denotes critical item in the federal 1999 Fond Ccde of 105 CNIR 590uO0. DD/BR SALEM MR JACKSON Fax:1-978-741-4795 Aug 1 2008 1321 P.01 t .Dunkin Donuts 152 Washington Street Salem, MA 01970 (978) 744-9888 fax 978-741 -4795 To: Joe Reale,Salem Board of Health Fax: 978-745-0343 From: Joe Jenkinson,General Manager Pages: 2 including cover sheet Date: August 1,200fl Joe, We had Medford Wellington Service in this morning to check our sandwich station refrigerator.They determined that the thermostat wasn't working properly. He didn't have the part available and needed to order it.He doesn't believe the part will be in until Monday or Tuesday.He will install the same day the new thermostat arrives. If you have any questionsrAydin,the repairman,says please feel€m to call him at 781-953-9441,or please call my cell at 978-809.8877. 1 just wanted to give you a heads upiw case you wanted-to change your reinspection, day. Than , o e inson DD/BR SALEM MR JACKSON Fax:1-978-741-4795 Aug 1 2008 13:21 P.02 i y Ptf\�M VIG D17 Locust Street SERVICE REPORT P.O.Box 239 � Medford,MA 02155 WOR ORDER 781-396-5279 FAX 781-396-0290 Refrigeration-Air CondiGnnbrg Dar sheet Metal :Electrical t MARtl - i CUSTOMER r- \\ i - MOlria l %r_1�13 - _ - sT1�Er ,-' C" UNIr0—!F=r--t-kTh t\A\,, \ ,.._, I d"SERVICE CALL oPM ome FOLLOW LIP - U-'6NUFAcnjRERS NWRRAMM - TIIWWEREPORIEp—`�T�� 1N �� :a1� ._17Gi5-'1 T WORKPERFOWED ��n\ ii- 7n Gn F---Nv CSE 1 � rr tom€ OtIANOIY I RARTNUMBFA DESCRIPRON - PRICE EACN TOTAL COST IlKl\t " ra 20 ,_*A,I r•.e I I I I I r I I I DATE \\ �t I HOOPS TECHNIC" Is Om QYES D40 ^1, , l G 1_�_ � .� 'T - NY MA USED i Q YES ' ay 11 YES / -- I hereby agree tathele mTsutedonthebackafthiteerwereWrt � I ENVIRONMENT CNECKLIST l SR7iANRE AEFItc,TYPc RECOVFAED, O YFS [)No CRY. RDUMNFA vFs C] PRINT NAME No t}lY. DUMP WHITE COPY.OFFICE YELLOW COPY.CUSTOMER Smite aM InsWlatien Sir,,1961 • _ y •^r'v'Y.v+t a+twas fir"`-r+,ea-,ri;,niw+sr,..m.�n..P1^h+. 'rr« •`t1.. :„q,.,.,r-..'rI'^M,+,11�+FY,��3•.,:A7�.SP �nr}�,!M"�°."*w.e-<�r"% +7 *"fes 'r"d" s1ti4�•i^i--M'+'+`+^'^ Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4`"Floor Division of Food and Drugs Salem, MA 01970.3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978)741-1800 Fax(978)745-0343 Name Date Type of Ooeration(s) Type of insoactfon Food Service ® Routine Address ' 171 Re-inspection c;xiv !� � Risk ` ( �]' Retail 'tai i `i Level ( []`Residential Kitchen Previous Inspection Telephone'a.'( !<, ,i 4<, r� j\� . . 1 � f � ❑ Mobile Date: 1 Owner " to HACCP YM ❑ Temporary ❑ Pre-operation i + �� « }� �l r�n ( ❑ Caterer ❑Suspect Illness ..xR -� ❑ Bed&Breakfast ❑General Complaint Persor, In%Cha?ge`(PIC)^ Time ❑HACCP In: Inspector �� v Out: �� Permit No. 71 Other � .//1)rnrt Each violati6r dKe k d req`ul-fe ani 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 N Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E)Y 590.009(F)11 2 action as determined by the Board of Health. FOOD TlO 12. Prevention of Contamination from Hands "i 1. iOutPIC Assigned/Knowledgeableie , 3. Handwash Facilities 'EMPLOYEE HEALTHPROTECTION FROM CHEMICALS ❑ 2- Reporting of10�nfections ood Employee and PIC �) � 15.Toxic Chemood or Co r e i0r Addit ves n, `) icals ❑ 3. Personnel w' y Restricted/Excludedr•, y f -`FOOD FROM APPROVED SOURCE;�,', ,` �° '„; - ( "TIMEITEMPERATURECONTROLS(Poternfally Haza�Foods), ` ❑ 4. Food and Water from Approved Source 4 ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements J! ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans }1 ❑ 18•Cooling % 7PROTECTION FROM CONTAMINATION '°"'"' !!! ❑ 19.Hot and Cold Holding i, [3"8.Separation)Segregation Protection ❑20.Time As a Public Health Control ❑,9. Food Contact Surfaces Gleaning and Sanitizing l t REQUIREMENTS KOR_HIGHLY SUSCEPTIBLE POPULATIONS(HSP),,,.; �t V {! ❑21. Food and Food Preparation for HSP ❑ 0. Proper Adequate Handwashing 1/ El11. 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 cf Health. 590.0001federal 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: Inspector's Signature: Print: PIC's Signature: `r ry Print: * V ;F �, Page_pf ages VvWk j , Violations Related to Foodborne Illness r 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(An!) Raw Animal Foods Separatedfrom 590.003(B) Demonstration of Knowledge* C,x)ked and RTE Foods* 2-103.11 Person in charge-dimes j ( Contamination from Raw ingredients 3-302.1 t(A)t2) Raw Animal Fends Separated from Each EMPLOYEE HEALTH I I Other' 2 590.003(C) Responsibility of the person in charge to Contamination ttom the Environment require reporting by food employees and ( 3-302.11(A) Food Proiection* applirmrs" ?-362.15 Washing Fruits and Vegetables J 590 003(F) Responsibility Of A Food Employee Or An j 3-304.11 Food Contact with Equipment and Applicant To Report To The Person InI Utensils* Charge* 1 1j Contamination from the Consumer 590.003(G) Reporting by Person in Charge* j 3-306.14(A)(B) Returned Faod and Reservice of Food` 3 590.003(D) Exclusions and Restrictions* Disposition or Adulterated or Contaminated 590.003(F,) Removal of Exclusions and Restrictions I I Food 3-701.11 I3iicarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Frwdt" 4 Food and Water From Regulated Sources j i 9 Food Contact Surfaces 5g0.004(A-B) Compliance with Food Law" 4-501.1 t I Manual\Varewashing "Hot Water 3-201.12 Food in a Hermetically Scaled Container* j Sanitization Temperatures* l 3-201.13 Fluid Milk and Milk Products* j 4-501.112 Mechanical Warewashing-Not Water Sanitization Temperatures"` 3-202.13 Shell Eggs' 4-501.111 Chemical Sanitiinion-tem H, 1 3-202.14 Eggs and Milk Puxluds,Pasteurized* j I I p"P 3-202.16 Ice Made From Potable Drinking Water' concentration and hardness. 5-101.11 Drinking Water From an Approved System" I 14-60!.11(A) Equipment Foal Contact Surfaces and 590.005(A) Bottled Drinking Water* ' Utensils Clean" - 590.006(15) Water Meets Standards in I10 CMR 22.0' ( 4-602'11 Clearing Frequency of Equipment Fond- Contact Shelitish and Fish From an Approved Source j Surfaces and Utensils" l ( 4-702.1 I Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipments' Shellfish" I 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed I Chemical* Sources` ( to ( I Proper,Adequate Handwashing Game and Wiid Mushrooms Approved by Regulatory Authority 2-301.11 Clean Condition-Hands and Arms"' 3-202.18 Shel(stock Identification Present" j 2-301 12 Cleaning Procedure* 590.004(C) Wild Mushrooms* j 2-301.14 When to Wash* 3-201.17 Game Animals* ( i II j Good Hygienic Practices g Receiving/Condition 12-401.1 l Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2401.12 Discharges From the Eyes, Nose.and 3-202.15 I Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock I ( 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.0(9(E) Preventing Contamination from 1 3-203.1'_ Sheltstock Identification Maintained" Employees* Tags/Records: Fish Products I 113 I Handwash Facilities 3-402.11 Parasite Destruction- ( Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-213.11 j Numbers and Capacities* j 590.004(1) I labeling of Ingredients' ( 5-204.11 I Location and Placement* 5-205.it I Accessibility.Operation and-Maintenance 7 Conformance with Approved Procedures I .I /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing McOxxir.* Devices 3-502.12 Reduced oxygen packaging,criteria* -301.11 Handwashing Cleanser,Availability 6-301.12 8-103.12 j Conformance with Approved Procedures* ( 6 . Hand Drying Provision !e2 Denotes criaud item in the federal 1999 Fond Code of 105 CMR 590,000. c'� ' tiff rw1S CITY OF SALEM BOARD OF HEALTH f Establishment Name:N PAJ0 A—, U F 1 a •, .U,.. Date: I \—O Page: of ! Item, Code C-Critical Item-- DESCRIPTION v -OF VIOLATION/PLAN OF CORRECTION Date 1 No. Reference R-Red Item _ - - Verified PLEASE PRINT CLEARLY 1 AzV_SU!' <_ ��'t A.l`Ir� O i w -YO_ �1A t7J !!!F I -V got 1 , i` 2, t - 1(� l,; �n rc �o/1 � C��IkAc I� Y� AlO y^�?., /10 , i I - J _21 \ L U I^ //,� n � ) Y J n .l' � ..' l�Pa,� .r--' rn1� � \�'P��r�/\ � nt A-v .P.r ,•t Zt/i q�li ��-'�-}'n I \ � 0 .Q-- P � U/tP AX,L 0, , ! 'S A- 0.1 l.P ^ P (J-e �x /\� O n � , n PA n \ � ;;nt' 1(I�U�2.-� I..� ,�(\ 1 �l (,1in �_lh/o i sVi�. r i.DW � -i7> t l� P n .m1/ /a V�n o� /r r V I 11 /AX, 0 Oh>` �-1�P-F'(7 �-P/\ �n1�_� 1E11c'Ln APi w%r)4 /rtes A `�0)((l ��f: ' �_ .� �' t{-I 1 `-PA O 1 1.A/1 ( 7� 1 0AA Q? l4'AA,1�,4\__) n0_ d(_ ,(AAA PDQ_ � �'\�._'t1° -v��_�S ��n�� fa , /._ ,''�P'i, . I ��r'L'1 �`��l/\.� 1\��\r. a P c� � `:��.c+./S, - 1 C �� :i5�iln i',n� �.•. .X,. i Discussion With Person in Charge: i Corrective Action Required: I ❑ No Irt� les I I have read this report, have had the opportunity to ask questions and agree to correct all ❑r Voluntary Compliance ❑ Employee Restriction/ P PP Y 9 9 V\ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension j 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 Ll Emergency Closure S your food permit. \ ^ � i ( �(; IUAM ❑ Voluntary Disposal ❑ Other: i ;.�,}t,t�i l', I PitF, tZP:.,.FV�f$ai'T."niPYritlUrCc I Violations Related to Foodborne'f ipess tntervratrons and Risk ^�.,,tuicg:c:l.aw.`:'.x•te,I;o I Factors fherm1.2W) (Cont) J°I,ruie . PROTECTION FROM CHEMICALS T4 cPt@T•Pill Ind Gc:fd Holding I 14 ' Faad ar Ca!ar Additives ,...� i i 3-231'_ 12 I ri'?t#1711'C•'r I - i 41- 3-301,t4 j Pr"wc tien #iaii Unaprro=,*1 1 1 E-:,r!t.lfa.3i li,at'`tlt. .'sfi:anta,{}�<I;:talah,,v.. 1 Poisonous or Toxic Sutscances t6( ?7 trkttiitill,tr tntiatts.a:Oil - Urtox t , -'-3o1 .F. 1 ,. ,.tr K+ tet,S{c(d at or a',;<,re ?}{rp + ; i' 1 ' 1 imC as a r'utiit:lloatSn:onirot Coinil;,)tt\intr ir:'as::Ptai*:i•- i ie:t}+tl L'os,a...?, `.-?(ii.ii i Srnar't.toit- Sa7tnp. ., _ I '-Lt}?.it nu"Ind I'�r" 7-2,};.t2 ndi Toyi,itnn.nncIz REt UIREMENISFORHIGHL''f 5S1,`i!UMBLE I'„ri. C'ont2inri;. - Pct#n i^.nm: , i-2t1'}.t i Sattiti�r t,.Cdtcn:+ � t POPULATIONS(FSP) (.`t+rutic:,#t' I '-_''?-i.i' t7tet,u.atnt:�tR:l,hitttttY_„c!a'cc;C'titer:a'. { i j ' 'i}.i la C)n'sitx.'ls:ent., tt'ar„n::'�hals' ` tc,,tit:d 21,._¢`' I .-�t).`+ )i in;idraial 3=tr al f'tmt:r't l:lb.t.airs' 1 :)ri':at,a;{•, {.1.,r6r<;Animal !=tx✓i and �t):i.7 C f;e.tn..inti l:er Ve,tiatde:.Cxa,ir; ! 7 06.12 1 Tr to-It.tti Killit:,bi`iti V,'d.•” 17CJo.1.' j tta; Ing Y.t.i t#:.t<. P^ iConnv! uut ...-_.._ ..._�. - { 1 "VI+,a,tattn„ CONSUMER ADVISORY T'lt�El3 EhIPEFdATiLRE CONTROLS `: t:ti,.'t j ;'.t::-u:;, : •?a''.,t.,t fisieJ t ,r t on::ttn,ptcun of 16 I Proper Cooking Ton)pteatur^s f.rPHFs •, I it }i.:.'.',t iSC Pik"C„hi:{a)i'it atlatL' Tagil}Ariz{%) taut- tS;,rlgfi;;, f ? •;3? 's #':.;i _rtf„i T' :�: •c i,lat�til, xw 53n#1 i F;:^s tuaixdiafc 5er•ac: ! 5T user i f I _t-.}(,1,111 A)(2 t <`oa)airnut=•d F;tih, MCWa Anhui i, t?J i' t5 sf;. '” } -I6t.i?,H1(E Tilt 12110 etnu Ei,•c( Ku:t.i - 2'U'f' 1)! rain' SPE;CiAL.REQUIREMENTa f - fF:ctt VioLltt,tr,::r, :;c nt:n ::t3t7 tXt'3+:�} f D) it, f 'kl:S.21(A)i_'} ^K.,Ciit>,3iq,c;cd ML,q� i`S r t:i i s,c. ` s ,atet3t,g, tn,)t:3}c.;; ),3. «::tpt:raty and hCa 0n.x:t60,;,;.40,11Ed h: 1 .'r,nt'.1mint t ith, .1e.,r u;i.lci tilt, appiop6ate cc;,uotte J Poult:} or#taut , if 5 i S:;,:c. ” ;tx vc tf:ia!od io„rdf,True Illi,:>= 1 3-k}L31tCtr; if R'Itair• tnu,•Ic.intact #3;rf)'r34.; � s:lie ,r, :;,M: inri{i^c Other 390,`70') ,'ii).:.t:U.". relail ...Ji.?�' ._..-._ Kc,e .tmnsal K,ivl,i.rw}.•'+!in if txnctic;, .,tt,,wiJ"r.;dcl,ocd t.nder if 29 . Spo.iai r }nir�wesit• -4ol,i1(,AA!)!h) ( tli!{hlietPHI i•=S(' 2` ;c': ..__.....vim 17 Fleheafzng to;Mot Holding j VIOLATIONS RELATED TO C»t?OD RETAIL PRACTICES i 3-'03.111A'tk-,i)1 3't-[#'. )61'i, I,)o , I Ownia:3-Mi) . Z..fg?.71tH) 4L;rov'a+c iCY`E "1ara,: 5utndin„ .:: J.r:,r:;;r,- :-t $1ai 11 Clo:,I'i,, wq,,ri 3 t:l71: ,'nrY�iU:<'^C .ic5 Vi^1'4c:rti su,:hd Tt;';1114 ior," ','led if;:,. e, t,+n I•+' R1v t.fn kl - f /,•,L",i? t„t ; St;tiy <.,,.i:,r::. !r't:,e+t),`<,a, urrc7)f>,i _ 3.40,i1t):i Rzwflonw t;ntlutdYcrti.ntIS?s,'el . .fr,nrn. -}_.fi�o<}Ststa�+Procruves- �FL -- r59fi.Dt)D --� —f e')a t'•§r.;o'M..' FG l GV.t i i Ib Proper Coo!itrg of PHFS IA F,W#',ott i:L_.' FC- 0a «. _ . ._ai,lun_'en+and Gten �s-- — ---_ -' f 4, .. 5(si.:d(A) {,•r44)t PMF> 11ow 1-10-F!,' i - -- - --. I 79'I `,Yit6m 2 Huur.attrl 1'rwr•-1(i't• 1 i7. FtgM•,;u F2';�lii}'._ _ ... _ IFC-i, � ie`)1 Y!,.I,,l.{i F•lt'tiLin<+; lin}.{;.. '' ZS _ i'rnGn,:::>cr r'�wc tJ, t.;,t,_, ._ Fo - j_1._008 +:ras#iue I`HFt tout!, f¢o o AmNew �._-`�^ � . ;,.t2!q_rat',fer'c<sn^ T<:tuxrauta #t:};rrcticisrs 1114”i,'45 F ' - ---i---- - —"i- ------ --`� I I CITY OF SALEM BOARD OF HEALTH Establishment Name: 0w I, \ f n , ,t U l A)r. ,A Date: — � , '� Page: of Item Code C-Critical Item,.- DESCRIPTIONbF VIOLATION/PLAN OF CORRECTION Date ' No. Reference R-Red Item". nhed I PLEASE PRINT CLEARLY Ve - ( I I A ie 1�> t P�� - r,",,,�ck U P. X�t7 1 inn c t;, o o, a P il ,n\� A C� P �.� ,0 Aratc �tl- c -v/VVI,V,( l�� l�r F X it — r� -off Zm Q I-AIo,Q �, 00_Q M01, A Die `1 l (l 1 (X Y lin c/ p n : _n _ 0_,4 (a �Y tV\ AA n� - I i 1 r` I 1 I I I I j Discussion With Person in Charge: Corrective Action Required: I ❑ No I-izYes I have read this report, have had the opportunity to ask questions and agree to correct all 2� Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: v i ;_<,:.i.l:tt C'. � PliF<.I:rct'rr<d'rt'c c°mperaWree I Violations Related to Foodborne illness Interventions and RISK j AccIlydi n;;io(.aa i"ook"d to Factors(items 1-22) (Cont.] 4 -t( Frd`:'E t§-otlrin.s H„ws ( I3.5ttt,i5 jC:tx+€it+xll�thciXl;f„t PROTECTION FROM CHEMICALS PHFt I ( 1.1 f Food or Color Additives ( 1`r ( + PHF fiat and Cold Holding ( ( 1 3-5C, lhiCti rmo PHF,,.k1aint,iwi:e1 at to bcit,w ?-Zit2.i2 Ad,lithrv' 3.302.14 Ptneec.'ti=)ntnom Unaa2:io'all Addillveg, 3loaPHI;NlArrfooedatarabove 15 Poisonous or Toxic Substances 7 k I(li.11 Identifying infrnnnatn,n Original i Rv,,<-�{it.lr,r:>: v.,+is Ht fit at or abt1v^' 1 iU::i: '* ( Containers { 7-i(I:.'A i (:orchil Name -R i-=ricins i ontain,tn,” I 20 ( Time as a Public Health Control .asaPutti:'ltetlihC'wrol' ?-20 1.1i �rpa,atxon-5ulajee' 7 202.11 Re'tritiion -I'r-scnce and G:r,' ( 7`1U_'1(A1tH} Vm;ance kryuircnicrit ( ',-202.12 Claidition,of rjtie, ( REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7203 11 Ttt;ic. coo a llcl: -Prohfhnion� .'204.11 Sanittzers.Crit,-ria -chenai+,dk” ( POPULATIONS(HSP) «I I .iitA} I..nlra:reunredf'ac•-pa•:}.arrcdluxexw+d jAvOt.?2 h.yuicn3sG)tGt`a.hn: Y:nd:,4c.Ctit::t+s' ` 1 kl�r;ta:e: witht4;;rrtnc leu=.Is' i 7-7{ta.t�l Urging.A):ent..('riteria" ; t'�cufPa.teu,izedE�t�y.�° ( ;.205,17 Incidental t..d C'urita"t,Iuhf rtwiw i 17 i i Si;! 1' I) Raw rPwliatly L4ok-,'d Alihtat Food and .20i 1I t;sr rc\n.,File"Crttena° , Sited St)r=xsts ik•a 7.200,12 R(Jigil Rill stslton," !:I : ? I ', ..�_: f 3 !iC) , L r:=a;t:ner T'I n+d l a:}<.i.. Nor €tc sen'e: � '20tt t? 'I ratktng Prnsclea, t?'So Control and ' Nttau tot i t+„ ;'C}NSUP.4ER ADVISORY TIME/TEMPERATURE CONTROLS j 22 3 1 C?n<u;rt .r idFisor, PwK d if,r C,ticaimption of 116 I Proper Cooking Temperatures for ( `'o+t�;; 3 i=cx,1 That are {2„w. t-?uc7ecax.ked of 1 1 PHFs ( -:ot f}tht,wise +'rtvessed to Ulirun,tte 3101A IA(l)(-) Fggs 153'F 15 Svi,. ` r-• ;- I:nttr:diatr 5errice i^ ;'1'l .,e�' .t-au^_.!.} F:.st.�t=.rrr:'d F,,Z,.:Snhatit+nr for Rain SShelf.1 t„, ` -40I.t It:1}:,17 ( Comf nintaed 4;;,h. (i:unr i thorn tl.: I5 f'15 vel.. ” SPECIAL REQUIREMENTS -401.11(13)t I if 21 Pork asd Chef Roost (.+f)"F 121 Dion' $ ,`c!(:3trtolatto�ns C+( S"I'ltLt -irh).t}()�(.A,}-(I-)} in'i-,€OLI((A)t_1 � f?atite, tuird'ar. k•teaA- t'S'Fi`� , *c grist,,. tao'h&f fcxecf, ta:ntpi raty and 3401 IVAWI" Poulrr),!l(;ima, Stultcd YHFs, rt%ldvnzi: ll kiii,hen oprr::tio rs;hould ire St„flute Conlan»nt,Fish. Morn, 003ited wider the appru!)riate ,ecuons I'o ltrytn'Itant s-InS't- t5;; c. ' 1sn'sifteLtl:dt;lRNAborn::.liiccsk ( 3-401.iIic)(3) Whale-inwAc, Inaaa.t Ilrcf Sleh,A iniwveo'tUoar;and risk factors Other V40{}pg;;ridden:relating to g(Ar i rota,! 3-x(11.1' !� ka% .),mn'tal}'Cads cook,..d lira ltt'.it!iece ,hoa:Id lx;detaiteet under +'_) - 'liic."wave 165"1- * silwat Ii�rtlutretn..nl;. E ,'.-401.11tAi(iifiri ,tri (hnei PHF,-- 145`F 15 sec ( 17 Reheating tot trot Holding I VIOLATIONS RELATE® TO GOOD RETAIL PRACTICES I3.403.111 A}f(U) 1'iIF, 165°F 15 e,:. -1 ' ( eins '3-30 ) J-4(13.11Iii) Mmowa,:- 165"F 2 f4lhtut'Standing Cr:ii, a;.d no.r-(ruca+ .'n4atr.,io, which dc,nor ,elate to the Torte" ;nndburne i1ln;:)i arvrreniio).v enid rtsd t,rtXccs 1^.t,=d arorc, tom be 3 403.1;t( I L'oa)iner:nally RIF 1't.Et- itlt;ul in th< o=i„•a,n,G te:'r:=;at o(;hv load Poste and 1f,,i C'MR 1-I0 F' 500.(t(lo. 340311(E Rcmatmngt.',xhcedPotticnkofRoe; IFC 590.000 It=:ast,i 23 ei ..-_ -_. c FG-2 " ,l4anaoerne-:t and Per<im^&� i 1 _ Ft+xt and FW Prulcotor - VC -3 ; OCa 1 1$ Proper Cooling of PHFs ( - ..-_ �:'5. _cauinir,Lnt.,nd Uten,as i FC- 4 _ _.00S _,.� -.^(it.t4oA) Con?linecook,(APflFsfrontFrr'Fit` 2G. - Vlairt Piumcin:la��+d:^loxia � FC -5 -�_ik-- " 7,)"F Within 2 Hour<writ From 19"9 ; ?7. pt:va��:?[Fac+lity_-,---_- - _ K-o .. .Ot)i -- t=,41'F/s5 P lvitE,in 4 linsu;, 0 Pn+S=,r,.:ir+;or toxic td.:ttenal: --.._ FG - 77 W2 3-501.t4+Ii) Cuc,ling PHFs Mmle Ft'on),lntyient ?_0. I-=i � FiSetuE;nE.ytf" .IX}3 I �.._..___.., j 'Fcfnl,etaUrcr iuwrcthevtka n,wt`4:'45.Ir : 3n Other i Within ittatr? I)c:n.i,::rnteati nc+h m ih: Ir:br,a 1S,N Friel Cads or tfli.CN.P.,39a pfh; 0f54 WASHINGTON STREET Dunkin Donuts-Washington City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-9888 Food Contact Surfaces Cleaning and Sanitizing PASS Critical ❑d RED Owner: Comments: Front sanitizer is reading below mandated ppm. Sanitizer to be reading at 200 ppm. Robert and Anthis Jackson j PIC: Violations Related to Good Retail Practices (Blue Items) Kathy Foley Food and Food Protection PASS BLUE Inspector: Comments:There is a thermometert being stored directly on cheese in Delgeld unit. Thermometer must be in proper area to John Gehan prevent cross contamination. Date Inspected:Correct By: 7/2/2007 There are personal items being stored with food products. Items to be stored in designated employee area. I Risk Level Equipment and Utensils PASS BLUE Permit Number: Comments:Walk in floor requires general cleaning. BHP-2007-0168 Walk in freezer floor requires general cleaning. Status: Fron two True beverage units require general cleaning. SIGNED OFF #of Critical Violations: Front Delfield unit(1-4)requires general cleaning. 0 Time IN Time OUT. { Physical Facility PASS BLUE Comments:There are water stained ceiling tiles over the counter. Find source of leak and repair. Replace tiles. Urgency Description(s): BLUE: GENERAL COMMENTS: i Violations Related to Good All violations from June 25, 2007 have been corrected. 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 02,2007 ) Page I oft "r Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) J l 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 02,2007 ) Page 2 oft mac` Commonwealth,of Massachusetts City of Salem Board of Health 1Qmbedey Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/29/2008 ESTABLISHMENT NAME: Dunkin Donuts/Drew's Donuts File Number:BHF-2004-000132 282 Derby Street Salem MA 01970 LOCATED AT: 0154 WASHINGTON STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2009-0284 Dec 29,2208 Dec 31,2009 $140.00 / WATER SOURCE:CITY ESTABLISHMENT WATER SEWER DISP: CITY WATER Total Fees: $140.00 PERMIT EXPIRES (December 31, 2009 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 Y CITY OF SALEM, MASSACHUSETTS • BOARD OF HEALTH 120 WASHINGTON STREET,4"FLOOR .,;-. KIMBERLEY:DRISCOLL, 745 0343 NLIYOR iD1ONN}C).SALE.Nf.COM " 's"` G 8Y y�� JANET DIONNE, ®EC 15 2008 ACTING HEALTH AGENT of, ShLALNl 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT � NAME OF ESTABLISHMENT \ — Jl1�c TEL# ADDRESS OF ESTABLISHMENT M'�``�r�t `� p ��QA FAX# Lh L� "VI 4144 MAILING ADDRESS(if different) P-6\ EMAIL-Business':�P—\ Website: —tI �i ' —y`—� OWNER'S NAME 1 R�'--� �E'7V�fKjJ TEL# G_Ilk —1 I"44" �� 1 1 I ADDRESS -POA I � STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME,(S) CERTIFICATE#(S) (Required in an establishment where potentially haz r ous food is a ared) EMERGENCY RESPONSE PERSON Ulf \ HOME TEL# DAYS OF OPERATION,- 1 . Monday I Tuesday I •Wednesday. I° Thursday Friday- ! Saturday iSunday' ')I HOURS OF OPERATION Please write me of day. For examle 1lam-11 pm) (-AR (9 da '7 ,1—1— namaJ u _ _ TYPE OF ESTABLISHMENT EE (check only) / RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 1 0,000sq.ft. =$420 = — ------------------------------------------------------------------------------------------------------------ .......... RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats = 80 more than 99 seats =$420 BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES ADDITIONAL PERMITS MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES $135 ALL NON-PROFIT(such as church kitchens) YES O $25 'Please pay total with one check payable to the , ity 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 ums 11�xeqreu, r the law. Signature Date $mor Federal Identification Number Revised 424/07 FOODAP2008 adm Check#&Date $ LyL,,— vcv veru 0 Yr vY� �� rO N l 7- 116 vju - a � ur ; , - . _� �; � h 1 \J!_i � 1 � �i x � � � 1 . 1 \ 'r 1 �� \ . . X1 `1 \\ • � i l � .' . . 'alt .�� r \. �., � � t . s � r � .0 , ,., �. is r , . �� \\ "� 1 � F .r � i Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street,4th Floor IGmbedey DriscollMayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/04/2008 ESTABLISHMENT NAME: Dunkin Donuts/Drew's Donuts File Number.BHF-2004-000132 282 Derby Street Salem MA 01970 LOCATED AT: 0154 WASHINGTON STREET - SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2008-0187 Jan 4,2008 Dec 31,2008 $140.00 / WATER SOURCE:CITY ESTABLISHMENT WATER SEWER DISP:CITY WATER Total Fees: $140.00 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 4 of 11 QTY OF SALEM, MASSACHUSEM BOARD OF FIEALn-i 120 WASHINGTON STREET,4"FLOOR qEL' (978)-741-1800 L YA MAYOR isooTrca)SALEM.COM JOANNE SCOTT, HEALTH AGENT 2008 APPLICATI NFO PERMIT TO OPERATE A FOOD ESTABLISHMENT I - NAME OF ESTABLISHMENT TEL# ADDRESS OF ESTABLISHMENT \T=J:;k "!k 72AFAx# -11AN 1qV1TL7) MAILING ADDRESS(if different) EMAIL-Business': (��,UK,,M "VVMWebsite: ' ,-M TEL# OWNER'S NAME � ADDRESS _rkq\\ C__AkPX1\ VA qlTY _1 T CERTIFIED FOOD MANAGER X CERTI I T (S) STREET 'S NAME(S) (Required in an establishment where potentially hazardous food is preloired) it2��iil� D M -H4;*E TE EMERGENCY RESPONSE PERSON AJJ%t-�� j L# �v DAYS OF OPERATION Monday Tuesday Wednesday Thursday Friday Saturday Sunday HOURS OF OPERATION Please write in time of day. (For example I lam-1 Ipm) TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than I 000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 1 0,000sq.ft. =$420 ------------- RESTAURANT ------------ - FRE�_FKJRXNT------------------------ K6--------------------------------------------less 25 seats---------6 (Outdoor Stationary Food C 25-99 seats =W- 0 more than 99 seats =$420 ------------ ----------- ----------------------------------------------------------------- 100 CHILDCARE SERVICES -- ------------------------------------------------------------------------------------------- SERVICES MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES $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 ry 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. Pursuantlo MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that 1,to my best knowledge and belief,have filed all state tax re wired n er the law NA 5 Signa Date 3eeiekSoGw4y or Federal Identification Number Revised 4/24/07 FOODAP2008.adm Check#&Date 0154 WASHINGTON STREET Dunkin Donuts-Washington City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-9888 Food Contact Surfaces Cleaning and Sanitizing FAIL Critical 66 RED Owner omment: Front sanitizer is reading below mandated ppm. Sanitizer to be reading at 200 ppm. Robert and Anthis Jackson j PIC: Violations Related to Good Retail Practices (Blue Items) Kim Grant Food and Food Protection FAIL BLUE Inspector: �o :There is a thermometert being stored directly on cheese in Delfield unit. Thermometer must be in proper area to prevent John Gehan cross contamination. Date Inspected:Correct By: i� 6/25/2007 /There are personal items being stored with food products. Items to be stored in designated employee area. Risk Level: Equipment and Utensils FAIL BLUE I Permit Number: —Comment:Walk in floor requires general cleaning. BHP-2007-0168 1 1JI latk 9free zer floor requires general cleaning. Status: Open on two True beverage units require general cleaning. #of Critical Violations: vont Delfield unit(1-4)requires general cleaning. 1 Time IN: Time OUT: Physical Facility FAIL BLUE Urgency Description(s): ""'Comment:There are water stained ceiling tiles over the counter. Find source of leak and repair. Replace tiles. 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. Jun 26,2007 ) Page 1 oft T 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. Jun 26,2007 ) Page 2 oft lsw n�yx,y�n.^ r„"..._ afL �}. y 'Y k .u.{ r`i.5 -r'it'`.,y, fX�,1.pCommoirWkthofMassachdsetfs $ 4 r ,� � °�i $�` �, 'H, '.1 �:,+:;•r9'`+„g,,, -3'.iI' � .-" � s.x Zai;fix. City of Salem. JA.y}4, 1u ri.>• • • M L, ,.i`'Sk"! �, �� F•' i c'HErrE>."�"t"f 'b .• - '°r'r'? *rr.• a" xx�"eE"d`�Q�.3 � > sss ,{$..rpA�S:ry��7>%i^2 �� Klmtierley Driscoll 4 120 Washington Street '4th Floor . - < K -,F.,r.,h�,-i-.,':i•.:-'_...�_. MB OfS:r` s^ �� .i§ SALEM,MA '01970 Food/Retail Establishment Permit DATE PRINTED: 12/20/2006 ESTABLISHMENT NAME: Dunkin Donuts-Washington File Number:BHF-2004-000132 282 Derby Street Salem MA 01970 LOCATED AT:'~0154 WASHJNG_TOYSTR_E 3TE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2007-0168 Dec 20,2006 Dec 31,2007 $100.00 / WATER SOURCE: CITY ESTABLISHMENT WATER SEWER DISP:CITY WATER Total Fees: $100.00 PERMIT EXPIRES becember 31, 2007 Board of Health �f— This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 6 of 8 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH RECEIVED 120 WASHINGTON STREET,4TH FLOOR SALEM, MA 01970 DEC 142006 TtL'978 Ekx978 Kimberley Driscoll WWW.SALEM.COM Mayor JOANNE SCOTT� MPH, RS, CHO HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT -- - TEL#CMZ. q � -ILI I ADDRESS OF ESTABLISHMENT MAILING ADDRESS(if different) ;�W—A - ),A FAX enl�T-A EMAIL--Business': _lClowner's: ('281C) 6- 6,q,1q_t-t( P 7T��64!5� OWNER'S NAME TEL#al(g --114 LA ADDRESS X 6 0>m\ STREETCITY I STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) P/4-T-14y Jrk4y CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) 97P EMERGENCY RESPONSE PERSON. Adll� HOME TEL# — Nior— L071 DAYS OF OPERATION Monday Tuesday Wednesday Thursday Friday Saturday Sunday HOURS Of OPERATION Please write intime Of Call. (for example Illam-lumil TYPE OF ESTABLISHMENT FEE (check oniv) RETAIL STORE YES NO less than 1 000sq.ft. =$ 60 1000-10,000sq.ft. =$100 more than 1 0,000sq.ft. =$250 ..... ..... .... ... ..... ....... ...... ...... ----------- ------------- ------ RESTAURANT-- ---- '*_ "---- ------(DES NO less than 25 seats r=$100 25-99 seats more than 99 seats =$200 ...................._------ ............... ----- .... ...... ....... ...... ..... ----- ......... ...... ------ -----I ------ ---- BEDIBREAKFAST 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 6A, , Section 49A, I certity under the pains and penalties of perjury that 1, to my best knowledge arid belief. have fl all stale tax �all slate,taxes required under the!aw. 914�4, CF9 Signature pate Social Security or Federal Identification Number -- -------- ------ ------ ---------------------- ------- Revised 11113/06, `00DAP2007 adni i/Cneck#&D_�.ite_ I ------------ - ----------- ------------ ---- A�A �M_ WkIlIk\% 0154 WASHINGTON STREET Dunkin Donuts City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: i Violations Related to Good Retail Practices (Blue Items) 744-9888 Equipment and Utensils FAIL BLUE Owner. Comment:Walk in freezer has a broken cover of fan. Repair or replace cover. Robert and Anthis Jackson PIC: Walk in freezer has accumulation of ice. Find source of leak and repair. Remove ice. Kathy Foley Walk in floor requires general cleaning. Inspector: The shelves on the right side of the ice machine require general cleaning. John Gehan Date Inspected:Correct By: Physical Facility FAIL BLUE 12/4/2006 Risk Level: , Comment:Outlet beneath window missing cover. Replace cover. There are water stained ceiling tiles above front counter. Find source of leak and repair. Replace tiles. Permit Number: BHP-2006-0319 Status: Open #of Critical Violations: 0 Time IN, Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Dec 04,2006 ) Page / of ' Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) Cityof Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Dec 04,2006 ) Page 2 oft t 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 ESTA&SHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name ) + _ Date Type of Operation(sl Type of Inspection , /lj 06 I ®) Food Service ❑ Routine AddressI A Risk [I Retail [QRe-inspection 11n1' 1^ e it Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile Date 11** ULO_-)� �/ /,)(, Owner HACCP YIN ❑ Temporary ElPre-operation ) )I �a 1 fi /f»1 /A, a \ �i l C �G,l, I ❑ Caterer ❑Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑❑ HGeneral ACCP Complaint In: Inspector ( civ )X 0r,i �i, I Out:)a�� 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. 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" '.' El 4. Food and Water from Approved Source 11MErrEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures l ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑�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 rf 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)(590cited in this report may result in suspension or revocation of _ 25. Equipment and Utensils (Fc-a)(sso. 0a)oo5) 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: i L/J` Print. PIC's Signature: Print: Q \ i t`l/ O I Page of ,Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINk6ON FOOD PROTECTION MANAGEMENT { S Cross-contamination - { 1 590.003(A) Assignment of Responsibility* 3-302-11(A)(D Raw Animal Foods Separated from { 590.003(B) Demonstration of Knowledge* { Cooked and RTE Foods* J 2-103.11 Person in charge-duties { Contamination from Raw ingredients 3-302.11(A)(2) Raw Annual Foods Separated from Each EMPLOYEE HEALTH ( I Other* 2 590.003(C) Responsibility of the person in charge to { Contamination from the Environment { require reporting by fowl eniplayees and 3-302.11(A) Food Protection applicants* { 3-302.15 WashinsFruits and Vegetables J 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* I Contamination from the Consumer { 590.003(G) Reporting by Person in Charge* { 3-306.14(A)(B) Returned Food and Reservice of Food'* { 3I590.003(D) Exclusions and Restrictions* j I Disposition of Adulterated or Contaminated 590.003(F,) Removal of Exclusions and Restrictions ' Food .370IJI Discarding or Reconditioning unsafe FOOD FROM APPROVED SOURCE Food' 141 Food and Water From Regulated Sources ( i 9 Food Contact Surfaces { 590.004(A-B) Compliance with Food Law* 4-501.11 i Manual W'arewashing-Hot Water { 3-201.12 Fotoi ma Hermetically Sealed Contamer* ( Sanifization Temperatures* ( 3-201.13 Fluid Milk and Milk Product,;* ( 4-501.112 Mechanical Warewashing-Hot Water{ { { 3-202.1.3 I She11 Eggs* { ( Sanitization Temperatures* { 3-202.14 Fggs and Milk Products,Pasteurized* { 14-501.114 Chemical Sanitization-temp.,pH, 3-202.16 ( Ice Made From Potable Drinking Water" concentration and hardness, * J 4-601 5-101.11 ( Drinking Water from an Approved Svstem` 1 .11(A; Uteensmilsits Clean- 590.006(A) Food Contact Surfaces and { 590.006(A) Bottled Drinking Water* { 590.006(B) Water Meets Standards in 310 CMR 220* 14 fi02.11 Cleaning Frequency of Equipment Food- { Shellfish and Fish From an Approved Source { Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish'" 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed I I ( Chemical* Sources* ! { t0 I Proper,Adequate Handwashing Regulatory Authorityority { Game and Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Aims* { 3-202.18 { Shellstock Identification Prevent" ! ( 2-301.12 Cleaning Procedure* _ { 590.004(C) Wild Mushrooms* ( 2-301.14 When to Wash* { 3-201.17 Game Animals* { it Good Hygienic Practices _ { { 5 Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* { 3-202.11 PHFs Received at Roper Temperatures* 12-401.12 Discharges From the Eyes,Nose and { 3-202.15 Package Integrity* ( Mouth* M 3-101.11 Food Safe and Unadulterated* { 13-30 L.12 { Preventing Contamination When fasting* { { 12 Prevention of Contamination from Hands 6 Tags/Records:Shellstock { { 3-202.18 Shellstock Identification''` { 1590.004(E) Preventing Contamination from 3203.12 Shellstock Identification Maintmned' { Employees" Tags/Records:Fish Products { ( 13 I Handwash Facilities 3-402-11 Parasite Destruction* { Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* { 5-203.11 { Numbers and Capacities* { 590.0040) Labeling of Ingredients' { { 5-204.11 { Location and Placement* { 7 Conformance with Approved Procedures I 5-205.11 { Accessibility,Operation and!Maintenance { /HACCP Pians f Supplied with Soap and Hand Drying 3-502.11 . Specialized Processing Meth,xls* { I Devices { 3-502.12 Reduced oxygen packaging,criteria* { { 6-301.11 Handwashirm Cleanser,Availability { 8-103.12 { Conformance with Approved Procedures` { { 6-301.12 j Hand Drying Provision Denotes critical item in the fedei al 1999 Food Cale of 105 CMR 590.000. t CITY OF SALEM ` f3OARD OF HEALTH / Establishment Name: I/, 't K. �[��f 1, .�1 { S a ) n Date:-3/,2/,)Ie. Page: r'�- of 1 Item Code C-Critical Item DESCRIPTION 6F VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified t _p\�dPLEASE PRINT CLEARLY p r ( ,�Zxl1d lrf." �l� � II< UC1II I/Lt i l/� o r��.r .t 01) 1 �nr�an �/1 �o cfy . , .f flci/1 � cc .x,✓1� 7r�n�o. �. c �7rDl� SS . F �rr,nc t zfcl n ac o L,no I.r� /-Cf hr '-a.ioo �;u� �r �, r �Jol . ,�h• ,� e� I I I 1 � I Discussion With Person in Charge: �Corrective Action Required: I LINo IX Yes I ha/e read this report, have had the opportunity to ask questions and agree to correct all •oluntary Compliance ❑ Employee Restriction/ F violations before the next inspection, to observe all condidescribed, d t tions as escre , ano t Exclusion � P El Re-inspect of n Scheduled ❑ Emergency Suspension ' comply with all mandates of the Mass/Federal FonRd C I understand that f noncompliance may result in daily fines of twentytfiv of rs ors spens en/rerp �jof ❑ Embargo ❑ Emergency Closure your food permit. Q ��\� � • ❑ Voluntary Disposal : ❑ Other: -�- '� 1j 3-�0;.i !;C; PHFs 1(.�cea•e:i at-:riuperutr:a ! Violations Related to Foodborne tltness Interventions and Rist: Acc;vdi no to i aw Cnoled to Factors(items 1-22) (Cont.) '4;'F1-45'F\b,;hindflows. I PROTECTION FROM C14EMICALS 3-5(ii.!5 Ccolirw Nlydxxi, tot PHFs i4 Food or Calor Additives 119 ( PHF Nat and C,a!d Hatd,ng 1, , . .., - I 3-501 16(B) ('old PIIFs.Mmnt:nted ul er beiges 3-202.12 I Additive', 590.')u:!(F) ',1145'F' 3-301;4 Protection from (Inappruved AddIIt ves� -501 16(A) Hid Pl{E�rLlaiutaiued rat or abnva Poisonous or Toles Substances 4 � - 7-I0L11 ldentilvnn,Intonn.d:on-Original ( 140'F. * -"] 16A) Roasts field at or nbuve 130°F. " Contpntel'S' i v-102.1 i Common Name-Working Containers' ( 20 Time ass Public Health Contras l 1 3-501 i9 I 'Flue a:, a Pnb(ic I lealtlt Control*7-20LI; Separation-Shoage' , J 1 590.OU4iH} �iariancc Rrquirenleni : 7-Zti2 i 1 Rcariction--Yrrseuce and User i ! 7-2(}1.;2 Condrti<maofUse" ! 7-103 11 `toxic Container.-Mohibitionsr_ REOUIFEMENTS FOR HIGHLY SUSCEPTIBLE 17-204.11 J.n»tizers.Cisterna -Chemicals-' POPULATIONS(HSP) 1 ( 121 3-801.111W j lisp❑steunzed Fe incl:z;ed juices and 7-.04 1_r � Chenncals for't�raahm;:Produce Gitcria" i ! 7-204.14 Drying Agents.CriteriaT Bowe;axes w^dt W'arm]IL I,hels� - - 7-205.11 Incidental Food Contact,Lubricants` 3-801,111BI I Ise of Pa.tcmized Eg", 7-206.11 ResirtctedI-sePesticides,Criteria* 3-80Ll1;D) Raw orPattiallyCooked,angfedFood and R.or:Seed S;uouts Not Scr,,ed. i-ZOfi.12 Rtxicnt Han Stannns°' 3.80i.1ItQ, Urnrpened , d PackaEe Not 12e-seracd 206.13 Tracking Powders,Pest Centrol and Mruihnir'n 1 CONSUMER ADVISORY 71V9Eti EMpERATURE CONTROLS 22 3-603.11 Consumer Adsisory Posted lin Con=umpticn of Anima! Emus'Phai;re Raw.Undercooked on th Proper Cooking Temperatures for ;Not Otfierwisc Processed to Elinunate PHFe Pa[ho , 'Ce,se,.1.;.11.11 ;; '+-401A1,A(I)(2) FBfrs 1.5i`F15SvL, ens.* ` Eggr-In:medrzte Servile 145`Fl5secr i 309.13 Pasieurn'+ed Eggs Substitute fix Row Shell 3-401 11(A)(2) Comminuted Irish, Meas&Game Animals- 155°F I;sec. 3-001.1 l(S)(1)(2) Pork and heelRoast- 130"F1^-1ndn* SPECIALPEOUIPEMENTS 3-4.O.I I(A)Q) Ratites, Injab:divicau-155'FIS -590009(A)-IDI Violations of Section 590.009(A)-(D) in s,,c w catering, mo-Nle fired. temporaryand 3 •401.1l(A)(3) Ponhry, Wild Game, Stetted PHFs, rctidenlial kitchen operahom should be Stuffing Containine Fish; Moat, debited ender the anmmprinlc sectians P:+uhry ur Rulite:; 165';15 ser. - above il';elated it+Ioodharne il!ucr; 3-401.1 !((`)(3; Whole-oow;cle,Intact Beef Steaks into ventiom and risk factors. Other 145°F* 51610.009 violations relating to good retail 3-4ul.12 Raw Animal Feod� Cooked in a pracnccs should be debited under ,929-- Microwave 105`9• r Spe:inl Kegt;irenien:.. j 3-411 i.I i(,i)(I)t b) All Cfther PHF•ss- 145°F 15 sec. 17 Reheating for Pat Holding VIOLATIONS R�:LATEO TO GOOD RETAIL PRACTICES 3-W3.l!(A)&(D) PF1Fs 165`F 15 sec. .:! (Ite11t.5 23-30) 3 1113.1:(B) Microwave lbs° F 2 M nto,Standing Criki a7 unrl nrrrrritiea'ciuArt;or+e', +rnrch do not retiree to tirr 1'i ntc"' foodborne:(hte::.e iuu rven,i++ns urr:f r o.eb r°rr:tr:;'s 1is11 A above. an be 3-.463.11(C) Commercially Processed RTE Food- I ,found in the JLIlundug +,-bins++f die Food C'udr rnd 105 CAIR 140"F 500000. _ 3-403.11(E) Rcntcining L`nsliccd Portions irf Becf I Item GOod P.ataif Practices __ FC 1590.000 Roasts'. 1 23 Manaeement and Persorne! FC -2 ! 003 fit Proper Cooling of PHFs I 1 24. Foodand Food ProtFction FC-3 004 25 Eeuipn gent and Utensils FC--4 !', .005 3-561 14(A) Cooling Cooked P17Fsfrom ':-10'Fto ( _26._--.-- `Nader,PlumFdngand Wac.te FC-5 .COS 7WF Witnin 2 Hours and From 70'F j 27 ?hvslca'Facility FC--6 007 to 41';/4-5`F Within 4 Hours. '" j ! 28. Pol,onous or Toxic Materials FC-7 ,008 3-501 l41 B; Cooling PFIFs Made From Ambient 129. ,Special RAquiremarts j 1309 I Tempctature Ingredients to 4I°F!-li`F 30. 41her 'Within a Hours" •i)cm.dev cruel 0010 m 1111(rdr+al 1904 Cody,-r W5 CMI:990 o0o. IMPORTANT MESSAGE ) FOR �C�e-' v M DATE TIME P. OF PHONE U BER fE ION ❑ FAX ��I��IJJJJJJ O MOBP F AREA CODE / NUMBER TIME TO CALM TELEPHONED Vl PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE VOU , RUSH RETURNEDY ll ' rll-�FAX TO YOU ME AG ,K-t 1004 I�l � lI� CA Q _ i ��nI � RQ SIGNED �p IT Wr0psFORM 4009 \ ' MADE INUSA v \ NOTES Massachilsetts Department of Pu0jlc Health Salem Board of Health 120 Washington Street,0 Floor Division of Food-and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Namej� Date Tvpe of Operation(pl Type of Insoection in t,+.Z; OG Foocl Service ®Routine Address �� 1 `� n Risk pRetail ❑ Re-inspection Level Tele hone rfO` i l in/ C� - ❑ Residential Kitchen Previous Inspection p r p ❑ Mobile Date: (/L.(uG Owner Kt J�7 f� , HACCP YIN [-ITemporary E] Pre-operation 71 t 1Yl-r . G r C I ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) (�1/ � Time ❑ Bed&Breakfast ❑General El HACCP Complaint Inspector �(�IA^ K r)6 A I put .�p0 Permit No. ❑Other Each violation checc ed regLires 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. _,... .. . . ,a = FOOD PROTECTION MANAGEMENT�', � ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties „ )„ y El13. 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 " b ,.; - " TIME(TEMPERATURE CONTROLS(Potentlalty Hazardous Foods) El 4. Food and Water from Approved Source , ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements [117. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling ; PROTECTION FROM CONTAMINATION El 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control s ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing El11. Good Hygienic Practices CONSUMER ADVISORY -El -, 22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C N by a Board of Health member or its agent constitutes an _ 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 u 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: /(n'I y(y Y y 5 SBOlnspeclFom�IC Da / ' V V�� Inspector's Signature: l �ry/' 0 Print: ��13P1�i1 PIC's Signature: -^� '" Print: Pae of_ Pa es '�i�a� g L g I 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* 3-302.1 t(A)(1) Raw Anim:d Foots Separated from 590.003(B) I Demonstration of Knowledge" Cooked and RTE Foxis* l 2-103.11 Person in charge-duties Contamination from Raw Ingredients 3 302 11(A)(2) Raw Aluinal Foods Separated from Each EMPLOYEE HEALTH I I Other* 2 590.003(C) Responsibility of the person in change to Contamination from the Environment require repotting,by foal employees and 3-302.1[(A) Food Protection* f applicants" 3-302.15 Washing Fruits and Vegetables 590,003(F) Responsibility Of A Fool Employee Or An 13-3n4.11 Food Contact with Equipment and Applicant To Repots To The Person In Utensils* Charge" ( Contamination from the Consumer 590.003(6) Reporting by Person in Charge* 3-306,1 i(A)(B) Returned Foul and Reservice of Food* 3 590.003(D) Exclusions and Restridmns* ( I Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restuctions Food 3-701.11 Discarding or Reconditioning unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Nater From Regulated Sources y Food Contact Surfaces 590.0(9(A-B) Compliance with Food Law* 4-501.1 11 Manual Warewashima-Hot Water 3-201.12 Food in a Hermetically Sealed Container* ( Sanitization Temperatures" 3-201.13 Fluid Milk and Milk Products* ( 4-501.1 t2 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures" 3-202.14 Eggs and Milk Products.Pasteurized° 14-501.114 ( Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water" concentration and hardness. * 5-001.11 Drinking Water from an Approved System- 14-601.1 1(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean- 590.006(B) lean-590 006(B) Water Meets Standards in 3 00 CMR 22.0* ( 4-602.1 1 Cleaning Frequency of Equipment Food- Contact Surfaces and Utensils* Sand Fish From an Approved Source 3-702 1 Frequency of Sanitization of Utensils,and 3-201.74 Fishish and Recreationally Caught Molluscan ( Fcu)d Contact Surfaces of Equipment* Shellfish* 703.11 Methods of Sanitization-Hot Water and 3-201.15 I Molluscan Shellfish from NSSP Listed ( V I Chemical" Sources* Game and Wild Mushrooms Approved by 14 proper,Adequate Handwashing I Regulatory Authority 12-301.11 Clean Condition-Hands and Anus* 3-202.18 Shellstock Identification Present* j 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Came Animals" 11 Good Hygienic Practices 5 Receiving/Condition I ( 2-401.11 Eating,Dunking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 12-401.12 Discharges From the Eyes,Nose and 3-202.15 Package Integrity` 1 Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting4' 6 Togs/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification` ' 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification MaintainedA Emplovees* 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(7) Labeling of Ingredients" 5-204.11 I-vocation and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP PiansSupces plied with Soap and Hand Drying Devi 3-502.11 Specialized Processing Methods* � 3-502.12 Reduced oxygen packaging,criteria* 1 6-301.11 Handwashing Cleanser, Availability 8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drying Provision 'Denotes critical item in the federal 1999 Forxi Cote on 105 CMR 590.000. k CITY OF SALEM BOARD OF HEALTH �7 Establishment Name: ✓)f�/n ��M / �t (r��linG/�rin Date: 7�0 //c3C Page: of r�_ " Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION v Date t No. Reference R—Red Item Verified PLEASE PRINT CLEARLY e-6.)x.4 nIrJer-4CAA�. a &rl/Y,.),.��, ,S, r, I C P�f_ A (A0 -1,2 � �-� 1,�<l 0 �- I ri✓. �a Ic7 �� .�. �t,r11�I✓M .S ,0 11�� n 1 /0-O ` CoJ.n yp< n/h� s�ielv,,.! n�s'nc f I r%P ' 4-0 15_ L _3An t-/;x/l Q Vc. - 1 L,LK .I e .5U1 L in ,.,,y4 ,UltsS,r �� I l�► P '�-,n .h�v��.� ��/,� f I 0 ii L ,� ��-i_;�1, it I �," ��` Hil.),rc^12u�✓i h %/)/bc C�Aw/I• S,nf� n.'7n�T �r�s��-,�-' + ko- tace WRte/ S nad Ce ' �/6i_-t7L-e y �'lr'.,M /TI"A�7,wt n c.rl �, �L✓L c-�J T i-- �-p S� c-`lYl c AL ALIIjJnVv�l::' ? f J11 C,YIN S 'U'V/ ( RC1 I ' D Discussion With Person in Charge: Corrective Action Required: I ❑ No IXYes 1,have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance L3 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 Fo9dCode. I understand that noncompliance may result in daily fines of twe Ive dollars o uspension/revocation of ❑ Embargo t, ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: i F -._spj.l {,;;, PHFs Reee.rest a:lemry_ratures Violations Related to Foodborne illness interventions and Risk :1c,;ordir,y to S.atro'Coated to Factors(items 1-22} (Cont) I -11°F,45`F Within d 4cuts ' PROTECTION FROM CHEMICALS � 3-501.15 C:,oling Me hor;,z for PHFe 14 Food or Calor Additives j :9 PHF Hot and Cold Holding 3-202.12 Additive< 2-501.1:iB) Cold PI(Fs tlaintaimd m or helot+ �90.004t,F) 41114f F,: 3-302.24 Protection from Unaopruted Additives^ ' 2-5t)1.16(A; Clot 4i ;rtan;e:i atnrahrne j 1.5 Poisonous or Toxic Substances ( 140`r-'Y * 7-101.11 klentityinglntouna:ion-Ori1iaal ( :'4-501:6(A) kuasisHaldat.;r;,bove Containen,' c-' 130"F ' 20 Time as a Public Health Control 7-10211 CummouName-14orkml,CantaineW ! -, 't j01.'9 1 Tune as a^:;bite Health Control' j 7-201.11 Separation-Stortee'' 7-2()7.11 Restriction-Presence and Use iiO.r,p4l H'. ( Vanonee Requircuicrn 7-202.12 Conditions of I(;e' REOI;':REMENTS FOP. HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Proluh,tions" 7-204.11 Smti67M,Criteria-Y'hemirds^ j POPULATIONS lLapa reurrP} 7-204.1'_ Owmicali r,x Washing Produce,Criteria" I 1 ^I a-801.11(?.) Lnpas�rettnzed Propnakaged luit es and ( Rever.;pes mirk Warnin;;1 ab�ls^7-204.14 _ Dr':iu€:�`<Yent:,Criteria" i -F,01.11/131 lis;of Pecteu;iz�d Eves" 7-205.11 Incidental Food Contact. Lahrieants* .j - - 1 3-EDI II(D) Rae or Pat(ia11v:.'c ol;ed Animal Fcxr.l and i 7-'_06.11 Restricted Use Pesticides, Cllwna'° I ' ! 7-206.12 Rodent Bait Suuiortn` ( Raw Scrd Sprouts \nt 4c\ed. 'x j i x,01.1 l(C} t!: tend Food Packace,Not Rc-serwd, 7-'_06.13 Tractt m,Powders.Pest Control and ' Vlonitotinn^ CONSUMER ADVISORY T11MEJTEMPERATURECONTROLS 22 3-60 I Ccrtt.r stet Adtisury Posted for Consumptionof 'xmitoal Foo&Thai it-,, I'Wv.undercooked ca 1( I I Proper Cooking Temperatures for l-t,cetsed to EliminatePHFs Not Other",is,p 3401 I]A((i(2) Eggs- 155'F I S Sec. E,,> s-he nediate Service 145"I.13sec, 3-302.13 Pastenri?ed E_gs Sub.,itute for Rcw Shell Comrimunt l Fisli, Mcats(Y G:unc ]-pgs Animals- 155-F 15 sec. :` j 3-401.1 i(B1(1}(2) Pork and Heel'Rotst- 1301 F I?I nun" SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites, Inieeted Meats--155°F 15 590.pn;(A)-(0) Viu;stions of Section 590.009(A)-(D)is se(,. ` ' cater g. moin le food, temporary and -401 11(A)(3) Poultry, 4`•-'ild Game,Stuffed PHI-4. residential kitchen operations should be Sttnf'ing Cotw aing Fish,Meal, dzhited unc?x the appropriate sections Poultry of Rcaice::165-F 15 sec. ,_ above '1 stated to t:>{r3borrte illness 3-401.11(C)(3) Wnole-nnucle,Intact Deci Steaks Interventions and risk factors. Other 145-F .; - 590.009 violations i alatine to good retai l j 3-401.12 Rats'Animal Fowls Cooked in a pracuccs should be debited under di29 -- Miciowave. 165 F Special Reyairenlews 3-101.11(A)(I)!b) Ail Other PHFs - 14:5"F IS see. 17 j Reheating for Hot Holding VIOLATIONS Rc"L.ATED TO GOOD RETAIL PRACTICES 3.403.1 1(.-`.)341.)1 j PHFs 1650F 15 sec " (Items 23-30) 3-103.11(6) I btictownve- 165°F 2 Ml iiwle Standine C,itirtd and trig critical violauonv, which do not relate to the Tine' fordhome I!srss mrerdertioat and ri.ek fin turn limed above. (Litz be 3-403.11(C) Commercially Pioeessed RTE Food - imazd in the f,lhoi i,,,,se,,,ii;ns o/'the Food Cade and 105 C.AIR 140-F- 1-403.1 40-F"1-403.!1(1;) Rema ming Unsbced Portion;of Bcef Item Good Rrfail Practices FC ' 590.000 j Rnadsz: 23. tdarage:tent and Personnel FC -2 _ 003__ j 18 Proper Cooling of PHFs 24. Foca and%xi^rotectrai FC 3 .604 25. Egwpmeni and'Jte.^.ai!s FG-4 _005 3-501 14(:�) Cooling Cooked PHF, rrom 140"F to j 26, W akff -"lumbinu and W ante FC-5 .006 70'F Within 2 Hours and From 70'F 27 Physical Faeiliiy r:;--6 .007 to:1'[;/-,15'F Within 4 Hours. ' i 29. ^osonous or Toxic kla:enai; --0--7 1.:00 1 j 3-501.ia(B) Cochin,PHFs Made Prom Ambient 29 Soecia!Requirerents .00- Temperature Ingredients tu.11"F/45'F 30. Giber kk nhin 4 l-htar,` . ^•r, e.,r z;,: Dcuonrr critical iien,in.hr 4-doral live Pond ode or 105(':NI i'!0 0pp. 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 Datb Tyoe of Ooeration(s), Tvpe of Inspection 02/ EP Food Service ❑ Routine Address JPS✓ Risk ❑ Retail aRe-inspection Telephone �•/ � - Level ❑ Residential Kitchen Previous Inspection 4/1 f _ CiPRf�n ❑ Mobile Date: J/al/(x Owner HACCP Y/N ❑ Temporary ❑ Pre-operation t.r S I ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) ` Time ❑ Bed& Breakfast ❑ General Complaint ^1'// /////�� In: �j i O ❑ HACCP Inspector nc�(J KO/ Out;;)Ati Permit No. El Other Each violation checked requires an explanation on the narrative pages) 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 ElEMPLOYEE HEALTH 13. Handwash Facilities PROTECTION FROM CHEMICALS `'•� ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded El 15.Toxic Chemicals FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating El7. Conformance with Approved Procedures/HACCP Plans El 18. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding •I ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY , ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices �h 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 Boardt and Risk Factors (Items 1-22): of Health. Non-critical (N) violations must be corrected - immediately or within 90 days as determined by the Board Official Order for Correction: Based on an inspection of Health. today, the items checked indicate violations of 105 CMR C N 590.000/ deral 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 2�}"Food and Food Protection order of the Board of Health. Failure to correct violations (FC-3)(590.004) N ) 5. Equipment and Utensils (Fc-a)(sso.00s) citedyi 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 r (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 7 S 5ZIaFom 14 d. Imo,//� ( J G��, MM Inspector's Signature: A Print: I�•��Q„�� PIC's Signature: C1, A � IZ( C(J - Print: �� \�/�C�Ufa-� Page_�of_aages Violations Related to Foodborne illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CUNTAWNATION FOOD PROTECTION MANAGEMENT 18 I Cross-cordancnaticr, 1 � 500.0'✓NA) Asstgnnten*ni Respnumbfl4v' I ' 3-3011:(1)(1[ Raw Animal Foods Separated hum j 540.003(13) DunonsIre!ton of Knowledge;, I Cooled z:xl RTL, FO, -v° ! 2-h)1.11 Pensunincharge-duties CaMsminaticnfromRaty'rgredients j 3-302,i !(,%)t Z) Raw Animal Fcsods Separated from Each EMPLOYEE HEALTH Uel' 2 590k03(C) Resp0mobility of tl:c person to chat;x to j I Gcntaminairon-ren,the Ermnonment require a;purtntg he food employees and ( 1 54302.11(A) Faa1 rrotectiolO applicants" 13-302 15 3t,'asr;::g Fn::ts.and`:e" .c" "ec 590.003(F) Responsibility'Of A Food Employer 01 An >-34.11 Food Coatarm l with Ea;upment oi A:plicant To ReptaS To Tli=Per::on In Pten sds* C'h;u,"e, j C.vaarn!nation from the Consume, 590.003(0) Kepurtins by Person in Charge* j 3306.1-(..)(R) Rctnrned p,,od and Rc.servtcc of Food` 31 590003(D) Exclusions ata Restrictions' DisposNan of Adulterated or Crrraminated :[90.003(13) i Removal of Exclusions and Restriction. I Food 3-701.11 Discardm, ):RecoEdltiomng Pnsa`C FOOD F MM APPROVED SOURCE Food* 4 ! Food and Water From Regulated Sources j ?' Food Contact Surfaces 59U.004(A-Bi Compliance with Food La" I 4-K1. i; 1,ianual `, vv asnha:-Hut W'aicr * Sseit zation Teniperafti 3-..01.1'? Food in a}iet'tnc•u:•ally Scaled ContainerI I 2 NfcZael Warewashim, fm Water 3-20LFluid RfilkundMilk Prouacts* 3-202.13 Shell Lpgo` j ! Sanid7annn Temperatores* 3-202.14 Eggs and Milk Fraduu -} s,Pasteurized -501,7 E- t`h„micrd Sanuization-temp.,l;H, corcenhatinn and baldness. 3202.16 lee Made From Potable nriokind Water^ ` I 1 1 itA) Egn;n:n,nit F,`,od Contact Sm faces and 5-101.11 Driuking Water f omu an Approved System" - . 590.006t A) Bottled Drinking Water' I iheusi'.sCle:m:r � ^0 n j -tfi{)'.1 1 Cleaning Frequency of Equiptnrui Food- ! 590.006,B) 'A'ater',Meets Standards in 310 EMIR 12 Contact Surfaces,aid Jtensii," I Shellfish;and;iso From an Approved Sootce i 1-702.1 Freque!:cy of Sanitizsaon of Utensils.aid ?'201.14 Fish arc!R-ecreatiunall;,Caught blolluscar, l Food Conhu.0 Sarfara of Egnig;nent' Shellfish" J = [:311 Men Frnk,oF Sannvafiun- ]-for li ater and ' _5-201.15 Molluscan Shellfish from NSSP Limed i Che.n�cal" j S',utces* - i j 10 Proper,Adequate Handwashing j ! Game and VV#d Mushrooms Apptoveo by -I Ren✓hafory Authority ! 2-30s,(1 Clean Condition-Hands and An ars" 3-202.18 Shellstocli Idennf cation, Present* I 2-'OL:2 Cleaning Pr„rxdvrc" j 590.G(bl(C) Wild Mushrooms`" 12 361.i4 When to Wash- -1-201.17 Game Animals'" I 111 I Gcad Hygienic Practices j 5 I Receiving/Condition I 12-401.i I Eating, Drnd.ing or Using Tobac-o" j 3-202.1 i PHFs Received at Profit..i emncramres` j ! ?"40!.12 Discharges From the Eyes, Nose and I jvs,�ilYr•,a 3-2((J2.15 Package htteerav' 13:ti)1.12 Frevennn Gmtarrination 6b'E.ien'Casting'' °-101.11 Ftxrd Safe and Lhnrdulterated's I g I {; � Tags/Records:SneEistoek 112 Prevention of Contamination from Hands i 1-2[[1.18 Slielisn,ck Idendficxhun* i 590.0094 E) Fie,.-enOug Coutmninaircrs from 3-2(13.12 Sheilstock Identification Plaintained.` Emparyccs" Tags/Records:Fish products j I l:S }landwash Facilities , 1 ` Ccnvsn,enYy Located anrr Arc^ssib'c 3-401..t I Parasne Dcstructiun' ' - 3-d0_ 2 Record, Cteation and Ret-onit.n i i ' -ii 3.t i Nmnbas and Cnpac;na,. Labeling of Ingredients' 15-20'.I I Location and Naccme rs' 590.00-10) 9 ( I ? Come,mance with Approved Procedures I 5-205.11 ? cesr.a wilily.Operation and Maintenance lHACCP Plans i Suppled with S;.,ap and Hand i-hying f ev:ces 3-502.11 4pecialized Processing Mcflnxl,* „ ?-402.12 Reduced oxygen packaging:criteria" j I 6-301.11 I-lundwshiug Cic.anscr. 4vaiiab,luY .- 8-l0clA2 Confommnce piIll Approved Procedures' j ! 6-310 12 Hand t:)rymg Pro"is,-ri j '*r,1n.GP.niaea,arm in ite,`ede,al i999:',,od Cockm IOWNIR CITY OF SALEM 1A11'F HEALTH / Establishment Name: a�1/Ce _/r� L✓ Date: /'tea Page: :::P— of _2 Item Code C-Critical Item DESCRIPTI N OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item _ Verified PLEASE PRINT CLEARLY 1.✓1�O i �r{/p�� f��/P est //14na, �) l �i/I..Nr✓� 5lO/l�j //J'i k",o Cts/a,,` //AY, 1, ._.-� * f/ ! fllt�P , fli/,I ,:lA/'�n � � Com, I - '1.4 ;E V4/I�� y.v �4_,sp>, fr J _L_c jj C r - yI J I I I I 1 Discussion With Person in Charge: Corrective Action Required: ❑ No � y 6 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 condltlorr as described, and r Exclusion P I ibdd to � Re-inspection Scheduled ❑ Emergency Suspension �I tprcomply with all mandates of the Mass/Federal Food Code. 1/6nderstand that noncompliance may result in daily fines of twenty-fiveldolla'rs or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. WnvYc' ❑ Voluntary Disposal ❑ Other: �_ t — i r i.501 1 7tC: PHF::P.eo-I,ed at Temperatures Violations Related to Foodborne illness Interventions and Risk Accurdin2 to Iaw Cooled to Factors(ttems 1-22) (Cont.) i "11'17145`Fl+ ;' hin,ffloms : PROTECTION FROM CHEMICALS I 3-50!.l5 i Cooling medimis for l:HFs 19 ' PHF Hot and Cold Holding lA Food or Color Additives 3-501 I6tB; Cold PflFs Maipta;ced at or below I - 02.12 Addiii,es'" 3-3o2 14 Psutecimn from Unauproted Additives" r.5g1.16(A) Hoi PHFS Maintained at or above is 1 Poisonous or Toxic Substances 7-101.1! fdentif}ine Information-Original Gnuainers^ ( 3-50:,i 6(A) Roasts Held at or above 13VE 7-102.11 ! Common Name-Working Containet," ! ! 20 Time as a Pufilic Health Control 201.11 Separation-SiomizOt 3-50I I Tine as a Public,Health Control* 7-20111 Restriction -f>re,enee and I!s: 590.604(H) Vauancc R.u,uirorncnt 71-202.12 Conditions of Ilse" 7-_03"I 1 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 sanitizcrs.Critern,-Chemicals- POPUL AT!ONS(HSP) 7-2U.7.12 Chemicals for W'ashuu Pr:done,Cnterhx 21 3-801,11(A) impavteurized Pic-packaged knees and 1 7-204.14 Drying Agents.Cnierta' Bet eiages with tVarnint?IAlt s -801 Ii(Bl tkeofPasteuiizedLe•2s:_ l 7-205.11 incidental Food Contact. Lubnamis'" ( 3-801 I1tL`•) Ray.-orPathaI , Cooked Aninuil Food and i 7-206.11 Reelected lac Pesticides.Cnteru:* Raw Seed Surouts Not 7-206.12 Rodent Bail Siations' = Siil.lt(C. L'"aP r. ''ac}a)� otRe-served. 7?06 13 'Franking Fowde•rs.Pest Control and � 7 ened I'a,d t� •: �•N x Monitorinl,x CONSUMER ADVISORY TIMElTEMPER'ITURE CONTROLS 22 3-003.i I Consumer Ado:tsory Posted for Consumption of .Anitval Foods Thai arc Rawl Undercooked cu" 16 Proper Cooking Temperatures for ( PHFn Not Otherwise Prexetscd to Eliminate t>, P+n.o,r n:goat 3-101.i i A(1)(2) Eggs- 155'F 1.5 Sec. - Eges- lnmmdiate Service 145°F75sec' 3 '02.13 Pasreurped Eggs Substitute foi-Rain Shell 3-401.1 I lA)(2) Commmurzd Fish, Meal:;&Game 1:"sW .Aninmle- 155'F 15-c. '^ 3-401.11(8;l I I SPECIAL REQUIREMENTS 1{_) Pork and Beef Roast t3U'F 1.1 min -401.1 I(A)i2) Ranres,Injected bleats- i55'F 15 I 590.009lA)-(D) Vioaations of Section 590.0150(A)-(D) in see. I caieri:lg• Montle food, temporary and 3-fol.11(A)(3) Poultry,Wild Game,Stuffed PI-}7e, ! residential kitchen operations d:ould be Sluffing Contaiuiuc Fish,Meat, debited under the appropriate sections Poultry or Ratites-165`P t-S sec. ' above it reJzI, i': to Grodhorne illness 3-401.11(C)(?) Whole-muscle,huact Beef Steaks interventions and rise, factors. Other 145°F T 590.009 vioiations teiaeing to good retail 3-401.12 Raw Aminal Foods Cooked in a pr icta es shoulol he debited coder N29 - Microwace !(,5`FSpecial Requi etnents. 3-401.11(A)(10) All Other PHFS- 1.75°F 15 sec. * j I7 ( Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)K(D) PHF, 16,5'F15sec. '" (Items23-30) 3-403.11(P) Microwave- 1fi5'1;2 Mntuie Standine Ci iltca!amd non,rite al violations, who rh oto ern; relate to tine "fittre"' fe+udtmrre iUn<°c.+'inu•nornNnn., and rick f wtcmc (torr.'•vbo�-e, can be 3-403.11(C) Comincrciallq Ptc i:essed RTE.Food fo...id to for jollo rhes sections .f tire Fw:67 Cotie and 105 CAIR i 14,1°F- 90.000_, 3-403.11(E) Remaining Unshce:', Portions of Reef Item Go-od Retail Practices FC 590.000 Roast,'" 23. Manaaament and Personnel FC -2 003 13 Proper Cooling of PHFS I ?4. Food and Food Proteaticii FC-3 004 3-501.14(,) Cooline Cooked PIFs from 140"F to 1 2.5. Eau:omen:and'JtersB, FC _4_11_005 5 006 - 1 26. Water, Plumbing and Neste FC- 1 -110-F Within 2 Flours and From 70-F ?'. PhVsical Faci ily FC--6 l .00. to 41`17/49`F Within 4 Hotus. " 28. Poisonous or Toxic rdate nala FC-7 '�� .008 _ 3-501.1.4;13) Coolin,*PHIS Made From Ambient ( 29. Sueciat Rcauirements 009 j Temperature Ingredients to 41"Fj45-F 30 Other i Within 4 Uoutc.` :'mm•. i ' Ueu-.Hes cnacal item r.:the fedeial 19',19 Font Code or 105 CN1R 591600, ,. .. ll - ..i hi. Massachusetts Depa'rtmemt of Public Health Salem Board of Health 120 Washington Street,41h 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 Ooeration(s), Tyoe of Insoection � �f I _ s l /1 ff D5i� l i Food Service � �] Routine Address ( In f � / Risk l ❑ Retail ORe_inspection Telephone �� Level E]❑ � Residential Kitchen Previous nspection Mobile Date Owner � _` r` - ""'J -� HACCP YIN ❑ Temporary ❑ Pre-operation ❑ Caterer ❑ Suspect Illness , iBed& Breakfast ❑ General Com Person in ChArge`(PIC) �� 1 I Time ❑ plaint E] HACCP Inspector /1 n I In:1®' I Permit No. ElO herr IrXa1/r'2a � I Ou �ID-?r Each violation checkedyrequires an explanation on the narrative page(s)and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ EMPLOYEE HEALTH 13. Handwash Facilities PROTECTION FROM CHEMICALS El2. Reporting of Diseases by Food Employee and PIC [:114.Approved Food or Color Additives El 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) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans [118. Cooling / PROTECTION FROM CONTAMINATION _ ❑ 19. Hot an&Cold Holding ❑ 8. Separation/Segregation/Protection' ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing 't REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) El 10. Proper Adequate Handwashing \❑O21Foodand'ER ADVISORY E1\22. Preparation for HSP C ❑ 11. Good Hygienic Practices E1\22. , �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�Nbn-critical (N)violations must be corrected 0 immediately or within 90 days as determined by the Boards f"-' �, Official Order for Correction: Based on an inspection of Health. today, the items checked indicate violations of 105 CMR C 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 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 �. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you T 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 5Mnsp fForm 14d c Inspector's Signature: ��/-� Print: PIC's Signature: A/X ,fie-^ V� Print: I r)r-\;, I Pagel of I Pages Violations Related to Foodborne Illness interventions and risk Factors(items 1-22) FRO'TFC:Fjt)N FROM CONTAMINATION* FOOD PROTECTION MANAGF-MENT ( 8 Cess-:ont;,;:inaton t 1590.0030) As,apme,t id ResPonsibi114 1 301 1 l(Al(1) Raw Amwal Foods Se_iarutzd`:rom 590.003(13) DCnu)tiSt,-Ii,P11 of Knowledge" I Cooked:nd R E F.r.xls''' 2-10?.i I Person:n charge- duties C nmamina6cn from Raw Ingredienis 3-3D= I I(A1,,2) R V, ':noted F xids Separated frum Each EMPLOYEE HEALTH Other' 2 590.60310) Re,,Pnns,uility of the persrn in charge to Con'amin»rion Lrom the Fnwrrninent requite reporting bt food es:;Idovacs.nod 3-302.11 A) loud Pror,Ction- applicants' 3-302.i s 01a,!:i g butts and Neg_tables 590 003(F) Responsinilit) OCA F(x•d Employee Or An i 3 iiia.i ! food Contact with Equipment and Applicant Po Report o The Pel stn?Ir II:c;tsds` Charge Cc marmnatio,t tram the Consumer 3 + 590 003(G) Repor,use by Person in C'hatge' ( 3-306 I f,'AKE) Returned_c:,d and P.escrvice of•roxi'' 590.003(D) Exclusions and Restrictions'° i :0Njor s3ion of Adulteraled or Contaminated 59Q(xii(E) Re hovel of Exclusions and ReslrscG,_ns Food 3 11:1 II o, Reconditioning Unsafe FOOD FROM APPROVED SOURCE 1'ovA' 4 ! Food and Water From Regulated S ouices I r) Food Contact Surfaces { 59U.t104(A-B) Compliance with Food Ltu't - -- 4-301.11 MvaualWwtwat,F::ne,-hut'Aatei 0 .`:snit:zsrtion Temperatures, 3-201.1_ Focal :nil Hertttk4ilkly Scilca Contut,er" i 501112 Mechanical Vkaiewashing- !-tot Water :i-201.13 Fluid Milk and boll:Products,* a-50 Sanitiza!ionTcm�>ertu,cs' 3-?02.1:, Shell Egg;* 4-50i.i;.; Ch<nical 'amtir,vo:-temo.. ,H, � !-M0 14 Eggs and Mi!1:Produces.Pasteurized" 1 cvncentrat!r.n and h.rdr,:ss " 5-202 lfi ke blade 'rrurn Potable Dsi.^.king Water" i I4-bG1,1il A; Egnilxnent �nrd<'vn;act Sln-Faus and 5-!01,11 Drinkiuf Water Gum an Approved 8ystem�� 1590.006(A) Butticd Drinking Water* litznspi CFean` l 4-602.11 Cieamng Frrqurncv of Equipment Food- 1 590.0(16!111 Water Meet:.Stmxlards m 3!0-r.-FMR 22.0" Contact Surfae_s and Utensils^ Shellfish and Fish From an Approved Sourre 4-702.11 Frequen-y of Sanitiz,tion of UteTsils and 3-2ul.14 Fish and Recreationally Caught A4011LISCtnr i Food Cnntar Sud;rrcs of Equ.pment'° Shc'ific I I-103.1 t Ml ihnd:,:»Santtizullur:-Hut Water and 3-201.15 Molluscan Shel!fi::h innn NSSP F,ided C'heuncal'' Sourco:;"' ! 10Proper.Adae'sate Handwashing i Game and MId Mushrooms Aop:oved by RegNatco Authrrity 2_30H.l l Crean CondiYon-Ft:mdc and P.rm:."' 1:)2.13 5110114ock Identrfication Pres,nit, ( 2_301.:2 Craning Pnca urc" 590 004(0} Wild Mashrooms_" 2-301 14 When t•.Wash' j 3-20:.17 i ( 3-e ( Good Hygienic Practices { I ' Game Animals* F RpceivingtCondEtion 2-401.11 I-atinF, Drinking or L'eing Tchacro* -1-20'_'.1 I MR;Received at Proper Temperatures* 2-101.12 Discharges From ti, Eyes. Nnse and ✓loot 3-202.15 Package httegrih" I 3-301 12 Prevcntm,C_'oTuarainaijon wheu'rie t:ag' 3-10:.!] Food Safe and Unadul'etateu 16 Tags/Records:Shollstock I Prevention of Coaiamioatier,from Hands 3 2,)'.18 Shellshsk ldeaufic:ronn' ( 590.U(l=:f^t P:e;enting C,mtwnination from Sheistoc. Maintained` i ntpio}cec" TayslReccrds:Fish Producte Handwash F acilities Cbhvon+'enty Located sono Accessible 3--902!1 Parasice De,tn)ction' I nf:3.11 Ntunbrrs and Capactu.•a" j 3.40'_.12 Records,Creation and Retentwn' - i ._z,i4.11 i.:KatH`n and PlaCenitni� 5)90.O040) Labeling of Ingredients' •t I Mmance with Approved Procedures 5-205 11 ACCAcc.'cs!brit} C;;elation and ihtiutenancc iHACCP Plans l SuppNed ivi:r,Scop a.nd:-land Dry,rnn Devicos "s.502.11 Specialized Processing NleHtnds' 3-502.12 Reduced urygen rackagiag.criteria' 6-301.1 i Nandtra;.hiug CFeaaser,Av,:i ,hdity li-103.t2 l (':rnfctanauce with Apptuved PrvcMuro;.,' j 6-101.12 Fiend Drying Ptovis:un *D,notcc�,idea!a n,in the teder:d 1901)F,,,xl C,wIe.a h:5"_'MR 500 000. CITY OF SALEM B�bAR/D OF HEALTH Establishment Name: I_/, //)C .� lh✓1 %> WSJ �� //�, Si�.Sr Date: r7l.YFC Page: of , Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION I Date r No. Reference R–Red Item Verified 3 i PLEASE PRINT/CLEARLY u n n'c / j'. Ate. / //I,c' /r I/Pil r.-Y _/' '4 #J0V4&" '7�- .(roe) L 117�!- 1061 i Ao.�/ t-Yl/+k'I .4 17 ✓Qr� c_�. / _/,)/1)� �p �Oy� � /))/1/b7p' (':,.7�w�J _S,:I7K I /v//Y Ii//-/t ,Wil /.� r7T-✓/ � I vC,at lGC � /I/n., � /:.J.•s�tle n7— }-tea ,/� �� I � 1 I � I is Discussion With Person in Charge: Corrective Action Required: I ❑ No 12 % Yes 1 I have read this report, have had the opportunity to ask questions and agree to correct all �oi ntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all con? as described, and to // Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension comj,j with all mandates of the Mass/Federal Food de.,l understand that noncompliance may result in daily fines oft nty- d ars or suspensio mveeation of ❑ Embargo ❑ Emergency closure your food permit. ❑ Voluntary Disposal ❑ Other: PI-'FsReceived .,tlcomer iures.- Violations Related to Foodborne Illness Interventions and Risk Accardmg to Lnr:Cooled to fl Factors(Items 1.22) (Cont.) 41 F.!4.`,•'F With;n 4 flouts. �a1.15 Coo!ms Mcthods for PHP's PROTECTION FROM CHEMICALS 14 14 Food or Color Additives loll,) Cold Hot and Cutd Holding P}if's Maintainc,l at or below -202.1'1 AdditivecT ti90.Ut)41Fi! C4l''ohi!d;'F" s 302.14 Protection from Unapproe:d sNddittvec* t 13-501J6(s.) HuAHF:htm:nnined 'rt er abure 1 15 Poisonous or Toxic Substances - PT. r ?-10!.11 L:lentityang Brtbnr,;pu> n-Ongiant i 13-SUL Iir(�) Roasts Held at or above 130"F. Convorcrs" 7-102 11 Co:nr,;un Nantc-Workiae Conu.Jners' ( 20 Time as a Public Health Control 7 , 1 3.�C! 1 q Timc as a Pnbtit (-lealth Crawrol' -_O1.I 1 Scntrati,m-Stula;'C" � 7-2U2 11 Restriction-Ptcteuce and Use* -'tJli.01141 14l Varianct,Roquircment j 7?0'_.13 Conditions of tJsc" 7 203 11 Toxic Containers-Prohibitions' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 1 7-204.1! Sanitizet's,Criteria --Chemicals' POPULA71ONS(HSP) „ i 21 ' uU ;l l I1:C,! up:r..teurized Pre-packaged krces and 7-_n 04.12 Chemicals for Washig >c S roduce,Critoria' Rwerroes with Warning Labek: 7-204.14 Drying Aeents.Critetia, 1 3-601.1 :(4) Use of Pasteurized E^gs' 7 205.11 Incidern it F:u?d C•intact.Lubncam,; ( 3-80 Ll (Di Rain ur Patti:!!y Cooked Animal F'cxxl and 7-206,11 Rcsiricted use Pe;tiade,,tYtterut" Raw Se,d S1'r01.1is Not Served. ., 7-206.12 Rodent Bait Stat[uns" ' 7_206.13 Tr:-:cking Powder;, Pest Gomm] and � � -9011}(C) Unopened Fuad Package Not Re-sened ' Momtnrrm,,' l CONSUMER ADVISORY TIMEITEMPERATUPE CONTROLS 22 3-503.11 Consumer A(Frtsory Posted for Consumption of 16 Proper Cooking Temperatures for Aaitu:il I-norlc That are Raw.undercooked or PRFs ( t Otherwise Processed to Elut:9:;ae 3-401.1 iA(l)(2) Egg,- 15-s"F !5 Sec. 3-1D2.13 Par.teuriycd E•>> Substinrte for R::w,SEe11 Eggs-lmn,ediate Serai,e ;a5`PIS:.ecF =_°' 3-40 1.11(AK:!) Comminuted Fish,Mcats :C.Dante Eggsw Animals- 155T 15<ec. ,a 3-401.11(13)(1)(2) Pork and Beef Roast- 130'F 121 min' SPECIAL REQUIREMENTS - -:DLI 1(A1(2) Ratites,Injeaec{Mcat:. -155"F 15 590.0119(A%-(D) Vio;ations of Section 590.0u9(A)-(D) 1n sec. catering, n-mbile Laid,temporary and 3-401.11(A)(?) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Contam!ne Fish,Meat, debited under the appropriate sections Poultry or Ratites-165"F 15 sec. * above it related It,Iitodberne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks mtervcntions and risk factors. Other Ids'F" 590.009 violations relating to good retail 3-10!.12 Raw Animal Foods Cooked in a practjces should be debited under h'29- Mictowave 165`F* Snou:al Roquirc,netits. 1 3,101 111At(1)1bl All Other PFIF;: - 145"F 15 sec. ( 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PPACTICES ;--03.11(A'WD) PRFs 165'F 15 sec. (Itens;2330) 3 403.11(Bi Microwave- 165"F 2 `.Finule Standinc Caicai mkt non-crvical!violation:", tdr"h ao not rctare to the Tome' foodhorn,iilrtesr lnuo,' eRiions anti rtskJa<iorc listed above, can be, 3-403.11(C) Commercially Pno.essed RTE Food- fund in da'.fol(nu4n,g ser,riwis of rhe Foua Code and 165 CWR 140"I' 3403 1 (6) Remaining Unshced Puttiom;of Beef ( Item Good Retail Practices FC 590.000 kuash* 23. tdanagsment and Personnol FC --2 .005 24 F000 and Food Protection FC-3 004 -- 1 N Proper Cooling of PRFs 25 c qu:f%meso;and Utens!Is FC-4 :JCn 3-501.14(A) Coding Cooked PHFsfrom l•1(PF,n 1 --- -------r ------ 26. vVntor, 14:mbit:q and 6'Yasie FC-S A06 7W F Within 2 flours and From 70"F 127 PIrisical Facili!v FC - E 007 to 41'F!15"F Within 4 Hours. W 1 28. Poisonous or Toxic t latenale FC .008 I 3-501.14(B) Grc9ing PHFs Made From Ambient ( 1 29 Sp'ciai W ouirernents .009 tuut - Temperare ingredients 4!cF!•35'F 1 30. Other W flun4 Hours.` .•.Kn,,::,:,-i a... Denotes mutat item In:ht;14?e!..I 1999 rood Cudr or 1::5 Ch11t 5W 000 9t ` Massachusetts Department of�Public Health Salem Board S Health Department 120 Washington Street,4i' Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978)741-1800 Fax(978) 745-0343 Name t / Da 7TVN of ODeration(s) Type of Inspection 0( Food Service ❑ Routine Address Risk © Retail Re-inspection r �� rrn� !�✓v Gn Level ❑ Residential Kitchen Previous Inspection Telephone (/ ❑ Mobile Date: a j jO )(( ❑ Temporary ❑ Pre-op' ratlo Owner �r v_( t„ k SAS HACCP YtN ❑ Caterer [ISuspect Illness Time E] Bed&Breakfast El General Complaint Person in Charge{PIC} ❑HACCP In: ll '7 Permit No. ❑Other Inspector �� k'kPl�h Kell-" l? OuC 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 ❑ 14, Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE - TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION ❑ 19.Hot and Cold Holding ❑ 8. Separation/Segregation/Protection [120.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑21, Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑22, Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Items 1.22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR 0 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 2 :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-9)(990.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (Fca)(e90.008) 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 5901nspecifomi6'-14 tla' I ' Ins ectors Signature: Print: a J P g � PIC's Signature: Print: Page-Z,of Pages �_ J � Ity ( �11i 1� ViObtiOns Related to Foodborne illness Interventions and Risk Factors(items 1.22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Coss---ontsanirmlor i i9o.owi(A) A'sigion-ut � 3-30' 1 [(A�tl) Raw Animai ScramIQ0 irom 590.003(B) Demonstration of Knowled' 90 Cooked air,! Wfl- Foods* -)-b, Per soit in cliarse -dw ties Cortamtnaso'n from R�o,Ityru,11'rMs 3- Raw Anozail Focyi,Separated rrom Each EMPLO"EE HEALTH Olhrl 2 590.003(0) Rueponsibifit'� of tlw person in cheol�e to C:nfamnation fro-,,the require i-cporill"by 16(KI-,n1pl0Vtcs and 11 t!V) Foo]Plotemon I I aprilicnus* 5 t,Iwx;h,1IF Fruit's a-d VC Lltaules 590003(P) ResponsibihIty Of A Fooll, (lupine-Or Art 1 Food Conta,,i viih Applicant To Fepurt 10 J he Peron In U!,11sib.I Charts' Centam nation from site Consumer 590.0031,G) Reixrtinjijby Person in Charge- b A)(H) Returned Food rod vswiviceof Food:' 3 59e),003(1)) Exclusions and Restrictions, Dxuositirn ofAduterat,7G or Contasi,na,vd 590 f 103(H) Reio;,%al of Exclusion,;dad Restrictions Food I Diwarding of Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food 4 1 Few and Water From Reguatec?qourcp; 9 Fund Contact Surfaces 590.004(5-ffi Compliance with F000 Lawt, d-501 111 Manual %volowtohm'-,-Hot Wai-I ? 201,12 Food an Heantritically Scaled 0anaine,- j Sanitization Tenwt*oures* 31-201 13 Fluid Milk and TOOk Prodta:t,," 4-_501.1 12 Pylcch,:!IlLal Iso?Water i-20?.13 Shelf E-gl Sarutizwion Tejripe.-aiufe,' "n 4-50 1.11 Chemical Saratiz-nion-ternp.,PH, ?02J4 1-'S and Mi1V PCOdUCi[N. PaSttLitiZedt' co,icennation and h:irdncLqs 13 202.16 lee Made FroinPotable Drinkine Water, 4-601.11(,`,1 Eodipment Food Contact Surfaces and -�-i 01�I I Drinking Water fronn an Approved System, 590.0U.6(A1� Buttlzd Drinking Water* Utensils Crean" 590.006(6) Scu4-002.11 Ozarring,Frequen.-) 0 'Equiparear F-),.)d- 590.00601) Water Me�ts Standards in 311)CNIR.2210 Sholh7sh and Fish Fromanrcs, Co:i!act Sur'sce,and Uter,,flstl 4-702.11 Frequency of Sanitization ot Utensils and I-L01.1 i Food Contact Surfaces of Etau;rnu-rtt' Fish ant.R-creatiou,�Ily Cauelit Mullan. Shelh-'sir 4-703.1 1 M-,thods,ut saoaizat;oii- Hot Unit W" ,olluscal Shellfish from NS Listed an 3-20i Cheracalt't Sources It 11) Proper,Adequate Handwitelihig Came and Wild Mushrooms ApDrored by Reg.,waton,Authority 2-301.11 Clean Condl:ion- Hands and Amis" 3-202.18 shelWoolz Identification pre-st;ju* 2-301.12 cicalinw,rlocvdunc` 590.004(0) Wild mushfoonli- 2-301 14 Wheu to W".411 3-201.17 Game Animate* IF i Good Hygienic Practices Receiving/Condition 2-40:.I1 Eomm-Drinking cr Using Tobat.col %-202.11 PIFFs Received at Proper Tempmiwres* 240,[.!2 i 0r;,barl,0s Prom the Ey'-s, N(y;e and 3-2fJ2.15 pat:1.kag C Integrity- -1 !01.11 Food Safe and Unadultoratcd 3-301.12 P�evenijm,con�annoatwn V\heo'l alfirl. Tags/Records:Shellstock Prevention of Contamination Prom Hands 6 1 '- 5000-b--) pfeNvIn: Contat ljirjdj t,, Crow 1 3-202.18 Shellstock Ideutific.,tion , I -j12 r 3-203.12 Shellsiok Identifica-ion N1;o-.tabicd* Fjoplowrs', Tagsitlecords:Fish products Handwash Facilities 3-40-! 11 00r,vanionly Lo.=`cdand;Iciaessibls� 3-402.12 Rccorck.Cre.,nion and Retra,t-w,r 5-203.11 Numbers.and C-pacint-s 590.004(1} Labehog of Ingredients' 5-204.11 Lication w:ti Placement* 7 5-205.!1 AC�emsibfu�.Operation and Conformance w,!h Approved Procacuircs J Maintenance MACCP Pians Supplied'rv;lh Soap and Hand Prefiig 1-502.11 Spevial:zed Processing Methods- Devices Flandwishniv C lcauwr, A,,ailabilitt/ 3-502.12 Redocnd mwen rackattin-,ciomay 10.12 ConformanceArith Approved procedures 6 301 12 Hand D-vin',,?rovown aem in the federal 1499 Rn"I C't,it ot 1015 CMR I9U.0;0. S- CITY OF SALEM 'BOARD OF HEALTH / 3' Establishment Name: I / ,n K ,p1 // r,_ Date: i Page: 2 of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date it No. Reference R-Red Item t Verified PLEASE POINT CLEARLY r / ch Or lC c J 1 M/N rt sno -fC�� /ar_.A � JL .!n C��.,c°._ /Ja��= S/I(C l�J� � �/PP C n/AR./ �!/!��/J/ ✓� l� I �-5fig °i , fan-s �0 Avi e...tJ } I <�oMn� i/lF /� _�� _1.r01I. /AoJ , S.YI �rt.J ,ne f/Ci Ill r:14 /Ia, j� - 7 d-C ' L Tf, phi 4, / � 1- / / j NA 6k �_��/In_ ( V _./+_lLP1Ci�, �ly�-i,� Slnvh cm O n nr-d 1 �//1 ./' .m Pcl ii yy �Yj tY� )M Iry n Gt`�1r nJ c. t NOS _4ah/� fid, U 1 .U I L.X / G/IJ is Pte(?O, �_.1 __, �! .arm -4(:7C, I 1 I . i Discussion With Person in Charge: Corrective Action Required: I ❑ No rCST les 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 Qomply with all mandates of the Mass/Federal F�cftCode. I understand that noncompliance may result in daily fines of twen fi e dollars or suspension/revocation of Embargo ❑ Emergency Closure your food permit. ►/ , .1 ❑ Voluntary Disposal ❑ Other: Iv- - r r 3-i(1.!-1P„ PHFs Ric, red s Tempe ortmes Violations Related to Foodborne Illness Interverrtions and Risk A,:o.rdina to lain Cooled to Factors(Items 1.22) •(Cont.) 41'F/45'F Within 4 Huui:s. PROTECTION FROM CHEMICALS 3-SW I-`' Cootiut Medic& furYHF's � 14 Foad or Color Additives � ( 19 PHF Hot anti Gold Holding 3.501,16(B) Cold PI-iFsMamiamzdatu! below 3-202.12: Additive' 590 004(1) 41'45' r- 3-302.14 Proe,ction from Unzppmred Addinces" 3-SGA.16(A) [lot PHFs Mm.m:uiued at or above 1 j 15 Poisonous or Toxic Substances 10°F 7-IoLlI klentilvmg tnfn-manna-Orignrrl Containers, 1 3-501.16(,0 Roosts Held ar;r abu.e 130"F. '7-102.1 i Cunuraat Natrte-\Nor)dn;;Containers" � 20 Time as a Public Health Centro) ( ' j 3-51!1.19 Time as a Public Beath Control* ',-201.11 `+eparation-Stotayef ., ( 1590.U04(H) Nariancc Rrdtrirentc::!. 7-2U,..t I Restriction-presenandI ce � [,<e': - - 7-202.12 Conditions tit I[%- 7-203 11 Toxic C'nntaincrs-Prohtlimons:' REGU=REMENTS FOR HIGHLY SUSCEPTIBLE j 7-204.11 f Sanitizers,Criteria--Ch,mirds- POPULATIONS(NSP) + .' j 21 3-80:.!i sAI iinpactewaiett Pre-packaged Juices and ^0412 ( Chemicals for Washing 1 rodUBC,Criteria" 17-204.14 Drvina Aliens.Criteria.. ( t Bcvelages Willi Wamint Ulh,ks 1 7.2 �, 1 i, ; 3-801 il(B; Use(It P3Stew9ZedE,22S* �; 1 ( Incidental Food Contact.LubncantsT i ( 3 Si)t i 11 DI + Raw or Parn;;ily Cooked Aminal Foot]and 1 7-206.1 i Restricted Use Pesticides Cruena' ( Raw Seedmaro ';Vol Sewed. ?-206,i2 Rodent Bait Stations' 3;i!)i.i!(G Unnpencd fa;d Package Not Re-served206.13 •Tracking Powders,Pest Control and 1 Monitoring, CONSUMER ADVISORY TIMEtTEMPER ATURE CONTROLS 22 3-603,11 Conuimer Ada tsar} Posted for Co:suniption of 16 Proper Cooking Temperatures for -animal Fm,,9s 1°t.n arc Raw, Undo,cooked of r PHFs Not Oda rw;,e Prcesscc o ;to c,.,htmnate 3-40I.11A0i(2) r'.,,tis- 1s=-FlsSec. 1'athog,as.L Ehwc r-;c;o: iEggs-Immediate Scrvice i-15°Fl5sce 3-3112.'.3 Paaeur,red Eggs Scn:;titate fin Raw 3-401.11(A)(2) Comminuted Fish,Meats V Game gga`re i ' Animals- 155'F 15 sec, 3-401.1 l(B)(1)(2) Porkand Beef Roast - 130"'F 121 nun" � SPECIAL REQUIREMENTS 3-401.1 I(A)(2) Rattles,Injected %feats-155'F 15 590:109(1) ;D) Violairous of Section 5911.00'?(A)-(D) in sec. * catering. mobile fix;d, :emporuy and 3 401.1ItA)(3) Poultry, Wild Game,Stuffed PHFs', reaidcnhni kitchen upetations should be Sluffine Contamme Fish,Meat, debited under the appropriate sectirms Poultryor Ratites-165'F 15 scc. ^' above tf rci2ted to foodborne dloess 3-901.1!(C)(3) W1:ole-muscle,intact Becf Stinks mierven6uns and risk factors. Other 14517 590.009 violations ieiating to good retail 3=401.12 Raw Animal Foods Cooked in a pnuiices should be debited under.#29- Microwave 1115'F Special Requirements. 3-401.11(A)(lpIII A!I01berPHFs;- 145'FIS ;cc j 17 Rehearing for Hot Holding j VIOLATION'S R,LA TEL')TO GOOD RETAIL PRACTICES 3-403.11(A)&(I)) PI IFN 105'F 13 sec. " (Items 23-30) 3-40;.1if B) Microwave- 165°F 2 Mumte Smndiny C;itiral mrd win critical violano+rt: e'Srch do iw relate to the Time' pwdbornc dln<.rr irrrerdeatione and risk Jut tors listed abure, (an be 3-403.11(C) Commercially Processed RTE Food- !Pard in the fnitmvnrc se(,tions of the Food Cade and R»CAIR 140°F 590.0019. 3-103.111 E•) Remainin;,Cn,lir,d portions of Beef I t a in Good Retail Practices FC 590.000 j Roasts' 1 23. Manacl2menl and Personnel FC-2 .003 LS Proper Cooling of PHFs j 1 24 Food a:id Food Protecton FC-3 009 25 EUa:ummi and Uter.:0:3 FC-4 .005 4-501 14Crr) Cooling Cooked PHFS linin 1407tu 126 'Water Plumb,no and Waste FO-5 006 i 70°f Within 2 Hutu-,and From 7U'F 1 27 Physical Facility FC-6 .007 ---� to 4!`F/-5'F W;tbm 4 Hello- W j 25 Foisonous or Torc Materials r C-7 .DOB ! 3-50114(B) Coolime PFIFs,Vade From Ambient129 Soecol Pegw:emonm 009 --- -I Temperature Ingredients Io,I I'F/4i`F L30. -Other j Within s Ilours* Deumes crri¢al nem m IIIc federal 1999 Fund Cmle or 105:CNIR 590000. ry .. .ye. « . y„..s..H .^..�,.a^i'.+ rr.., r.w..- '^ �� r• -F. . V Massachusetts 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 (1 ` Date/ Type of Ooeration(s), Tyge of Inspection /rj4 !/ ® Food Service Routine Address Rldlk ❑ Retail ❑ Re-inspection Telephone ! w � Level ❑ Residential Kitchen Previous Inspection P R I ❑ Mobile Date: L?/(& 01- Owner rr �� ❑ Temporary ❑ Pre-operfation Y /4.A flr \,Q C��7� I HACCP Y/N ❑ Caterer El Suspect Illness Person in C arge(oil Time ❑ Bed&Breakfast ❑ General Complaint Inspector Asn In:a,3n ❑ HACCP �� KLb Ve Outt= Permit No. [3 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 clatermined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties El13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC El 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ' ❑ FOOD FROM APPROVED SOURCE 15.Toxic Chemicals ❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. 'Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling ' PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY_ ❑ 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 e immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR ofd eaNh. 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board•of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 26. Water, Plumbing and Waste (FC-5)(590.006) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: a'1 S 500lns IFo1m 14 �) IInspector's Signature: 1� ( _ - Print: \ !\ __/1�PIC's Signature: t /jOJC_ p -slit Print: l Ja-�Jr� UKY` Page f of-2-Pages I x14, ,, ( a `1� k/VNAA �l t�ie� tti.9 111 . v Violations related to Foodborne Illness Uftervendons and disk Factors(items 1-22) PROTECTION FROM CONTAMINAT;ON FOOD PROTECTION MANAGEMENT ( t3 ( Cioe:s-conam.nat:on 1 590.003t A) ( Assignment of Responsibility' 13-302-11(Ahl) Raw Animal Fails Separated frnn 590 003(Illi Demonstration of knot+ledge, Cooked and RTE Food." 2-103.11 Person in char pe--duties Cont=,r,ioatien from Raw eft edienis 3-302.J .(A)(') Raw Animal F,als Separated ratan Fach EMPLOYEE HEALTH ! Other' r i2 JhO.0030C) Respnns:bihty of the person in chatge to I Contar-^inat:on':aa the Envlrorment requite rwpurting by fond emp!uyre,and 3-302.1!(A) Fond Protectionr' app!i'ants' i 3-3(1'-'.i5 Washmz Fndtc and Veeetables 590.003(F) Respcntsibility Of A Food Employee Or An 3304.1! F;xK4 Contact v;iIh Fiq:;ipment and App!ieaht'fo Report To The Parson In IJ:ens;ls* Ch•rree' (:ontam,natron t.0;n the Consumer 590.003(G) Repel ling uy Person in Chane* j ;-3n6.14(A)(B} Returned Food and Rcsrrvi(�of Food` 1 31 590.01,31Di E.xclustonsandRe--trictions* CisposGtono,AAltan_ted0.Cor.tam%rated 1 590.003(F-) RemoNal of Enclusnms and Restrictions Food -71;1 I I [,;cording or Recol:ditionmg Lnsatr FOOD FROM APPROVED SOURCE FcKK!* i i 4 Food and Watsr From Regulated.Sources ( (T Food Cor-Act Surfaces 590.00(.(.4-B) 1I Conit-,liance with Food Law:k 4-501 111 Manual lVarewa,h3w, Hot W'atcr 3-201.12 I Foots in a Herint- ical!y Seaicd Contamcr`; S:mitizat,n-Temvrr.rtarrs" 3-201.13 Fluid MilkandMilk Products* 4-501.11= Mechar.ivalWarewashMl f-hit'v'iater j 3-202.13 Shell t-'��r' Sanitization Temperatuft.* l o .}- .i Chemical Sanitiz liar.-teugt,pH, 3-202,14 i Eggs and Milk Pn;ducc,,Fanteuu�e(. � 3-202.10 Ice Made From Pnlahie Drinking Wates' I nurcruh atir:n an;;taro ess. 5-101 11 Dnnkina Watcr trout in Approved Svstem' 1 4-60L i IfA) ELI at orient Pond Contact Surfaces and iiteu,i!s Clean" 50(:.006(A) Bottled Drinking Water° r 1 4-602.1! i'le:;n:rte Frec.nenati of Equipment Foo(I- 59u.UCn(B} Waler Meets Standards, in 310 CLLR 221.0<' Shellfish and Fish From an Approved Source Conn.:a Surf,ccS.tial Utrnsi!s' 4 702.1. 1 Frequency tai Saruti2a tion of Utensils and 3-201.1-1 Fish anti Recreatioraliy Caught Molluscan ?'aaI C:•.ntact Surfacr,of EquipuienY' _ Shellfish ! a-70?.i 1 yde:h.KN of Sanitization-Rot Water and 3-201-15 Molluscan Shellfish hour NSSP Listed I Cheuu(al Sources' -I Game and Wild blush ooms Approved by ( 20 Proper,Adequate Randwastsing I ! 2-3u 1.t; Clean Condition-Hands and Ann% Regulatory Authority ?01.'.2 Clennir;e Prxcdurc" 3"202.i8 SL-elNtock identification Pres:lit" : - - : j 590.0(11((.') Wild Mushraoms* °-301.14 When to WashT 3-261.17 thane Animals* 11 Good Hyg!enic Practices g , Receiving/Condition 2 '1'21.11 Eating, Drinking or Gana Tohac:o' 3-202.11 PHF,keceivcd at Proper Tenipetanues" I =-=ri)1.I' Dischzrres From the Eyes, Nose and 3-202 15 I package Integrity' h5uuthx 3-!0:.11 Foal Safe and Unadnitera%d 3-30!.12 Preventing Contamination When Tasting" I a i Tags/Records:Shel3stock 17. Prevention at Contanunation from Hands 3-202.18 Shelkttak Identification�` � 597}.0(1-ilFi Presenting Contamination from ? 20?.12 Shellstoek Lientification MaintainedEmployee,* TagsiRecords:Fish Products 1.3 rlandwash Facllities + 40211 Pwmsite Dc,tructiun' Convsnvertly Located and Accessible 5--'03.11 Nurihers and Capacities* 3-40'_.12 Records.Creation and Retortion` - � S90 0041((? Labeling of Ingredients" ( 5-2U1 I I 1 ncanon and Placeril t Conformance with Approved Procedures 5-21.15.11 Accessibility.Operation and t Lcimenance i /HACCP Pians I Suppled with Soap and Hand Dry;rg i 3-503.11 Specialized Processing Meth(xls* DevxeJ ! 3 502.12 I:educea u.rygen packaging.criteria" I 6-301.11 LlindwashineCbans,-r,Atailability i 8 10. t2 Con with Approved Procedures^ ti Li01.12 Haud Doing Prw ision Deno:a,shit al heti:in 16�ederal 1 N9 Rax(!Gxie:n ::U CITY OF SALEM ' BOARD OF HEALTH Establishment Name: J.(�� f vV1 Date: Ilar ,6 Pager of Item Code C-Critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item I Nf a -I�olu nOled/ rdT PLEASE PRINT CLEARLYIVerified c4hr'� f!®oro-verCot Yc-�, Un, 'M4r'Uc/ I r r7�a. ,a a r -�rMrb.�Jam. OJ- INP/d (A t, k s,,, 4- � f_bbU' ed -fir, kp In, f . /.fiAiA. A _5�,fIll✓ c34 Ilotlj" ra qv,A./ 04 r=� to� ,-1"ti _ I � I � I � f r t ✓ Gef cc 41J", 4 2c11 i Discussion With Person in Charge- Corrective Action Required: I ❑ No Yes + ❑ V luntary Compliance ❑ Employee Restriction/ t I have read this report, have had the opportunity to ask questions and agree to correct all Exclusion violations before the next inspection, to observe all conditions as described, and to Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that , noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. �n� > f�.fAJ(�t)AIK9 ❑ Voluntary Disposal Ll Other: r -moi - 3-50:.:dl C) PHFS Wcc iced at T'ntptretures Violations Related to Foodborno t?cress interventloas and Risk a.crordimg to law Cooled hi Factors(tfems 1.22) (Cont.) j a IFl=45=F'vVithin 1 How's. PROTECTION FROM CHEMICALS "1 ! I C=oolir,_Nietheds felt PHFs 13 I Food or Color Additives j 19 PHF Hot and Cald bolding ng 3-.101.16(t) Gold PFIPs':4taintaine:l at or beta„ 1 3-202.12 j Addititrc" 590.0;1='F) 3 302.14 Protection from tlnappro},cd Addinrec+ ( 1 i 1"'F 3-S0L],),A) lith PB+s Pdaiutained at or above 1 j 15 ( Poisonous or Toxic 8uliVmnces j 7-1(:1.11 Idennl}ang, lnibrmr,„rat-Oti.inal i ?-zttl.lt,(A; Roasts Held at or above 130c,+. " Containers' 1 1 40 lune as a Public Health Control "t-102.1 1 Common Name-Working Containers' 7-_01.11 Separation-Stortke` 1 3-5tH.10 Time as❑ Public Health Control* 7-2.02 11 Restriction-Preacmce and Use" 'I 590.00,`O H) Variance Requiremeot j 7-202.12 Conditions of Use* j 7-203.11 Toxic Contain.,,-Prohib;tioase REOUIREMENTS FOR HIGHLY SUSCEPTIBLE j 2u1.1 POPULATIONS{HSP) 7- Sanitizers,Criteria-Chemicals" i 21 I3$OL I!(A Urtpasteurizcd Pre packaged Runes and 7-2U1.12 Chemicals telt W'ashu(c produce,Criteria' 1 Bene:a e::w'tih v,:a n'mn"l;tbels* 7-204.71 j Drvmg:gents.Cri 1 3-501.11;B) Use:lP;atemizeUEegs' j 7-2U5.i f hicidental Food Cuntact,Lubricants' 3-80 i.i I+DI aaty or Pa;tiatly Cocked.4nnnal F'axl and 7-7.06,1 I kedr:cted lice Pesticides.Criteria' - - � Kat.-Seed Sorout; i,ls S=;led. ,w 7-206.12 Rodent Beit Stations- 3-SOI 11+C) thiopmed Pixxt Packa Not Rc-set,ed * 1 7-20h.13 "Frocking Powders,Pest Control and j t, Yinnitorin_k CONSUMER ADVISORY 22 3-603 1! Consumer Adrsoty Posted 6a'Cwrsumphun of TiMEREMPER47URE CONTROLS Anunii Fonds'fhat arc Raw.L'adereuoked ur lb i Proper Cooking temperatures for PHFs i`'+a Otherwise Processed to l!irmnute i 3.401.!lA(i)(2) Eggs. 15;'P 15 Sec. Pwh'. E;ts;r'-Immediate Servlet 145'PlSsec< j 3-302 13 f':i:,teurtz,;a .4'r;Substitutr For Raw Shell 3-401.11(A)(2) Comminuted Fish,Meats &Game i Eggs- Animals- 155'F 15 sec. 't 3-401.11(B)(i)(2) Pork and Beef Roast-130`F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)t2) Ratites, Iniccu:d Meats- 155'F 15 590.000(AHDI Violations of Section 590.(R)9(A)-(D) in sec. + catering. mobile ford,temporary and 3-401.11(A)(3) Poulti y,Wild Game, Slotted PHFs, resicicatial kitchen operations should be Stuffing Containing Fish, Meat, debited under 1 he appronriote ;:ectioa. Poithy or Ratite,-165"F 15 Sec. " above if retated to foodborne illness 3-101.110C)(3) Whole-muscle, hvact Beef Steaks interventions and risk factou:, Other 145'F: I 590.00v violations relating to good retail 3-401.12 Raw Anima! Foods Cooked in a ( practices should be debited under #29- Microw'av� 165'F r Special R;,quiiements. 3-401 A I(A)i 1)(b) All Other PHFs-145''F 15 sec. 17 Reheating for Hot Holding ( VIOLATIONS R_.LATED TO GOND RETAIL PRACTICES 3-403.11(A),F(D) PHFs 165'F 15 sec. `° (1tem5 23.30) 3 '403.11(B) Microwave- 165'F 2 Mnumr Standing ( Critical and ntm-crkilal veoiani as, r.ineh do nor reta:e to die Time" .Joodhorne ilineac late;nmlions t,nd r i,,i jwro,r Bated above, car,he 1 3-403.11(C) Cummerctall}Processed R r F RNA- d,und in thr JWro>einR sections of the Fsud Cor.?and I(l5('LIR !4Wt 590.000. 3-103.1 1(F) Remautina Unstized Portion,of Bttfi r]tem Good Retail Practices FC 500.000 1 Roasts'. 23. Mana(loment aid Personnel FC .M3 13 Proper Cooling of PHFs I 24 F000 and Paved Protection FC- 3 Allo j 25 Equiomon'and Utensils FC-4 005 3-50114(A) ('.oiling Cookers PHFs from 1400Ftr' j28. Water, Plumhinp and Waste FC-5 AltB-----_-j 70'17 W9thm 2 Flours and From 7WF 27 Phvsical Far+lity FC-6 007 to 4I'F/45`F Within 4 Hours. t 28. Poisonous or Toxic Matenal-, FC--7 ; om 3-50! 1=1(B+ Cooling PHFs Madc Froin.Ambient -29_ Sm-tial Requirements i 0p9 Temperature Ingredients to 41"F/45'F 30. Glher - _- ---- ,- --- ----i Within 4 Hours'r uomleii sd¢.al iie;x)m dt+Fd ral I0'-+9 F.;nd('ode or 105 C NIR 590 000 .. . n 'n .. .., rr .. fr.. r , F' _ , .. .L M _.....Y3,,.,,,,,..i.-k....-+,..m.-,^.✓.- �f..:.:-.ry�1+, r R.-. + �..,,,. . . :,.wA' t~e Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name y1, Dat I 'Tyoe of Ooeration(s), Type of Insoection t /._1� �P/4t �n �1u IS Q G,/-� VEd Food Service ] Routine Address I- �,'\IYT R sk / ❑ Retail ❑ Re-inspection Telephone ,�r� Level ❑ Residential Kitchen Previous lgsp Ttion� 'I-HL � ,� EI Mobile Date: r(2o b) Owner ) I {� Z�- HACCP Y/N ❑ Temporary ❑ Pre-operation K'�or�l' t �.tN,n_ � _I(.f(�'_(.9.� I ❑ Caterer El Suspect Illness Person in Charge(PIC) Time ❑ Bed& Breakfast ❑General Complaint Inspector (�y>ro/A�,. {li�n•�i Out: .:. Permit No. ❑ Other Eachviolationchecked Fequires an explanation on the narrative 040s) 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 r ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeab,e/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH El2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS El3. Personnel with Infections Restricted/Excluded El 14.Approved Food or Color Additives FOOD FROM APPROVED SOURCE ' El 15.Toxic Chemicals ❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling P PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑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 Health. 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590 004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 26. Water, Plumbing and Waste (Fc-5)(sso oos> the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: ( ((n 5500InsWfForm 14 do[ ^1 '�� ^ n4 tt 9� Inspector's Signature: I l Print: /I /1 \ PIC's Signature: _ R I Print: /�l CI Page or�Aages A Violations Related to Foodborne illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT ( s Cross-ccntam;na'-on i t 590.003(:1) Assignment of Kesponsibility` ( 3-30-1.1 I(A)U) Raw Animal Fo•.nls Separated !tom 590.003(13) Pemonstratton of Knowledge" Cooked and RTF Fxds' J-I G9 I 1 Perion in charge--duties j ! Contamination froin Raw Ingroorents 3-30111(A)(2) Raw Animal Food, Separated bent Eadi EMPLOYEE HEALTH I Odic"- 2 500.00Y0 ' Rciponsibility of the person in charge to ( Contarninatton from the Frivironment require reporting by fool employees and 3 302 11(A) Food Prosection' apnliefvusx 3-302-I5 Wasmn,Prim,;and Vc-xtables 590 003(P) Responsibility Of A Foca Employee Or An 3-304.11 P,ax1 Contact faith Egaipu;ent and Applsant To I:rpon To The Fer.00 In Uten,iis" 1 Chal-e•' Contamination trom the Consumer 90.0031 Gy", Reporting by Person in C'harlte" 13- 06.14(A)(B) Returned Food and Kesciv:ce of Food } 590003(ll) Exclusions and Resuictions* ( Dispostion efAdukerated or Contaminated 500.0038 Removal of Exdusionc and Restriction;; ( Food 3-701 11 Discarding or Rcconditimmuz I-W"d'e FOOD F ROM APPROVED SOURCE Foo 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Coctphancc with Ford Law* ( 4-501.111 ?VI.u:nal A4newashine-Ilot Water 1-201.12 Food in a Flennetically Seaicd Cu.^.tamer" Sanitization'Femperl"Lon: 3?Gt.l3 Fluid A9iln and Milk Products* 4-501 112 Meclw;acat W,;rewash;rte Rnt Wat r � 3-202.13 Jhcil E" q^ Saniliz:+flail Teun,:eratures" 3-202.14 F.eg::and Milk Producs.Pasteunrcd' 14-5U1,114 Chennerd aamnz:uion- temp..pH, +-202.15 Ice Made From Potable Drinkme){'alar" concent arc;m and hwdnes:;. 1` 5-lift 11 Drinking Water front an Approved Sy:;tcm` 4-601 I IIAI Lgeipment Y<xtd Ci:;iact Surfaces and Utesds Clean" 590.001,)(A) Battled Drinking Water' i 11.60'..1 1 Cleaning Frequency of Fquiprnent Fail- 590.006(6) Water ds m Meets Standar310 CMR 22 0" Contact Surfaces and Utcu".da, Shellfish and Fish From an Avoroved Source ( 4-702.:1 Frcyueucs of Satmizahon of Utensils and 3-201 1.4 Ftsh a ul Recreationally Caught Molluscan Ford Contact Surfaces of 6iluiprnentx Shellfish* 1-703.11 Methcxkrd'Simiounn HotSVarerand 3-201.15 Molluscan Shellfish from NSSP Li:ted ( Chemical x Source* to 1 Proper,Adequate Hand+aashing Gamr and Wild Mushrooms Approved by Regulatory Authority 12-301 t 1 Clean Condition--Hands and Amts" 3 262.18 %ellstocl, identifi�ation Present" ! � 2-301.12 C'Icmting 11tZ,lwe" 590.004(C) Wild Mu;hnxtms` ' 12 2n1.14 Whf,ji to WaiOr" 3-201.17 Garne Animals* it ( Good Pygsnmic Practices g Receiving/Condition 2-40i.!1 Fabs:g. Drinking nt Usmg Tobacco'' 1202.11 PIIFf, Received at Proper Tempemtures' 12-401.12 Discharges From the Eyes, Nose and 1 3-oI115 Package Integrity* j Mouth" 3-101.11 Food Sall and Unadulterated" 3-301.12 Prerenbnc Contatnim u;on When Tasting" ( g Tags/Records:Sheiistock 12 Prevention of Contamination from Hands 3-202.18 Shellxlockldentiticat;on° 590.004(6) PratantingConsttnntationfro:n 3 _23.12 Shellswc], Identification Raintained" Empl°gees* j I Tags/Records: Fish Products � 11 Handwash Facilities 3-402.11 Rn,site Destruction':' Conveniently Lxated and Accesaib?e 5-203.1 i Numbers and Caparcifics, 3-402,i2 Reconls.Creation and Rcienhon" 5L". )004(11 Labeling of ingredients' ( 5-1.04, 7 Location and t!acoment ACCP Flans f 1 ( 5-205.11 Accessibility,Operation mol Vf:dntnnance 7 1Hmance with Approved Procedures I Supplied mth Soap and Hand Drytrq MACC � 3-502.11 Speciahzcd ec Procsins Methods* Devices 3-51'.? 12 Reduced oxygen packamrig,criteria' 6 101.11 Handwashinv,C leaner Availability ! 1 6-301.12 }I:uul Drying• Provision 3 163.12 Confortnancc with.Approved Procedures`. � 1 P.crntr>rnrirui•iir,n is n:,e c,it<ra1 11)99 food Cock of 105 CNiR 510.00f) i CITY OF SALEM /BOARD O HEALTH 1§ Establishment Name: IJ�/l n !/ fT7 ITS l ✓/'41 LDate: �/�6�.7f Page: of a , �} - Item Code C-Critical nem DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date { No. Reference R-Red Item �1 4w- ,-*- .fied PLEASE PRINT CLEARLY rye cl <�a Iz KP ��P I, M� � .c .�m c e 14 J2 0A �.YJP✓ I e I - - 1 1. t � ' I � I - 1 �l � A.vtn-h n� 4 With Person in Char e: — Corrective Action Required: ❑ No Yes Discussion g I have read this report, have had the opportunity to ask questions and agree to correct all I Voluntary Compliance ❑ Employee Restriction/ i 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 twe ty f. o a or suspension/revocation of ❑ Embargo El Emergency Closure 67 your food permit. /J�, pVll J ❑ Voluntary Disposal ❑ Other: — v \ r , i-hc') FHFs Received at"Temperatures i Violations Related to Foodborne Hirers Int?rventlo^s and Risk Accrmti ng to I.aw Cooled to Factors(items 1.22) (Cont.) 41'F/=45P'Within 4 F,oars. ' PROTECTION FROM CHEMICALS 3. 0:.15 ^0,:',a;vi,uwcs Ccr PHFS 14 Food or Color Additives ( 19 PHF Hot and Cold Holding - 3202.12 Addititesa '-501.I(,B; Co':d 'ral's Maintained at or below s90.(�U1(i=) 4''/15"F^ 3-302.!.4 Protecti,nn font Use;rprooed Add,hves, ( 390.0 (( ) 4F PH::1ti1aiu4uned at or above IS Poisonousor'foxic Substances 7-101.11 1dentifyme lnformahna ihi�i ra( ( i4{)'P' „ Containers" - 13-501 I!,(A.t Rousts Held-:or❑have 7 7 102,11 C nuarnon Name. - Working Conutiner<"' � � 20 Time as a Public Health Control ( ' i 7-201.11 C;.parauon Stoi sec^ 3 .101.19 Tim:as a Public Health Control*-- � ' 7-202.11 Restriction--Presence and Use" 1 i`>0.0441-1) Variance Regturemcol J 7-203.12 Toxic Containers i l rTie- 7-20111 ,. � REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-'_1)3.11 Tozic Obs,Criteria Prohmuions; I POPULATIONS(HSP) 7=204.11 Sanititers,Critena --Chemicals= : - ! r , i 21 1-801 I It-N) L)ap%stcurized r'rc-packaged!itices itod 7-20.1.12 Chemicals for Washiiw t ruducc,Criteria"' ()4.1.4 Drying Acents,Crite,ia" Beverages with R"atTme!.:bels` 7-2 - ! I ( 7-205.1 ! Incidental Feud Contet.Luhn3-801,11(B) Use ofPaaem!zedLegs, can:c�- 3-,101,1!(Di Raw o:Paltialty Cooked Amaral Food and 7-206.1 I Resin,_ted Use Pesiicidee.Criteria' Rao Sced S proms Not Served # 7- 06.12 Rod-mt Ba:t Stations- 3-801.1 I'C) Unopened rood Pau,,age Non Re-served. "" J 7-206.13 'Tracking Powders,Prat Control and I i4'In(1t[cnlP;l;M � CONSUMER ADVISORY 22 3 60;.I I Consumer Adn+sory Posted for Ccncrui non of 7IMEJTEPdPER1TUREGCNTROLS - P Aninnd Foods That arc Raw, Undetc u,ked or 16 I Proper Cooking Temperatures for PHFS Fut Other''vise Processed to Eliminate I ! n ! Pnthveen~.*c`av:-_vr.o-nnr 3-40l..IA(1)(�) tiggc- 155'F 1.,Sec. Eggs- Immediate Service 145`170sec, ' ?"-.1? Pasteurized Figs SubLLLtlltC for Raw.SheH 3-401.11(A)(2) Comminuted Fish, k4ras&Game E�'-s ., l Aniuwis- 155`'1` 15 seg. " 1SPECIAL REQUIREMENTS 3-401.11(8)(1)(2) Pork and Beef Roast- 130"'F 121 inin* 3-401.;7(P,)(2) Rattles. [njut(-ti :bleats-155'1- 15 5o0.0ruiA)-t D) Violations of Section 590.009(A)-(D) in seC, w catering, nrohile food, temporary and 3-401.11,A)(3) Poultry, Wild Game,Sm17u1 PHPs. residential kitcher operations should be Staffing Contnnrmn Fish,Meat, debited under the opAiOprialC sections Poultry or Raines-165-F 15 sec " ahovc if related to foodborne illness 1 3--401.1!(C')(3) Whole muscle,haaut beef Steaks interventions and risk factors. Other 145-F : ! 59(1.009 violations ielatinv to good retail 3=40;.12 Raw Animal Foods Cooked in a i practices should be debited under tf29- Micro"ave 163'F* Special Requiietnents. 1-40111(A](1)(51 All Other Pffft - ids'F15see. '' 17 Reheating for Hot Holding f VIOLA77ONS RELATFD TO GOOD RETAIL PRACTICES 3-40111fA1&U) PHFs165'F15sec. ' I tlteuts23-30) 3-103.1 If Microwave- 165'F? Minute Standior, Criprrd and min-rrittan(vinlnrrpm' which de r,at valvae to the Time* ,roodbornw i li sr intervertionc and rdsk jartors li.,ted above, ran be 3-403.111 C) Commercially Puxessed RTE Food- (maid in the jollmvin,se:lions of the Food Carie and 105('ttiR 14WF11 5!0.000. 3-103 11(8) Remaining Unsliced Poiticnis of Beef I item Good Retail Practices FC 590.000 J Rnasrs* ^9_ VManacrente't and Personne! rC-2 .003 F, FG 18 Proper Cooling of PHFS 14. Fnod area t and Prot"Ill!3 FC-3 AOe ?5. ECc!prnsni and U:enni!s r„-4 .005 1-5t1L14U1) Cooling Cooked PHFS from 140`F to 26. Water,Plurnbino and Waste FC-5 .006 70:F Within 2 Hears and Pruni 70"F =7. Phvsical Facility FC -6 .007 to 41-F/451,`r Within 4 Huui T 20. Poisnnous or Toxic ivaterials FC -7 .008 i 3-501.!4(8) Cooling PHFS'Made Front Ambient 29. Special Reuunvrnmts I rr0 ' Tempeiature hngredierns to 41'Fi45"p Within 4 Honrs)i o,,r,:w-z 111: I)awtes crncal IT=In thr federal 1999 Fond('ode or 105 CNIR 590 000. 4 p !4 �^�. �'9Th^4"')'!t` '+YN•M.:• -�''�°.vit'.. Nv� � Y �� tM' `� „c+f' ..ek'Y:SA„RfE, u YqS'+”' " '' ;$?' � 's.�9.x'.y,-vk'h"mlr-4 A,,•;,.ysP*ca - Jt�?Ja�#&:r!^ `k .,. . ,,.,,..t,..«ns .:r! .r✓e>;+�-:�� !'sM„�- ��'k.?# �Sq Y `i j2 �:M r CITY OF SALEM9 MASSACHUSETTS ABOARD OF HEALTH ..i' • - axy.,', "'ar` "< 4:,':>:.`_"'- ` ♦ > iY•r, ^120 WASHINGTON STREET, 4TH«FLOOR .n s 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: Dunkin Donuts - Drew's Donuts Inc. Address of Establishment: 152 Washington Street Owner's Name: Robert M. and Anthie Jackson Restrictions: Application Date: 12/22/05 Permit for Food Establishment 166-06 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2006 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. qeLf-� HEALTH AGENT CITY OF SALEM, MASSACHUSETTS o R o BOARD OF HEALTH / s 120 WASHINGTON STREET, 4TH FLOOR X111 SALEM, MA 01970 IWiV DEC 12 2005 TEL. 978-741-1800 STANLEY J. USOVICZ, JR. FAx 978-745-0343 CITY OF SALEM MAYOR W W W.SALEM.COM JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH HEALTH AGENT 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT\Nol 1.�%�Cm 14 T��Jt.1\' I`(L�I��GO Y1"LV� ADDRESS OF ESTABLISHMENT Nst tlKlm MAILING ADDRESS (if different) �1 (9-C\o( OWNER'S NAMEQ� -( �S��ui L" a �C ``tll �'1 TEL# ADDRESSVXN � � ,n CITY T TE ZIP CERTIFIED FOOD MANAG R'S NAMES CERTIFICAT (required in an establishment where potentially az r idLs food prepared.) n^ EMERGENCY RESPONSE PERSON W�1/ \ �V YT!Y{/ll N U; TEL# ' h `t� ' � ^ ^ HOURS OF OPERATION: Mon,.— ue. ea. 1 nu. TYPE OF ESTABLISHMENT 0 FEE (check only) RETAIL STORE YES Ilv0 7 less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YE /VJ_NO 1 / -0/ less than seats =$10 11n 2-5---9-9-seats more than 99 seats =$200 = --- -----------------------------------------------........----------...... ..------------------- BED/BREAKFAST IONYES-------------- O ..... ......... - $100... iM ADDITAL PERMITS KE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES $5 TOBACCO VENDOR YES $50 ALL NON-PROFIT(such as church kitchens) YES $25 *Please pay total with one check payable to the City of Salem . This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowled e d b , have filed all state tax ret ns and paid all state taxes required under the law. �a SiC g?atl re Date £eeiel-P�or Federal Identification Number ----------------------------- -------------------------------------------- -------------------------------- Revised 11/03/05 FOODAP2.adm Check#&Date J✓3 N9 ia�S /oa Massachusetts Department Of Public Health Salem Board Health � Mpn120 Washington S 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 D to Tvge of Operation(s) Tyap of Inspection �-D. ,I �< I 1 Jr) 11 )+4 i I � ab-�'I �I Food Service �® Routine Address ! y , ' Risk ❑ Retail (� Re-inspection �'� 1 1�)C 11 t l�i V) C �- . ; Level �/� ❑ Residential Kitchen Previous Inspection Telephone M Q I i r ' I ❑ Mobile Date: Owner�r '� I HACCP YIN {{ ❑ Temporary El Pre-operation 1�Vtii P. � r � . �/icvSo ) I ❑ Caterer ❑Suspect illness Person in Charge(PIC) j� �. Time 1 ❑ Red&Breakfast ❑General Complaint f'Y 4v y) G i)IPJA In: I ❑ HACCP Inspector ��itlrip j I Permit No. El Other Out: Each violaeion checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-comptiance 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 590.00%E) ❑ 590.609(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition [116.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing CONSUMER ADVISORY ell. Good Hygienic Practices 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 !1 immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): V 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 �4. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 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 7. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: 5 5901nspe IhFn 14 da SUP rto '• rg tore: I Print: PIC�signature:,. �,}- Print:l,(/,., tr�� M =,� Pagel of ages T Violations Related to Foodborne Inness l Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT N Crass-cantan,rnabon I 590.0031\) Assignment of Rcsponsibility" 3-302.1],A)(]) Rs;a Animal Foals Separated Gam 590"003(B) Dcmansttatiou of Know lecke" ( Cooked and RTF Foods" Person in charge-duties ( Contamination from Raw higrsdrents 1-302 1 ((A)(2) Rare Animal Fwws Separated front Each EMPLOYEE HEALTH Other 2 390003 C) Responsibility,)[ the person in charge to ( ContamG7ation from the Environment regm rc reportao by fart emploptes and 3-302.11 t\) Food PrutectionT appliccnts^ ,-302.15 __ Washm4,Fruits and Ve;,etablrs j 590.OU3(F) Responsibility Of Fund Fmployec Of An 3.104.!1 Food Coriart wits-Equipment and Applicant To Report To The Peden In Utenaiis''' t Charge" Contamination from the Consumer 500.003(6) Reporting by Person in Charge" I 3 306.14(A)(B) Retu wil Food:,rid Rcaert^ce of Food' 3 590 0931 D! Exclusions and Restrictions" Disposition of Adulterated or Contaminated 590.UO3(L) j Removal of Exclusions and Restriction, Foot 3-70!.11 Disaanhngor Reconditioning thnafe FOOD F IOM APPROVED SOURCE Food" Food and I'Vater Fiom Regutatra Sources ! 9 Food Contact Surfaces 590.004(A-B) Compliance wi', Food Law" 1-501.111 Mallard Wamwashine- Hot N%ratc' 3-201.12 Food ma Ilcnneticaily Sealed Container' Senitbatinn"I'enzperatnres* 13-201.13 Fluid Milk tied Milk Products d 501.1 i2 M:chanica! Warcwashiug-Not 10,'awr 3-202.13 Shell Eggs"' Sanitization Temperatm'eFt 3-202.11 Eggs and Milk Produce. Pasteurized" I •1-Stt1.4l 1 Chznurul Sanitization-temp.,pH) ccn;a•ruratian and!tu'duess. ' 3{202.16 ]ec Made FromPotable Drinkinc 1Fatet=" 5-bi)1.11i A) hquipment Fad Contact Surf ices and 5-101.11 Urinkmg`,y''atcr from an Approved Systcmx La:n;ala Clean °' 590.006(A) Bottled Drinking Water' f 1 (:02.11 Cleang H, inequzno-AEquipmentFond- 590.00o(13) Water Meet,Standard;in 310 CNIR 22!)'" Cont<ct Surfaces mai (ilea:tls Shellfish and Fish From an Approved Source j 4-70211 Fcquencv cf Sainiivanon of Utere ill,and 3-201.14 rt,dt and Recreationally Ceught Molluscan Fad Contac'Suri;tccs of F.r!uipmcnN' Shellfish r 4-703.11 Methods of Samhration-Her Water and i 3-201.15 Molluscan ShellINb from NSSP I- aed I I Chemic.n u Sources} cr Propos,Adequate ifandwashing Game and Wild Mushrooms Approved by ( t' Regulatory Authority i 2-30:.3 1 Clean Condition--Hands slid At 3-202 18 Shellsleck Identification Present' 2-301.12 Cleaning Prnceduie' 5901004(1c) Wild Mushrooms: 2-301.14 "h';ien to W h" '-2')1.17 Oame AnimalsIt Good Hygienic Practices g Receiving/Condition 2-401.11 Fitting,Drinking•dr Usit a"IbbaccnT I ! 3-?02.1! PIiFsI ccci%ed tit Proper Temperamres" ?-401.!2 1:iseharges From the Eye,. Nose and 13.202.15 Pack.ge hnc/a tty" Mouth'' 3-10!.11 Food Safe and I'unadulterated'' 3-301.12 Preventing Contamination When Tasting ( 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 33-202.18 Shellstock Identification" I 590.0OAi E) Preventing Contamination from i-'1.03.12 Shellstock Identification Maintained, Lmplaye_s' Handwash Facilities Tags/Records: Fish Products ' i.-; C 3--402.11 Parasite Destwccionm uroaven!;y Located ard'AcceasrJ,'e 3-402.12 Records.Creation and Retention" 163.11 Numbers and Cap❑cities' ! 590.004!1 t Labeling of Ingredients' T"2Od.t l Lir anon smd Flaa;mems 7 Conformance with Approved Procedures } ?05.! ! Ac;rasibility.Operation all,">daintcuunce /HACCP Plans ( S,,,pplied with Soap and Hand Drying 3-502,31 Specialized Processin,-,R'Iethods* Devices 3-502.12 Reduced oxvectj packaging,criteria" u-M1.11 Nu:ndwashi!tg Cle,inscr. Availability 8-0)3.12 Conformance with Approved Pta:edures" 6301.12 Hand Diving Prrn"""i<ion 0C)IOWN> Ilbca!dem in III,1'.&ral 1099 Food lode or Ins C61R 590,01;1. t CITY OF SALEM / I BOARD HEALTH Establishment Nam e�lJl��IYIhlli ( ��,1'�1t� 1� �71 . � Date: Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified - PLEASE PRINT CLEARLY I Kir r{ ,ne IY,51-�er^-knn YLUY'll t/lam J1AJ)kY I �G� �1�1( r(V l ,Y)f �5 `I•'7� i�ni;n°- i/ISMn ��. V nin r Y1 re-4I red i o -rein n 0� 41°F ny l�irx v 0 ' '(Wi it P n4 iP() 7 Sfi� IIS°hf �rn�v ��os 1vrPQ �1 } i��rS/Jna n- �--t7)� nl? Nnnu4' U( XPs; hi) l��2M6na .I 1 - _-VIA s n) hCG S-7v mC� �A 61t n 4 _ ��n (zf rt`'1 �!5): t cam. . 4C' o- -4Pla r u rHn 1 i-io � 41 )l x_(11 RP i - r'��)U - (YYtnRI,et/ ,o GP D04C woo -) o(rrQ /-m-ho nC ronnlnovc itAllio oid 11k (rQ . I I 1 } I i i �y,'A tuo \',d 1 ✓r�.e�li�� 1� Pr�� -F�r a� - �i i ��.1� �� ,l c�imres 1 — 1 Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion valations 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 no6rompliance may result in daily fines;Ofwknty-,ive dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. A,41M ❑ Voluntary Disposal :1Other: P1-1F: Recei"ed:t 1'euiperanures ' Violations Related to Foodborne Illness Interventions and Risk Accorim^io Ia¢-Cooled to Factors(Items i-22) (Con.) 41'F745`F Within d Nutri. ' PROTECTION FROM CHEMICALS I 2 1.15 Coohnt,Methods ihr PI-IFs I ]a ' Food or color Additives 119 PHI'Hot and Cold Holding y I 3-501.1((R) I Colt{PRFs Mmmaincd at or below 3-,.0...12 .ldditive>', 590A04(F) -11"1-"F' 3-302.14 Protection from Iinappmved Additives I ;-501.I6iP.) ' I for PH F; i\1,untuEned at orabove 15 Poisonous or Toxic Substances 7.101.11 klenatymclnformatinn-Uiigina( Containers . .I6(A) Roasts Heid at or above 130T. 120 Time as a Public Health Control 17-102.1 I Comrr ( a,n Name -14'orkin;Crntwinerc" I , 17-201.11 Separation-�toraae" 3-.-i01 J Time as a Public Health Control'° 7-202 11 Restriction-Presence and Ut e� I ( Sc)0.004(H) Variance Requtrement f 7-20112 I Conditions of Use" 7-203 11 Toxic Container.-Prohibitions' ( REQUIREMENTS FOR HIGHLY SUSCEPTIBLE ! 7-2104.11 I Satutizrrn.Criteria-C'hemicals^` POPULATIONS(HSP) 1 7-_'01.12 Chemicals let,Washing Prndu;e,Criteria' I 121 j 8„�L I I(A) ffnp.:siruiized Pre-pac• aged Juicea and 7-204.,-1 I Dryin,Assents.Criteria" ! Bevcrac,.e s with Warainu,[.,the 3-80 t.I i(R) Use of Pasteuuied E!_gsi 7-205.11 Incidental Food Corract.Lubetrartis` 7-206.1 I Reciri:aed Use Pesticide.,Criteria' i 3-50:.?1(D) Raw or Parttaliy Cooked Animal Food and Raw Seed Sprouts Not Served. -206.12 R:xirnt Linn Sta!wm;"` 13-801.111C'i Unooered rood Packaec Not Re-served 7-206.13 Tracking Powders,Pest Control and ! lloniturinp^ CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3 603 11 COn'illmLr Advisory Posied&+r Consumption of Anu ru!1'ouds'Fhat are Raw. findarcoul.ed or 16 I I Proper Cooking Temperatures for I PHFs Not Ckherwise Processed to humiliate 3-40!.11 At17(2) ( Eggs- 155'F 1.5 Sec. ;_3p2.13 Pnsteun?ed F=f',r n Subm tate for R::w Shcil _ Eega s-brediaieServicc145°F'1.5se& 3-401.11(A)(2) Comm:ntaed Fish,Ddeats&Grunc 's Animals Animals- 155` ' 15 sec. 3-401.11(11)(!)(2) Pork and Beef Roast - 130"F 121 min* SPECIAL REQUIREMENTS 3-ri(il.l I(A)Qi Ratites; fnieded b'frtt,-- 155'�F IS 590.009'A)-(D; Violations of Section 590.U(i9(A)-(D) in seu, . catering, motile food, temporary and 3-401 1](A)(-') Poultry, %Vild Game,Stuffed PFIFs residential kitchen oneradons should be Stuffing Containing Fish,Meal, debited under the appropriate sections Poultry or Rio ites-I65F 15 sec. above if related to fnndborne illn;cs 3-40 1.11W)0) Whole-muscle,Intact Beer Steaks interventions and rick. factors. Other i45 T;. 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a ( practices mould be dciated under #29- blicrowate 105'F j Special Requirements. 3401,l1(A)(1)(b) All Other p!-1Fs-- 14>`" IS sec. * ! 17 Reheating for Hot Holding I VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.1IfA)&fD) PHFs 165'F 15.sec. * I (iterns 23-30) 3-403.11(B) Microwave 165°F 2 Minute Rtandine Critical and non-critEal vrolotioin. which do nut relate to the Timex, loodhnrne illness iorc'1 cciulon.s,;mf risk firctors fisted oboe, an he 3-403.11(C) Commercially Processed R-f F FtxA- ' find i„the jt,"fou mg sections of file Feud Cock aruL25 CNH? 140:Ft 590.000. 3-403.1 l(F) Remaining Unsliaed Portions of Bc�f I ("-iteGood Retail Practices ! FC 590.000 23. Management and Perso^.ne! FC- Roasts" 2 .003 18 Proper Cooling of PHPs I 24. I Food and Food t'relectton FC-3 004 25. Ec uiomen+and Utersits F0--4 .005 'z.501.14(A) Cooling Cooked PHFs from 140"F to 26. Water, Plumblrq ane Waste -G-5 006 70°F Within 2 :lour+and From 70`F 27. Physical Fr_.cility -G-6 .007 I to 4]'F/45F Within 4 Hours. ' 25_ Poisonous or Texic Materials FC - 7 .008 3-501.14( i) Cooling PFiPs blade Fmro Ambient 2'3" I Son:inl Regwreme-,rs I OCg ---1 Temperature Ineredients to 4 t"Fp17'R 30. ; other Within 41loms* ' Deno:r:crutcal item m the tadrrnl 79ov Pond!lode or IU<.C'�9R 570(700 CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date 1 No. Reference R—Red Item Verified PLEASE PRINT CLEARLY I I � I 1 I � I 1 I I I I 1 11 Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal 0 Other: 3-501 IY{C) PHFs Recerved.u'remperatures Violations Related to Foodborne Illness Interventions and Risk According to I mN Cooled to Factors(items 1.22) (Cont.) 41'F145'F Within 4 Hour,. PROTECTION FROM CHEMICALS 13-567.15 Cooling Methods for PHFs 19 i PHF Hot and Cold Holding 1; Food or Color Additives 3-50;.16(B) Cold PHFs Maintained at of below 3-202.12 Additives" 590.009(F) 91'f45'F" 3-302 Id Protection from Unapproved Addihvei* 3-507 IL(,q) Hot * Maintained at or abuv;• 15 Poisonous or Toxic Substances :41) 0zF. N. 7-101.11 identifying htformatton-Original ( I ;-50:.16(A) Roots Held et or above 130°F. .k J 20 Time ac a Psbhc Health Control 7-102 11 Comsnun N:,rne-W:eking Containers � f 7?01,I 1 Separation-still age" 3-507.19 Time as a Public Heabb Control" q u:reupent 7-202,1 1 Restriction --Yresenee and Ilse r 590 004(H) Varwnee Rea ! 7-202.12 Conditions of Use' 7-203.11 Toslc Containers--Prohibitions" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criterw- C'hemicals» POPULATIONS(HSP) 7-204.12 Chemicals for Washing Produce,Criteriar' 23 3-801.1 If A) i CnpasteunredPre-packaged JUILeSand 7-204.19 Diving Agents.Crirrtia" I `'evern+tes with Warning labels* 3-Sill 11(B) i 7-205.11 Incidental Food Use of Pasteurized ELes'Contact. LubncantsT i 7?06.1 7 Restricted lisz Pesut;des. Gulose* � ( 3-SU(.i lt7)) Raw or Fat Sprouts shot S Amnuil Poxxl and 7-206.12 Roden, Bait Stations' Rm-Seed Sprouts;;\ot Set's zd. 'x 7 206.13 Tracking Pov.ders,Pest Control and 3-vO!.11(C) Unopened Food Packag: Not Re-screed Morrito Ti " CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-60'.11 Constuncr Advisory Posted for Consumption of initnal Foods That arc R rw, Undercooked w 16 Proper Cooking Temperatures for I Not Othereise Processed to Eliminate PHFs I 3-401.IIA(1)(2) Eggs- 155'PiSSee. I i latho;;zns.x P"'"` 3-30'.1° Pasteunzeo F. ^s Substitute for kkoti Shell Lggs-luumediatr Service 145`P75sec* gc 3-40I.i t(A)(2) Comnunuted Fish.Mealsts k Ganicesz y Animals- 155'F 15 sec. ` I SPECIAL REQUIREMENTS 3-401.11(B)i,l)(2) Pork and Beef Runs! i30'F 121 mini ! 3-401.1 I(A)12) Rautes, Injected Pleats- 155`0 15 590.009(AHD) Violation;of Section 590.009(A)4D) in ec,+ Catering. mobile ran!,temporary and 3401.1 I(At3) Poultry,Wild Game.Staffed 11111�s, ic;idential kitchen opereiions should be Stuffing Containing Fish,Meat, dehited under the opproprmte sections Poultry or Ratite,-165'F 15 sec. ^` above if re!aled to Riodborne illness 3-401A 1(C)(3) Whole-muscle,intact Beef Steaks interventions and risk factors. Other 145°F' 590.0119 vioiation3 rclatin;, to good retail 3=;01.12 Raw Animal Foods Cooked in u ( pra,tic.---s should be.debited under Microwase 16YF � Special Regnirernent,. 3-401AI(AI(I)(b) All Otiaa PHFs-- 145'F 15 sec. * 17 Reheating for Hot Holding ( VIOLATIONS R2LATED TO GOOD RETAIL PRACTICES 3-403.11(A),&(D) PHI. 16591 15 see. (Items 23-3€)) 1-403.11(B) Microwave- 165'F Minute Standin:, Ciid:'r,;,:n,l nun-rrUi<rr ctol„hanr, ichLh do not rs,',:a to the 'rime* foodborne illness intcivcntirrs and iiA J:rc toss lived above an be 3-403.11(C) Commercially Poicessed RTE Fe"I- found in the(,ilem ni;rrrtioro,q(IHr Peed Cod,aad 10) 1 MR 140'F* 590.000. 3-403.1I(L) Remaining C'nsliced Portions of Beef I Item Good Retail Practices ! FC 500,000 Roasts" 23. Maneoement and Personnel FC - .003 Ift Proper Cooling of PHFs 24 Food and Food Protection FC - 3 .004 25. Equipmcntand Uiensls FC-4 .005 3-501 14(A) Cooling Cooked PHFs from 140'F to 2E. Waler,Plumhinq and Waste K--S 006 J 70'F Within 2 Huun,and From 70'F ( 27. Physical Facility FC-6 .007 to 41'F745"F Within 4 Hours. * 28. Poisonou3 or'I-oxic Materials FC - 7 ! .008 3-501.1.11 B) Cooling PHFo Made From Ambrem ' 29 Special Recuirements 009 � Temperature Ingredients to 41'Ft45'F 30. Other j Within 4 Hours* . ^•;nr,a..z a•< Denotes cnmc,il nem m:hr ftderal 19()u Fund Cade or III°.CMR a90 000, CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Item code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY I 1 I I j � 1 I 1 I � I 1 I 1 j 1 I _ Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ .violations before the next inspection, to observe all conditions as described, and to Exclusion cofiiply with all mandates of the Mass/Federal Food Code. I understand that P ❑ Re-inspection Scheduled ❑ Emergency Suspension ' znoncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your,food permit. ❑ Voluntary Disposal ❑ Other: M 3-5ol 141' PHF,Recer.rd.:: Temperatures Violations Related to Foodborne illness Interventions and Malt Ac:ording to tatw C ogled to Factors(Items 1.22) (Cont) 4!'F/45 F V,ithin 4 Hour::. PROTECTION FROM CHEMICALS 3-K1.:5) Cooling Methods (or PHF, 19 PHF Hot and Cold Holding f1S Food of Color Additives 3-50;.i((B) Cold P1117,Nl,nnmincd at of belo•A 1 3-202.12 Arlditives,^ 590.,,Y' 41F) ( 41''45"F= 3-302.14 Protection iron Unapproved Additives" p j Poisonous or Toxic Substances -50I 161A) [lot FHEs hinintaineti at or above 40`F. 7-101.11 Identifying}nfixlnahon-Original Container:," I :._501.16(A) I Roast;Field at or above 15(7']-•. Container,' ' 7-102 11 Common Nome--�:'i orkina Containers" 20 ( Time as a Public NealOt Control 3-501.19 'lime as a Public Health Control=' 7-20 1.I 1 Sepera;ion-Storage" ( 590.0041 H) 4'nrhmte Re 7-202.11 Rezrriction-Pre,ence and Use" qntrement 7-2.02.12 Conditions of Use, 7-203.11 'Colic Container,--Prohibitinus� REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-207.11 Sanit;zets,Criteria -Chcmicals� POPULATIONS(HSP} 7 '_03.12 Chc,nicals (ur Washing Produce, Criterin" 121 ! 3 SCI :,i(A) t'n^asttu:'tred Pr-packaged.luicrs and Hevei::•_es s;ith \b'arnlne Labels( 7-20.71.4 DrvtngAgents Criteria' 13-80!. ;(b) Use .rfF'astemizeciLI 7..205 11 hici kntal Fnod Contact. Lubricants. ... 7-200.11 Restru;tra Use Pcsticicks,i?rteria* 13-80:,l 1 iD) Raw ur Factially Cxaked Annual Food and 7-7.06.12 Rodent Bait Stations, --801 Seed Sprouts Nut Served. t -801 I 1 i C) Unopened Food Package Nut Re-ser<.ed. 7-206.13 Tracking Powder,,Pest Cnntroi and Monituring:< CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Cor.sumcr Advisory Posted fur Consumption of Anitnnl Fonds That are Raw.Undercooked w 16 Proper Cooking Temperatures for ( PHFs No"Otherm"Is"Processed to hlinnate ac+w,r;v�iar -401.I I At 1)(2) Egg,- 1.55`F1.5See. I Patho!,cm.T Ens-hnntediate Service 145°Fl5,ec� '-3(1'-.1 }'csteurtrzr. E;gz,Substitute got Raw Shell l314OLIItAl(2) t'om.n:rtutedl-ish h'lca[s&Game FQgs� .Animals- I55-F' 15 SPECIAL REQUIREMENTS3-401.11(fill1)(2) Pork and Beef Roast- 130T 121 min" 3-401.11(A)(2) Rattles, lttjccted Meats- 155�F 13 .590.000(A)-(G) Violations of Section 590.009(A)-(D) in seC, catering. ;nubile Pool,temporary:ud 3-401.11(A)(3) Poultry, Wild Game,Stuticd PHPs, residential]kitchen operations sli,xdd he Stuffing Comaining Fish,heat, debited under the appropriate sections Poultry of Ratites-165°F 15 sce. ^` above if related to foodborne illness 3-401.11(C)(3) Whole muscle,hitact Becf SteAs interventions and risk factors. Other 1.45=1,'- 590.009 violations relating to good retail 3401.12 Raw Animal Foods Cooked in a pi acuces,hould he debited under#29- M1Lcto•wace 165°17* Special Rcquitements. .3401.'.1(A)(1)(b) All Other PHF, - 145T 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.1l(A)&,(D) PHF. 165'F 15 see. ." ! (Ite=ns 23_30) 3-403.11(B) Microwave- 165"F 2 Minute Standing• Cdt<ral and rz,w-rtim.al vrolnttwn. ahirh dr,not relate to the Time" Inndhorne irbtery into a-enlion.c and rirkJartori listed above, ran he -40:i.11(C) I Commen mlly Pua%essed RTE}-aid- fudurd i;, tkr Jitiiou=Ing see!iorac of the Fond t'c•de and/OS CAIN 14017" 3-403 11(17) Rnownimg Unshced P•.;rtivas of Beef I Item Goad Retail Practices FC 590.000 Roasts* 23. Ivlanagamrnt and Personnel FC -2 .003 Ig Proper Cowling of PHFs 24 Foci and Food Protection FC-3 .004 25. Equipment and Utenails FC-4 005 3-501.14(1) Coling Cooked YHFs from 14W17 to 26. Water Plumbing and Wa,lo FC-5 : .006 70"F Within 21-Sour,and From TFF 27 Physic al Facihly FC-6 .007 to 41"'r745°F W'iti-:ir:4 Hours. " ; 28 Posonous or Toxic klal:mals FC - 7 .003 3-5011-1.(13) Cooling PHF.,Made Fiam Ambient 20 I Soaazi Fequi-ements oo0 Temperature Ingredients in41`7745°F 30. Other I Within I Ilours* •Deiarie>uncal it in m the f,,Jend i 101)Food Code of ISIS CN41t 590 000, . !;•4-±y+i�.b'y'�..,w:;wy. w €" .d;', -.wK?W. .ra. ' `""' - Sa�:92SFX»'i:'•�_` fes' `• «�'-`»�.+�,}'�f!'' .+&'�!`Pi�f4e�Yii£B'�. y. xF'' t'.ti^9T'+', � 'w+�:nc::Wa�-..e.m„s�....•� , -L ..,, FF r, a _;r...M• . d' +^.- z ,+Y .'}�,"t � �«. ., T�'-'"'" ..+,nrt«: r..., ., +. . ..._... o .e.-..s=..--,.-... ...... .«...-. -'. ...nyn,'•f .+Ei` '.�.5 �: . CITY F SALEM MASSACHUSETTS -, - BOARS: OF HEALTH . 120 WASHINGTON STKEET, 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: Dunkin Donuts Address of Establishment: 152 Washington Street Owner's Name: Robert M. and Anthie Jackson Restrictions: Application Date: 12/2/2004 Permit for Food Establishment 114-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT CITY OF SALEM9 MASSACHUSETTS BOARD Qfj HEALTH N qq 120 WASHINGTON STREET, 4TH FLOOR �V ® COO SALEM, MA O 1970 CITY �F TEL. 978-741-1800 BOARD SALEM OF FAX 978-745-0343 HEALTH STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2005 APPLICATION FOR OPE PERMIT TO TE-A FOOD E T BLISHMENT _ OPERATE'A NAME OF ESTABLISHMENT��.G �� .W�� S tl •It ADDRESS OF ESTABLISHMENT A MAILING ADDRESS (if different) if OWNER'S NAME \ ��"rin/ ''t- - - w --TEL#�1�D ADDRESS ,�rGG_ i� •I CITY 0-7(1.RCP'(` -' v= I�i <' ,�.:v - 'ZEP MQ- U CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (`�o v` 14 (required in an establishment where potentially hazardou food is prepared.) 'n EMERGENCY RESPONSE PERSON }' C �¢j[T�(1 6#E3fNE TEL# HOURS OF OPERATION:- on. Tue. Wed. Thu.Fri.-Sat. Sun. h TYPE OF ESTABLISHMENT FEE check only F RETAIL STORE YES NO less than 1000sq.ft. =$50 77 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT &) ' N � �I / f_ less than 25 seats =$100 �UJ 25-99 seats more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state t xes re u. ed under the law. Signature��1 I _� Date 1�1`(� Social Security or Federal Identification Number �� 1 I�FII + T T Revised 11/03/03 FOODAP2.ad Check#&Date 76 I'1Ta7J ( IMPORTAW MESSAGE ) , FIR '15-71_ ' /.1 / D DATE � � —D�Y TIMED' M OF p PHONE ///�2)i 7 MFA CDOE NUMBER EXTENSION O FAX ❑ MOE311 F AREA CODE N ER TIME TO CALL TELEPHONED PLEASE CALL I ', CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU I RUSH RETURNED YOUR CALL 1 WILL FAX TO YOU MESSAGE y _ -•A��c�;�H�1� SIGNAb i ib" FORM 4009 MARE IN IJ$A NOTES 7 - e;- - - r CITY OF SALEM9 MASSACHUSETTS r' BOARD OF HEALTH g} 120 WASHINGTON STMIFET, 4TH FLOOR . a SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, 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: Dunkin Donuts Address of Establishment: 152 Washington Street Owner's Name: Robert M. and Anthie Jackson Restrictions: Application Date: 12/15/2003 Permit for Food Establishment 201-04 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. AG CITY OF SALEM, MASSACHU!3ETT BOARD OF HEALTH 5 SALEM, MA 0 1970 TEL 978-741-1800 FAX 978-745-0343 CITY OF SALEM �.1�d ` NAME OFE3TABL|8HW1EN |EL# �4��Qh �� Ct�� | � ADDRESS OFESTABLISHMENT , MAILING ADDRESS (if different) OWNER'S NAME TEL# CITY ZIP fzy�a C _'O ANA(5ES NMI (required in an establishment where poten t ally-hazard&s f�oiodl tis frepared.) EMERGENCY RESPONSE PERSON H4iiM TEL#" M�33111 HOURS OF OPERATION: lvlon.ATue.2�A�Wed.-A A4\ FrQ�Sat.A�S.n.�tqk TYPE OFE3TABL|SHMENT FEE check only RETAIL STORE YES �l,y//0 7' less than 1000nq.M. =$ 50 � �/ / ~�� (7V/ 1000'10.000nq.M. =$100 more than 10.000sq.ft. =S250 RESTAURANTG NO less than 25seats E_ 25-99 seats =Q150 more than H9seats =$200 ' BED/BREAKFAST YES $100 \ ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES $5 TOBACCO VENDOR YES $50 ALL NON-PROFIT/�u�has �hurch/��cheos) YES /0O� $25 ` , Please pay total with one check payable bothe City mfSalem This Permit is not transferable and must be reissued upon change of ownership. The Permit must bmposted inaprominent location inthe Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant toMGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that 1, to my ofiled all state tnsd id || stateto eoroqui,odundortho |aw. 0/�\ ~ 4�`\� ^8�9A Signatu�u � 0 � Date'" odera| Identification Number --------------------------------------------------- -------------' Rovisod11/03/03FO0UxP2.adm Chock#$Date-W'\CkOJA �)Vr / _ Massachusetts 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 i Name Date I Tysfe of Ooeration(s), Type of Insoection _7a,)Alk.A/ 1� n., Yc /a-8-D7 ® Food Service ��loutine Address -�- Risk ❑ Retail Re-inspection /c 11 /rr .Ct Level El Residential Kitchen Previous Inspection Telephone El Mobile Date:G-/ 6� 4J U_ ?5?75 CCP Y/N - E-1Temporary El Pre-operation Owner HA UAA91L�jl, v-t&_Ty'.c.t- ��c r q I ❑ Caterer ❑ Suspect Illness Person in ChargVg(PIC) �/ Time El Bed&Breakfast El General Complaint K r �.. ,r i/ -YAl, In. ❑ HACCP Inspector 1I,. s It F I Out: Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH - El2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS E:13. Personnel with Infections Restricted/Excluded El 14.Approved Food or Color Additives ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection 1-120.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) El 10. Proper Adequate Handwashing F-121. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR 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) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(55990.0 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)(590.008) 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 50Ms,UFormB-14 d. Inspector's Signature: Print: PIC's Signature: ��//..��jj �r Print I Pagel of-J Pages Ll .AAA,r/.in Qir I Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT N Crow-umtaminat4un 1 590 UO3(A) Assignment ul'R--sponsibility" 3-303.11'A){t) Rev, Anitml Foots Sy:areicd hom 590.003(B) Demonstration of Knowledge` Conked and RTF Fi,o& 103.11 ( Person in charge --duties Conta,mnar,on from Hawing:edierts 3-3021 1(,l){'?i Raw Animal Funds S.rarateci front Each EMPLOYEE HEALTH Othcr' 2 S90.003(C) Rcsponsibliry of the person in change to ( Ccrtarovalion non,the Eavirorment j require reponinr by fo(xl employees and ' 3-302.: 1(A) Food Protecti nn" applicants" 3-302.15 Wi..,time Ptvitc,md Veyetablrs j 590 003(F) R,Nponaibiht} OCA Fotd Employee Or An ' 3 ;(4.11 Fond Contact roeh Equipment unit Applicant To Reper i To The Person In Urensah'" Charge* Go,tamrnahon trona the Consumer 59(;(N)3(G) Reporting by Person in Charge" ( '-=,OG.t t:Ait B) Rclumcd Food an;Rever,4ce of Fo)d, 3 590.003(ll) Exclusions andkcsnictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Erclusions,md ReQncnur.s Fuca 3-701.11 Discarding of Reconditionnte Uns.tfe I FOOD F IOM APPROVED SOURCE Food* I .41 Food and Water From Regulated Sourcos 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law` ( 4-501.111 Manual Wanawashing-f-Int Witter J-201 12 Food ma Hermetically Sealed Container` Sanitization'ieuipelaatreO 3 701.13 Fluid Milk and Milk Products'' j ¢ 501 1 t2 Mechanical Ciarcwa,hin,-Hot \eater 3-202.13 Shell Eggs. ( Raniuzati,,n Temperatures' ,x 4-501.7 1 1 Cba;mcal Sanitization-temp ,pFI, j 3-20_.1 3 Egan and Milk Products. Pastemized" � rroueneration and h.u'ducs< ' -,-202.16 Ice Made Front Potable Drinking Water` d-hw.l I(A) Equipment Fod Contact Surfaces and 5-lUl.11 DrinkingWatcrTr,nnanApprorrdSvsteni ( 590.006(A) Bottled Drinking Water" (Itensd.Cle.:n" 590,006041 Wam,Meets Standards jr;310 CMR 22.0 ! 4-602.11 Claaning Frslueny of Equipment Food- S'helHish,and Fish From an Approved Source Contact Sutl:aces and Utaniii 4-70'_'.; 1 Frequency of Sanitizaron of Utensils and .3-2Ul.ld Fish and Recreationally Caught Molluscan Fool Conlact Surfaces of Equipment* Shelltich^ 4-703 11 Merhods ut Samtizai.on-- Hoa Water and '3-,101,15 Molluscan Shellfish from NSSP Listed I Chemical° Soutces" 110 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority '-3017.1 Clean Condi:ion--Hands and:\rots* 3 2011S Shellstock Identification Present" 2-301.12 Cicanitri Proeu'uie" 590.004((7) Wild Muchroems, 2-301.i4 When to Washt" 3-201.17 Came Annuals* { Ti Good Hygienic Practices 5 Receiving/Condition 2401,11 Latina,Drinking or LlsimZ robaeco- 3'_'02.1 1 PRFs Received at Proper Temperatures* 2-40 1.12 Discharges From the L'}es. Nose and 1-70215 Fxckaeeluic�eritY;: Moui:W ( 3 101.11 Fcxd Safi and Lnachdteraa.d., 3-301.12 Prewnting Contamination When TasungT 6 Tags/Records:Shellstock Prevention of Contamination from Hands j 3-202.18 Shell•acxicldentification' j 590.0UAI E) Preventing C`nntanunation from ' 3-203.12 Shellst(•:k Identification Mauauined* F.ntpluyees' ( I 13 Rmcwash Faciilnes TagstRecords:Fish Products Go 3-?0'_.11 Parasite Destruction, I r;vententry Located and Accessible 5-402.12 Records,Creation and Retentwe", `='03.1 l Numbers and Capxc:ne>` 590.00417) Labeling of Ingredients` ( 5-204.71 Location and Plac?trent' ;r Conformance with Approved Procedures j 5-205.11 :lccesnbi!ity, Operation and 19arnteaatter /HACCP Plans I Supplied wdh.Soap and Hand Drying -:302 11 Specialized Processing Methods* Dimal s 3->02 12 Reduced ox. Len ackazm criteria' (;-301.11 [landwa�hnt, io6Clc, se!'.Availability 8"10'3.12 Conformance with Approved Praxdures': 6-301.12 Eland Diving Aotis,n;, Denote;.critical item m the federal 11499 Food(.oJe v iii Ctill;`.90i00D CITY OF SALEM BOARD OF HEALTH Establishment Name: A>.v<1 a/ /�rnc� �ua.c�ii vc � St Date: 0 f( Page: of Item Code C-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item ; tie ^�.� Verified , ,-� � PLEASE PRINT CLEARLY , /9,�.n�sliFr�io� .fr�Tei,/: ` 1 I . . I I 19 — 44�rl72lg?.AWt,/ ftURL, /4511,,i gy=m 0 '/K of - 77� A_z LIS` RPS II /9 — � 10/9 1 f ZPGT' o>' ruIt,?v it /�AG� 7��/h 416 -,Ao x, 4o(S`'T e alofwr I ,n) 0?7 — 1�/�nR/srv�rt Uo/{fc D¢ ./�i� rl� /7rS17/az� nircr_S �G �Ii�v� �P1J/2�(�l//_ �iTUY/PS I I I I I I I I . Discussion With Person in Charge: Corrective Action Required: ❑ No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. WA-&'1 ❑ Voluntary Disposal ❑ Other: r � u 3-50E.:,VC) PHFs Received at'F�nwuratures Violations Related to Foodborne Illness Interventions and RisA Accciding to Ian, Cooled to Factors(Items 1-22) (Cont.) sl`F/45'F Within 4 Hours. PROTECTION FROM CHEMICALS 3-Sr)1.15 Coohng;MrethodsforPH'Fs ' 19 PHF Hot and Cold Holding 14 Food of Color Additives 3-501.16(1.;1 gold pflPs Maintained at or below 3-202,12 Additive 1-302.14 Protection from Unapprnocd Additives` 511000^.('-; 41`1445'F" i-501.Yi(,^,) 11,Y,YIiF, iv:aintaiurrl ut or above 1� Poisonous or Toxic 5uostances 7-101.11 Irlenuf}anc Infornt.nron--Original 3-5u 0 r. Coutaincre" i.l.I!(A; Pearls Held at or abode 1JO0F. " 7-10111 Common Nam. -Working Containers" � ( 20 Time as a Public Health Control '3 '(t' () Time as a Public Health Conr;o!* 7=L( L11 Separation-`,n±: > ' 7-21211 Rcsttiction--Presence ad tce'° i90.U!h7{H) Variance Requirement i 202.12 Conditions of U;o' j j 7-203.11 Toxic Container-Pidabitinns' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 17-204.i i S'anitizers,Criteria --Chemicals* POPULATIONS(HSP) 7-?1)•1.12 Cher for WaSbno:� Produce•.Larteria" 121 ? Sol I I(A) UnpisIeurized Pre-packaged Juices and Bcv.lages with Warrflo� 1 vbclsT 7-204.14 Drying Aeents.C'nrerm' - -- 7-' r 3-SW.I1;B) I.'se A pasteurized Egin ' (15.11 ittcidcnh,i Food C�mtae Lubucam 3.501 11j)) Kra cr Pa,tially Cooked Amina;Food and 7-206.11 Restricted Use Pesticides.Criteria* Kae.Seed Sprouts;vet Served "^ 7?06.12 TrackiRodenng g R. 5dc rs. Pe 3-8OL I I(C l Unopened Food Pecka c: 'Not Re-served. c 7=06.13 Tracking F„wders. Pest Control and Monitoring' CONSUMER ADVISORY TIME!?EMPERrtTURE CONTROLS 22 3-603.1 i C'onsum:r Adr,isorp Po,ted for Conson)ption of Aliacial Frods That arc Raw. Undercooked ter 16 Proper Cooking Temperatures for PHFS Vet Otherwise Ptm rocessed to Eli ,tate � g er,P ,-401.11A(U(2) Eggs- 151°F 15 Sec. iaihngcns. E�rzs-ltrmiediateService145`F15sec' 3-?02.13 Pas!euri-/edEo,nSubstnut, foiRaw Shelf 3-401.1It.h!(2) Comminuted Fish, M14eats& Gantt Elags" Animals- 155R IS sec. = SPECIAL REQUIREMENTS 3-40 1.11(B)(1,1(2) Pork and Beef Roast - 130''F 121 nun* 3-401.11(A)(2) Ratites. Injected Meats- 155�F 15 5`-100''WA)-tD) V,VitttiOnS of SeUion 590.009f'A)-(D) in sec, ` catering, mobile texxl, temporary and 3-401.11(A)(3) Poultry, Wild Game,Shifted 111-fFs, residential kitchen operations should be Stuffing Contaminp,Fish,Meat, debited under the appropriate sections Poultry or katitee165'17 15 sec. abo•,e if related to foodborne illness 3-101,11((7)(3) Whole-muscle,h)taLt bee1'Cleaks j ir-tervenhons and risk factors Olhcr 145=P* 590.009 violations relating to good retail 3-40 1.12 Raw Animal Yotxis Conked in a (n,actic.;sluwid be debited under tr24 - Miclowave 165"F* I Special Requirements. 3-401.!1(A)(I'.rb) All OthmPHFs- 145"F IS sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.111A)&(D) PHF:, 165"F a sec. " (I ferns 23-30) 340_;.1 I(B) Microwave 165"F2 Minute to Stands); Cri:r.ala:ud non-,'ritical virkmnvs, ndrich do mrt'-elute w the Timc" foodborne diners Ivtervcrhons and risk,4utois li.lered above can be 3-403.14C) Commercially Pioce,sed RTE Food- ,found in theJullov,-ark sections u(thr Fund Cody and 1015('MR 140°F* 590 000. 3 103 11(E) Remaining Unsliced Portions of Reef i Item .^:cod Retort Practices FC 590.000 Roasisr. ( 23. 6lanagement ano Petsornel FC-2 .003 18 Proper Cooling of PHFs ! 24. Feat and Food Protection FC-3 004 J _ - 1-�(11.14(A) Cooling Ccxi4:ed Pl-IPs from 14q`F 25. Equipment crld utensils FC 4 .005 to ---------------� 26 Water,Plumbing and Wase FC 70'1-Within 2 flout;,mid Fran 70 27, Physical FaciIry F('--6 007 to 41`F/45"F Within 4 flours. " ! 28. Po,sonous or Toxic Materials FC--7 1 .008 3 501.141 R) Cooling PFIFs Mad. Front.Ambient ' 29 Spaara:R,0-arerents 019 Tempeiatuie Ingredients to 4I'F/45-F 30. Other j Within 4 I lvar ° 4 Denote:,enucai ilem m the imeial 1,199 Food(',ode cr hill CHIP."'a)0004 .Massachusetts Department of Public Health Salem Board of Health 120 Washington Street.4i' Floor Division of Food and Drugs Salem,MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978)741-1800 Fax (978)745-0343 { Name Date yoe of Operation(s) TVoe of Inspection 71 IAA ,f %�5 f r I (9. i d tl I �G1 Food Service ® Routine Address Risk ❑ Retail ❑ Re-inspection /rn . Sf Level I 171 Residential Kitchen Previous Inspection Telephone _ 1 ❑ Mobile Date/-0k- i n1i.r_ nSA ❑ Temporary ❑ Pre-operation Owner I HACCP YIN ( F1 Caterer [I Suspect Illness .0 IP Person in harge(PIC) Time 1 71Bed&Breakfast ❑General Complaint /(;rwfikihr r11/01.1In: ( ❑ HACCP f Inspector > Out; Permit No. El Other r/r j1'�"'A1P, r/XYtn..r'rf e C Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Nan-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 ] 14, Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE - TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition [116.Cooking Temperatures !❑ 6. Tags/Records/Accuracy of Ingredient Statements [:] 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans [:118. Cooling PROTECTION FROM CONTAMINATION E 19. Hot and Cold Holding ❑ B. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) [:121. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction:.Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report, when signed Gelow N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590A03) 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 5. 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.o07) 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.o09) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: 5&Wjnspsci On -14. f _ l P PIV naturgr�ea:ttuure:� Print: 61 '�g' .:fn , +Fkint: �uftir Yw Pagej- Pageses 1. Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 "as' taminaticn I -ioft.003lA) -302.11(,x.:(:;lRaivAnimaliood SE crated from i Cookedand RTL 5,od s'- 4,90.00:0) Demonstration ol'Knoiviedl,e "-I(),A I Person tn charge duties ContaminaEcti froff,Raw Ingteatents 3-30111(A,i(2) Rao,Aninitt!Fads Serara*,M{rota Fach EMPLOYEE HEALTH Other' 2 590.003X) Responsibioty of the jr:tricri in change to Ciroiatramrior.,[tort,the Ei.wronmont recitUre lep'll-ring by food --niployces and 3-342.:;(A) Ford Protpaiw- applicants* 3-301IJ Wa;hini: Frui18 av,t V,,gettibles 590M1t3(F) Responsibility Of A Food Employee Cr An Food Contau with Eqtupimernand Ptpplicant'to Rcport'l'o Tire Person In Iltcnsils* Charge" I I Confattrinat;oo fictnthe Consumer W0.003(G) Reporting b}Person in Cterui-306.I^(AtiLI R,-tum�d F nod and Reser-,ice of Food' 3 590 003(D'i Exclumonsand Pesuici ons* Disposition of AduJtsra.�Pd or Codamir�aled I -EXdog 590.01,13(Fi Removal(11 ioni,and Restrictions Food 3-77,1.11 Disc.mciue or FOOD FROM APPROVED SOURCE Foods I 4 Food and'M,..-&r Frons Reoulated Sot;rcev 9 Food Cor-.tact Su--faces 59,0.i,1u;4(A-B) �Jnpintnce with Food laws 41-501 111 6ianual Wwtwa.hing- Hot ,,Vat._,r 3-201.1: Food in i. Het uiefi�alh Scaled Cont,,Anc& S, I 3-201,13 i 4-50 1,� 12 Mechanical Wttre��asbirnFiat Water Fliou Milk and Mill, i!lrodwts* I 3-2o2.[I I Shelf El-as- 4-�ud,114 C'heriacal Sanittioa i/imon-retail.,pH, 3-202 14 Eggs into Milk Pr(Aucts.Pasteuriz-_-& tollmltral:tttlalld haldne,,s. 3-1.02.16 Ice Made From Potahle Dr-inking-Water' 4-6,01 1 ItAl) Equipluen'! Foi,j r7onfat, SUlIaLu,i and 5-1o'.1 1 Drinking Water from Approved S�rtexn- I;tensilf.(']call* 590.006(A)90.006(A) i Bottled Drinking Water' 4-602.11 Cicaning Frequeo,.y of E-quipment Food- 590 006!13) Water Meets Stan-lards in 310 CNIR 22.W4 r' I Coro art Surl":,:eeand Utc-wnl-;;` Shatffivihsnd Fish From an Approved Source 1.702. 3201 14 Fish and Recreationalk Ciai,ht Mollusciat Ft�,]Co:,rid Surfacer, ,Ti71tilni Vf tTlentils and d ' -J-7f13 It ModittL*.s of Saintization—Hot Water and 3-201.15 it'1101JUSLan SheMisli froin NSSF Listed cheriliciv Sources` Proper,AdequateHar-dwashing Game and Wild,Mushrooms Approved by ilF 1 2-301.11 Clean Condo;un—Hainis and Arms" Reioulatotir Authority i 3-20118 Shelktock Iderinfication Present" 2-30IJ2 1`10C_dLd'� 590.004iCt, Wild lvlushrooms' 2-301.1=1 When In Wnsll* 201.17 Game Animals* it Good Hygienic Practices 3 Receiving/Condition Drinking or rising Tobai,ia)" 3202.11 T'Iffs Received at Propel Temperatures'" 2 4ul,12 Dischorges From the Eyes.Nose and 13-202.15 Packaze ljttegrity* I 1'rteuth:- 3-1W.11 Fot,d Safe and Unadulterated 3-30;.!2 Preventing Cculamillation Wien Tasting" Tags/Recordb;SnePsittic 6 k -12 Pnivention of Contamination frorr,Hands 1 5qfl 3-20.18 Sliellstock Idemiti(ation 3-201 12 Sheflstock Identificis;un Maintained'" Er--pirvoe:,' Tags/Records:Fish Products i 13 Fiandwastl Facilities "onveoJently Locateiand 14x6sOle 3-402.11 Parasite Destruction' 5 U3 I I 3'402.12 Rccoids.Creation and Retention S-_,o-�.I I I oI. t'ation and Ps and lacement" 5w.00wi) Labeling of Ingredients* Conformance with Approved Procedures 7 5-2(15.11 A:•cctviliilnv.Opu,_n.jn and%'iiwensmlx- /HACCP Plans f Suppled with Soap and Nand Drying 3-:102.11 Specialived Processing kIttluAs* j 3-502.121 Reduced oxygen packaging,criteria! 1.11 Ilandwishing 8-!o3 12 Confoinrai:ce with Approv-2d latoiedure,' f-301 12 Hand Drying Provision "D-11AV"trio;alat in in the :090 Fem!C(klc,lj I M CMR 50l:0:10, CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Z-1—all Page: of Z - r Item Code C-Critical Item NESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY I 9 a 7 C — Fi�✓ � cr�rr y �.�/ r <.x�ar2�s r v /�irnd f G�1C put / G�.r►L1 / � 1 cl /9 ARC>ofr%7 ,b 114A,oa w S h/N q N� E X�,f'n�ia✓4�0� ,[�a`� O'?CC L.OP.,� ?YlID?Z i vl I d Sftr�i�i�iaV9 N/A Aol✓nso'e(/ ✓ Ro es,)r /v rl 'e'?e Discussion With Person in Charge: I Corrective Action Required: I ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next' inspection, to observe all conditions as described, and to Exclusion f� ❑ 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 ❑ 13your food permit. yea 11�� Voluntary Disposal Other: 3,50: !4(C} YHF's I:ec�:aed at"1'entperatures Violations Related to Foodborne ttlness interventions and Risk .lcroriling to lav/Co"ded h; Factors(items 1.22) (Cont.) 41` A75'F Within d Hours. PROTECTION FROM CHEMICALS I 3-•hl 15 Cia,ling Methods ibr PHFs j 14 PHP Hot and Cold Holding { 14 Food Color Additives 3-501 6(F) Cold PHFe,s4amcainc d at of below 32(12,12 Additivve:` 590.00?(F) ( 41-/-i5`Pc 1-302.14 Pnnection from unapproved Addihvec Poisonous or Toxic Substances 3.501 ib(A) Not PIi'rs hlaintaiiied ar or above 13 140 F x 7-101.11 Idennt arae Infornkobon-(Original ! - 7 ' 5:11 161 A) i'oasis I I.ld at or e.bove 130''F ` Containers` { 7-102.1 I Common Name-Working C(untainers'° I ( 2!) Time as a Pvbli�Health Control 7-201.11 Separation-Storage' I 13-501.!9 Tune a�a Public Health Cottrul° 7-202.11 Restriction-PicaencrandUse,: I i 590.001(Fi) Variance Requirement { { 7-202.12 Conditions ut I lscr' { { 7-203 11 Toxic Containers-Prohibitions" { REOUIREMENT3 FOR HIGHLY SUSCEPTIBLE I 04.11 Sanitizes,Criteria-U,emica's POPULA o'IONS(HSP) 21 ( --801 I)(. ) 7-'_04.12 Chemicals for Washing Prnclu:c,C rinuia" { .O, Unorstewized Pre-packaged Juice;and j Leveiages with Waraing iabels^ 7 204.14 Drying Agents.Criteria'" { ?-801.14(B) u,e.of Pasteurized s* 7-2205.1 Incidental Fond Conrcct. Lubricants' j Egg { 3-:i01.;i(D} katy or Partially Clio',eel Anim.,l Fucxl and 7-206.11 Restricted Use Pe�itcides, Criteria" Rae Scd Spn.uis lc o!Sei vrd 7-206.i2 Rod-mot Bait Stations' { 3-„01.11((') Undo-,,ed Faxi Package Kni Re-served. '06.13 'Tracking Powder,,Pcst Control and &nitoi-in;;^ CONSUMER ADVISORY 22 3 603.11 Consumer Advisory Posted for Consumption of TIMEtTEA4PERATURE CONTROLS Animal Focus"t7rat me Raw. itndc:'cuuked or 16 Proper Choking Temperatures for I No,(1m.-rkse Pmcesscd to hiiminatc PHFs a=cin,,.v;aim Yathu_•rn..". ,401 I IA(U(2) Eggs- 155°F 15 Sec. - Eggs-humeri i:ue Scrv�ce 145"FiSsee* 3-302.13 Yasteunzc•d Egg,Suh:,tiune fcr ka„ Shell 3 4(71.11(2)(2) Commntuted Fish,Meats&Game Egg' j Animal.- 1552F 15 sec. " gPEe!AL REQUIREMENTS i3-401,!1(B)(I)(2) Poik and BeefP ,est- IXF' 121 min-; 5Q0 )Oc', t, ! 3-401.11(,0(2) Ratites, Inic cted Meat, -- 155'F 15 i t { ,uti ,LO) )olauous of Section .590.009(2)-(D) in sec. ' catering. mobile feed, temporary arid 3-401,11(A)(3) Poultry, Wild Game,Stuffed Pt Ws. resident,a! kitchen operations should be S'.ufting Contsinin,Fish,?vies,, detntcd under the appropriate sections Poullry nr Ra:itcs-165'1`7 t5 sec. * above if to foodboiae ilhnoss 3-401.1l(C)(1) Whole-muscle,Intact Brcf Sicaks ( 1nte�ventions and risk factors. Other I45'P* 59 09,Aclalions relatiry to good retail 3+01.12 Raw Animal Food,Ccxrkad in a practices should be debited under #29- Alicrowave 165'F " Special Requirements. j 3--!01.1 I(A)(D:b) All Ou:ei PHPs - 145"F 15 ici. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES j 3--403.11(A)&(D) PHFs 165°F 15 sec. ° (Items 23-i0) { 3-403.11(13) Microwave- 165'F 2 ilJlnttle Siandifig Ctiural and non-critical vm1erion.s, .:hich d„not telale to the jTime* foodbor-w diner;bete,ven,:ion,s una risk)actors Mated chore, can be; 3-403.'1(C) Comnrcr.inlly Prcccseed RTE Food, - (o0ud in the ti,llow"Px.sec:::s tit the Food Code and H)'i("I'll? 1404'14° 590.000 3-40".i 1(E) Remaining Unsliced Portions of Beef Item I Good Retail Practices FC 580.000 Roasts* 23 iManagameni and Persrnnei FC-2 .003 Proper Cooling of PHFs j 24. Fond ana Food Pro'netion FC--3 004 3-501 14(A) Cording Cooked PHFs fool 140'1=10, i-25.---.Equ:prnirt and Utesi!s FC-4 e i 20. Water, P 01iumU nq and W este pC-5 .00-, 70"F Wiifun 2 flour,and From 70"F 27 Ph'vslGal Fzcnity FC--e 007 J to#I`F(A5'F Within.4 Hours. 29 ?osoncus cr Tome Iv1a?aiiais FC - ] .00P, 1 3-501,11(B) Cooling PFIFs Made Fiom Ambient 12n sooaal Requirements 009 1 Temperature Ingredients to 4 1,145'F 3'J. Other ---i Within 4I1„urs'# i ' Deuoiec cnuc..d iie:u to Ov Cd,eil ](I",,)Fvod Code cr N",0,1P,$91 U(10. ty' L Massachusetts Department of Public Health Salem Board Health M 120 Washington S Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978)741-1800 Fax j978)745-0343 Name !_ Date T�'PPe%f Operafionfsb T e of Inspection '' �v fv11,)/.✓ /�fiY7uTS I f D8-D4V I [y'Food Service Routine ( Address / / Risk 71 Retail ❑ Re-inspection I /S 2, /1(J17K /ei7477 S- Level ❑ Residential Kitchen Previous Inspection ❑ Mobile Date:iI'far"(U Telephone /�9 ) ,,a. 9��Ir ❑ Temporary El Pro-operation Owner //�� /9 � �// HACCP YIN , ❑ Caterer ❑ Suspect Illness /1� F/t?f o //yr Thr TYr SiJ 77 ❑ Bed&Breakfast ❑General Complaint_). Person in Charge(PIC) [} Time ❑ HACCP 11-I4 s i7:IGi A.Ln 7"'/L t/2 T P� In: Inspector //� 7�l�ixr6�f7A0 S I Out; Permit No. 71 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 ❑ 14.Approved Food or Color Additives � ❑ 3. Personnel with Infections Restricted/Excluded [115.Toxic Chemicals FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source TIMEtTEMPERATUREOONTROLS(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 r [119.Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) _ ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices, Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report, when signed below c 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 (17C-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 5WffileclFpr 74,0. Inspector's Signature: --yam .yam` PrinE':t ✓ �} PIC's Signature: /, l Print: ^� �� Un (� ( Page of PPages �C_t_Y�/: JV� f A Y1R, 1 Violations Related to Foodborne illness lnferventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Ctnss-r:nntaminatirn � I 500013;A1 I .4s;ignnteuK•!'Re:ryrzistbiiav' i_3t 2.>'.tA:'1) Raw AwmalFtldsv;p::rah-dtium 590.0034) i Demonstration of Knr wh d€!er: j _ Coo ed and RTE F-xms' 2-103.11 Parson in charge --d:uies Contanvr rtien',•o:::Raw!uradents 3.3(1'2.1 l(A)1,') RxAli:awl FrsdE S-,m ated from Each EMPLOYEE HEALTH U:f,er- ------------------- 2 W0.003(C) Responsibility(d the person in stooge to - - Cantt:miraticn from 7ne Envirrnmeia � require wpoitm¢by fond emp!uyecs and 3-302 11 i A) FrxKi FrJteoounr applicants"' 3-302.1 i Vdashin, Fl WiS and Vvvetacle; 590 001(F) Rcapousibiht} Ot A Fusin Lv:iplo.�ce Or An 3-30.{.1 l t-'aod Crnh:a with)?gaipmrnt:unl Applicant To Report lo The Psson In ; iltenetP;'- Chatge' ! Contamrnaaon from the Consumer I 49n.Cf}31 G} Repurtingb}'person in:.hii!•g„% 3-306.'4G>l(%) Re.urnedFo:r'and P..:;rrv:cr,of 131 590,p03(0) Eschtsnnnsand Restrictions* Drs;;n:;ibon rfAdulterated or Contaminated j9WIi13(E; Removal of Eng- usions anu Restrictions I 3-ii?l l l D:ecwxling o: Rceoudrtimmng lircate FOOD FROM APPROVED SOURCE Fwds $ Fond and Water From Regulated Sovrrec { 9 Food Can?act Surfaces r 0.004(A-B) Compliame with Food Law'r 4-501.111 Manual Wartwathine-Not Rater 3-201.1" Food m a i-lu'meucally Sealed tont:mer Sanitizmion'1-emp:ra;ores" j I <4-50;.1 C Mcch-'.-al`n'a-.wasF,in 1`nr Water 3-201 t� Fluid Milk and Milk Frociuce�` � ! m i 3-7(2.13 _Shell hogs'" I Sanitization ,emparaturez" 14 Hg_ „ ur ,;and Milk ProducePas-Eize& 4-501.'.i d Cheantal Sanitiratiou-lent1 t.}1'H, : 3.2Q2 r. I Conten rmirm and hardnecti. ' -2i'n.lh tee Made From oahle Drinking 'rater` 4-:=.r;1.1 !(A) Etluipmen: Font!Conn.ct Surfaces and 5_!{11.11 Dank;nz'r4'nterfrumanApproved Systea:" Gznsils Clean' 590.O(':t,(A) Bottled Drinking Watcr* ^ 60'.11 Ci>.anin'".-Freuenv� -_ of'Ec;u:nmeutYo�,id- -,90 fr)bI Bi INM ,n 'atet Mets 3,endards 310 CMR 2.2.0* ( 9 Sheli ish and Fisn Froman Approved Source 4 Conine r Surface•:and U:en:;itsr 4-701, 11 Frequency of Saniri7an01) of 140110;and ' 3-101.:4 Fish and RecrVALLIIN4dIV Caught:VIoihisCm Peed Covr[act Surfaces of 13umtnaient" Shellfish* 4-103.1( lv;:_thndz of Sanhlzntioa-:hit R4acr and 3--2701.15 Molluscan Shellfish fronutiSS?Listed � C7icnm;al" Sources" ( 10 Proper,Adequate Handwasn;ng Game and Wild Mushrooms Approved'by ! : ; _ o Recrvrator, Auihodty 2-301 'le.�r, Condition-11 rak;,.:..I Arms. 3'02 IK She!lvtnek ldentiliicat;on present" .1; Cleamr,? P,Oceduie" 590.0,01(C) Wild Mushrooms* 1-z(71.:d Nihon to Rash" 3-201-1-1 Game Animals* "t Good Hygien,r Prarliens i c Receiving/Condition 2.-!()] 11 Eating,Drinking o, Lsi::e Tobacco* ! i }222.i PHPs Received at Propel Temperataresr 12401 12 Discharge,Flue ti:e E}es. Nese and 3-201 15 Packa:'e -t01 11 Focid Sate and Un,:dulterated'" 3-30:.'2 Preventing Cuatantinalion When Tasting' ti TagsrRecords:Shellstoc!e f 2 ?rever,!Eon o!Contamination from Hands 590.004(l:) Preftt:n�'"ont<o,ti:;::oor:from 3-202.1 s ShelistocL idcntificatiou ' o 11 Shellmock rdo t fined' f Emplov .,s* lags/Records:Fish Products t3 ( Handwash F acihhes j 3 .1(g2. Deatn:ctian''' � Co^venranttr tocarad and Aaessivls 3-102.12 Record,:,Creation and Retenrion 203.11 Numbers and Capacities' 5;d)0040) Labeling of ingredients' 5.7(;4.i i Locari<rn and ph,cemc^.t* Centorrinnre with Appieved Procedures i =-=('5 1 I Ac.ess;cilnv'Oprratwn and Maintenance /HACCP Plans i Suvoued ovim Soap and Mand Orytn_o 3-502.i 1 Spec;ahzed Processing tiieth:alst ( Devices 3 102.12 1 Reduced n:wgen packaging,enter ia" I G-?Ul.I I Yaudsi,4,hing Cleanser,Availability £-1(1.3.12 I Conformance with Approved Procedure." j 6 'i?1.12 Nand Jr.in_previstou Dano».s coir al:xn:in[lie trdend 1999 Fend C,,de.0 1015 Clr1R 1'90 00:;. CITY OF SALEM h L / BOARD OF HEALTH Establishment Name: j�i�N�'iIv , Q,,^lVI ' / /Sa /f/�rsh�y , ST Date: Page: of ;�L Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified Y PLEASE PRINT CLEARLY I I yp /_.vsa, -?7&'t. 41010-W, A4//AGr11't14 Alley ass X7191 I / L GtGt Os��7dj[ -7d Dy! - -. I I I I v�rC Coa�srs 6ePm)' I I I i/ HtiO, �rs/liv� C�,Peer 1W /71N,,Vs �a,Flej I I AV 11�1 &111dy T 011� I I bA I � UiSaC� I I �✓ I P..o.e��n �w e,(�.�ev� I I I I 1 Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes '. lave read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion • Oiolations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension foomply with all mandates of the Mass/Federal Food Code. I understand that " noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: i — — — 3-501.14(0:) PHFsRecei edat'iempeiatures Violations Related to Foodborne Illness Interventions and Risk Acne don,to L:nr Cooled n, Factors(items 1.22) (Cont.) 41'FNS"F Within 4 Hours. " PROTECTION FROM CHEMICALS 3-501.15 Cool ng lvl hdw is for PHFs 14 + Food or Color Additives 19 PHF Hot and Cold Holding 3-501,16(B i Cold PUTS blaint:+incl :t or below 3-202.12 ,Additives* i 590.004;,F) 41"/45^F* 3-302.14 Protection from unapproved Additives" ( 3-501.16(A) [lot PHF,Maintained.t or above 15 ( Poisonous or Toxic Substances 140','. '" 7-101.11 Identifying Intonnat ion-Ongi nai ?-SUI.I(;(A) linnata Hcld at of abuse 130`F C um ainers" " 7-102.11 COMITI Hl Name-Working Containers ( 20 "rime as a Public Health Control 7=301 it Separuiun-Storage" 3-501 19 Tome as a Public He:il+h ControP" 7-20211 Restriction-Presence and Use* 590.004(H) VarianceRegwrerient 7-202.12 Conditions of Use, -1-2U?.I 1 1or:ic Containms -P+ohibttions" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Smntizet:;.Criteria -ChemicalsF ( POPULATIONS(HSP) l 21 ( 3-801.11(.A) 'Unpasteurized Fre-packazed.forces and j 7-.04.1_ Chemicals foe Was'ion;;Yrudace. Criteria'" � � Beverages with Warning I,;Ihcls* 1-2 .1 t Drrmg Ai`enu:,Criteria' ( 3-801.11(6) Use rf F;steuiixecl Eagi* j '7?(i505.I t Incidental Fond Contact,Lub icants' ( I 3-S01 11(D) Raw qr Partinll}'Oxakect Aminal Food aid 7-206.11 Restricted Use Pesticide,,Criteria"' i 7-?06 12 Rodent Bait Stations* Rasa Sced Sprouts No;Served. 7-206.13 Tcackin;',Powders,Pest Control and 3-801.1 1(C) Unopened rood Package Nut Re-served. Munittxin•" CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 ( Cog umet Advisor,Posted for Consumption of Animal Foods"1'hat are,Raw", Undercooked or 16 Proper Cooking Temperatures for erw Not Othise Pnxcsscd ra Eliminate PHFs i n Pathogens.* 3-40-.I lAt 1)t_) Eggs" l55`F 15 Sec. Eggs-Immediate Srrvice 145'Fl Ssec` 3-302.13 Pastem-tred Eggs Substitute for Raw Shell 3-40L 1I(A)(2) Comminuted Fish. Meats&:Game Fgg':i :lnintals- 155°F 15 sec. '' SPECIAL REQUIREMENTS 3-4(lLll(,B)(1)(2) York and Beef Roast- 130"F t21 thin° ) 5g0.009(A)-W) I Violations of Section 590009 3-401.11(A)(2) Ratites,Injected Meats- t55"7 15 econ . (,0)-(D) in sec. * ( catering, mobile food, temporary and 3-v01.11(A)(3) Poultry,Wild Game. Stuffed PHFs, j I residential kitchen operations should be $tutitng c entraining Fish, Meat, i .::.a..ai ::acct the s;:pr"p:izi, poultry or Ratites-165'F 15 ser, "' above if related to Coodborne illness 3-401 11(03) Whole-muscle. Intact Beer Steaks ( mterventiuns and risk factors. Other 145`F* 590.009 violations reiating to Brod retail 3-401.12 Raw Animal Foods Cooked tit a practices should be debited under#29- Miciowas-e 165`F* Special Requiretnents. 3-40 L t 1(A}(1)lh) All Other PHFs- 145'F 15 sec. " 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3403.1 t(A)&(D) PI IFs 165`F 15 sec. * 1 (Items 23-30) 3-903.11(B) Microwave- 165`F 2 ;Minute Standing Ci'itn:al and non-cnlical violations, i+-hich do not relate to the, Tune` foodborne e(lness inten•entions and risk}kcturr listen above, can be 3-403 1 t(C) C'ommercialby Processed RTE Food- � /outd tit thelnllowbit sections g(tne Iva!Code and 105 C'.11R 1.40cFT 591!.000. 3-403 1 1(E) Remaining Unsliced Portions of Beer ( Item Good Retail Practices FC 590,000 Roasts'' _23-_ : Man.gement and Persor nol FC-"2 003 18 Proper Cooling of PHFs i 124 Food and Fcrai Protection FC-3 .004 25. Equipment and Utensils FC-4 ,005 3-501.141A) Cooling Cnaked PHFs from 14WF to 2r;, Water,Plumbing and Waste FG-5 .005 70'F Within 2 Hours and From 70`"F 27, Physical Faciity FC-6 007 to 41'F/45'F Within 4 Hours. * 28 Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29, Special Requirements 009 Temptanture ingredientS to 41'F/45'p 30 Other j Within 4 Hours" Deme,rniicnl itam in d+e federal 1999 Fund Cole o, 105 CMR.500,000. • CITY OF SALEM, MASSACHUSETTS v��col:ul'\ BOARD OF HEALTH e 120 WASHINGTON STREET. 4TH FLOOR SALEM, MA 01970 �s9e 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 : Robert M. & Anthie Jackson Name of Establishment : Dunkin Donuts Address of Establishment : 152 Washington Street Type of Establishment : FOOD SERVICE Application Date : 01/09/2003 Restrictions : Permit for Food Establishment 244-03 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 . CITY OF SALEM, MASSACHUSETTS � o r �"� '� BOARD OF HEALTH • a 120 WASHINGTON STREET, 4TH FLOOR ` ' SALEM, MA 01 970 gB�MI� TEL. 978-741-1800 FAX 978-745-0343 STANLEY USOVICZ, JR. ,JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2003 APPLICATION FOR PERMIT TO OPERAT—E1�A_FOOD ESTABLISHMENT,, , I NAME OF ESTABLISHMENT A M11C�1Mr � �,Y{�V 1 113 TEL#Cl`1O I�`I- ADDRESS OF ESTABLISHMENT MAILING ADDRESS (ifdifferent) OWNER'S NAME C7A�� v`4Q�C�� TEL A V;'_144) ADDRESS 1-6-Q CITY .sCl1aM STATE 'Met- ZIP v/y"r0 CERTIFIED FOOD MANAGER'S NAME(S) f CERTIFICATE#(s),oYt *,eco. (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HGME TEL#urd —��a 3o2fJ HOURS OF OPERATION: Mon.dy Tue.�L/ Wed.&/Af Thu d74As Fri.1 Y1 Sat/Sun.o� TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES less than-1 000sq.ft. =$ 50 1000-10,000sq.ft , =$100 l� 6 3 more than 10,000sq.ft. =$250 RESTAURANT YES NO d, r" less than 25 seats ; 10 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES (NO/, $100 ADDITIONAL PERMITS v� MAKE ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $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 knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Signatures DateSocial Security or Federal Identification Number `C`�� -- ----- --------------------------_1---�--` Revised 1125/02 FOODAP2.adm Check#&Dale 0QS-'_2 CITY OF SALEM BOARD OF HEALTH Establishment Name: /�,��./� i�_�.z1i'�� Date: ,ii�5/� Page: / of / Item Code C-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date 1 No, Reference R—Red Item Verified PLEASE PRINT CLEARLY , + � -- r I � \ 1 1 1 I 1 Discussion With Person in Charge: Corrective Action Required❑ No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ��AA f . -Fes/ 4 C - ❑ Voluntary Disposal ❑ Other: 7 3-501 14((" PHFs Re-ei%-it remlrratures i Violations.Related no Fendbornc iilnees interventions and Rick Acro,. ,L ;_1"Ccxricd to Factors(Items 1-22) tCont.) vi PtdS'1='14itlnr,=Hours ' PROTECTION FROM CHEMICALS ( ;-591 1 i Ccolilw Me*hod; :a_'Flps 14 Food or Color Additives 1° PVF Hot and Cold Holoing t-21111" ^.dduiscr^ j 3-501.1.<,;H1 C,;d PI-TFs tiimmainrd at,+r below -302 1 i Protection fluor lh:approvrC '-501.15(A) Hut Pl i,Maintainea d at, above- is Poisonous or Toxic Substances ' -101.11 ld¢:ntitymg information-Or!gir,:d 1401F. ;-50LWAl ( C'outamrrn`. Kcraitt. Held:,?.-n -t,t. :- .e 130 F ' Time as a Public Health Control 7-1112.11 Cormnon Name W'rrktng Canutinrrs ' ?-2.01 11 Separation�-Stortve, ?-5Ol 19 Time:c:b Public I-ir:hh CocamP F i .(i0d(1T; Vanaun;R:.quir,cment 7-202 11 Res¢irtiou-Prea•nce and (se' � 7-202.12 C'nndtdrnsn.[is.' REQ� 7,-203.11 'toxic Containers-Prohibitions` � POPULATIONS 7-201.11 Sanitizern.Crite.+ia -Chern:als^ POFtFLAT10NS(N$P} 7-204.C Uentic.!s fill Washing P!odooc.Cr;t,riar i 21 1 3-x11!.!i(A) U^^.tet:mz:d Pet-peckaged Juices and Beaeravrs with l*;arn.r�L,'-els" 7-2(14.11 Drying, Agruia.Criteria* i ?-BOl.li(ti) Use of Pasteurized ?-1_05.11 hu•tdenbtl Food Conflict l.,ahr!,auts" 7-206.1 l Ro;tricted Use Peatiri cs, Crktc+i:+" 01 I i(i)) Raw of Part idGy C,hi6 ed Animal Foo;i and Row Seed Sprouts Not S,n,tied. 7_?06 ;3 Rodent Bait Sta?tons" 3-891,11( ) ITnopened Fo.x! Packaec Not ito-;erwd i 7-206.13 Tracking Pot+ders,Pest Contro:.md Mor!turine' CONSUMER ADVISORY TIMEiTEMPER4TURE CONTROLS 22 3 n0l I I Conaumcr A liv ory Posted lbr Consumption of j 16 i Proper Cooking Temperatures for Anunal Foods That are Row. Uucicr(ooked or PHFS Not U?hcrwise Processed to Elitrunatc I 1 i ! 3-d0111 At l)(0. Eggs I55'F- 15 Ser. Y,ttluut:ns ,. ",,,o:..,,•,.:�;: ' Eggs- hnnaxhe!le Srrvic. 141°FI°,':e:" 3-?'('2J3 Pastzrn,cd F...., Suh,titate fo:Rav,•Shell 3-401.1 I(A)(2) Comminuted fish.Meals K G:mw ! ,kiiinfals- I 55 15 rec. " 3-401.11iU)(Ipa) Potkand BccfRo.,st- 130`FI2! inin' j SPECIAL REQUIREMENTS 3-4C t.l itAif2) katitc.; Infected 64cata- 155"F 15 ='�`-)'=091.4) (U) Violations of Section 590.000(A)-(U) '111 sec e ( .alcring, mobil: foal, icmporaryand 13-401.11(A)(3) Poultry, Wild Goin-Stuffed PHP,, residential kitchen operation', should be Stutfmg Containing Fish, Meat. aen$ed undo tli.apoii�l)riate SectionsPoultry or Ratites-I7,5"F 15 sec " abocc. if related to Foodtmrne illness 3-401.11(C)(3) Whole-muscle• Intact Beef Steaks !ntert-ntions and risk foc•lots. Other 145-F If 5O0.(1(,19 violations relating to i,00d r,tail 1-101.12 Raw Animal Foods Cooked m a i piact:o,s should be debited under #29- Microv:a;e :05 t= Special equireu)ents. ? 401.11(A)(t t(bi A0 Other E'HFti - 1,45T 15 sec L' Reheating for tint Holding VIOLATIONS Ftz'LATED TO GOOD RETAIL PRACTICES 3-403 I t(A)&(D) PFIFs 165'F 15,sec. " (Items 23-30) 3403.11(13) Miciuv;ave- 165°F 2 Mmutc Standing Giticat and rumgrWcar!violations, ,:dch do not rrtnt,to the Tin;ca` rootlhunae i!htesa int>:nru6ear3 and tisk factwr iisted abntc, can be -1403 11(C:) Commercially Processed iiTE Food- ( /Land ui the jnHowing sa<tinni of the Tiiod('ale ane!105 CAIR 1,10^F* ' 5o4.t)0(f. 3-403.1 If E) Remoming Unshccd Poflinns of Bee( I I item I Good Retatl Practices FC 590.000 Roasts"' 1! 20. Managemorf anti Pemonnsl 1 FC- 2 003 18 Proper Cooling of PHFs I 24. Feed ane Fool Floted.:on j FC-3 .004 --- 2b __ _gupunsnt and Utensils FC- 4 905 { 3-501,14(A) Cooling CookedPT[Fs (rom140"F:o 26. � vdat=r.F!umb:ngand Waste IFC-5 005 7WF Within 2 lloun and From 70'F 27 Physical FaciPhy FC -6 .007 to 4t'F145'1'R'ithm 4 Flows. * 28. _ Poisonous or 1"obis t,laierials FC-7 .0-a8 3-501 1 t(Bt Cooling PHF,Made Flom Ambient '-0 Cnes:al Reouhernents .0'9 Tempec.a -v Ingiediern,to 4i'Fi iti"F 34. Othsi m Within 4 llours' ""u. ... 'l+,noo,anneal f:ein in the tcdrral 19nf,Fail CmIe u, 10�CMR 590.0X0. Nov-A3-03 03:370From-D P H FOOD AND DRUG 617-963-6770 T-658 P OZ/02 F-813 Massachuseds department of Public Health Alnsion of Food and drugs 305 Soutts St, Jamalca Plain,MA 02138 Ph(817)883.8712 Fax(617)963-5770 _.._........................................................_............................._................................ Complaint Number: 83-150 ...................................................ft----..................................•..................._.. Dateof Complaint. 1111312003 Finabornoturans? Care& RIgut Irw000ram""form Form of Complaint: To"hone Source of Complaint: Consumer pnaM Name i.draine Winds give ds Address. AK out Pitonpe. (617)394.0300 NamoM to company Notes_ Descnpl=of complaint Complement purchases coffee wicream at Dunkin Donuts m Salem. Noticed strange Wats Returnea suilpliCt coffee to Dunkin Odnufs tbCataa in Evens(Seacnam St.) next to net place of empwymorit Manager of Everet Dunkin Obnufs,alio that igore was bleach M coffee and exchanged for new cup. At request Of camplamam,Manager called and aarted Dunkin Donuts.n Salem. Nature of Complaint Unwholesomeness t3podage,tray laaterambil) visaed haalm Cart Progger Visit Daus Name of Pro.taor Product Information Product Brand Name Dunkin Donuts Coffee Category- Other oeverage Pr044M Name. Dunkin Donure Product Co(letSenal NumceC Product SizeNveignr Package Typa: Sed By Date uPC Code E.apiratwn$bst used Date_ E) Imported Product Date of Purchase: Product used Dare used Amount Remaining. Esmakstimem_Wners Purenasea: Manufactured aY Distributed By Salem Ounkm Dgnuts O Mer of Rt. 114 is Salem center Prone Phone: Pnohe Conlptant Received 9y: Eben Fict4labans Raterrea To Salem ROH for followup and response to DPH PhOtte Number (617)9636751 Comments, Complainant was Concerned aDiM possible interaction wile preScrlped preasl cantor orugS• She notifwa her PCP for advice as ..ear as ono Poison Control Conger. No auver6o symptoms were toted by the complainant. DisPgs4mn jea I yf 11> l p z t.tE (-rt rCc� Pada,of 1crY E' t "` ILke �l �5 A0 F Cyt n'" C44:�Q Nov-t3-03 03:37Pm Ftm-D P N FOOD AND DRUG SIT-983-6170 T-658 P 01/02 F-913 DEPARTMENT OF PUBLIC HEALTH DIVISION OF FOOD AND DRUC: S 305 SOUTH STREET JAMAICA PLAIN , MASSACHUSETTS 02130 - 3597 FACSIMILE TRANSMITTAL SHEET TO iauM joannc Scott Elea Fitzgibbons COMPANY OATC Salem 802-} 11/33/2003 YnX Nl ,MSRR TOTAT NO OF YACPS iNLLLUINC COVU (478)7409705 2 VAONF NOMA&R. sEmnrp b av Fcu..NCR NCMar* (978)743-1800 %E. YOUR RL kArNrr.NLMOLA ' Appendix N Testing X LtRaLNI-t 0 pot.Rl'43Fttr Q Pl.FiAsh Ct)MMFNT ❑FL.R 14)_Rh81.Y Q 1'LL:Ast:RhtYCLL Please review and forward findmg3 to DPH. (t,-iCK HERt AND TYl,F. 927 CAN ADDRL.i�j r [ r THE COMMONWEALTH OF MASSACHUSETTS ' CITY OF SALEM r' 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 NameDate �II ,Tyne of ODeration(s1 Tvpe of Inspection � � Food Service ,� Routine Address 1 �A)�/ -�- Risk ❑��\ Retaild Re-inspection a �J Level / El Residential Kitchen Previous Inspection Telephone C.- ❑ Mobile Date: Owner HACCP Y/N El'Temporary ❑ Pre-operation - . ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) (� `( - �^GS.-1-�,., Time ❑ Bed&Breakfast ❑ General Complaint In: ❑ HACCP Inspector�ry.�'7� /Y\, / c- 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 Calor Additives ❑ 3. Personnel with Infections Restricted/ Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEJEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source ❑ El 5. Receiving/Condition 16. Cooking Temperatures El 17. Reheating El6. Tags/ Records/Accuracy of Ingredient Statements El 18. Cooling El7. Conformance with Approved Procedures/HACCP Plans , ❑ 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20. Time as a Public Health Control ❑ 8. Separation/Segregation/ Protection EJ 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 a 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 r by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590 004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590 009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: Inspector's Signature: Print: ` ` PIC's Signature: /'� Print: I Page/-or-' Pages ✓!5 �i r - FORM 734A HOBBS&WARREN - BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from I 590.003(A) Assignment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Inoredients 2-103.11 Person in Charge-Duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) Food Protection* require reporting by Food Employees and 3-302.15 Washing Fruits and Vegetables Applicants* 3.304.11 Food Contact with Equipment and 590.003(F) Responsibility of a Food Employee or an Utensils* Applicant to Report to the Person in 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 9 Food Contact Surfaces 4 I 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 Satnnzation-tem H, 3-202.14 Eggs and Milk Products,Pasteurized* P gg � Concentration and Hardness* 3-202.16 Ice Made from Potable Drinking Water* 4-601 11(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved System* Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22 0* Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3.201.14 Fish and Recreationally caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization- Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Aims* Regulatory Authority 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* -- 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices 2-401.1 I 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 I 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(7) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance 7 Conformance with Approved Procedures Supplied with Soap and Hand Drying /HACCP Plans Devices 3-502.11 I Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability 3-502.12 Reduced Oxygen Packaging,Criteria* - 6-301.12 Hand Drying Provision 8-103.12 Conformance with Approved Procedures* - *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: �� J��i �J /"��(1%S Date: /a? �3 Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item PRINT CLEARLY Verified PLEASE /_/r/1 _ 1 I . Y I � , � y- ✓ 1 I � Discussion With Person in Charge: Corrective Action Required: I ❑ No ( ❑ Yes 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 youMood permit. - ❑ Voluntary Disposal ❑ Other: 3-501.14tC) PHFs Received,:i )emperahtrea l[. Vioiations Related to Foodborne Illness Interventions and Risk According to Law Conled to Factors(items 1.22) (Cont.) 4!°Fb45'F R5{bin 4 1lotne. ' `� PROTECTION FROM CHEMICALS ( 3-501.15 C coling Methods for PEl 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-501 lftBi Cold FRFs Maintained at or below 3-202.12 Additives* i).g04(F) 41'145' Ft 3-302.14. Proo:ction from Unapprotcd Additive,* _3-501.1G(A) Hot PHFs Maintained aria above 15 Poisonous or Toxic Substances _ 7-101.11 identifying Information-Original j i40'F. : Containers" ' 3-501.16(Al Roastc Held at no above 13C,;'F 7-102.11 Cununon Name-Working ContainenO ( 2t) Time as a Public Health Control 201.11 Separation-Skxuee' 4-ilii 19 Tim.as a Pub]rc Health Control' 7-20111 Restriction-presence and Use* 590.0047-1) Variance Requnnement 7-202.12 Conditionsof f Usc' 7-203.11 `fnxicContaim:rs-ProhibitionsT REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-201.71 Sanitir_arn.Criteria -Chemicals* POPULATIONS(HSP) 7-204 1' Chemicals for Washing llruoluce.Criteria'^ 121 13-801.1](A) Unpasteurized Prc-packaged clunes and 7-204.11 Dryum, Agents,Criteria* � I � Beveraces svnh Warning- 1.,:hels" 3-501.1 1(B) Use of Pasteurized 7-^_01.1 l Incidental Food Contact,Lubricants"` ( • 3-1.'101 1 i(D) Raw of Partially Cooked Annual Food end 1,-206.11 Restricted Use Pesticides,Criter,at ! Rata Seed Sprotils Not Served. 7-]06.12 Rudest Baits3-301.!1(C) unopened Food Pacl Not Ru-sci ved. 7-206.13 "fracking Powders,deerdrrs, sr,Pest Control and M unitunn-" CONSUMER ADVISORY TIMElTEMPERATURE CONTROLS 22 1-603,11 Cuasurner Advisory Posted for Consumption of 16 Proper Cooking Temperatures for I Amutal Foods That are Raw, Undcrcunked or PHFs Not Otherwise Processed to E!immate _• 3-4.01.11 A(1)(2) Eggs- i 5>`F 15 Sec. Pathsen` ': Fags-immediate Service 1451F1 Ssec3-302.13 Pasteurized Eggs Substitute for Raw She]] - 3-401.11tA)(2) Comminuted Fish, Meats&Game Big,* Animals- 155''F 15 sec. ;: SPECIAL REQUIREMENTS 3-401.1l(Ba l)('_) Pill It and Beef Roast - 130'F 121 min* S 3-401.11(A)(2) Ratites, Injected bleats- 155`F 15 u0.009(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 PHF,, residential kitchen operations should be Jtunm,Uontainal Fmh. NteuL ..�.iat« ..adeitic. .r_r_h >....,....;., Poultry or Rabies-165'F 15 sec, * above if related to foodborne illness 3-41)1.11(C)(3) Whole-muscle. intact Beef Steaks interventions and risk factor,. Other 145'F 4 590,009 violations relating to good retail 1 3-401,12 Raw Animal Foods Cooked m a ( practices should be dehded under #29- Microw•a%e 1659* Special Requirements. 3-401.1I(A)(1)(b) All Other PHFs-- 145'F 15.ec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3403 I1(A)&tD) PIIFs, 155"F 15 sec. * ( iItems 23-30) 3-}03.11(6) Microwave- 165"F 2 Muritte Standing ( Critical and noir-critical violations, which do not relate to the 'Piste' 1odborne illness urtenvntinns and risk factors bsied above, Cull be 3-703 11(C) Commercially Processed RTE Fail- I Lound in the f rllowbig setxions of the Mead Cuda and 105 CdIR 140°F* 500.000. 3-403.11(E) Remaining Unsliced Portions of Beef I Item Good Retail Practices FC 590.000 Roasist 23, 1 Manatiornent and Personnel FC-2 .003 18 ( Proper Cooling of PRFs 24, 1 Food and Fooa Protection FC-3 .004 25 Equipment ana Utensils FC-4 005 3-501.i4tA) Cowling Cooked PFlPcfrom 1409tu 126. 1 Water. PlUmbinitand Waste FC-5 .006 70'F Within 2 Hours and From 70'F 127 Physical Facility FC--6 .007 to 41'F/451:'Within 4 Hours. * 28 Poisonous or-toxic Materials FC--7 008 3-501.14(8) Cooling PRFs btacte From Ambient 1 2c, Special Requirements .009 j Temperature Ingredients to 41''FF45°F 30 Othet Within 4 FIours* `Denntea erhlcal nem in the lederal 1949 Find Crude o I0i CNIR X90.000. t 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 N1-1800 Fax: (978) 745-0343 Date fOperation(s) 7voe of Inspection Name / _�� ! �� ood Service ❑ Routine Address // ,, ��--�;/�/�� ,,/-�� ,�-�� CII Risk Retail ❑ Re-inspection W�J�7 i fit-+ /CI.J >l/L Level / I ❑ Residential Kitchen Previous Inspection �� Telephone ✓�-,r� _ C.- El Mobile Date: P / '� Owner HACCP Y/N El Temporary El Pre-operation In(� to - c1-�, I ❑ Caterer ❑ Suspect Illness IPerson In Charge(PIC) Time El Bed&Breakfast General Complaint ! ^>/ t �,�� G In: El HACCP Inspect \ /„ n� � ce yr 1 Out: Permit No. ❑ Other Each violation checked'irecii6ires 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 TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source ❑ 16. Cooking Temperatures ❑ 5. Receiving/Condition ❑ 17. Reheating ❑ 6. Tags/ Records/Accuracy of Ingredient Statements ❑ 18. Cooling ❑ 7. Conformance with Approved Procedures/ HACCP Plans ❑ 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20. Time as a Public Health Control ❑ 8. Separation/Segregation/ Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 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)(590.008) 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: 1 Inspector's Signature: Print.�� PIC'sSign /��A �� Print: V4 Pag,40i Pages FORM 734A HOBBS&WARREN - BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination - FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 1 1590.003(A) Assignment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11 Person in Charge-Duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) Food Protection* require reporting by Food Employees and 3-302.15 Washing Fruits and Vegetables Applicants* 3.304.11 Food Contact with Equipment and 590.003(F) Responsibility of a Food Employee or an Utensils* Applicant to Report to the Person in Charge* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated 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 F IOM 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* I 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 €€ � 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 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 12-301.14 When to Wash* 590.004(C) Wild Mushrooms* 11 , Good Hygienic Practices 3-201.17 Game Anim2-401.11 als* 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* J3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 61 Tags/Records:Shellstock 590.004(E) Preventing Contamination from 3 202.18 Shellstock Identification* Employees* 3-203.12 Shellstock Identification Maintained* 13 Handwash Facilities Tags/Records: Fish Products Conveniently Located and Accessible 3-402.11 Parasite Destruction* 5-203.11 Numbers and Capacities* 3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement* 590.004(J) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance 7 Conformance with Approved Procedures 1 Supplied with Soap and Hand Drying /HACCP Plans I Devices 3-502.11 Specialized Processing Methods* 16-301.11 Handwashing Cleanser.Availability 3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision 8-103.12 Conformance with Approved Procedures* I *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. r CITY OF SALEM /� OARD OF HEALTH Establishment Name: �C/�/� 2)6 , B.S Date: 1�� /�� Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date l No. Reference R—Red Item Verified PLEASE PRINT CLEARLY 1 . I I -c 6;� a - >< l\ 'F ,Z I 1 � �1JC> lJr�tS� Ah�S>� h_t6f�-G� . j k J 1 Discussion With Person in Charge: Corrective Action Required: I ❑ No ( ❑ !es ❑ Voluntary Compliance ❑ I have read this report, have had the opportunity to ask questions and agree to correct all Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: a 3-501 Hot) PHF*Received at Te eperann'es Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(Items 1-22) (Cont.) 41'I'145'F Within 4I-touis PROTECTION FROM CHEMICALS ( 3-5u1 15 Gwhn,Methuds for PHF'< 14Fa¢d or Color Additives 19 PHF Hot and Cold Holding i 3-501.161 B) Cold PRFs Maintained at or below 3-202.12 Additives'* 590.004(F'! 11'!-5"F' _ 302.14 Protection front Unapprorrd ,Vlditives" 3-5('L1btA) Hot( A4aintained at of shoe 15 Poisonous or Toxic Substances 7-101.11 Identifying Information-Oto,inal I 19u F, Containers^ Roasts Hvid at or shote 130'F 7-102.11 (7mmilon Natne--Working Containers" � � 20 Time as a Public Health Control 7-^_01.11 Separation-Storage", 3-501.i 9 Tone ac a Public Health Control;' 7-202.11 Restriction-Presence and Use* 5'm0.001(H t F'artance;P.equcaneut 7-202.12 Conditions of Ilse" i REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-20_ I I Toxic Con[a tors-Prohibitions'- POPULATIONS(HSP) 7-204.11 Sanitizers.Criteria- Chen icdr^ � 7?61 12 Chemicals for�'v-ashore Produce. Cmiteria'� 21 13-801.1 I(.4) Unpa ages wit Pre-packaged.Juices and 8c%eragrs with Warning labels* 7-204.11 Doti ental Food Contain' ;-801.11(8' Use of Pasteurued Fggs' 7-205 11 Incidental Food Contact,Lubricants* 3-801 11(D) Raw or F iliaily Cooked Annual Foil and j 7-20ti.I t Restricted Ilse Pecf ieidec,Criteria'" j 7-'06,12 Rodent Hurt Stations" Raw Seed Sprouts Not Served. 3-801.11(C) Unopened Food Package Not Re-served. ' 7-206.1 3 Tracking Powders,Pest Control and bhmuoring" I CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Ads i my Posted fur Consumption of Animal Foods that are Raw.Undercooked or 16 PHFser Cooking Temperatures for Not Otherwise Processed to Eliminate Pathogens.* 3-401.11A(1)(2) Eggs- 155'F 15 Sec � -302 13 Pasteurrred Eggs Substitute for Raw Shell Eggs-Immediate Service 143°FI lace• b'-p„vm 3-101 1 I(A)(2) Comminuted Fish.Meats& Gaire Animals- 155�F 15 sec. " SPECIAL REQUIREMENTS 3-401,l i(B)(1)('_) Pork and Beef Roast- OWE 121 min- ig0009(A -(D) Vj e e 3-401.11(A)(2) Ratites,Injected Meats- 155°F . 15 ) oLdk ns of Section 590.0()9(A)-(U) in see ;. catering, mobile Iood, temporary and 3-401.11(A)(3) Poultry. Wild Game. Stuffed PFltrs, residential kitchen operations should be Stufnng Cpnhuumg Fish,Meat. I u:.bac,l dude the appy^prtauc Poultry or Ratites-165-,17 15 sec. ( above if related to toodboi ne illness 3-101 t Ir ')(3) Whole muscle. Intact Beef Steaks interventions and risk factors, Other 145`F* 590.)09 violations relating to good retail 3-401.12 ( Raw Aninr.d Foods Cooked in a ( practices should be debited under H29- Microwave 165`F " , Special Requirements. 3-401.11(A)(1)(b) ( All Other PHF*-- 145'F 15 sec. 'R 17 ( Reheating for Hot Holding VIOLATIONS RcLATED TO GOOD RETAIL PRACTICES 3-103.1I(A)X(D) PIJFs 165'F 15 sec. ' I (Items 23-30) 3-403.1 1(B 1 Microwave- 165'F 2 Minute Standing Critrcul and non-critical violations, which do not relate to the linter li)odhorne illness interventions and rusk factors l+sied above, roe he 3-403.1 I(C) Comntereially Processed RTE Food- (bund in the follou ing se(tionv[f'tloe Paod Code arra 70.5 CHR 140017* 590.00). 3403.11(E) R?maimne Unslmced Portions of Beef I Item Good Retail Practices FC 590.000 RnasW° 23. Managementand Personnel FC--2 .003__ 1 ( 1 g Proper Cooling of PHF* 1 24. Food and Foon Protection ; FC-3 .004 25. Equipment and Utensils ! FC-4 ,005 3-50L14(A) Cooling Cooked PHF* front 140"17 to 26. Wates Plumninq and Waste FC-5 006 700F Within 2 Hours and Frnm 70`F 27 Phvsical Facility FC-6 007 to 4101F745'F Within 4 Hours. * 1, 28 _ l Poisonous or Toxic Materials ! FC- 7 .003 j 3-501.14(B) Cooling PHFs Made From Ambient Ir 20, _ Special Requirements .009 l Temperature Ingrethenta to41'Fl45'F ! 30, Tother Within 4 Hours, Demote ernicai item in the federal 1999 FoW Cude oi 103 CMR 590.000. a �uxon CITY OF SALEM, MASSACHUSETTS ; BOARD OF HEALTH a .p 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 prp FAX 978-745-0343 STANLEY LISOVICZ, JR JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Owner' s Name : Robert M. & Anthie Jackson Name of Establishment : Dunkin Donuts Address of Establishment : 152 Washington Street Type of Establishment : FOOD SERVICE Application Date: 12/13/2001 Restrictions: Permit for Food Establishment 188-02 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products - These Permits Expire December 31, 2002 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. (c!! HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH r } • 120 WASHINGTON STREET, 4TH FLOOR ,_VvtV SALEM, MA 01970 TEL. 976-741-1800 43 FAX OTT, MPH, IRS STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, GHO iV'9 t1itN� .l (il, II(t MAYOR HEALTH AGENT 4 uL C 1TY 0=SALEM 2002 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABL�II-S�'FPfYtN/�NT�"F!T' NAME OF ESTABLISHMENT 1�1 VN}T & . Q TEL# a-I,�'' t�'`i� 6Qt G ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different) &�-AVNli�Ur p }{ p OWNER'S NAMEQ��j CITY SS STATE \MiV ZIP CERTIFIED FOOD ANE 'SNAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON 4ZIA c;i AVHOME TEL# DAYS/HOURS OF OPERATION; Mon.—Tue.—Wed.^Thu._Fri._Sat.—Sun._„_ TYPE OF ESTABLISHMENT FEE check only RETAIL STORE Y N RESTAURANT ES N BED& BREAKFAST Y S 0 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT SOFT SERVE YES $5 TOBACCO VENDOR YES $10 NO CHARGE FOR NON-PROFIT(sultrurch kitchens)PLEASE INCLUDE COPY OF TAX EXEMPT FORM Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted In a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that 1,to my best knowledge a d belief have filed all state tax returns and paid all state taxes required under the law. r Signature Date', Social Security or Federal Identification number Revised 11/1/01 foodap2.adm Check#&Date l'� �{ .5 /.2-7-0/ (rig ✓ '^•""".+*-i'�A�,".>•'�.'�rt,y'-r..+9.+v.�'+e+.'n+"r'"M��^.wt'e�+*rr.^PrT`�'+YJ�..•.+..•n�J.�+...w.rovo--...,T�y,..-np+,.y�4rr�ye•�,r '�1�'�'�"'t°n"�^..-'^+.....- . �-...�...•.. -. THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 120 Washington Street, 4th Floor BOARD OF HEALTH Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 745-0343 Name Date woe of Ooeratton(s) Type of Insoection 7),i ni/fr �% 17.a-s�i� 7L'S f/-,�_[),J Q Food YRoutine Address, / Risk ❑ Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone /3 ❑ Mobile Date: /9-Q2 Owner / HACCP Y/N - A;7, "f4U_ 7 �� El Temporary ElPre-operation d'�4,4v,a10-- W % 41V W)i e TAr.G.S.rn I ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) K / fin/FU Time ❑ Bed&Breakfast ❑ General Complaint In: El HACCP �� Inspector kIC' Out: Permit No. El Other 1/ .,J-y-n Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/ Knowledgeable/ Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS El2. Reporting Of Diseases by Food Employee and PIC ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/ Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) El 16. Cooking Temperatures El 5. Receiving/Condition ❑ 17. Reheating El6. Tags/Records/Accuracy of Ingredient Statements El7. Conformance with Approved Procedures/ HACCP Plans El 18. Cooling ❑ 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20. Time as a Public Health Control ❑ B. Separation/Segregation/ Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ElEl 10. Proper Adequate Handwashing 21• Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related Items) Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/Federal Food Code.This report, when signed below c N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590 003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.006) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: Inspector's Signature: q '1-��, /Ri Print: PIC's Signature: ��// •/ r ) � Print: Page_Lof Pages yrs] nr.rn X51/ G1'�trVw M g4lP � FORM 734A HOBBS a 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)(I) Raw Animal Foods Separated from 1 1590.003(A) Assignment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Inqredients 2-103.11 Person in Charge-Duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) Food Protection* require reporting by Food Employees and 3-302.15 Washing Fruits and Vegetables Applicants* 3.304.11 Food Contact with Equipment and 590.003(F) Responsibility of a Food Employee or an Utensils* Applicant to Report to the Person in - Charge* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701,11 Discarding or Reconditioning Unsafe Food* FOOD F IOM APPROVED SOURCE 9 Food Contact Surfaces 4 I Food and Water From Regulated Sources 4-501.111 Manual Warewashing-Hot Water 1 590.004(A-B) Compliance with Food Law* Samnzation 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 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 11 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* 11 1Good 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* ( 6 � Tags/Records:Shellstock � � 12 Prevention of Contamination from Hands 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(]) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance 7 I 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 Cb[R 590.000. CITY of SALEM BOARD OF HEALTH 4 6 Establishment Name: Date: /e2- .3-4a Page: 21 of Item Code C-Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date No. Reference R-Red Item PLEASE PRINT CLEARLY Verified No l�llGo�idrl.S .UST-Lt' rr � 7�is �-im� 77�i1irf/� 'Ida 1 x I v N DIla Y'Fj r1,vr.'rfitin,tffr �9 € ✓ F uY��h ,vo fo ' B r�rJe P DPP mr�n �� ✓ Znr)a✓ Y'�i/l XIS r r y I I � l°o?cell iro CGJn_ nay I Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑Yes have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ i# violations before the next inspection, to observe all conditions as described, and to comply Exclusion f with all mandates of the Mass/Federal Food Code. I understand that noncompliance may ❑ Re-inspection Scheduled ❑ Emergency Suspension resblt,in daily fines of twenty-five dollars or suspension/revocation of your food permit. ❑ Embargo ❑ Emergency Closure ` Qr ❑ Voluntary Disposal ❑ Other r FORM 734B HOBBS &WARREN - BOSTON t 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 41°F/45°F Within 4 Hours PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 119 PHF Hot and Cold Holding 13-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below 3-202.14 Protection from Unapproved Additives* 590.004(F) 41°F/45°F* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original 140°F.* Containers* 3-501.16(A) Roasts Held at or above 130°F.* 7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 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* l 7-204.14 Drving Agents,Criteria* 3-801.11(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 Ban 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.* Enecnve 1112001 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- 130°F 121 Min.* catering, mobile food, temporary and 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 Sec.*I 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 the following sections of the Food Cade 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 Unsliced Portions of Beef 23. Management and Personnel FC-2 .003 Roasts* 24. Food and Food Protection FC-3 .004 18 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/45°F Within 4 Hours.* 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special 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. '�."6'+'�'�'I......wrhs`R�^''",^✓W'�I'A./'1�vPb�+.'�y'^"'+�•"f"''"�,.�.-+iW"4..�wc S"w�-+iimr...r.+�+9+C+r.w..o-wrt :-..oi7e�¢f...+:+r...�s.r..:..N;O.;.r y.-mw-.r::,:..• t THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 9 North Street Board of Health Salem, MA 01970-3928 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (9781741-1800 Fax: (978) 740-9705 Name Date T oe of Ooeration(s) Was of Insoection 7J/)/LA/N �/YlJiifs / Food Service Routine Address //� Ris 1-1Retail ❑ Re-inspection dSR GI�CRSfI/�/9Y?Y/ �f. Level ❑ Residential Kitchen Previous Inspection (Telephone /�8 ) ry�� 9A� 1-1Mobile Date: /B-/c�-O/ Owner pp( ' El Temporary ❑ Pre-operation HACCP Y/N ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed &Breakfast ❑ General Complaint (Jn7c /JLL'i l ❑ HACCP Inspector ' / /� , ) In: ❑ Other V /"A7USyd�CS Out: Permit No. Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) - violated. Non-compliance with: RED Violations (1-22) 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. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source ❑ 16. Cooking Temperatures ❑ 5. Receiving/Condition ❑ 17. Reheating ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 18. Cooling ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20. Time As a Public Health Control ❑ 8. Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 21. Food and Food Preparation for HSP E110. Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories BLUE Violations (23-30) 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(RED Items 1-22): F1 of Health. Non-critical (N)violations must be corrected immediately or within 90 days as determined by the Board Official Order of Correction: Based on an inspection of Health. today,the items checked indicate violations of 105 CMR C 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 24. Food and Food Protection (FC-3)(*590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 26. Water, Plumbing and Waste (FC-5)(590.006) the food establishment permit and cessation of food establishment operations. If aggrieved by this order,you --27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S L0711 1� Inspector's Signature: J7 yylPrint: PIC's Signature: �C .-� Print: ��`I 1 � � �� t.0 1Q�� page/-of o2 Pages t Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION AND MANAGEMENT 8 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 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 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* 13 590.003(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 Temperatures* 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* 5-101.11 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 22.0* 4-602.11 Cleaning Frequency of Equipment Food- Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 3-201.14 Fish and Recreationally Caught Molluscan 4-702.11 Frequency of Sanitization of Utensils*and Shellfish* Food Contact Surfaces of Equipment 3-201.15 Molluscan Shellfish From NSSP Listed 4-703.11 Methods of Sanitization -Hot Water and Sources* Chemical* Game and Wild Mushrooms Approved by 10 Proper,Adequate Handwashing Regulatory 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* Good Hygienic Practices 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges from the Eyes,Nose and 3-202.15 Package Integrity* Mouth 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* Tags/Records:Shellstock f_12" Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records. Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(1) Labeling of Ingredients* 5-204.11 Location and Placement* Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging,criteria* 8-103.12 Conformance with Approved Procedures* 6-301.11 Hand 6-301.12 Hand Drying Cleanser,Availability g Provision *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. E CITY OF SALEM BOARD OF HEALTH t Establishment Name: 17ri/�Kinr_i7rifa�s ruN�No frr, .St� Date: 4-/B-OP2 Page: 02 of cz Item Code C-Critical Item DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date No. Reference R-Red Item Verified IPLEASE PAINT CLEARLY �S7"7O✓?/_/.CH/YI PM /� f a, /PPiYI AY/7/O__ L /S -. - _ �i�-rlr/A' , .PP SC�PJ NO I . /77/71/a O f' ThP__ 7?9,e OS \S;4 .1'P / II /Dim /IPFP/9PsP��o� 2iild �t /�l[rC U/d/6G t- Tl7Pp/r7 �v_lP e t T71 P G/N/J.e . I A/i�i Yr'77?1Jt /ro/1P. Gf// i v /rnf�e 7n2' W'-f/' r /7G /�PL.e,6v,Pnfe.£s � �°Fs- ✓�/�� FA.P t�P,�Pze2s I i 7/77/�YT.S�R�717 f/I'PC czev n 9' AArk _ SGC+/J. 15"Y e. &,"/a f Z1_,q'7e7e/1'_ /�.r�e,!•Pi/ `{x°/XS`/ rf�'.P/O�i7/SPS 9' S19ik5 /�OS�e,� / I nY.P'7 GA-r7dn ��/ CP,rSt. ,4000 Y. 'G� i��rri A3 p^r 6�4?w' n>LrPi,A.1..e S/;i,7'0 / 1�--ez'PlS A/$4 C. Y �X/fXr/I7/NO� ^'r, 'e f-,oN 7;1117+4 t4lC 1—�4.f If no t rV/,4 //'Arae°/i Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction / violations before the next inspection, to observe all conditions as described, and to comply Exclusion with all mandates of the Mass/Federal Food Code. I understand that noncompliance may ❑ Re-inspection Scheduled ❑ Emergency Suspension result in daily fines of twenty-five dollars or suspension/revocation of your food permit. ❑ Embargo ❑ Emergency Closure 9 Y c a �e ❑ Voluntary Disposal ❑ Other r _ sl FORM 734B HOBBS &WARREN - BOSTON , i 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 41°F/45"F Within 4 Hours.* PROTECTION FRO 0 CHEMICALS 3-501.15 Cooling Methods for PHFs 14 I Food or Color Additives { 19 _ PHF Hot and Cold Holding 1 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 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original 140°F.* Containers* 3-501.16(A) Roasts Held at or above 130°F.* 7-102.11 Common Name-Working Containers* { 20 I 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* 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* 121 3-801.1 I(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* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.* J 7-206.12 Rodent Bait Stations* 3-801.1](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.* ERective vvzom 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- 130°F 121 Min.*I catering, mobile food, temporary and 3-401.11(A)(2) Ratites,Injected Meats- 155°F 15 Sec.*I 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 3-401.1l(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 the 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 3-403.1l(E) Remaining Unsliced Portions of Beef 23. Management and Personnel FC-2 .003 I Roasts* 24. Food and Food Protection FC-3 .004_ { 18 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/45°F Within 4 Hours.* 28, Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special 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. 1 at"".�,p,,;'. .�,~ 1" - 'i��' � ,.t. - T't'�'. e�eti'�:'D D.Fry'.�wA• ••*2 i°`b.,..`r�, .I�, . ✓" ,1'y9 ds , " sea'-' e -.,+'1 :s,Y'*, F u5i 1> ` ' r.YIP k� 9f ". ,AK y -4 F'•. P'i+. .:'i .. - Y *}� _ ag < o `:'w,,,y9ai-gi,rf; '..1 i .s y r a b• e CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT,MPH, RS,CHO NINE NORTH STREET HEALTH AGENT Tel:(978)741-1800 Fax:(978)740-9705 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 herelW granted` to: _ Owner 1 s Name: Robert Robert M. s. .. Name of Establishment : Dunkin 'Donuts: ;.;' . Address-,of Establishment -.' " 152 . :Washington Street?Nva, = ;Type of Establishment - FOOD SERVICE° IN ,�'� r '•�_+' � � `• f '3' - 3•ti Application• Date: 12/01/2000 f y. ri'a - - r' ' '4 i ISN 'v'F d e M aJ�e '• '� ye \ , s ReSt YiCiion^BR: ^ 4 `'. .r,' 4 w�4 yd '+ A t lr t✓ 'r S +. as ."` d..F , �e'•,I „ :i•1., .. ;' '.a i - i .`. - 1A� '�� - J - "� n' , � - ayy,."A� r}x� a�•Is.i :-4-ev xi :n �- r,. Permit', for Food Establishment 27-01 Frozen -Desserts/Ice Cr'e'am` Permit for the-.Sale of Tobacco}Products`. 5 ` y These':Permits-Expire Decembers 31, 2001 " 'F This permit is not, transferable and 'mu'st be reissued upon change-ofa . 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:chaiiges. are made;.eall'plans for such-must be submitted to and approved by the Salem"�Board- of 'Health., HEALTH AGENT . a ' DEC i 2000 C— GF SALEM CITY OF SALEM BOARD OF HEALTH HEALTH DEPT. Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH, RS,CHO NINE NORTH STREET HEALTH AGENT Tel (978)741-1800 Fax (978) 740-9705 2001 APPLICATION FOR PERMIT TOO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT �U nn n. . kJC lY�n11�/�� TEL#QQ-�� - —144 " 0*6 ADDRESS OF ESTABLISHMENT V 9,�r11��,(IM J� 3\ MAILING ADDRESS (if different) ,,f� n r, OWNER'S NAME �Y Na f YI.Sp�YI TEL#Q-7 -_T-Qq " ADDRESS LQ�/t ?�S - CITY M11PrUY\ STATE (M1 ZIP ��'l' /y,1 , CERTIFIED FOOD MANAGER'S NAMES)��Q PJIn1kM CERTIFICATE#(s)�1M n (required in an establishment where pote ntn �ntia lly hazard us food is prepared EMERGENCY RESPONSE PERSON RF�6 '-SO H� Gl h6 TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO 'W Al RESTAURANT YES NO #seatsi-L #nonsmoking (440 \�a� BED & BREAKFAST YES NO $40 .aG, v� ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT SOFT SERVE YES $5 TOBACCO VENDOR YES 10 NO CHARGE FOR NON-PROFIT(suc church kitchens) PLEASE INCLUDE COPY OF TAX EXEMPT FORM Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Signature Date \ Social Security or Federal Identification Number u - - -- ---- - -` ------------------------- 11010 _ Revised 11/2food 1adm Check#&Date ��r COURT DOCKET NO. Q CITATION NO CITY OF SALEM VIOLATION NOTICE A2 7 4 0 NAME(LAST,FIRST,INITIAL) JJ f - STREETADDRESS CITY/TOWN STATE ZIP k I �/ei/h /S2 j�rStfrx-Oit�S�' �r_ll LICENSE NO. LIC.E%P 'TE DAT OWNER L�S''NAME(LAST FIRST INITIAL) ADDREj AT STREETTADDRESS CITV/TOWN STATE ZIP ,sa. �r�,TSNsf� REGISTRATION NO STATE fEXP DATEOLAMAKE?YPE YEAR COLOR DATJ OF/ITOO) TIME DAM DATE LCITATION WRITTEN PERWOAL �� // El PM /�Zjr-p�,�ljf iwua ONO ❑YES LOCATION OF VIOLATION Jf VN/t'r,J ADnU ENFORCING DEPT. 15_2 //li c 1A,A.7 4n-„ ,Sf OFFENSE I CHAP SECT FINES ,I cw/ /ado B _S/-&/-, C /p f-nxn.e OFFICER 10 1 D NO. TOTAL @ pp� LIAr// // 70 DUE W / y-4Kr2 l&5- DUE /per OF*ICER CERTIFIES COPY GIVEN TO VIOLATOR n// �n -/-'(�� / El IN HAND X /// LCGCd/A�fZLR/ L_H'RY MAIL DO NOT AIL 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 COURT DOCKET NO. Q O. CITATION TN CITY OF SALEM A CITJ� VIOLATION NOTICE A2740 NAME(LAST,FIRST,INITIAL) �-/ STREETADDRESS CITY/TOWN STATE ZIP LICENSE NO LIC EXPRTH OWNER'S NAME(LAST,FIRST,INITIAL) �QATII i STREETADDRESS CITY/TOWN STATE _ZIP REGISTRATION NO STATE EXP DATE MAKE/TYPE YEAR(COLOR DAT60F VIOLATION, TIME DATE CITATION WRITTEN PERSOONn- e�V/ ❑AM YES iwuR [I Pm /'S!- Roe/ [I NO LOCATION OFVIOLATION r.jrl.JJQywf$ ENFORCING DEPT /sx. LUdsl- , vii SJ` OFFENSE CHAP(SECT FINES e s 90. OFFICER I D NO. TOTALOZ1 vwaus/'7/&u 7c3 DII UE $ OFFICER CERTIFIES COPY GIVEN TO VIOLATOR - �/ ❑ IN AND X �. �/'��,fl,�p .(,-B/ BY MAIL DO NOT MAIL CASH-PAY ONLY BY POSTAL NOTE, MONEY ORDER OR BY CHECK MADE PAYABLE TO: CITY CLERK CITY HALL 93 WASHINGTON STREET SALEM,MA 01970 TEL.(508)745-9595 X 251 1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE PAYMENT IN THE AMOUNT OF $ CASE# SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL i•. .THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 9 North Street Board of Health Salem, MA 01970-3928 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 740-9705 Name h / \\ Date Tvoe of Ooeration(s) Tvoe of Insoection �l/.�lG.-� LCwaTS 1611)16/ R-Food Service Routine Address Risk ❑ Retail ❑ Re-inspection /Sad �v/a.</1. . 7a CT Level y.j ❑ Residential Kitchen Previous Inspection Telephone11Mobile Date: 978 /�y �� ❑ Temporary C�Pre-operation Owner 13a 4 HACCP Y/N ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed &Breakfast ❑ General Complaint /):ou ❑ HACCP Inspector _ / ate In: ❑ Other f/ Out: Permit No. Each violation checked requires an explanation on the narrative page(s) and a citation of'specific provision(s) violated. Non-compliance with: RED Violations (1-22) 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. 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 1 FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source ❑ 16. Cooking Temperatures :z ❑ 5. Receiving/Condition ❑ 17. Reheating ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 18. Cooling ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20. Time As a Public Health Control ❑ 8. Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) , ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 21. Food and Food Preparation for HSP [110. Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories BLUE Violations (23-301 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(RED Items 1-22): of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board Official Order of Correction: Based on an inspection Af Health. today,the items checked indicate violations of 105 CMR C 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 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (Fc-4)(590.005) cited in this report may result in suspension or revocation of 26. Water, Plumbing and Waste (Fc-6)(660.006) 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)(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 TX;1,11TR- is as n Inspector's Signature• Print: PIC'sSignature: 711,(,A�,_ Print: Page-/-of Pages Violations Related to Foodbome Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION AND MANAGEMENT 8 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 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 Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charee* Contamination from the Consumer _ _ 590.003(G) Reporting by Person in Charee* 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD F IOM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 19 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 Temperatures* 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* 5-101.11 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 22.0* 4-602.11 Cleaning Frequency of Equipment Food- Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 3-201.14 Fish and Recreationally Caught Molluscan 4-702.11 Frequency of Sanitization of Utensilsand Shellfish* Food Contact Surfaces of Equipment* 3-201.15 Molluscan Shellfish From NSSP Listed 4-703.11 Methods of Sanitization-Hot Water and Sources* Chemical* Game and Wild Mushrooms Approved by10 I Proper,Adequate Handwashing Regulatory 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* 11 I Good Hygienic Practices 5. Receiving/Condition 2-401.11 Eating, Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges from the Eyes,Nose and 3-202.15 Package Integrity* Mouth 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 1_6 �I Tags/Records:Shellstock 112 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(J) Labeling of Ingredients* 5-204.11 Location and Placement* q Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drying Provision *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. I c, THE COMMONWEALTH OF MASSACHUSETTS I �! (a";q Establishment Name / \ Date Address Page' of a Item No. In the space below describe all violations checked on front page. 16S7AI,' 1.7- /(A4,-i 7-8 df, 4, U / Z �h v-c .S�..rr.:.z.. i.V /4,4 cx /1? /,.c WW K K a 3 m m M M 0 s m a Z , rc ' O LL v � v Discussion with Management y'rp`�r1..f�,-v2.�"'y,.r+ i.-^rfl,.vr'x�`�-Ni�ni�'^''p++i",�""�TM��-1�'.ai..snywye.,:�'.�...i+aw::...wr..«�.dPw..:r`ha+u'+^•!:ii'+...+"fi�'.a..ys"e�.ry,,,f,....,,.srna a THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 9 North Street Board of Health Salem, MA 01970-3928 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: L) 740-9705 Name Dat Tyne of Ooeration(s) Tyne of Insoection /Ja/( S 3l Qr ❑ Food Service ❑ Routine Address \\ Risk ❑ Retail Ll Re-inspection Level / ❑ Residential Kitchen Previous Inspection Telephone1 ��/�� nY � C� ❑ Mobile Date: ��Y) d' LlTemporary LlPre-operation Owner �pG� - c4 HACCP Y/N ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) cv Time ❑ Bed&Breakfast El General Complaint �r ( ❑ HACCP InspectorIn: 11Other �� L_-017 L _ Out: Permit No. Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: RED Violations If-22) Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 59o.00g(E)❑ s9o.009(F)❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source ❑ 16. Cooking Temperatures ❑ 5. Receiving/Condition ❑ 17. Reheating ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 18. Cooling ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20. Time As a Public Health Control ❑ 8. Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 21. Food and Food Preparation for HSP 1-110. Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories BLUE Violations (23-30) Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions Fo 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 immediately or within 90 days as determined by the Board Official Order of Correction: Based on an inspection of Health. today,the items checked indicate violations of 105 CMR C 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 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 26. Water, Plumbing and Waste (FC-5)(590.006) the food establishment permit and cessation of food establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION:- Inspector's E-INSPECTION:Inspector's Signaturer� Prmt. L PIC'sSignature..{�\� Print: t ��F' i Jtv Page of I Pages Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION AND MANAGEMENT 8: 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 3-302.1 l(A)(2) Raw Animal Foods Separated from Each EMPLO"EE HEALTH Other* 2 590.003(C) I 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 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(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 Temperatures* 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, 1, 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 22.0* 4-602.11 Cleaning Frequency of Equipment Food- Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 3-201.14 Fish and Recreationally Caught Molluscan 4-702.11 Frequency of Sanitization of Utensilsand Shellfish* Food Contact Surfaces of Equipment* 3-201.15 Molluscan Shellfish From NSSP Listed 4-703.11 Methods of Sanitization-Hot Water and Sources* Chemical* Game and Wild Mushrooms Approved by 11 10 Proper,Adequate Handwashing Regulatory 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* Il Good Hygienic Practices 1_5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges from the Eyes,Nose and 3-202.15 Package Integrity* Mouth* _ 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 I Tags/Records:Shellstock 112 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employees* Tags/Records:Fish Products x_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* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging,criteria* 8-103.12 Conformance with Approved Procedures* 6-301.11 Hand 6-301.12 Hand Drying Cleanser,Availability g Provision *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. b s THE COMMONWEALTH OF MASSACHUSETTS Establishment Name Date Address �S r�( �� —' Pageof Z. Item No. In the space below describe all violations checked on front page. U Z W m K a 3 m m m m 0 x M a - n f 0 O 1. Discussion with Management v��cosur7• (y,,.. �,�� 9@�rhtnar v/L�r�//ate f/ CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH, RS,CHO NINE NORTH STREET HEALTH AGENT Tel:(978)741-1800 Fax:(978)740-9705 2001 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT T)Rew's 't 5 D� n T Al') TEL# - -Jar{'?RRY ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different) , OWNER'S NAME A0 TEL# 9�� 35a-air 2 ADDRESS l) CITY- —1) STATE_/ 1a . zip B/9 7- / CERTIFIED FOOD MANAGER'S NAME(S)bah CKS-0 aJ CERTIFICATE#(s) -712{/6/0 'O ti/TKr d T4C <S V -7/ 2f/bS (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSONHOME TEL# TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO $40 RESTAURANT K E-S NO #seats_ #nonsmoking $40 BED& BREAKFAST 'YES NO $40 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO NO CHARGE FOR NON-PROFIT(such as church kitchens) PLEASE INCLUDE COPY OF TAX EXEMPT FORM 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. ttbeo o MGL apter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my ledge d belief, have fled all state tax returns and paid all state taxes required under the law. l /a-/a-a ! o (13 - 1r29 — ZF9 Signature Date Social Security or Federal Identification Number -----------.... ------------------------------------------------------- -------------------- ----------------------------------- Revised 11/21/00 foodap2.adm Check#&Dat�/yLO— _ ,....r. , �r-w +•F.-. . .n - ...rwr�.s.r n aE -yYyew.*.r... � r n 'a•'R-... ry . ...:-..s-f`' 'q-.-,CYaj+'^.wi....�.- .�.,�,y.,y.., y , THE COMMONWEALTH OF MASSACHUSETTS City of Salem Establishment Name Date Address Page of / /5a GVoli may + �/ Item No. In the space below describe all violations checked on front page. /� rP>r o'f th Y / A(n) /2rJ(4W 0 9 /�l.a� fix^ inspeetien of this establishment was conducted in accordance with the State Sanitary Code for Food Establishments,Chapter X, 105 CMR 590.000.The following violations ere observed: Me {,�P P�'v i✓/.>-+eYr-1 /vie f��-n ..��i/ ,��a�� u3ur�r I ; . (�jdl✓" ,>n ]a/U ) (1 1 - I v F r Discussion with Management - 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 comply with all mandates of Chapter X. I understand that noncompliance may result in daily fines of twenty-five dollars. Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,40' Floor___" Division of Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax(978) 745-0343'- , __--- City/Town of Address: FOOD ESTABLISHMENT INSPECTION REPORT Tel. Name On Type of Operation(s) Type of Inspection QIP) C O It ®' Food Service ® Routine Address ( �� Rik ❑ Retail ElRe4nspection Telephone QodZ Level ❑ Residential Kitchen Previou Inspection P G �4, ❑ Mobile Date: IIW0lv,i Owner I � (-� HACCP YIN ❑ Temporary [IPre-operation l` 1 i VSD,�J I ❑ Caterer ❑Suspect Illness Person-in-Charge(PIC) Time ❑ Bed&Breakfast ❑General Complaint Inspector I /� In: �'34 Permit No. ElOt Other OW55� � Each violation checked iequires 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 Anti-Choking 590.009(E) ❑ Items) Tobacco 590.009(F) ❑ Violations marked may pose an imminent health hazard and require immediate Allergen Awareness 590.009(G) ❑ corrective action as determined by the Board of Health. _F000 PROTECTION MANAGEMENT 4 41 _ _ . ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties _ EMPLOYEE HEALTH Handwash Facilities ❑ 2. Reporting of Diseases by Food Employee and PIC- PROTECTION FROM CR-EM-1-CAS _ El 14.Approved Food or Calor Additives E] 3. Personnel with Infections Restricted/Excluded _ ,,. ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source TIMErrEMPERATURE CONTROLS_ (Potentlalty Hazardous Foods) -' 3 ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ IT Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding El8. Separation/Segregation/Protection ❑20.Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLYSU$CEPTIBLE-POPULATIONS(HSP). _' E]21.Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing [111. Good Hygienic Practices CONSUMER ADVISORY ❑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. Noncritical(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 9 Management and Personnel (Fc-2X590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (Fc-3X550.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4X590.005) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food 26.Water, Plumbing and Waste (FC5X590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (Fc5X590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7X590.008) 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.aa nn _ Inspector's Signature: I Print:\ lI- PICsSignature: I Print:��- hn � �i , Page-j-of$Pages I v III Violations Related to Foodborne Illness interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION g Cross-contamination FOOD PROTECTION MANAGEMENT I 3-302.11(A)(1) Raw Animal Foods Separated from 1 590,003(A) I Assignment of Responsibifity* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* 1 Contamination from Raw Ingredients i 2-103.11 Person in chargeduties 13.302-1 I(A)(2) Raw Annual Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 1 2 59&W3(C) ( Responsibility of the person in charge to 13-302.11(A) Food Protection* require reporting by food employees and I 3-302 15 Washine Fruits and Vegetables I applicants* 1-104,11 Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An � � Utensils* Applicant To Report'T'o The Person In I Contamination from the Consumer Charge* , i-306.14(A)(B) Returned Food and Reservice of Food* G 590.003(G) I Reporting by Person in Chaise* j Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions' I Food 4 590,003(E) I Removal of Exclueioms and Restrictions 3-701.11 Discarding or Recononing Unsafe Food* FOOD FROM APPROVED SOURCE 4 Food and Water From Flegulated Sources I 9 Food Contact Surfaces C 590.004(.A-B) I Compliance with Food Law* # 4-501 111 Manual Warewashing-Hot Water 3-201.12 1 Fcrott in n Hermetically Scaled Coniainer* � Sanitization Temperatures* 4-501.1 t2 Mechanical Warewashin Hot Water 3-201.13 Fluid Milk and Milk Products* ) Sanitization Temperatures* ( 3-202.13 Shell Ears* 4-501.114 Chemical Sanitization-to { 13-202.14 I Eggs and PAilk Products.Pasteurized* �"PH, f � 1 concentration and hardness.* _ ( 3-202.16 lee Made From Potable Drinking`=x'ater* * 1 4-601.11(A) Equipment Food Contact Surfaces and E 5-101.11 Drinking,Water from an Approved System i Utensils Clean* 390.006(A) Bottled Drinking Water* 1 4-602.11 Cleaning Frequency of Equipment Food- 590.0()6(13) Water Meets Standard,in 310(:MR 210* 1 Contact Surfaces and Utensils* Shetirish and Fish From an Approved Source j � 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Re=atiunaliu C iaglit Moliascan I Fain Contact Surfaces of Eauipment* Shellfish" 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 MoOui can Shellfish from tiSSF ll tcd Chemical* Sources* E 10 ; Proper,AdequateHandwashing i Game and Wild Mushrooms Approved nV 2-301.1) Clean Condition-Hands and Arms* J Regulatory Authority 3-202.13 Shells eek identification Pie�cnt" ) 2-301 12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.t i Game Animals* 1 I it Good Hygienic Practices ( Receiving j 2401,11 Eating,Drinking or Using Tobacco* g I 3-202.11 I PHrs Received at Proper Tems*perature -'101.t 2 Discharges From the Eyes,Nose and � I � mouth* 3-202.15 Package frttegsity" ) 3-301.12 Preventing Contamination When Tasting* 3-1;?i.]t 1:,,«1 Safe and Unadulterated* n Prevention of Contamination from Hands 6 1 '+ags/Flerord=_:Shelistock t" 3-202.1$ 15hetl:tock Identification* ) 590.004(E) Preventing Contamination from Employees* 3-203.12 Shellstock identification Maintained* t3 Handwash Facilities I Tag 0' Fish Prad:tcfs Conveniently Located and Accessbte 3-402.11 Parasite Destruction* 3-402.12 Records,Creation and Reie.nuon�* 5.203.11 Numbers and Capacities* 590.004(1) Labeling of ingredients* I 5-204.11 Location i and Placement* 15-205.11 Accebilify.Operation and Maintenance 7 Conformance with Approved Procedures .Ii IHACCP Plans Supplied with Soap and Hand Drying 3-502.11 I Specialized Processing Metbods* Devices ( 6-301.11 Handwashing Cleanser„Availability, � 3-502.12 Reduced oxygen packaging,criteria" , 9-103.12 Conformance with Approved Procedures* 6.301.12 Hand Drying Provision *Denotes crifiwl item in cite fuieral 1999 Faid C,)&w t:t5 ChtR 590tM, CITY OF SALEM BOARD OF HEALTH Establishment Name:RIJ Kr n (�nli� - / J)), - Date: I Page: of �— Nem Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION I $ate. No. Reference R—Red Item I Verified 11 PLEASE PRINT CLEAR �r I � 1 � / l C-Od'T hflyc(,- �✓. p' 'Ile/� 1 Q _ ' -lel Oo . I � I 1 I I / ► K•� / �I I QrgeAl Cot.,)- ✓ C.AM s� A-A/ DD csiussion With Person in Charge: JCorre�e Action Required: I ❑ No Yes 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 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 f twenty-five dollars su r cation of ❑ Embargo ❑ Emergency Closure your food permit. jJV�\V�� I C3Voluntary Disposal 0 Other: i s 3-501,14(C) PHFs Received at Temperatures i Violations Related to Paadborne 91ness tntetventions and Risk - According to Law Cooled to Factors(Us=1-22) (Cont.) I 41'FI45F Within 4 Hours. 3-501.15 ( Cooling Methods for PHFs PROTECTION FROM CHEMICALS I J 119 PHF Hot and Cold Holding 14 ( Food or Color Additives 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 1 1 Additives* 590.004(F) 41'145°F* + 3-302.14 Protection from Un proved Additives* I c Substances 13-501.16(A) Hot PHFs Maintained at or above i5 Poisonous or Toxic 140T. t 7-101.11 Identifying Information-Original Roosts Containers* -SO1.I6(A) Roasts Held at or above 130'F. t 20 I Time as a Public Health Control 17-]02.11 Common Name-Workiug Containers° 1 J 3-501,19 Time as a Public Health Control* ` 1 7-:101.11 Separation-Storage"` E 17-202.11 .Restriction-Presence and Use* i A 590.064(H) I VarianceReauirement w { 7-202.12 I Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE i 7-203.11 Toxic Containers-Prohibitions* � 7-204.11 SanitizePOPULATIONS(HSP)rs.Criteria-Chemicals* J 17-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Iuices and ( Beverages with Wanting labels*7-204.14 Drying Agents.Criteria' I 3-801.11(6) Use of Pasteurized Bg,gs* 7-205.11 Incidental Food Contact.Lubricants* } 3-801.11(D) Raw or Partially Cocked Animal Food and 17-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served # 7-206.12 Rodent Bair Stations* I 3-801A I(C) Unopened Food Package Not Re-served. I_ 7-206.13 Tracking Powders,Pest Control and Man Loring* CONSUMER ADVISORY T1MEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Coolnng Temperatures for Animal Foods That arc Raw.Undercooked or PRFs Not Otherwise Processed to Eliminate t 3-401.I1A{t}(2) Eggs- 255°F 15 Sec. Pathogens.'�� ""cae li o Eggs-immediate Service 145°Fl5sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game Ems* ` Animals-155°F 15 sec. * SPECIAL REQUIREMENTS f 3.401.11(6)(1x2) Pork and Beef Roast-130'F 121 min* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec.* catering, mobile food,temporary and s 3-401.1 I(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-mascle,intact Beef Steaks interventions and risk factors. Other 145*F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a } practices should be debited under#29- Microwave 165*F* Special Requirements. 3-401.1I(A)(1)(b) Ail Other PHFs- 145°F 15 sec, 117 Reheating for Hot Holding I VIOLA77ONS RSLATED TO GOOD RETAIL PRAC77CES 3403:11(A)&(D) PHFs 165"F 15 sec. * (Items 23-30) + 1 3-403.11(B) Microwave- 165'F 2 Minute Standing Critical and non-critical violations, which do not relate to the 'rime* foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140*F'* 590.000. f 3-403.t i(B) Remaining Unsticed Portioav of Beef I tisrn Good Retail Aractices FC 59A.4Qt7 i +1 Roasts* j 23. 1 Management and Personnel I FG-2 .003 i i 24. Food and Food Protection FC-3 .004 18 Proper Cooling of PHFe% I 1 25. 1 Equipment and Utensils i FC-4 .005 ' 3-501.14(A) Cooling Cocked PHF%from 14TF to � 1 26 ! Water.Plumbaia and Waste i FC-5 .Mfi i t 700F Within 2 Hours and From 70°F 27. 1 Phvsical Facifity FC-6 .607 to 4 VF/45'F Within 4 Hours.* i 28. I Poisonous or Toxic Materials FC=7 .068 1 3-501.14(B) Cooling PHFs Made From Ambient 29. 1 Special Reauirememrts .ow Temperature Ingredients to 41°F/45°F 30. 1 Other ! I 1 Within ,-, Htwrs* lknoms critical loan in the federal 1499 Fexd Code or 105 C.MR 590.000. i