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3N CONVENIENCE - ESTABLISHMENTS 31� CanV�n�tn Ct fw universal one www.myuniversalop.com phone: 1-800-756-4676 UNV16162 MADE W USA Commonwealth of Massachusetts +� City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2011 ESTABLISHMENT NAME: 3N Convenience File Number:BHF-2004-000112 3-5 Paradise Road Salem. MA 01970 LOCATED AT: 03-5 PARADISE ROAD SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2011-0054 Jan 1,2011 Dee 31,2011 $280.00 TOBACCO VENDOR BHP-2011-0055 Jan 1, 2011 Dec 31,2011 $135.00 Total Fees: $415.00 PERMIT EXPIRES December 31, 2011 Board of Health 1171 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 t - r CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4"`FLOOR TEL. (978) 741-1800 KIb1BERLEY DRISCOLL FAx(978) 745-0343 MAYOR DGREENBAUT'JaSAIEN4.COM DAVID GREENBAum,RS ACTING HEALTH AGENT 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT -t q NAME OF ESTABLISHMENT tn� I�_`D2R 1-SIE TEL# -f7STI D V 4 I ADDRESS OF ESTABLISHMENT '�— FAX# 0 O _ MAILING ADDRESS(if different) �L t Lp1 / 1 [°l-p EMAIL-Business': ebsite:7 OWNER'S NAME }EL# d 11b ADDRESS NI % S wl ) DI Tri STREET J CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) /A- CERTIFICATE#(S) (Required in an establishment where potentially hazardous f is prepared) a, EMERGENCY RESPONSE PERSON V' 1 OME TEL#e /TI 44 03�t d M y ay-, friday 1 8atu�day� �< `r `.Sunda DAYSyOF,OPERATION r x onda '^ _ TueSda -` `°rWednesda ,'. Thyr d „ - HOURSOFOPERATION � �� 6 �itPm 6A1nd bfr)yL. �M i Please write in time of day. r� For example Ilam-1lpm L% Pot 1 u PM 1 L1. PTA PM TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 - ------------------------------ _ - RESTAURANT YES NO less than 25 seats $140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 --------------------------------------------------------- - - BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES/NURSING HOME - - ADDITIONAL PERMITS MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE YESNO $25 TOBACCO VENDOR Q 135 ALL NON-PROFIT(such as church kitchens) YES N 25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State 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 sl as required under the law. paid all Signature �R Date 11, Ell J_CT Social Security or Federal Identification Number Revised lOn/I I FOODAP2ol Ladm eck#&Date 9bBT�f��U $ I-t 1 / Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4`" Floor Division of Food and Drugs 120 W MA Don Street, FOOD ESTABLISHMENT INSPECTION REPORT Sal23 Tel. (978) 741-1800 Fax (978) 745-0343 Name Datie Type of Operation(s) ftof Inspection k U!'flin Q ❑ Food Service - Routine Address ') Risk U_Retail ❑ Re-inspection _ Level 0 Residential Kitchen Previous Inspection Telephone I �^ I ❑ Mobile Date: I Owner HACCP WINElElTemporary Pre-operation I /< � El Caterer El Suspect Illness Person in Cha ge(PIC) Time ElBed&Breakfast ElGeneral Complaint In,", ❑ HACCP Inspector15eI out. f Permit No. ❑Other Each violation cYiecked 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, .„,„.. ,, ., n#.�, .� ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties ❑ 13 Handwash Facilities _EMPLOYEE HEALTH'S 1 A P , ROTE&ION 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 ".TIMErrEMPERATURECGNTROLS(Potemially Hazardous Fnatls)=Trn .�u..a:.z El 5. Receiving/Condition El 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling f°PROTECTION FROM C'oNTAMINATlON ❑ 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 SUSCiiiPTIBL.E POPt)LATiONS(H$P) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMERRADVISORYj„j' ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board 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)(550.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.006) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: s ssoi�sae«Fo.,,a-ia.eoo Inspector's Signature: ��, / / Print:, l f�ages PLC's Signature: ) !.-, �I .� PrPrint:. 1 : 14 1 C1 Page 0 Violations Related to Foodborne Illness interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Cross-contamination 1 590.003(A) Assignment of Responsibility* 3-302.11(A)(1) Raw Animal Foods Separated Irom 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* 253.11. Person in charLe--duties Contamination from Raw Ingredients 7302.11(02) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(0) Responsibility cat the person in charge to Contamination from the Environment require repotting by food employees and 3-302.11(A Food Protection* applicants* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and - Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590,003(0) Reporting b j Person in CIxtrge* 1-306.14(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 3-701.1.1 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a lleiiiieticall y Sealed Container* Sanitization Temperatures* - 3-20'113 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.14Eo gs and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water' concentration and hardness. * 5-101.11Drinkin Water from an Approved System* 4-601_I I(A) Equipment Foal Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(B) Water Meets Standards in 31.0 CMR 22.01'. 4602.11 Cleaning Frequency of Equipment Food- Sheltflsh and Fish From an Approved Source Contact Surfaces and Utensils' 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* to Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authori 2-301.11 Clean Condition-Hands and Arms'i' 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201..1.7 Game Animals` 11 Good Hygienic Practices g 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 Packa e htte it * Mouth* 3-101.11, Food Safe and Unadulterated* 3-301.12 preventing Contamination When Tastin * 6 Tags/Records;Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.1.2 Shellstock Identification Maintained* Employees* tR Tagsecords:Fish Products 13 Handwash Facilities 3-40211 Parasite Destruction* 5-203.11 Numbers Located and Accessible ers and Ca - acities 3-402.12 Records.Creation and Retention* I 590.004(J) Labeling of Ingredients" 5-204.11 Location and Placement* Conformance with Approved Procedures 5-205.11 -Accessibility,Operation and Maintenance MACCP Pians Supplied with Soap and Hand Drying 3-502.11. Specialized Processing Methods* Devices 3-5(Y21.2 Reduced oxygen acka ham,criteria* 6-301.11 Handwashin Cleanser, Availability 8-103.12 Conformance with A roved Procedrues* 16-301.12 Hand Drying Provision *Dentes critical item in the federal 1999 Foal Code or 105 CMR 590.000. - CITY OF SALEM s BOARD OF HEALTH Establishment Name : 3N' Qvwgingce y Date: 4 t-xs IUCD Page: of d� k Item Code C-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item. - - - Verified r PLEASE PRINT CLEARLY f q (6 bI IIJP ) e U Cr. r cites G a ,l _ Isom Isr e"tv.e �f rS�PnIVCA CeA —1^ i n ,� �P a I Lr Ac_o r (_6 & V UZ, —I)tce,, 1.1 L,) 1S, d L) r 7.1 1 ) Gill OJ ou 7?fi 0 0, n 144_t 1 c 1220 A K6 I 6c, Qen EA 4 or,, o N 3 4 1 t o A.�. � Pf AAI �I i � Cti14 �v ••r�vi Wn �7f7V' cD'1 f Sb1 tf i - nA , F 0 .J 5i� �7- P/I e Ls- Ie I Discussion With Person in Charge: Corrective Action Required: ❑ No I k Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction inspection, to observe all conditions as described, and to Exclusion violations before the next ins P ❑ Re-inspection Scheduled ❑ Emergency Suspension -" comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. '��,� ^ ' a / ❑ Voluntary Disposal ❑ Other: 3-SOL14(C} PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to I-aw Cooled to Factors(Items 1-22) (Cont.) �4 PF/45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 CoolYa,Methods for PHFs 1g la Food or Color Additives PHF Hot and Cold Holding ---- 3-202.12 Additives* 3-501.16(73) Cold PHFs Maintained at or below 3-302.14 Protection fromUna) rovAddtives* 540-.904(F) 4 °/45'F" HntPHFsMaintaipeda[orabove 15 Poisonous or Toxic Substances 140'F 7-101.11 Identifying Information-Original 3.50116(A) Roasts Held at or above 130°F. Containers* 7-102,11 Common Narne-Working Containers* 20 Time as a Public Health Control 7-20'1.11 Separation-Stora*e* 3-501.19 Time as a Public Health,.ControP* 7-202.11 1 Restriction-Presence anti Use-' i90.004(H) variance Returewent' 7-202.12 Conditions of Use" - 7-203.1.1 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitlzers,Criteria-Chemicals* POPULATIONS(HSP) 7-2(4.12 Chemicals for Washin Produce,Criteria"' 21 3-&Ol.I1(rT) Unpasteurized Pre-packaged Jwcas anti Beverages with 1'JarnineZabcls* 7-204.14 Dr ing A ants,Criteria'" 3-801.11(B) Use of Pasteurized Fees* 7-205.11 Incidental Food Contact.Lubricants* 7-206.71 Restricted Use Pesficides.Criteria* 3-80Ll l(D) Raw or Partially Cooked Aminal Food and Raw Seed S routs Not Served. 7-206,12 Rodent Bait Stations* 3$01.11(0) .Unopened FoUd PTjka e Not Re-served. " 7-206.13 Tracking Powders,Pest Control and _ Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods'Fbat are Raw,Undeacooked or PHFs 16 Proper Conking Temperatures fori 155°F 15 Sec. Not Otherwise Processed to Eliminate _ 3-401.11.A(I)(2) Fgg �.._ Pathogens.* �necovarr,2ra Peer-Immediate Service 145°Fl5sec* 3-302.13 Pasteurized Fgg<Substitute for Raw Shell 3-401..11(A)(2) Comminuted Fish,Meats&Game E gs* Animals- 155"F 15 sec. - 3-401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites, Injected Meat's-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. * catering, mobile food,temporary and 3-401.11(A)(3) Poultry, Wild Game,Stuffed P11Ps, residential kitchen operations should be Stuffing Containing Fish, Meat, debited under the appropriate sections Poultry or Ratites-165`F 15 sec. "= above if related to foodborne illness 3-401.1 1(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F a` 590.009 violations relating to good retail 3-401 12 Raw Animal Foods Cooked in a practices should be debited under 1129- _ Microwave 165°F* Special Requirements. 3401.11(A)(1)(b) All Other PHFs- 145°F '15see. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165°F 15 sec:. * (Items 23-30) 3-403.11(B) Microwave- 165°F 2 Minute Standing Critical mrd non-critical violations, which do notelare to the Time* .foodborne illness interventions and risk factors listed above, can be, 3-403.11(C) Commercially Processed RTP Food- ,found in the fo{lowing sections q/the Food Code anal 105 CMR 14WF* It 590.000. 3-403A I(E) Remaining Unsliced Portions of'Beef Item Good RetailPraCSCes - _ FC 580.000 * ana emeni and Personnel Roasts Personae,l _ . _, ' FC-2 .003 __..... _ 1$ Proper Cooling of PHFs 24. Food and Food Protection FC--3 .004 _ 25. _ E uipment and Utensils _ FC-4_ .005 3-501.W(A) Cooling Cooked PHFs from 140°F to 26. Water. Plumbinq and Waste FC 5 006 70°F Within 2IIotrrs and From 70°F 27. Ph sisal Facillty 'I .o07,. to 41.°F/45°F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs,Made From Ambient 29. S eclat Re uiremsnis _ _ .009 Temperature Ingredients to 41°F/45°F Other ik abin 4 hours* •'°0r"","^'''*�21oc *'Dellis critical item in the,realeral 1999 Food Code or 105 CMR 590.000. Commonwealth of Massachusetts • f City of Salem Board of Health ._____fmberley-DriSCOII -- - - - - - 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/12/2009 ESTABLISHMENT NAME: 3N Convenience File Number:BHF-2004-000112 3-5 Paradise Road Salem MA 01970 LOCATED AT: 03-5 PARADISE ROAD SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2009-0367 Jan 9,2009 . Dec 31,2009 $280.00 TOBACCO VENDOR BHP-2009-0368 Jan 9,2009 Dec 31,2009 $135.00 Total Fees: $415.00 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 .. .. ... . .. . ........ . ............... . .. -Jan 09 09 1 1 : 12a ' *Joanne Scott ,Salem BOH 978' 745 0343 ', ; P e1fi " ,C..�� ..D•;iV•� �� 1 q.-.��4 \,•r .f' t�.,ri' •,`�i-.-� , � `_'ti'1".r'-'�.. -v >r�-a a.tciit9% •,-� �I'7`;'e 1 �i.,'•'.:. SALFJM SSACHUSETTS ' , r v. a: I r i 130ARD OF FIrALTH . t U n' e e 120WASHINGTON STREha.,4'u I•LCi(JR 1 P k4";;-M: 'TFI .{9iS) 7-11 1500 t yw. 'v r . Kl\d11r:121.1?1'i0!:LscoLl. i'-\\(97 8)745-0:14.3 :\t v.rlalns v.i at('O\i t 2009 APPLICATION FOR PERMITJTO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHINIENT ' ADDRESS OF ESTABLISHMENT ( �1�G19PFAX AtAIUNG ADDP.ESS{If d:ffc:c:,t) �/� - , EMAIL- Business'- Y``4_ ��\ Website: ( ` OWNER'S NAME�S ��u.,__- j�T3/DDIN_. TELP1�J&�7L+ O�j40_ ADDRESS -�ql 4U�n ✓ Y .r- S� rl n `"` ©19_0 ,: i STF1EeT CITY t 9t"ATL" Zir= CERTIFIED FOOD(;1ANA.GER'S N'AME(S)___�_r m 1 IV.IYT CERTIFICATE><(S1•_ ' (Required in an c5labiishmu,t n'here xKeni.oily na2areous r,oc is prepared,, /t ��11 ff�� ff11 -f11��I1 motif EMERGENCY RESPONSE PERSON �UL I Pr�� HOME TEL#(��b� - DAYS OF OPERATICN I Nbrday Tuesday lNednesdav ii_ Thursday , Fnday_ Saturday Sunday ,HGURS OF Jocn4710FI 6rlr•I'I1 PM /'J1�kJiIPm /1�.y� /t,, I /1 .{t/y� J (� r��7,,y 'lipml TYPE OF ESTASLISHMENT FEE check oniy� , i{I RETAIL STORE YES NO - less than 1000sq+1. =S 70 !000-10,000sq.ft. =5280 - h more than.T0lJUUsgA. =7,4zu t z RESTAURANT fE5' NO less than 25 sea's =5140 + (Outdoor St3hanary FOod C2it S210j 25-99 neat& -5280 more than 99 seats =$420 R BED/BREAKFAST! fES NU............................................................ ..'.._`..,. --.S100..... CHIC DCARE.;ERVICESiNURSING HOh1E �0 T'` ,,3 T' ADDITIONAL PERMITS r ................................. .......... n. r ` MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE ' YES NO S25 IOtIACCUVENDOR YES NO135 ALL NON-PROFIT(such as church kitchens) —YI:S -NO, $25 - • •p •-- *Please pay total with one check payable to the City of Salem. t t This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. ' In accordance with the State Sanitary Code, before any renovations,improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. r I Pursuant to M11GL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief.have filed all SIata tax •` a' returns and paid all state cases required under the la%,. 1 Si gnaturc' 1i �, I p�q�p,r D:11� © r O or;")1 c.cwn%,. r V' d o iticatio r ,,r �S uC cdc�al I c t n \umber }• - - - - -- - ._..°J. 04 9.9--9.13---- nC};,al Jizavl7,000,,r2a0g.zdm tt P i Ua-- 1.3' VA.. l.y 41 '��, '................................................... ................................................................................................................................................................ • :. Aj ( irk• A 4-,�.� ^-"^'irr.A � . bl�• ! a+Y..,<'yF4q�,-,<,�'t�•nr�$sv^q✓k'-LL$4.+y�,.�f.ar. A. .. :..�� ,:, ,.^.-�<•'v+a»Y�'+*^:<S:i,f�r;1+r. f+'r,V'P4'•^•'w1'tU+�iw.F,..,.v vt•* ' 3.� -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 1 Date Tvoe of Operation(s) Tvoe of Inspection 3 N \/0 /1 UJB ❑ Food Service ❑ Routine Address -7 . Rik ( 01-Retail I'Re-inspection O Uri Level Residential KitchenPrevious Insp tion Telephone 3 El Date: 10,103 Owner I HACCP Y/N El Temporary ❑ Pre-operation S L- ,/ A d ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint n InIll'oo ❑ HACCP Inspector /U LL 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. T'FOOD PROTECTION MANAGEMENT_ ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties t��y» » � ❑ 13 Handwash Facilities €»EMPLOYEE HEALTH -"""" i ��:,E .,.,c�....�. ..,.� ,<......R.x:�-„a.�'..�m(;®� ,3 a;" .,•.� PROTECTION FROM CHAICALS 'r','"' '�rr_r�n x�n'� ❑ 2. Reporting of Diseases by Food Employee and PIC ,�n� El 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded r e *� y ❑ 15.Toxic Chemicals .�FODo FROM APPROVED SOURCE,„_ , ��6,;»,�..,,,�.,,„-_„„,�, . ,„„»Qi ° TIME/TEMPERATURE CQNFIJOLS{Potentlalty Haxardoua Foods) ' '�� E] 4. Food and Water from Approved Source ».» » r v�• $ ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures " El 6. 17. Reheating 6. Tags/Records/Accuracy of Ingredient Statements g ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling f PROTECTION(= x� [119. Hot and Cold Holding fiOM CONTAMINATION ❑1 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing 'REQUIREMENTS FOR HIGHLY SdSCEPTIBLf POpULATtQNS(FtSP)m j ❑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 rC:r qtr:; p g 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-a)(sso.005) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.006) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION. f Inspector's Signature: Prin E. LM ' PIC's Signature: Print: f� , n - Page-4of�ages 1I cJ U Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Cross-contamination 1 590.003(A) Assiunent of Responsibility* 3-302.11(A)(].) 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 I(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590A03(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 WmIring Fruits and Vegetables 590.003(F) Responsibility Of A Foul 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* 4-501.1.11 Manual Warewashing-Hot Water 3-201.12 Fnod in a Hermetically Scaled Container* Sanitization Temperatures* - 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashinn Hot Water 3-202.73 Shell Eggs* Sanitization Temperatures* 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. * 5-101..1.1 Drinking Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drmkin Water* Utensils Clean" 590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency oi'Equipment Food- Shelsh and Fish From an Approved Sourca Contact Surfaces and Utensils* 4-702.11. Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally' Cught 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* ig Proper,Adequate Handwashing Game and Wild Mushrooms Approved By Re utato Aufhorlt 2-301.11 Clean Condition-Hands and Anus* 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 Receiving/Condition 2401.11 Eatin ,Drinkin«or Usin 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 PreventingContamination When Tasting* 6 Tags/Records;Shelistock 12 Prevention of Contamination from Hands 3-2.02.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shelistock Identification Maintained* Em rlo gees* 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 Ingredfenty 5-204.1.1 l-ocation and Placement* ? Conformance with Approved Procedures 5-205.11 Accessibilit ,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11. Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging,criteria* 6-301.11 Hindwashing Cleanser,Availability 8-103.12 Conformance with A roved Procedures` 6-301.12 Hand Drying Provision Denotes critical Item in the federal 1999 F(W Code or 105 CMR 59000. i r CITY OF SALEM BOARD OF HEALTH Establishment Name: re )nVPn n Nle¢- Date: / /�� Page:_\ of f Item , Code; ;,_: 'C-critical item �.t n ';DESCRIPTION OF VIOLATION/PLAN OF CORRECTION ', ' - '41_ 4 =vDate erfi1i No. 3 Reference R—Red Item s, �, t -,. � „.. _x. .>. z• .._ -.. 4 .r.x} �-- x", � ) "i PLEASE PRINT CLEARLY .a � _ II!_,n r"Jo - . ;E V Discussion With Person in Charge: Cor ective Action Required: ❑ No = Yes I have read this report, have had the opportunity to ask questions and agree to correct all Voluntary Compliance ❑ Employee/ esiriction/ l violations before the next inspection, to observe all conditions as described, and to Emerg o cy P ❑ Re-inspection Scheduled ❑ Emergency Suspension } comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure I your food permit. ❑ Voluntary Disposal ❑ Other: i t Taniper ,1,14(C' M 'dips Received atures Violations Ralated to Foodborre,Illness Interventions and Risk Acvordi all to LaCooled to Factors Illebur 1-22) (Cone} I WF/45-F Withia,' Roam -L�... . ... ....... , PROTECTION FROM CHEMICALS 3-501,15 coohill Methods for IIHFs I L19 PHF Hat and Cold Holding 14 Food or Color Additives 3- Cold liffs Maintained at M below 202 12 1 dchhycs* 590,N)"(1-) —f41�/45"F� 3512 14 protection lrqm;Llh!�� w! dini' I So lot PHl'i Mainlamod at or above 1=5 Poisonous or Toxic Substances 146'F. 11 Identifying Itimi mvition -Otiginal 1 Conch.ners' 3-50lAte�\)---RctisLc Hold at or above. 13W'F.* Time as a Public Health Control 1-102,11 cribullon Name 3 7�07 IT Tinw, , a Public Health Control, 1-2oi.l I Isepal Variance,Raturament 7-20111 Rcstricnan-prescrtoo and Use � ...F�T—znaa--n:� 7-24)2.12 Conditious of Tjsv* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE --I') I Toxic Colvtlntlel�-prolobn1olli* POPULATIONS 'HS 4 sariftizer",crlt�ria-Ch intents 21 3-801 il(A) Unptv�tetc,iycd Tria-packtiged Juices an 7-��1042 Cheirlicais for 'r!xqLtea,Clito(W� llevcf evei,WiLh—Wal _()4 1 it pa't""I'm tge 2(J5 1 1 hicid-ittal Naod Contact,JAIN icajos,�� '801 I I(37) Raw or Panialk Oiokt�d Animal build and 1 7-206 11 R,�stricled Lse Peqjcidel,Criteria' R"or Seen�jLr,�ci,�,c served 7-200.12 ROKICul li0it St leans IPCi 1 wders', Pe-st Controf and _nc i 1�mdcr, 4onm ink CONSUMER ADVISORY 22 3-60; 11 Coosuirm Aioisoivflosccd forCousninfition 7.6 TIMErrEMPERATURE CONTROLS Animal k aro Thican: Raw. Under�lkM or Proper Cooking Temp;�atu;�s mi PHFs Net Other av ise Proce5s'ed to E'liminter 3A(1)(2) Eggs- L55 pall 15 S�,c. Fit�� Sllbsowte fol flaw Shell 14.5'F 1-40 1.11(A)(2 3 Comminoled F;eb,N4cats&, (cluic Anon ds - i551-* 15 sec, 'v SPECIAL REQUIREMENTS 3-401.11(13)0 (2) 1 Poll, and Beel kkmvt - 1301 121 rlan° 1 �) R t I jeood klc�,V,- 1,55�F 15 -1 '41")(y, -til 90.(W(A)41)) in scccalcrinemoltdc fooll,tomporary and rcsident.td kitchen ciperalieinshould be Sluffolit Containing Filh. Meat, l debiled a tater the appropriate,attars Pouloy or Ratitts-1 65115*c. * above if relatod to foerlborne ithiess 3-401 Whole-morde,Imact Boef Steaks intel ventions and isofactory Other 590.009 violatitsis relating to hood retail Raw Annual Fixxis Cooked in a i-401j2 prat'.1ices should Ix:debited under#29 - MiclowaW-W'F Special Requirerneliv,. 3-46 1,11(A)(1)(b) N!Otbei PHF,, - 145"F 15 sm I--Vj-0j.�-fj5N—S RELATED lot Hot Holding TED TO GOOD RETAIL PRACTICES T_ EC7 JE3 i7W)3,,1 FI( PI-Ip, 1,65'T !J sec. I (Rems 23-30) J(j I J(H) 40111(6) 'Aicromave-155°F,2 Minnie Standing, (3finCai and non ethical viuh'decro ohich do ner!relate to the Time, foodborne Wileis inn venrioro,and rr3 A-factors li vied libove, (on be 3-403.1 IW) 1 commercW)v lrroccssed RTE Flxxi- i'lord isi seenoro q/the Food Code altd J05 Oil? 140'F" 5<)0,000, ------------ ------ -- 3-483-11(E3 Remaining Unsced Porei�,n7,iBcl -Good Retail Practices FC Sgo,ow cif * Roast, Man aqfm and el 1 FC .2 '003 Proper Cooling of PHFs i Food and Food Protection FC 3 1=8 1 25, JEW �pnt and Uterwils L005 -26, W I 561 14(A) �4uqi Cookccl PHF�foirn 14WFto —----- ; iset.Rlxnb�,�,y and -6&3 "Wit; Within 2 1-iourss and From 7fPF Nz: Tc—_ ---- T PHF,,,N ell[ 3' "OF.14i1h) Cooliulg .lade From Ambr S Tempe,noure Ingredients to 41 vf,!,45'F LV- I Other L----Within4-I1ouW . .: , .�; �-.�.. _�,..,.:.-'•'�Yj� .,.Y.>��..K"ow^'f��i�V1Pr-��4«4....��a( . .`Y .:.-_ .,..,..�.....;..++rw.wl':.:iY S'..ir .lt:. -.. :ey,+^,L:.;.'y,+a '"''. Massachusetts Department of Public Health 120 W sHealth Division of Food and Drugs Sal WashBoard aro ngton S Street,4x Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name �, 1 Dat Tvpe of ion(s) Type of Insnection I j (� j �� Cil% ❑ Food Service Routine Address Rik {9- Retail Re-inspection f Level ❑ Residential Kitchen Previous Inspection Telephone J - 3111 ❑ Mobile Date: Owner HACCP YM [ITemporary ElPre-operation ❑ Caterer ❑ Suspect Illness Person in Charg (PIC) Time ❑ Bed&Breakfast ❑General Complaint Incl. El HACCP Inspector F Out: Permit No. El Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factorsl 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. e FOOD PROTECTION MANA(iEMENT, ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13 Handwash Facilities +'EMPLOYEE HEALTH E- AI iMk (9 tv-3 1f g;PROTECTION FROM CHEMICALSk��E .., t .�i 4 . ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15 Toxic Chemicals FOOD FROM APPROVED SOURCE m F„s�, �� rw ,�„�,„r„�,F.�, TIMEtrEMPERATURE CONTROLS Potentiall Ha4ardous Folids ❑ 4. Food and Water from Approved Source _ ( y ) 4 PP � F. , r-15. Receiving/Condition El 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling i PROTECTION FROM CONTAMINATION' � "� j 1`�'=. ,a El19. 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 POP ULATIONS(NS_'P)u ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing - CONSUMER ADVISORY;1 },'„» ,gi' m i� e ' a w l`1 a W ❑ 11. Good Hygienic Practices » " � » �� 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 &L 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: j1I� 5:5901nVecfFor 14.x Inspector's Signature: Print: PIC's Signature: Print: I I c I Page ofd Pages .de Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 590.003(A) Assignment of Responsibility* 3-302.11(A)(]) Raw Animal Foods Separated from 590.003{B) Demonstration of Knowledge* Cooked and RTE Foods* 2-]03.11. Person in charge-dirties Contamination from Raw ingredients 3-302A I(A)(2) Raw Animal Foods Separated from Eacb EMPLOYEE HEALTH Other' 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment _ require reporting by food employees and 3-302.11(A) Food Protection* applicants* 3-302.15 Washin Fruits and Ve*etables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) Reporting by Person in Chame* 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 HermeticalI ;Sealed Container* Sanitization Tem eratures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical W arewashing-Hot Water 3-202.1.3 Shell Eggs* Sanitization Temperatures* 3-202.14 Eggs and Mitk Products.Pasteurized* 4-501.114 Chemical Sam fiiation-temp.,pH, 3-202.16 Ice Made From Potable Drinkina Water* concentration and hardness. * 5-1.01.1.1 Drinking Water from an Approved System* 4-601..i 1(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean- 590.006(B) Water Meets Standards in 310 CMR 22J)* 4-602.11 Cleaning Frequency of Equipment Food- Contact Surfaces and UtensIls'r SheBlfsh and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of E ui ment* - Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-30111 Clean Condition-Hands and Arms* Re ulafo Authorit 3-202.18 Shellstock Identification Present* 2-301.12 Cleanin Procedure* 590,004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices ReceivinglCondition 2401.11 Eating,Drinkma or Usin Tobacco'* 3-202.11 PI3Fs Received at Proper Temperatures* 2401.12 Discharges From the Eyes, Nose and 3-20115 - Mouth* 3-101.11 Food Safe and Unadulterated r 3-301.12 Preventing Contamination When Tastin " 6 TagsfRecords:Shellstock LU Prevention of Contamination from Hands 3-20118 Shellstock Identification * 590.004(E) Preventing Contamination from 3-203.12 - Shellstock Identification Maintained* Em to•ees* Tags/Records:Fish Products 13 Handwash Facilities 3-40211 Parasite Destruction* Convenlentiy 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* g 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 packa rine,criteria* 6-301.11. Handwashing Cleanser,Availability - . na Provision 8-103.12 Conformance with A. roved Procedures* 6-301.12 Hand Dr *Denotes critical item in the federal 1999 R"I Cale or 105 CMR 590.000. - i CITY OF SALEM ' 7 BOARD OF HEALTH Establishment Name: tJ l J/� f�nir/1c� Date: I[ �//c� Page:- of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item s , Verified r. PLEASE PRINT CLEARLY s /.�- 7• .� Cull J Aw Via .j 'I"' , l`�fCi-PJ M U. Qsv N \I ,4 1 Q M O\/LJ lr/ J2 0,1/1 t r�'� X171 ( ?� K4 n�lfrl 1 t ,'9 ��7Fr/tn IV l o . ( :1l�no� rYS—` '�"rol f (`CyiG/1 I�.S icLcAlit rr .I , .e l \fin .kAn.__r" IC AL. n (1 -)(; oN, Nh TQ/ ,). ., 12- - k1vLr.l Iv\ ( �)Pn�1: �I 0/9 I ',.� :��^ IY)A<, Uni� n/,^:- GL. r/ Ji 7i NI�I " �(rcr5 I/ {_4, aG✓c _moi n7ccr r/1 CW7�/ 1 i.,, r�/ >' /, rP �VIO it.,/,17 c A ci, I J00A nr �, I k fC S of I . ,� - A' h. )el V 5he��,✓�� s �� . a ► — � Discussion With Person in Charge: Corrective Action Required: '❑ No` ' Yes s 4 ^.f,�-y ,',` x3�_.3x�.ms& +>'a P,rx "40. Wr�� E':,.m 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 I P p/' Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that I� noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. (\ �\ \ ❑ Voluntary Disposal ❑ Other: PHFs Rea ivedto Temperatures Violations Related to Foodborne fitness Interventions and Risk Accordial,to Law Ck�_*d to Factors(Iteins 1-22) (Cont.) IFF4 5'F WiTbin 4 Rows- Coolot,it,efficds for PIfFs PROTECTION FROM CHEMICALS 3.5E)i I7 Food or Color Addinves L 19 PHF Hot and Wd Holding 1501 16(B) Cbld PHFt;Mvinotined at or below —-202 1 2-- 1 590.004(l) 4P145"F� 3-302,14 tPmtcttionhonttna rovrxilddttz°�5= 3-501,16(A) Poisonous or Toxic Substances _ 140'F. 1011 F Identifying Intormadon- Original A) Roostat or NJ6� s field above 130'R contaitlem� Time asaPubfi,�Health—Control —1 7-102,11 Common Name--Work 'oner Sroataocn Oto alae 119 rhnc'at;a Public flealth Control'�� 7.2021PI- 4-Re'uictim-pro'"ce and U'e� �90,%4(fi) Variance Rttircmemt 7-202,12 1 cola[1601s'if'Use_ REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7 103,11 To-'k'Contemn, p1o!114i:;v1W POPULATIONS(HS 204.11 Sanitivccs'crile'riitC1jemicAS* n 7-2(4.F.2 CfitucaA fca b1 aches Pr xhtcccloetia'` cd joice,ant. Ivilh Wunitir, 7-204,I4____Dr,inn, 1-801'11(13) Ul;�Offatteiciwd _T r 2(5Incid"mol F�,,Xl Rwariued Use fc�tikufes'crit'na, I(f)) Rawor Puiially Cty,+cdAtaimal Food and 7-206.11 __�av, St-ed Erima,Nut Strved -T-:,06 12 Rodent 11tit sual"Is- � I �__'��'111:1 K-_�l R�-"Crved' -06 11 Tracking Poo Pest Control and L fLLd� lour inn ' CONSUMER ADVISORY F22 3-6071 F TIMErrEMPERATURE CONTROLS 16 oper Cooking Temperatures Luoulal tire Raw, or Pr PHFs No(Otherwiw Processed to Flimmate 3 4(1.17 A(I T( i f;X, I55 Ininexivoe Sorvict- 145"Fl 5see, Eggz,Subv;tul, lot Raw ShOl 3-401,11(A '))k" C- Fi<h' MeatiGame Lt_)TIT Animals. 15�; F is cec SPECIAL REQUIREMENTS 4(1,1 I(B)(1)(2) Po6: nnj 33-,,ef Rfxts!7T7'(Ti-' 121 toiO 590 fX)9( ii) V' 4ufiont;ofSection 590J )09(Af(D) in 40 1.11 Riiute' injco�d k1i caicring� mobi1c, fix)(1,te I mporary and 7J(Ai(3=' ..... icsidential kitchen operations, shobituld� snjffilnw Crmcmon'r;Fish,est at.. 1 i k1chited undci the approfnietc,sections llBull ry or fltitncs]65'1' l5sic. alvve if related to ftK)dhorne 1 h-'ess 3-401,11(C),'37 A4 de lateo 113uf Sicaky. Intel vent ons and risk: factors, 011IN 145F'� 590.009 violations rehuin� to"'oot]retail 3-401.12 RanAnnitat Fc ods Cot)kcd to a pnictices should he debited under#29 - Mietowav< 165-F'* spsial Requirements, All Othei PliFs-- 145'17 15 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAX PRACTICES 3103,11(Ai&d� )) PHF, 165t1' 15 wc.- (Items 23-30) — — _-K! 3-403,11(1#) jcrowanc1(v5'F 2 Nliaul,t Standing dotuniviateiorhe ,-403,11(C) corulner6a[IN Pax-'sied IZTE KX0- found in the /at sot ons of the Food Cade and 10,5 CztIR 140 J,` 911.N)0 3-46311(11) Rematiana LnMiccd N)iti�tmg of Beel m Good visit Practices590 000 FC " 23 IIALflsvfmenl and Pet -2 OM Proper Coaling of PH F 4 �nd;-cod Prot�tlon 25 _Equitip men}end -7FC --4--- jz, a _ I 501,14A) Cooling C"X)ktt(t PH 2�3. ater. 0 006 1 i--- Pt and 1�tVLmt 1 i 700F Within 2 Hours and From 70' —2 Phys Famlti)L FC-6 _to41'F/45tI'W-,,tI)jn 4 Hours. " i2a. Porion sus or ;iiC-Izta 14_(R-) frosting PUFs Ma&From Ambicat 1 emperUnI17C ft5�redimts n,'4!OF/451F 3O 1 Other ------- .-Whhot 4 jlkmrs `l enures critical umi in the federal 1901Foci Gxfcor 105 C','4R 5170 000 CITY OF SALEM BOARD OF HEALTH Establishment Name: t J�-`vWO Met Date: 1147L),) Page: of Item Code=. C=Critical Item �' e t,: -� ,. x DESCRIPTION OF VIOLATION/PLAN SOF CORRECTION : - ' Date No. Reference R-Red Item Verified Z ej_ PLEASE PRINT CLEARLY l y� / _� C+ �Y1C ni✓4c.L rX� I/l'lA dle . - fL,IAIA-1n C_)aiC� S Irk ��r 1 J �� fo�fanrl n �D A7f/1 1/ (sk �X UI o orl 1 C� n f r� A ,nhp1 , v45_eI o 1 D Yz p o� l� D NJ e el 14 '5 C _.'-la oT rn :#c �✓U 1 d I,-C. C a Tr / INC--��c r � . ` I re_ n r ia,. l7 Inr ur...Y 1 1 I f n ) ✓✓ ' 7 6U /- �� uI S� t 1 Discussion With Person in Charge: Corrective Action Required:" ❑ No Yes" tye Awl Z' ❑ Voluntary Compliance ❑ Employ Restriction/ I have read this report, have had the opportunity to ask questions and agree to correct all Exclusion violations before the next inspection, to observe all conditions as described, arid-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. ^ _ �1 � ❑ Voluntary Disposal ❑ Other: PlIFS Re r c�ivol"I "emporal" as Violations Related to Foodborne Iffness-Interventions and Risk Accrodial;to Law to Factors(items 1-22) (Cont.) 'l'F/4YFWithiu4H ei VV'-vi our 501 t5 oojoia'N HF PROTECTION FROM CHEMICALS r-- L 9_ PHF Hot and Cold Holding 14 Food or Color Moraine Cold PliFsklaundmixi at or belov)v 3-2021? - 41°t45`F 3-102,14 pro"'wal froin Un 3-50 1.IN A) Hot pHF�'%1aor1a6)e'j in or above 40'F, 10111 LE—— — 1 Poisonous or Toxic Substances IdontilyinL[nfoimmion (incirnill 3--";5 1 1 In(o') Rests Held at or ibovc 130e'F containers, L 20 Time as a Public Heaffir Control vT2-11 I Common 3-1501 19 rime as a Nblic I lealth Control, 01.1 i �Sepu cion St:m"ce 7-202.11 Rcsmiction-Pwstivcciui,l U ' 7-2202,12 Condn3on of tjse REQUIREMENTS FOR HIGHLY' USCEPTIBLE POPULATIONS(HSP -- T171i� 1,t I(A) Unfawjrizcd Pre-panagedAnces wul 7-?;(4.12 ch�nlical�for Wash 204,14 'k)5.3 I Incidental F(yxi Comam Lkilif icaivW 3-hi)i I I(D) Raw or Parlial),,Coole-cl Aviatal F<xx3 and 7-206.11 Ro'striJed Use criteria, I aw St t'(! 7-2W red Ll-�LP !L�'—�crWILL—i arol b R' '7-206,13 .211— CONSUMER ADVISORY [22 34,0 .11 TIME/TEMPERATURE CONTROLS Awricil Foods'Thatare Raw_Undercookt(i in Prom Cooking Temperatuees; 'TPHFs Not Othcr,�,i5c fIrkii:ossed to Eliminate 7 ato'n- ')i IF 5S'F I _jjcF.: rqrncdiaw Scr%rcc kf"F l5soc, FLv SuWituir for PAw Shelf 2) i-F01 II(A)(, coculzinrjicd F,N' ...... Anneals 155'F 15 w% --- -- ---) -7 �� SPECIAL REQUIREMENTS 40 I.T11()�)(1,2joT, jj,,oj -r(p i ji, hilwori klcaLN �I 590,009(A)-.D) 590.00)W-(D) m I I(A)t 15 1 seccatering.mobil Lr foixitemporary wid �740LWA)0) FIOLTtTil Fd trolly Slullu;YHFs. recidentiat kitchen vrpiaoons should he swffokt;Containinglisb Wail debited under the appionntis .ieoMons lioultry or katire5 1651 atrove if rolined to foodborne illness �4011 IC�'�,j CUtranin iom,', Other 59 590.009 violations relating to good retell 3-401.k2 Raw ArninAl R."Is Cookvrd in practice,,, should lx-debited under P29- Nliciowa%c ler f- Reqtiiremortts. 3-40,11(A)01(b; F 'V1 X1 lei fit IFS-145`F 11 sec Reheating for Hot Holding T --W0LAf1dW§RELATED TO GOOD RETAIL PRACTICES 3-403.t1S4)e(M PHF, 105-1 1'i sec. (items 23-30) 3-4011 t(B) -Yiic owavc I t 7 F2 Nbnule standing riOlaloriri, which do as rebate ro rho roar, "foodb(,rne illmv i cuo vention v and rick ja(rors kited above, (on be 1Z)3 11(C) i Commereially Procesinj RTEFasd- found in the following sernons of the Food Code and)05 C&I R WWF1 11(Ei Rtunfining Unslimil Portionsorl;T., Item Good Retail Practices FC 690.000 eol propa�h rosins` 24, 1 Fooliond Food Protection FC 3 W4 L.L2— r Cooling of PHFS -4 1 005 3 5�1 14(,N) Cooll it),-,Corvked PHFv,fi ona 14W F to ------- 1261 �VLatqL.Pljimbinqjzd Waste FC-5 %tv 7VF iii"ithin 1, Hour. and From i 27, Phys cal Fwili!y_ 1_f��:6 ------- 4 1'F/45�F W'iflnn 4 Hour�'. _LL:_ I Pix%orvous or Tom Materrils FC-7 008 41 3-501.14.{13) Coolim,PFTs McdcFoxWl�Ibleia Trvnporawrc Ingredients u,41°F/45`F -othert. 4 1 ImW Nn'ge'mwahe'll Lit the f�dend 1,K39 Fo'�X!0Jz yr 165(%IR 59{i 000' ' 03-5 Paradise Road 3N Convenience City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION (978) 740-371. 1 Handwash Facilities FAIL Critical ❑d RED Owner: Comment:The back hand wash sink is missing soap. Provide soap at this hand wash sink at all times. Syed M. Rajiuddin PIC: Nahid Sultana _ Inspector: David Greenbaum Date Inspected:Correct By: 3/31/2008 Risk Level: Permit Number: BHP-20_08-001.0_ Status: _PARTIAL COMPLY #of Critical Violations: 2 Time IN: TiTi e 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®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 02,2008 ) Page 1 of Item Status Violation Critical Urgency e RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Food Protection FAIL Critical BLUE Foodborne Illness Interventions and Risk Factors (Require Comment:There are many price labels obscuring expiration/sell by dates. Do not obscure any expiration/sell by dates with price immediate corrective_action) labels. The following items removed outdated: 25-Slim Jims 13-Beef Jerky 2-Sunflower seeds 13-Popcorn 2-Cheddar riffic popcorn 3-Jello pudding 1 -Turkey broth 1 -Beef-a-roni 2-Ragu pasta sauce 1 -Campbells soup 5-Campbells gravy 3-Kraft macaroni&cheese 2-Oreos 2-Tang 3-Tomatoe juice 3-Bisquick 1 -Jiffy corn muffin mix 5-Bread crumbs 2-Cookie dough 3-Celeste pizza 1 -Pepperidge farm 3 layer cake 2-donuts Owner must closely monitor all expiration/sell by dates to insure no expired product is out for sale. These violations are repeat violations and will be subject to monetary fines. Equipment and Utensils FAIL Non-Critical BLUE Comment:The slush machine needs a thorough cleaning. The walk in floor needs thorough cleaning. Clean and dispose of all trash. Physical Facility FAIL Non-Critical BLUE Comment: Replace all water stained ceiling tiles. GENERAL COMMENTS: Owner to notify the Board of Health within one week that the above violations have been corrected. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 02,2008 ) Page 2 of Item Status Violation 1Critical Urgency � 1 City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 02,2008 ) Page 3 of Commonwealth of Massachusetts City of Salem Board of Health lGmbeliey Driscoll 120 Washington Street,4th Floor Mdey SALEM,MA 01970 Foo&Retail Establishment Permit DATE PRINTED: 01/03/2008 ESTABLISHMENT NAME: 3N Convenience File Number.BHF-2004-000112 3-5 Paradise Road Salem MA 01970 LOCATED AT: 03-5 PARADISE ROAD SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2008-0010 Jan 3,2008 Dec 31,2008 $280.00 TOBACCO VENDOR BHP-2008-0039 Jan 3,2008 Dec 31,2008 $135.00 Total Fees: $415.00 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 1 of 28 e 3� CITY OF SALEM, MASSACHUSETTS as3 4�c` BOARD OF HEALTH r 120 WASHINGTON STREET,4"'FLOOR TEL.(978) 741-1800 KIMBERLEY DRISCOLL FAX(978)745-0343 _ MAYOR ISCOTOSALEM.COM ITEC 7 JOANNE SCOTT, DEC 3 HEALTH AGENT BOARD 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT N 1?0NVENI�_:N0.1- TEL#(978) X40- 3711 ADDRESS OF ESTABLISHMENT PA ZADI E ROADSA L� 11 AX# N/A MAILING ADDRESS(if different)_ A. IAS f� EMAIL-Business': H —Website:—N �fT OWNER'SNAME SYE7 RA IUDDIN TEL# bjS ]L1 ,- 0340 ADDRESS39S R D AVE SALGM u11A 0197TO STREET ,' / CITY STATE ZIP (yJ CERTIFIED FOOD MANAGER'S NAME(S) A CERTIFICATE#(S) (Required in an establishment where potentially hazardoug food is prepared) EMERGENCY RESPONSE PERSON 1�1` D SyLTANR HOME TEL#61 -03 o DAYS OF OPERATION 1 Monday Tuesday Wednesday Thursday Friday Saturday Sunda HOURS OF OPERATION ObhMI PM 0(jflm-I)Pn1 OCAM II VM OW4-11PM 06WiI If PM 06AM-II PM Please write in time of day. For example Ilam-1t m TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. 420 - - - --- ----- � ---------------------------------------- . -s-t-h.... --------=$1-40--- (Outdoor $1--- -- RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 scats =$280 more than 99 seats =$420 - ----- - --- - ------------------------------------------------------_.. ------- BED/BREAKFAST/ YES NO $100 CHILDCARESERVICES--------------------------------------------------------------- ----------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO 25 TOBACCO VENDOR YE NO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. , Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns and paid all state taxes required under the law. p Signature Date 11 9 r O Social Security or Federal Identification Number O u' 8 913 Revised 4/24/07 FOODAP2008.adm CheckN&Date t j k 2 _-0_1 S 4150t, 03-5 Paradise Road 3N Convenience City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION (978) 740-3711 Handwash Facilities FAIL Critical RED Owner: Comment:The back hand wash sink is missing paper towels. Provide disposable paper towels at this hand wash sink at all times. Syed M. Rajiuddin Violations Related to Good Retail Practices (Blue Items) PIC: Food and Food Protection FAIL Critical BLUE Nahid Sultana .Inspector: Comment:There are many price labels obscuring expiration/sell by dates. Do not obscure any expiration or sell by dates with price labels. David Greenbaum Date Inspected:Correct By: The following items removed outdated: 10124/2007 3-Pregospaghetti sauce 1 -Pineapple juice Risk Level: 1 -Celeste pizza 1 -Banquet chicken nuggets 2-Weaver hot wings Permit Number: 1 -Totinos pizza rolls BHP-2007-0044 Closely monitor all expiration dates. Status: Equipment and Utensils FAIL Non-Critical BLUE SIGNED OFF Comment:The slush machine needs a thorough cleaning. #of Critical Violations: 2 The ice cream freezer has an accumulation of frost. Thoroughly defrost this unit. Time IN: Time OUT: The walkin flooring needs a thorough cleaning, including under all racks. Physical Facility FAIL Non-Critical BLUE Urgency Description(s): BLUE: Comment:There are some water stained ceiling tiles. Investigate the source of the leak and repair. Replace all stained ceiling tiles. Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMSO 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Oct 24,2007 ) Page 1 oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) m 1 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. Oct 24,2007 ) Page 2 oft J 03-5 Paradise Road 3N Convenience City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION (978) 740-3711 Food Contact Surfaces Cleaning and Sanitizing PASS 0 RED Owner: Comments:Sanitizervreading too strong. Sanitizer to be between 50-100 ppm as mandated. Syed M. Rajiuddin Handwash Facilities PASS RED PIC: Nahid Sultana IComments: Soap dispenser at front hanash sink has come off of the wall. Repair dispenser so it is back on the wall. Inspector: John Gehan Violations Related to Good Retail Practices (Blue Items) Date Inspected:Correct By: Food and Food Protection PASS BLUE 2/22/2007 , Comments:2 Hellmans Mayonaise were taken off of the shelf due to being outdated. Risk Level: Equipment and Utensils PASS BLUE Permit Number: Comments: Reach in freezer requires general cleaning. BHP-2007-0044 Reach in refrigerator section floor requires general cleaning,especialy beneath shelving. Status: SIGNED OFFMilk unit shelves requires thorough cleaning. I #of Critical Violations: No sanitizing log available at time of inspection. Log to be maintained daily. 0 Physical Facility PASS BLUE Time IN: Time OUT: Comments:There are water stained ceiling file above the reach ins,above the fruit refrigerator,and in the hallway. Find source of Urgency Description(s): leak and repair. Replace all stained tiles. BLUE: GENERAL COMMENTS: Violations Related to Good Ceiling tile above reach in freezer needs to bechanged. Retail Practices (Critical violations must be corrected All other violations have been corrected. immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 01,2007 ) Page 1 oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 01,2007 ) Page 2 oft 03-5 Paradise Road 3N Convenience City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: I PROTECTION FROM CONTAMINATION (978) 740-3711 Food ContactSurfacesCleaning and Sanitizing FAIL EV RED Owner: !comment: Sanitizervreading too strong. Sanitizer to be between 50-100 ppm as mandated. Syed M. Rajiuddin Handwash Facilities FAIL ❑d RED PIC: Nahid Sultana ✓Comment:Soap dispenser at front hanash sink has come off of the wall. Repair dispenser so it is back on the wall. Inspector: John Gehan Violations Related to Good Retail Practices (Blue Items) Date Inspected:Correct By: Food and Food Protection FAIL BLUE 07 Risk Level: Comment:2 Hellmans Mayonaise were taken off of the shelf due to being outdated. Risk Level: Equipment a/nd/Utensils FAIL � BLUE Permit Number: `Commen:each in freezer requires general cleaning. BHP-2007-0044 ach m refrigerator section floor requires general cleaning,especialy beneath shelving. Status: Open Milk:unit shelves requires thorough cleaning. #of Critical Violations: No sanitizing log available at time of inspection. Log to be maintained daily. 2 Physical Facility FAIL BLUE Time IN: Time OUT: �— Comment: There are water stained ceiling tile above the reach ins,above the fruit refrigerator,and in the hallway. Find source of Urgency Description(s): leak and repair. Replace all stained 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. Feb 22,2007 ) Page 1 oft ' Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) 1 City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 22,2007 ) Page 2 oft CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH RECEIVED e 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 DEC - 7 2006 TEL. 978-741-1800 FAx 978-745-0343 CITY OF SALEM WWW.SALEM.COM BOAR) OF HEALTH Kimberley Driscoll JOANNE SCOTT, MPH, RS, CHO Mayor HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT .IV UNVE N104 CE TEL 4930-A0 - 371 I ADDRESS OF ESTABLISHMENT 2) PARADISE Rd-.SALFm,1yA01970FAX# N/A MAUNG ADDRESS (if different) WA EMAIL--Business': Owner's: OWNER'SNAMEe EID M - RAJIUDDIR TEL#(C)IS) �44-o34a ADDRESS 593 HIOLAND AVE SALEM Dry{} 01970 STREET ,tt CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) IV/A CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) �,,�l.bb EMERGENCY RESPONSE PERSON MD JA LAL HU ODIN HOME TEL#I- 93- SSI) DAYS OF OPERATION Monday rTuesday Wednesday Thursday Friday Saturday Sunday HOURSOFOPERUl 6flrn-�I �rj CjApl-H & 6AM-11 ,1,6AM- II Ni 6W I I PM 6AIN1-119,m 6M-I M Please write in time of day. [For example llam-Ilam] TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. = 0 - - T - YES NO--- --- -- -- - - - - - - - -- - - - less than 25 seats =$100 RESTAURAN 25-99 seats =$150 more than 99 seats =$200 - - -- - - -- - ---------- - ----- ----- ------------------ ---------------------- ----- --- - - $100 BED/BREAKFAST YES NO ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO TOBACCO VENDOR (= 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 lax returns and paid all state taxes required under the law. Signature * DatP i / SocI�gSLgt�pcu t 8r Fed/�eral Identification Number Revised 11/13/06 FOODAP2007.adm Check#8 Date LOQ_)-A- ��fi w a• .?^qG�.��, .J ,iu, .yrs�l "" v-.. �a '"i +. q r, � � 1.,��,�,�li#� a t rYp Ey+.,�•°s9t�Ys�°Er -9� ve b�}t �. _ '�3'9��rss�'. 4 °M� y,�� Y .+^,�., t-yy +3. a koea++& a. wr`.gw•�'ri,. +*y 2Y �H <�i�`� ati ,�. v�jW »bd+r..f��^ vx4 s y,.,,+ d n s � E. G o-� 'r t9 a '�6 ♦ 1�yF t� �CommOnwealthofMassachusettsr �nI � n • '' y` - a3 r Boe[d of Healtht& � "yv v 5 ti3 d '� 4n ct t lumbertey Dnscoll 130Washrngtou Street,4th Floor w x <ra . m rMa SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/19/2006 ESTABLISHMENT NAME: 3N Convenience File Number:BHF-2004-000112 3-5 Paradis Road Salem MA 01970 LOCATED AT: 03-5 PARADISE ROAD SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2007-0044 Dec 19,2006 Dec 31,2007 $100.00 TOBACCO VENDOR BHP-2007-0045 Dec 19,2006 Dec 31,2007 $50.00 Total Fees: $150.00 PERMIT EXPIRES Decernber 31, 2007 Board of Health ti This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 of 29 Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,41h Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date T of Operations) Tvoe of Inspection 3N O�NV d )a'ZOb Q Food Service ❑ Routine Address5 �$ n1 i� �\ Risk El Retail '® Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone ,) ❑ Mobile Date: Owner HACCP Y/N ❑ Temporary ❑ Pre-operation ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In: ❑ HACCP Inspector Y vc., 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 � �.� , � �r r,� � y, . r�t , ;�, � =�a, PROTECnON FROM CHEMICALS i ,�' _ i�` b 3 ❑ 2. Reporting of Diseases by Food Employee and PIC t' - _- r�-,�6_» ®-Z - 1114.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals 4 FOOD FROM APPROVED SOURCE " `e;,.!. '�?„�.41 E] 4. Food and Water from Approved Source f TIMErTEMPERATURE CONTROLS(PotentlallyHazardpus Foods) pp � m.� .i u.o[ �..;!o E] 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 '",-' Ftv '� ;"' ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing �iREOUIREMENTS FORHlGtfLY&USOEPTIBLE POPULATIONS(RSP),"„ El 21. Food and Food Preparation for HSP ❑ 10, Proper Adequate Handwashing ;;CONSUMER ADVISORY, n,u;` ,,"� , „;,,a- ��i a u°?r .�..h El 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 signedbelow -Cj 4N4 by a Board of Health member or its agent constitutes a i 23. Management and Personnel (FC-z) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(5590.090.0 044)) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (Fc-4)(990.009) 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: S'5001nVw Fo m 14,C Inspector's Sign r • Print: PIC's Signature: Print: Page of-D-Pages UkWVv Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Crass-contamination 1 590.003(A) I Assignment of Responsibility* 3-302.11(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* -� Calked and RTE Foods* 2-103.11. Person in charge-duties l Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated frorn Each EMPLOYEE HEALTH Other* 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3.302.11(A) Food Protection* applicants* 3-30215 Washing Fruits and Vegetables 590.003(F) Responsibility Of A P(xxl 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- 31 590,003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.1.1 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.1.2 Food in a Hermeticall•Sealed Container* Sanitization Temperatures* - 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-I-lot Water 3-202.13 Shell Eggs* Sanitization Tem eratures* 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 -Chemical Sanitization-temp.,pH,- 3-202.16 Ice Made From Potable Drinking Water- concentration and hardness. * 5-101.1.1 Drinking Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and 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 Foal- Coutact Surfaces and Utensils* - Sheltlrshand Fish Froman 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* Game and Wild Mushrooms Approved By 10 Proper,Adequate Handwashing Re u/ato Author(t 2-301.11 Clean Condition-Hands and Arms* 3-202.1.8 Shellstock Identification Present* 2-301.12 ..Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201..17 Game Animals* 1.1 Good Hygienic Practices y Receiving/Condition 2401.11 Eating,Drinkina or Using Tobacco* 3-202.11. - PHFs Received at Proper Temperatures* 2-40112 Discharges From the Eyes,Nose and 3-202.15 Package late it * Mouth* 3-101.11 Food Safe and Unadulterated* 3-30112 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock t 12 Prevention of Contamination from Hands 3-20118 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* - Em to ees* Tags/Records:Fish Products 13 - Handwash Facilities ' 3-40111 Parasite Destruction* Conveniently Located and Accessible - 3-402.1.2 Records;of and Retention* 590.004(J) Labeling of Ingredients* 5-203.11 Numbers and Ca acitiee 5-204 11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Nand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging,criteria* 6-301.11. l7landwashing Cleanser,Availability 8-103,12 Conformance with Approved Procedures* fi-301.12 Hand Drying Provision Denotes critical item in the federal 1999 Food Code or 105 CMR 590000. - CITY OF SALEM BOARD OF HEALTH Establishment Name: 354 Date: 1C3-Z�b Page: Z of �— Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified .. t - PLEASE PRINT CLEARLY 2 C �.a , xatt� marc vaa)�2 " \ Rs LP. k 4p,� r PLsa G �1L\ I Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes 1 have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion F 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: I 3-501,14(0) 'PRFs Received ar Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Iaw Cooled to Factors(items 1-22) (Cont.) 41'F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PRFs 14 Food or Color Additives 19 PfiF Hot and Cold Holding 3 202.12 AsldtuveS* ------- 3-501 16B) Cold PHFs Maintained at or below = � 590.0t)1(F� � 41'/45°b* 3-302-14 Protection from Una roved Additives* '590.0 -4(F) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances - 7-101.11 Identifying Information-Ori mai 3.5011 140°F, x .6(A) Roasts Held at or above 1in- Containers* _ 7-1.0111 Common Narne-Workw- Containers* Time as a Public Health Control 7-20'1.1I Se uation-Storace' - 3-501.19 Time as a Pablic Health Control` 7-202.11 Restriction-Presence mud (Ise`" 590.004(H) Variance Re uirement 7-202.12 Conditions of Use* 7-203,11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers,Criteria-Chemicals* POPULATIONS(HSP) . 7-204.1.2 Chemicals for Washin r Produce,Criteria+" 2.1 3-80J.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drying Agents.Criteria* Beverages with) armne Labels' ffO6 Incidental Food Contact,Lubricants* 3-801.11(13) Uc�of Pasteurized I e,�rs* Restricted Use Pesticides.Criteria* -- 3-601.11(D) Raw or Partially Cooked Animal Fond and Raw Seed S trouts Nor Served. Rodent Bait Stanuns' -${)1,11 tC) Uno ened Food Packarre NoC Re-served. Tcack,ing Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603-11 Consumer Advisory Posted for Consumption of Anhnal Foods That are Raw. Undercooked or 16 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate PRFs _ r, - 3-401.L1A(1)(2) Eggs- '155°FiS Sec. pathogens., - _ E res-hmnediate.Service 14S`F,1 Ssec* 3-302.13- Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish,Meats&Game E gs r Animals- 155'F 15 sec. 3-401.11(B)(1)(2) Pork and Beef Roast- 130`F 121 min* SPECIAL REQUIREMENTS - 3-401.11(A)(2) Ratites,Injected Meats-155'F 1.5 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sea * catering, mobile foal,temporary and 3-401.11(A)(3) Poultry,Wild Game,StuffedPliFs, 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 foodbornc illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F m -590.009 violations relating to good retail 3401.12 Rare Animal Foods Cooked in a practices should be debited under 7129- Microwave 165'F* Special Requirements. 3.401.11(A)(1)(b) All Other PHFs- 145'F 15 sec. * 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(I)) PHFs 165°F 15 sec. * (Items 23-30) 3-403.11(B) Microwave-165'F 2 Minute Standing Critical and non-critical violairons, which do not relate to the TiniC* foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Fail- ,found in the foGrowing sections glrhe Food Cotte and 105 CMR 140"fr r 590 000. 3-40311(E) Remaining Unsliced Portions of BeefItem Goad Retaft Practrees FC 580.000 Roasts` 23. Management and Personnel FC--2 .003 18 Proper Cooling of PRFs 24. Food and Food Protection FC-3 .004 2 _ Equi menu anU Utensils FG 4_ .005_ 3-50'1-14(A) Cooing Cooked PHFs from 140°F to _ 26 Water,Plumbing and Waste FC-5 .006 70'F Within 2 Hours and From 70'F 27. Ph elcal Facilit _-F-C-6-t .007 _i _-__ to 41.°F/45°F Within 4 Hours. ' 28.. Poisonous or Toxic Materials _ FC -7 .008 3-501.'14(B) Cooling PRFs Mala From Ambient _29- S ecial Requirements -009 Temperature Ineredientstd4l°F/45°F 30 ---. .Other Within4.Hours* rr ,e.,nem�� 4 Denoics critical iters in the faleal 1999 Food Code or 105 CNIR 590.1100. - CITY OF SALEM BOARD OF HEALTH �Y( _t Establishment Name: I f) Cl�� LP �_ C 4 Date: y 12Z I U �9 Page: Of f Item Code C-Critical Item v DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item .. - Verified e PLEASE PRINT CLEARLY -4 I IUw 1�1� 5 (r y1 n 1/p V _ � Q/nn 1 T � Q O ( _ T t 0 C� ) N)rVl f & C� � � . r Is rn - o r _M :Ln�- CA1 Il 11 18 0f'\ n n 1 cP P— c, .. 44 - h 14 jl r i ,1 -FZ V + _4-0 lie Cj 0L c� lf' I s CPs { y- r( `7G4�V o t lilt, t Discussion With Person in Charge: _ Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree-to-correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion r 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-fivedol a s or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. �. �� ❑ Voluntary Disposal ❑ Other: 3-501.14(C) PliFs Received at'femperatures Violations Related to Foodborne Illness Interventions and Risk According to 1aw Cooled to Factors(Items 1-22) (Cont.) 4I'F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Coolingg Meltods for PHFs Food or Color Additives 19 PHF Hot and Cold Holding 14 3-501-16(B) Cold PRFs Maintained at or below 4-202.12 Additives* 590.004(F) 11`!45°F* 3-302.14 Protection front Una roved Additives* 3-501.10(A) lint PAF'Maintained at or above 1j Poisonous or Toxic Substances 140„F 7-10t.11 identifying Intormation-Original 3-501.16(A) Roasts Held at or above 130°F. Containers" 20 7-102.1 1 Common Name �W - orking Containers* Time as a Public Health Control 7-201.11 Se araiion-Stora e' 3-501.19 Time as a Public Health Control" - -- 590,004(H) Variance Re turenit 7-202.11 Restriction-Presence and Use* 7-202.12 Condia nus of Use 7-203.1 I Toxic Containers-Prohibitions* REQUIREMENTS HIGHLY SUSCEPTIBLE 7-204.11 Satntizers,Criteria Chemicals* ...._ POPULLAA TIONS(HSP) 7-204.1. Chcmlcals for Washita;Produce,Criteria* 21 3 s I.11(.N) Unpasteurized Pre-packaged Juices and 7-204.14 Dr ins Agents.Criteria' Beveraizes with lA n mr,,labels* 3-SO1,11(B) Use of Pasteurized Lues'^ 7-205.11 Incidental Food Contact. Lubricants* _ 7-206.11 Restricted Use Pesticides-Criteria'" 3-801 1 I(D) .Raw or Partially f calked.Annual Food and Raw Seed S Trouts Not Served. 7-206.12 Rodent Bait Stationsa 3-s0'1.11(C) Unopened Food Package Not Re-served. 7?06.13 Tracking Powders,Pest Control and Moninxin�* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 3 03.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods that are Raw-Undercooked or PRFs Not Otherwise Processed to Eliminate Pathatens ` 4or Tanta a-401AIA(L)(2) Eggs- '155 F 15 Sec. p'-s-humediate Service 145`'F15sec* 3-302.13 Pasteurized Eggs Substitute for Rain Shell 3-401.11(A)(2) Comminuted Fish,Meats&Game FgEst Animals- 155°F 15 sec. s SPECIAL REQUIREMENTS 3-401.11(B)(1)(2) Pock and Beef Roast- 1'30°5121 nun* 3-401.11(A)(2) Ratites;Injected Meats 155°E 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. * catering,mobile food,temporary and 3-40 Ll I(A)(3) Poultry,Wild Game, Stuffed PHFs, residential kitchen operations should be Staffing Containing Fish,Meat, debited under the appropriate sections Poultr; or Rsatites-165°F IS sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle.,Intact Beef Steatcs interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3401,12 Raw Animal Foods Cooked in a practices should be debited under 929- Microwave 165"F* Special Requirements. 3-401.11(A)(]Hb) All Other PHFs-145°F 15 sec. p Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(.A)&(D) PHFs 165°F 15 sec. * (Items 2330) 3-403.11(B) Microwave-165°F 2 Minute Standing Critical and non-critical v{olatfoos, which Ifo not relare to the Time" .foodhorne illness interventions and risk factors listed above, can he 3-403.1 1(C) Commercially Piocessed RTE Food- found in the following sections of the Food Crede and 105('A'IR 140"F* 590.000. 3-403.1.1(E) Remaining Unsliced Portions of Beef Item Good Retail Practices FC 590 000 Roasts* 28. Management and Personnel FC-2 903 Ig Proper Cooling of PHFs 24. Food and Food Protection FC_3 _ .004 20 liui muni and Utensils FC 4 l_005 3-501.14(A) Cooling Cooked PHFs from 14WF to 2B. - Water,Plumbin and Waste FC 5 .006__ 7WF Within 2 Hours and From 7WF 27. Ph sinal Facility FC-6 t__ - to 41.^5/45°F Within 4 Hours. * 28. Poisonous or Toxic Materials PC-7 l .00II 3-501.1413) Cooling PFIFs Made From Ambient P9. S eeiai Re uirements _ ' .009 Temperature Ingredients to 41°F/45 30.°F --Other- - Within 4Iiours`k *Denotes critical item in the faderal 1999 Food Code or 105 CMR 596000. CITY OF SALEM BOARD OF HEALTH Establishment Name: �-/� Date: g ZFa e, Page: of / Item Code C-Critical Item DESCRIPTION.OF VIOLATION/PLAN OF CORRECTION Date No. Reference- R—Red Item Verified i. PLEASE PRINT CLEARLY p� 4 - �� A-C y- t LW 4 i Y '3 Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-f' dollars or suspension/revocation of Ll Embargo ❑ Emergency Closure �= your food permit. / ` ❑ Voluntary Disposal ❑ Other: l f 3-501.14(C) PHFs Received at Temperatures Violations Related to foodborne Illness Interventions and Risk According to Law Cooled to Factors(items 1-22) (Coat) 41.'F/45'F Within 4 Hours.'" PROTECTION FROM CHEMICALS 3-501.1 S Cooling Metbods for PHFs 14 Food or Color Additives I9 PNF Hat and Cold Holding - 3-50L16(B) Cold PHFs Maintained at or below 3-202 12 Additives* 590.004(F) 41`145° F* - 3-302-14 Protection from Unapproved Additives* 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 14WF. * 7-101..11 Identifying Information-Original3-501.16(A) Roasts Held at or above 130°F. Containers* - 7-102.11 Common Name--Wo,rkin4_C:oatainers` 20 Time as a Public Health Contras 7_-?01.1] Scxration-Storage^` 3-501.19 Time a9 a Public Health Control* 7-202.11 Restriction-Presence and Ilse* 590.004(11) Variance Re uiremeat 7-202.12 Conditions of(Ise' 7-203.11 Toxic Co»tainerr;-Prohibitions"' REOUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-2204.11 Sanitizers,Criteria-Chemicals*` POPULATIONS(HSP) 7-204.12 Chenucals for Washing Produce,Criteria,, 21 3-801.1](A) Unpasteurized Pre-packaged krises and 7-204.14 Drvina A encs,Criteria* Beverages with Warning labels* 7-205.11 Incidental Food Contact.Lnb�icants^ 3-801.11(B) Use of Pattemized Eggs° 7-206.11 Restricted Use Pesticides_Criteria* 3-801.11(1)) Raw or Partially Cooked Animal Food and Raw Seed S marts Not Served. 7-206.12 Rodent Bait Brans,"` 3-801.11(C) Una erred Food Packs re Not Re-served =' 7=306.13 Tracking Powders,Pest Control and Monitorint,* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Fo els''hat are Raw,Undercooked or 1F Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate _ er cr > ooi 3-401.L1A(7)(2) F„gs- 155"F15Sec. Pathogens.* b ss-bnntedtate Service 145`Fl5sec� 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3401.11(A)(2) Comminuted Fish,Meats&Came F. gs* Annuals- 155'F 15 sec. ' 3-401.11(,B)(1)(2) Pork and Beef Roast- 130'F 121 min" SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,injected Meats-155°F 15 590.009(A)-(,D) Violations of Section 590.009(A)-(D)in sea * catering. mobile fend, temporary and 3-401.11(A)(3) Poultry, Wild Came, Stuffed PFIFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate seclions Poultry or Ratites-165`F 15 sec. " above if related to foodborne illness 3401.1 l(C)(3) k%bole-muscle,Intact Beef Steaks interventions and risk factors. Other - 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foals Cooked in a practices should be debited under//29- Microwave 105'F* Special Requirements. 3-401.1 I(A)(1)(b) All Other PHFs- 145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-40111(A)&(D) PHFs 165°F 15 sec. * (Items 23-30) 3-403.11(B) Microwave- 165°F2 Minute Standing Cidical and non-critical violations, which do not relate to the L- Time* foodborne illness interventions and risk factors listed above„ can be 3-403.11(C) Commercially Processed RTF Food- foamd in the following sections of the Fund Code and 105 CMR 14WF* 590.000. (. r Item Good Retail Practices FC 580.0---. 3-40311 L) Remaining Uns)ieed Portions of Beef it0 Roasts* 23. Martaclentent and Personnel f FC-2 .003 Ig Proper Cooling of PHFs 24. Food and Food Protection _ FC-3 004 _ 25. E�{t u�ment and Utensils FC 4 _.005 :;-501.t4(A) Cooling Cooked PHFs from 140'F to 26 Water,Plumbing and Waste FC 5_ .008 70°F Within 2 flours and From 70'F 27. Ph sisal Facilit _ FC-6 .007 to 4l°F/45'F Within 4 Hours. * 26. Poisonous o_r Toxic Materials _FC--7 .008 3-501 IJ(11) Cooling PHFs Made From Ambient 29. 8 colas R uirements _ _ .008 Temperature Ingredients to 41'F/45'F 30. Other Within 4I3ours'z or r.,tiazdo� Denotes critical item in thr leder l 1999 Food Code or 105 CNIR 590.000. Massachusetts Department of Public Health Salem Board of Health 120 Washington Sreet, Division of Food and Drugs Salem, MA 01970-t35234 1h 190-35234`" Floor FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name //�� Dat T P2 of Operations) Tvpe of Inspection 3 �'� 4 C✓1 C Q 2)/Jo ❑ Food Service ❑ Routine Address S- '�G .0 �� Risk CRetail Poe-inspection Level H Residential Kitchen Previous Inspection Telephone c 4n _ 3 ' ❑ Mobile Date: Owner 7�+o / HACCP YIN ❑ Temporary ❑ Pre-operation S� �� . _q i G ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑General Complaint In: 0-5-0 El HACCP InspectorO Permit No. [3O herr Q Out: 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,„„.„,'�,�,mm .m�, E ..� ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties *EMPLOYEE HEALTH v = �""'�""+� El 13. Handwash Facilities PROTEGTIQN FROM ❑92.'Reporting of Diseases by FooddmEmployee andPIC CHEMICALS, Vie , ) g " �� ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVEDSOURCEm" 71ME1TEMPERA7URE CONTROLS Potential) Hazardous Foods ❑ 4. Food and Water from Approved Source (_ - ( Y )€ ❑ 5. Receiving/Condition ( ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling El19. Hot and Cold Holdin FPROTECTION FROM CONTAMINATION r' ,� e i 9 - 9'- ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSC,EPTIBC POPULATIONS(MSP)�' [--]21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing El11. Good Hygienic Practices 'BCON$UMER..AOVISORY�. ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C a 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-4)( cited in this report may result in suspension or revocation of _25. Equipment and Utensils (Fc-0)(9590.090.0 a4)))09) 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)(59o.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 (590.009) within 10 days of receipt of thisorder. 30. Other DATE OF RE-INSPECTION: O (/ 5:5801nspeclFo�14 Ex F � \\1 _ 1 rte\ Inspector's Signature: \ Print: 1 P PIC's Signature: / Print: ��,0 "j U D D I "1 Page) of�Pages et 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**_ 3-302.1.1(A)(]) Raw Animal Foods Separated from 590 003(B) Demonstration of Knowledge* Cooked and RTE Foods* 2-103.11 l 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 foot 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(0) Ra ordng b�in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 31 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003{E) Removal of Exclusions and Restrictions Food-- 3-701.11 ood3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 1 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 3-20113 Fluid Milk and'Milk Products* 47501.112 Mechanical Warewashin;-HotWater 3-202.13 Shell Eggs* Sanitization Tem eratures* 3-202.14 E<>>s and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinkin Water* concentration and hardness. 5-101.11 Drinking Water from an Approved System* 4-60 1 A I(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food- Shellfish Surfaces and Utensils* 3he1!@sh 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* 4-70311 Methods of Sanitization-Hot Water and 3-20115 Molluscan Shellfish from NSSP Listed Chemical* Sources* 1g Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulattirt,Authority 2-301.11 Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present* 2.301.12 Cleanin Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices g Receiving/Condition 2-401_11 Latin ,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2401.12 Discharges From the Eyes,Nose:and 3-202.15 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventft Contamination When Tasting* TagstRecords:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identil'ication Maintained* Ent Flo gees* Tags/Records:Fish Products 13 Handwash Facilities 3-402-11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.1,1 Numbers and Capacities*890,004(1) Labeling of Ingredient5-204.11 Location and Placement* Ingredients' 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized ka Methods* Devices 3-502.12 Reduced ox )zen packaging,criteria* 6-301.11 HandwashinR Cleanser, Availability 8-103.12 Conformance with A roved Procedures* 6-301.12 Hand Drying Provision Denotes crinin item in the Wei el 1999 Foal Code or 105 CMR 590D00. CITY OF SALEM -2 BOARD OF HEALTH ;4 Establishment Name: 7 ��nv0/II� n�Q Date: 3 a25 Co Page: of Item Code C-CriticalItem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date -° No. Reference. R—Red Item Verified PLEASE PRINT CLEARLY --. t _ 2') t l7 1 c r f QG I t , t r _II // I ! (\I 0. C nr� I /f M,,i r4j o OC. i r I i c I t I I I E I I Discussion With Person in Charge: Corrective Action Required: ❑ No Yes i have read this report, have had the opportunity to-ask questions and agree to correct all ' Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five d Ilars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. j ,l �, I n�A ❑ Voluntary Disposal ❑ Other: 4 I ', i .r 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne fitness Interventions and Risk According to Iaw Cooled to Factors(items 1-22) (Cont.) _ 41'F/45'F Within 4 Hours. " PROTECTION FROM CHEMICALS 3-501.15 Coolin_Methods for PHFs lA v Food or Color Additives 14 PHF Hot and Cold Holding 3-50t.16(B) Cold PIIFs Maintamed at or below 3=20212 Additives* 590,004(F) 41V45'FA 3-302.14 Protection from Una z roved Additives 't-501.t6(A) Hrzt PHFs Maintained at or above t5 Poisonous or Toxic Substances 40'F. 7-101.11 IdeContainers Information-Original 3-501.M(A) Roasts Held at or above 1.30'F. Containers- ?-102.11 Common Name-Workmo 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 Re uirement 7-202.12 Conditions of Use` 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers,Criteria-Chemicals POPULATIONS(HSP 7-204.12 Chemicals for Washinc-Produce,Criteria' 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Beve'aees with Warnin Libelsm Ur inR t�1=eats,Criteria* - -- g 7-205.11 Incidental Food Contac[, Lubricants* 3-801.11(B) Use of Pasteurized ELLS 7-206.11 Restricted Use Pesticides,Criteria* 3-80111.(0) Raw or Partially Cooked Anm ial Food and 7-206.12 Rodent Bait Stations^` Raw Seed Sprouts Not Served. 7-206.13 Tracking Powders,Pest Control and 3-801.1 I(C) Unopened Food Packa=e Not Reserved. Monitorim, CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw.Undercooked or 16 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate PHFs = se Processed 3-401.11A(1)(2) E cgs- 155°I 15 Sec. F atho m-' fits-Iumedt ate Service 145°Flisec' 3-302.13 Pasteurized Bggs.Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish,Meats&Game Eggs* Animals-155'F 15 sec. ,r. 3-401.1l(B)(1)(2) Pork and Beef Roast- I3(TF 121 min* SPECIAL REQUIREMENTS 3-4.01.11(A)(2) Raines, Injected Meats-155'F1.5 590.009(A)-(D) ViolalionsofSection 590.009(A)-(D)in sec. * catering-mobile food, temporary and 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHI^s, residential kitchen operations should be Scuffing 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) Whale-muscle,Intact Beef Steaks interventions and tisk factors. Other 145°F* 590.009 violations rehiring to good retail 3.401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165'F* Special Requirements. 3401.11(A)(1)(b) All Other PHFs- 145'F 15 sec. * )7 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(0) PHFs 165°F 15 sec. * (Items 23-30) 3-103.11(B) Microwave- 165°F21 Minute Standing Cridral and non-critical violations, which do not relate to fire Time* foodborne illness inter venoons and risk factors listed above, con be 3-403.11(C) Commercially Processed RTE Food- /ound in the following sections of the Food Code and 105 CMR 14WF* 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef Item Good Retail Practices FC 590.000 Roasts" 23. Mina ement and Personnel- FC___ FC--2 .003 18 Proper Cooling of PHFs -24. Food and Food Protection FC-3 004 25. _ Equipment and Utensils _ _FC 4 _ 565 3-501 14(A) Cooling Cooked PHFs from 140°F to 26 _ Water, Plumbing and Waste FC S .006_ 70°F Within 2 Hours and From 70TF 27. Ph sicai Facsit�____ FC-6 .007 to 41°F/45°F Within 4 Hours. * 29. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. S ecial Re uiremonts _ .009 Temperature Ingredients to 41°F/45'F 30. Other Within 4 1lours'z sooen.srse.z.:x,� - "'Denotes critical itean in the tedertd 1999 Food Code or 105 CMR 590.000, Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4�' Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978)'741-1800 Fax(978) 745-0343 Name Datg Tvoe of Operation(s) Type of Inspection 3 h l�. a ❑ Food Service ®® Routine Address �) Risk ' ® Retail ❑ Re-inspection Odor Level ❑ Residential Kitchen Previous Inspection Telephone1AQ�I ( ❑ Mobile Date: / �/e Owner. ' HACCP YM El Temporary El Pre-operation t t El Caterer El Suspect Illness Person in Charge(PIC) J Time ❑ Bed&Breakfast ❑ General Complaint In: �o ElHACCP Inspector yr Out& Permit No. [I Other Each violation checkea 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) ❑ 59o.00e(F) ❑ action as determined by the Board of Health. "FOOD PROTECTION MANAGEMENT ..'; ;„"„� v, 11115f "F' ,-. ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13 Handwash Facilities EMPLOYEE HEALTH=_M_": M_ _ e�ss i ,"� ';�`� r:hEeg s aPROTECTION FROM CHEMICALs r ' ❑ 2. Reporting of Diseases by Food Employee and PIC t„ rC [114.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15 Toxic Chemicals `,FOOD FROM APPROVED SOURCE „.', ,� '� ms° tPny)EREMPERATURE CONTROLS Potential) Hazardous Foods - °t E❑ 4. Food and Water from Approved Source (, � r r„ rh j 6t r 1� �-u y )"- �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' _"� -x p El 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control E) 9. Food Contact Surfaces Cleaning and Sanitizing L�REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP);' ❑ 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing tr..CONSUNtEHADVISORYi': El 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C N by a Board of Health member or its agent constitutes an 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-a)(sso.00s) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (Fc-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (Fc-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: ` f /j � n r Inspector's Signature: Print: i PIC's Signature: / Print: f` Page of Pages /! M Violations Related to Foodborne Illness interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 1 590.003(A} Assignment of$esponsibility* 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 Annual Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11.(A) Food Protection* applicants* 3-30215 WashingFruits and Ve. atables 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 1 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(F) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111. Manual Wazewashing-Hot Water 3-201.1.2 Food in a Hermetically Scaled Container* Sanitization Temperatures" , 3-201.13 Fluid Milk and Milk Products* 4-501.1 t2 Mechanical Wazewashing Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.14 Eggs and Milk Products.Pasteurized* 4-501.11.4 Chemical Said temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. * 5-101.I l Drinking Water from an Approved System"tem" 4-60 1A I(A) Equipment Food Contact Surfaces and Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Foo 590.006(B) Water Meets Standards in 310 CMR 22.0* ShelBish and Fish From an Approved Source Contact Surfaces and Utensils* 4702.1 t Frequency of Sanitization of Utensils and 3-201.1,4 Fish and Recreationally Caught Molluscan Food Contact Surfaces of E ui ment* Shellfish* 4-70311 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* lit Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Requfatory Authority 2-301.11 Clean Condition-Hands and Arens" 3-202.18 Shellstock Identification Presenc1 2-301.1.2 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* . 3-201.17 Game Animals* 11 Good Hygienic Practices Receiving/Condition 2-401.1'1 Eatin ,Drinking or Usin 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 Tastin w 6 Tags/Records:Shellstock 12 - Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.1.2 Shellstock Identification Maintained* Em to°ees* Tags/Records: Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 3-402.12 Records, and Retention* 5-204.11 Location and Placement* 590.004(J) Labelingg of of Ingredients' dients' 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Nand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.1,2 Reduced oxygen packaging,criteria' 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* fi-301.1.2 Hand Drying Provision - Denotes critical item is the federal 1999 Fond Code or 105 CNIR 590.060- - r CITY OF SALEM BOARD OF HEALTH Establishment Name: Z , �� Innry Date: "' Page: o �`6�.. }r. Item Code C-Critical Item DESCRIPTIONS OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item - - - - Verified PLEASE PRINT LIARLY f /_riff.' Q t'-... 1 20 - - �. a, P �rl L jar- �f ,✓ �,� ,S r�I vL —r �� yI -4- 4/ _ fi pp {wl�al r-X..-L rIPIM�_! pi- COG � �o fir 4n . , COG a r , JWnA ,Nr/1. tern , 0I Q 0 O(— AIW4 - S.-tea., rlL on '4 CLA'e ,se 1d c�z� < Soilf- i^ o r c. i tel/, ,, .. t.)2o� v• n an 1 , , i c �/ � " K iJIA N S 157l �tai J14 ��v cxcy✓1 C G ,. r ✓ (—era ��. I/fin n Sfzv �e�✓I t Discussion With Person in Charge: Corrective Action Required:113 No ' Yes z 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 b Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that t noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. o� ❑ Voluntary Disposal ❑ Other: i4 3-501.-14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Iaw Cooled to Factors(items 1-22) (Cont.) 41°F/45"F Within 4 Hours PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods forPHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-501.16(B) Cold PHFs Maintauned at or below 3-202.12 Additives* 590.004(F) 41°/45°F 3-302.14 Protection front(Jeal roved Additives* 3-501.16(A) Ifi>t PHFs b-laintained a[or above ij Poisonous or Toxic Substances I40'F 7-101.11 Identifying Information-Original F 3-501.16(5) Roasts Held at or above 130°F. Containers* E2 K 7-102.11 Common Name-Working*Containers* Time as a Public Health Control 7-201.11 Separation-Staaee' 3-501.19 / Time as a Public Health Contr+.ai* 590.004(H) 7-2(72.11 Restriction-Presence and Use* Variance Requirement 7-202.12 .Conditions of Use* 7.203.1.1 Toxic Containers-Prohibidon.0 REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-2(A.I1 San izers,Criteria-Chemicals* POPULATIONS(HSP) 7-204-1.2 Chemicals for Washing Produce,Criteria* 21 3-80'1.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drying A eats,Criteria* Beverages with Warning,Labels' 7-2051 I Incidental Food Contact,Lubricants* 3-2301.11(B) Use of Pasteurized Eqs* 7-206.11 Restricted Use Pesticides.Criteria* 3-801A 1(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts, Not Served. 7-ZU6.12 TraRodci Bait dors.Pe 3-501.1](C) Uno ened Food Package Not Re-served. 7-206.13 'SYacktng Powders.Pest Control and Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603-11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods'That are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate Pathogens 3-401.11A(1)(2) Eggs- 155°F 15 Sec. _ E L, htnnediate Service 145°F15scc* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish,Mears&Game Eggs" Annuls- 155'17 15 sec. '" 3-401.1l(B)(1)(2) Pork and Beef Roast- 130"F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) 'Ratites, Injected Meats-155°F 75 590.009(5){D) Violations of Section 590.009(5)-(D}in sec. * catering, mobile food, temporary and 3-401.1I(A)(3) Poultry, Wild Game,Stuffed PRFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the.appropriate sections Poultry or Ratites-165'F 15 sec. "° above if related to foodborne illness 3-401.11.(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°I7* 590.009 violations relating to good retail 3-401.12 Raw Animal,Foods Cooked in a practices should be debited under#29 -- Sher owave 165"F* Special Requirements. 3.401.11(A)(1)(b) All Other PHFs- 145'F 15 sec I7 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(.5)&(D) PHFs 165°F 15 sec. * (Items 23-30) 3-403.11(13) Microwave-165°F 2 Minute,Standing Critical and non-critical violations, which do not relate to the Time"` foodborne ier llness into and risk factors listed above, con be 3-403.11(C) Connnercially Processed RTE Forel- found in the fadlnu-rug sections of the Food Code and 105 CMR 140°F" 590.000. 3-403.1.1(E) Remaining Ilnsliced Portions of Beef item Good Retail Prac_tiees FG 590.Opp Roasts" 23. Mata ement and Personnel _ FC"-2 .008 1g Proper Cooling of PHFs 24,_ Food and Food Protection FC.-.3- 004 25. Equipment and Utensils _ FC--'4i--- .005 _ 3-507.14(5) Cooling Cooked PHFs from 140'F to 28_ T Water,Plumbin and Waste FC 70° 5'_ .006 F Within 2 Hours and From 70°F 27. Ph 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 PRFs Made From Ambient 29. 5 ecial Re uirements _ ! .009 Temperature(ingredients to 41'F/45`F 30 _Other 1 ]Within 4 Hours:* xs�or��.ea-.xa-aac *Denotes critical item in the Federal 1999 Food Code or 105 CNIR 590.000. . i CITY OF SALEM BOARD OF HEALTH Establishment Name: "2) I'j Date: Page: of _ Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item -- Verified PLEASE PRINT CLEARLY- - �/� f 1✓1( / 1�f/ G T 'V� IIA 1_)-41) V /7 _ a A,- Q-iA O i// / ri 6L _ ' i i 1 CG o /I 1 / (51 �1 i l C �1.✓ n S On^ ,. sP ho I a -v d ?r) I — K r n lRr /l n Discussion With Person in Charge: Corrective Action Required: ❑ No Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P �o /Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that �/ noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. �a n R ❑ Voluntary Disposal ❑ Other: 3-SOL14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According*to Law Cooled to Factors(items 1-22) (Cont.) 41°F145°F Within 4 Homs. PROTECTION FROM CHEMICALS 3-501.15 Cortina Methods for PHFs 19 14 Food or Color Additives PHF Hot and Cold Holding 3-501.16('B) Cold PHF.,,Maintained at or below 3-202.12 Additives* 590.004(F) 41'1451F" 3-302.14 Protection from Una , roved Additives` 1.5 Poisonous or Toxic Substances 3-501 16(A) Hot PHFs Maintained at or above 40°F.* 7-101.11 Identifying information-Ori�.nal 3-50L16(A) Roasts Held atorabove130°F. Containers* [:2:0:: Time as a Public Health Control 7-102-11 Common Name--Working Containers* 3-501.19 Time as a Public Realth Centra:* 7-201.11 Separation-Strange" Use* 590.004(H) VarianceRequirement7-202.11 Restriction-Presence aid Use 7-20112 Conditions of Use, 7-203.11 ToxicContaners-Probibitioiis" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizes,Criteria-Chemicals:': POPULATIONS(HSP) 7-204.1.2 Chemicals for Washing Produce,Criteria" 21 3-801-11(A) Unpasteurized Pre-packaged Juices and Beverages with Waring[Abels- 7-205.11 D ying. euts,Criteria* --- 7-205.11 Incidental Food Contact. Lubricants* 3-801.1I(B) Use of Pasteurized Eg�,s* 7-206.11 Restricted Use Pesticides. Criteria* 3-8011 t(D) Raw or Partially Cooked Animal Food and Raw Seed S routs Not Served.s 7-206.12 Rodent Bait Stations* 3-801.I I(C) Unoened Food Pucka � 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY _ TIMEITEMPERATURE CONTROLS 22 3 603.1 t Consumer Advisory Posted for Consumption of animal Foods'11tat are Raw.Undercooked or 16 -Proper Temperatures for PHFs Not Otherwise Processed to Eliutinate 3-401.11 Ail)(2) Eggs- 155'F 15 Sec. Pathogens* erN�"`u'�ooI- B es-lnuuechatt Service 145`P15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish,Meats&Came F gs* Animals-155°F 15 sec. * 3-401.11(B)(1)(2) Pork and Beef Roast- 130'F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155*F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. * catering, mobile food, temporary and 3-40111(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Youftr or 12arites-165°F IS sec. a, above if related to foodborne illness 3-401.11.(C)(3) Whale-muscle, Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Mierowave 165`F;t Special Requircnlents. 3401A I(A)(i)(b) All Other PHFs-145`F 15 sec. " 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 1650F 15 sec. * (Items 23-30) 3-403.11(B) Microwave-165°F 2 Minute Standinu Critical and non-critical violations, which do not relate to the Time" foodborne illness interventions and risk factors lasted above, can be 3-403.11(C) Commercially Processed RTE Food- found in zhe foliotving sections of the Food Code and 105 CMR 140`F* 590.000. 3-4031.I(F.) Remaining Unsliced Portions of Bee[ Item Good Retail Practices FC 590.000 Roasts* 23. Mane ement and Personnel _ FC-2 .003 I8 Proper Cooling of PHFs 24. Food and Food Protection _ -_ FC-3 1 .004 25 Eau ment and Utensils F674- .005 _ 3-501.1.4(A) Cooling Cooked PF1Fs from 140°F to 26 Water,Plumbin and Wasie FC 5 _ .006_ 7WF Within 2 Flours and From 70°F 27. -Physical Facilit FC-6 -007 -__ Co 41.°F145°F Within 4 Homs. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient29_ S genal R uirements _ .009 Temperature Ingredients to 41°F/45'F 30__ Other Within 4 Hours* 1511T raafi�za,, *Denotes critical item in the federal 1999 Food Code or 105 CMR 590 000. 'r 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 r Date 'v VP/1)Q r / j Tvoeorvns) Te of Ins ection ❑ Routine AddressRisk LQ� Retail M Re-inspection S Vo rot At S 0 Level ❑ Residential Kitchen PreviousInspection El Date Telephone �/�1 J2 : I OwnerHACCP Y/N ❑ Temporary [IPre-operation ❑ Caterer ❑ Suspect Illness Person in Char a(P C) NJ Time ❑ Bed&Breakfast ❑ General Complaint Inspector In: 1 o') Permit No. ElHACCP out:/-� 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 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 'i FOOD FROM APPROVED SOURCE EI 15.Toxic Chemicals ` + _ El 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 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) El 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP El 11. 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 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)(550.004) 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-s)(sso.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:590/ns OFO. 14tlo Inspector's Signature: Print P PIC's Signature: Print: Page ofPages A 'J� U ► v -2r7ld� ------------ Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Crass-contamination 1 590.D03(A) As, t of Respomibilit y* 3-302.11(A)(1) Rat. Animal Foals Separated from 590.003(B) Demons u�nnof Coowted e* Cooked and RTE Foods* Contamination from Raw 2-103.11 Pviscminchage-duhes Ingredients 3-302Al(A)(2) Raw Anitrial FcxxlsSeparated from Eau h 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 Washirm Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-;04.11, Foal Contact with Equipment and Applicant To Report To The Person In Utensils* Charge` Contamination from the Consumer 590.003((1) Re orting b,Person in Charge* 3-306.14(A)(B) Returned Mood and Reservice of Food* 3 390.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Rcnrovai of Exclusions and Restrictions Food 3-701.11 Discarding of Reconditioning Unsafe FOOD FROM APPROVED SOURCE Fes* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law" 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Tem eratures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing Hot Water 3-202.13Sanitization m Teeratures* Sbell Eg s* 3-202.14 Eggs and Milk Products.Pasteurized* 4-501.114 Chemical Sanitisation-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* cancenh:atioa and ha<dness.`k 5-1.01.1.1 Drinkin Water from an Approved System* 4-601.1[(A) Equipment Food Contact Surfaces and 590.006(A) Bottled DrinkingWater* Utensils Clean* . 4-602.11 Cleaning Frequency ofF.quipmcnt Food- 590.006(B) Water Meets Standards m_3 10 CMR 2 2 0 0 Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 4-702.1 1 Frequency of Saniiizntion of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contac Surfaces of E ul menC* Shellfish` 4-703-11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 1p Proper,Adequate Handwashing Game and Wild Mushrooms Approved 8y Regulatory Authority -1301-11 Clean Condition-Hands and Arns�` 3-202.18 Shellstock Identification Present* 2-301.12 Cleating Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals' 11 Goad Hygienic Practices Receiving/Condition 2-40 LI1 Eating,Drinking or Using Tobaccos` 3-202.,11 PRFs Received a[Pttt ter Tem eratures* 2-401.1.2 Discharges From the Eyes, Nose and 3-202.15 Package hrte it . Mouth* 3-101.11 Focal Safe and Unadulterated*. 3-301..12 Preventing Contamination WVhen"fastin 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 ShelistockIdentification Maintainefi'` Emtlo ses* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction, Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-303.11 Numbers and Capacities* 590.0(}40) Labeling of ingredients' 5-204.11 1ax;ation and Placement* 7 Conformance with Approved Procedures 5-205.11 Acccssibilit ,Operation and Maintenance IHACCP Plans Supplied with Soap and Nand Drying 3-502.11 1 Specialized Processing Methods* Devices 3-502,1.2 Reduced oxygen tacky .ng,criteria* 6-301.1 I Handwashin Cleanser,Avai itit ed Procedures* 6-303.12 Hand Drying Provision 8-103.12 Conformance with A. rov *Denotes critical i4m in the federal 1999 fund Code or 105 CMIZ 590.606. CITY OF SALEM - ` BOARD OF HEALTH Establishment Name: N COnVAtC'/ICC Date: Page:_ of Item Code C-Critical Item DES RIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item _ .*` Verified "PLEASE PRINT CLEARLY -- I-,D14M -t S& �ir�G � rn , J4 IA v I U C4, VS a 17 O I r . r / 2 4J , • I 1 I 5 G v1 e-1' a ( / dry . / o ih � / 037- 4 sR� 1rJ ct�t ,l G �� u i, Discussion With Person in Charge: - Corrective Action Required: ❑ No .9lt—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 ode. I understand that noncompliance may result in daily fines of twenty-f' a dollars or suspension/revocation of ❑ Embargo ❑ , Emergency Closure your food permit. n 7 ❑ Voluntary Disposal ❑ Other: P - 1 3-51)1.14(0 PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(Hems 1-22) (Cont.) _4 FF(45'1`Within 4 Homs. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFS 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-501.16(B) Cold PIfFs Maintained at or below 3-202.12 Additives* 590.004(F) 41"/45`F4' 3-30214 Protection froth inao roved Additives* 3 1.5 Poisonous or Toxic Substances -501.16(A) Hot PHFs Maintained at or above 40'1 * 7-101.11 Identifying 7nfrn�mation-Oeigina( 3-501.16(A) Roasts Held at or above 130'F. Coners' tain 7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Se aration-Stor tge* 3-501.19 Time as a Public Fledin Control'% 7-202.11 Restriction-Presence and Use` 590.004(6) Variance Reamornent 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS(HSP) 7-204.1.2 21 3-80L11(A) Unpasteuriyed Pre-packaged Juices and 7=204.14 _Drvin� Agents,t riteria* Beset a es with R truing labels* --Q-`- 7-205.11 Incidental Food Contact,Lubricants* 3-801.1 l(B) Use of Pastewized 1---s* 7,06.111 Restricted Use Pesticides,Criteria* 3-801.11(D) Raw or Partially Cooked Animal'Food and Raw Seed S monis Not Served ° 7-206.1.2 RodenTracks Bait dors,P4` 3-801.11(C) Unopened Food Package Not Re-served. ` 7-206.13 Tracking Powders,Peat Control and Monitorine* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate 3Ega15'F5Se. Pathogens." F s-Immediate Service 145'F1.5sec* 3-302.1.3 1 Pasteurized Figs Substitute for Raw Shell 3 401.t I(A)(2) Comminuted Fish,Meats&Game Em=s* Animals- 155'F 15 see. 4` 3-401.11(B)(1)(2) Per and Beef Roast- 130'F 121 mut* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats- t55°F 75 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. * catering, mobile food,temporary and 3-401.1l(A)(3) Poultry,Wild Game, Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited tinder the appropriate sections Poultry or Ratites-I65'F 15 sec. "` above if related to foodborne illness 3-401.11(0)(3) Whole-muscle Intact Beef Steaks interventions and risk factors. Other 145"F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under 1129- Miorowave 165'F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs -- 145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-103.1 I(A)&(D) PFIFs 165'F 15 sec. * (Items 23-30) 3-403.11(B) Microwave- 165°F2 Minute Standing Citical and non-critical violations, tchieh do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3-403,11(C) Commercially Pro essed RTE Food- found ix the followinh sections of the Food Cade and 10.5 CVJR 140°F" 590.000. - 3-4031 I(E) Remaining Unsliced Portions of Beef item Good Retail Practices y FC 590.000 Roasts* 23. Pnanaace_ment and Personnel ` FC-2 .003 1g Proper Cooling of PHFs _7Z4_. _ Food and Food Protection __- FC--3 A04 --. _a 1------------- 26. -- __.4 3-501.14(A) Cooling Cooked,P14I'sfrom 140'F to '� Water Plumbin andWasI F----- 005 ?6 E ui meat and Utensils F - 006 70'F Within 2 Hours and From 70'F 27. Physical Facility FC-6 .007 -1 to 41'F/45°F Within 4 Hours.* �28: _Poisonous or Toxic Materials I FC-7 .008 3-501.14(B �goling PIIFs Macte From Ambient29 S ectal Requirements -� 009 i roperature [ngredients to 4VF'145'F 30 Other Within 4 Hours* ' '"-"`1°°` Denotes critical item in'tic federal 1999 Food Code or 105 C.MR2 90.000. - r %A ;..J Commonwealth of Massachusetts City of Salem } ` ° Board of Health 120 Washington Street,4th Floor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/04/2006 WHO'S PLACE OF BUSINESS IS: 3N Convenience File Number:BHF-2004-0112 3-5 Paradis Road Salem MA 01970 LOCATED AT: 03-5 PARADISE ROAD SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2006-0296 Jan 4,2006 Dec 31,2006 $100.00 TOBACCO VENDOR BHP-2006-0295 Jan 4,2006 Dec 31,2006 $50.00 Total Fees: $150.00 PERMIT EXPIRES December 31, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page I of 20 e CITY OF SALEM, MASSACHUSETTS u fi BOARD OF HEALTH O s 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 STANLEY J. USOVICZ, JR. _ FAyyyyy78-745 0343 L'l DSC o,?��Jr v� MAYOR JOANNE SCOTT, MPH, RS, CHO e�'q 0OFS HEALTH AGENT of 'qq 4 y�4ry 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENTN � N V E N I E N� TEL#(CM) 7 4d 37l l ADDRESS OF ESTABLISHMENT PARA-DiSG hR©AD, SALIPM, PPr 1W6 MAILING ADDRESS (if different) r� OWNER'S NAME S TED M • u�A�IU�DIN TEL# 7_ 4-0340 ADDRES `392) h}MLAND � Lg CITY t �l STATE__ CERTIFIED FOOD MANAGER'S NAME(S) "T� CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON MD JALAL HUDDIK HOMETEL# SSI 593 83I1 HOURS OF OPERATION: Mon.6fl Tue. -11 Wed.6 II Thu.(J_f Fri._&__1Sat. (—il Sun.(. AM- II QM TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE ES NO ^� _ / less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. 50 - -------------------------------------------_----.. .. RESTAURANT YES NO less than 25 seats $100 25-99 seats =$150 more than 99 seats =$200 ......... . . . ......................... .............. .... ...... .. . .------------------- BED/BREAKFAST YES llNO $100 ADDITIONAL PERMITS -----------------------------------------------------------------------------------.........------------------------------- AAAKE-(not -serve] ICE CREAM, YOGURT SOFT S-RV YES NO $5 TOBACCOVENDOJR 3S -O 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 d belief, have filed all state tax returns and paid all state taxes required under the law. I01� 0410 (33-16- 8498 Signature Date Social Security or Federal Identification Number ---------------------------------------------------------------------------Q------------------------------- ----------- Revised 11/03/05 FOODAP2.adm Check#&Date-72 Z K�" { � � 0 01161-� 3 � �Shak�/Qafj'� / _� Saer�e Byes S �„ �i3y G'e2eals s epee-a-.E'o� , �Yaxdc71es ✓rte rt 1 a ;" 0 e S;P- G,EACAF'9 /Y/,O< Tie S uvolllP.s rgese. 104F-S ' ° Be�G cTP e /S /® c, 7L o s � 7' -71VL6 /D 4 u d�,�-1eh1 e e CC 6 aIt Olhoal'- m/� itis oZ p Vu-7--t-C-4- Av T7-L-X- CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH qj 120 WASHINGTON STREET, 4TH FLOOR c SALEM, MA 01970 .pB4M1 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: 3N Convenience Address of Establishment: 3-5 Paradise Road Owner's Name: Syed M. Rajiuddin Restrictions: Application Date: 11/16/04 Permit for Food Establishment 008-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 002-05 These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. `HEALTH AGENT CITY OF SALEM, MASSACHUSET S BOARD OF HEALTH ' 120 WASHINGTON STREET, 4TH FLOOR EM, MA 0 970 TEL. 978-741-1800 I �� i S �004 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO "Ai__M MAYORFr V�1;'i r- �t-- HEALTH AGENT '� L-�r' ,EALTH 2005 APPLICATION FORPERMIT tPERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT 5N V eCNVE N I E W E TEL# (9-72)-M0-?)"711 ADDRESS OF ESTABLISHMENT �flRRDIS� Rd-, SALEM, MA o1970 MAILING ADDRESS (if dii/fferent) OWNER'S NAME kEh M• RATIUDJC-IIIF TEL# (°rl8)`144-034� ADDRESS Sqa HIt^HLAND AVE- CITY GA EG ►'1 STATE 1W-A'-Zip CERTIFIED FOOD MANAGER'S NAME(S) N jAr CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON MD. -'ALA L /HU➢D)tJ HOME TEL# 7SI 593 ?31 I HOURS OF OPERATION: Mo -IIAITJ-11 Wed.b'II Thu. 9- Fri.�-11 Sat. -11 Sun.6-" 11 ypp TYPE OF ESTABLISHME T FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$10 more than 10,000sq.ft. =$250 RESTAURANT YES less than 25 seats =$100 6G p 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO j $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 taxes required under the law. Signature Date Social Security or Federal Identification Number ----- ------ --- - -- -------------------------4J-I k'-°-Li---------------6 3`3g---------------------- Revised 11/03/03 FOODAP2.adm Check#&Date a * 363 06�- ll, .O4 )56 03-5 Paradise Road 3N Convenience City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Telephone: Item Status Violation Critical Urgency Nature of problem or correction ',740-3711' 'Y = „ Non-compliance with: Not Done Owner: .„ - , - Anti-Choking N/A ❑ ,Syed M. Rajiuddin Tobacco PASS ❑ PIC: ahid SuFOOD PROTECTION MANAGEMENT Not Done N6ltana I ahid o1 - PIC Assigned/Knowledgeable/Duties PASS RED =David Greenbaum - - EMPLOYEE HEALTH Not Done Date Inspected: Correct By: Reporting of Diseases by Food Employee and PIC PASS RED 4/4/2005 Personnel with Infections Restricted/Excluded PASS ❑d RED Risk Level: _. FOOD FROM APPROVED SOURCE Not Done Permit Number: - Food and Water from Approved Source PASS d❑ RED 6HP-2005-0070 Receiving/Condition PASS /❑ RED Status: _ Tags/Records/Accuracy of Ingredient Statements PASS RED VIOLATION y Conformance with Approved Procedures/HACCP PASS ❑d RED #of Critical Violations: Plans 1 Time IN:, Time OUT: Notes 56:' Urgency Description(s):' BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within X10 days)(Non-critical violations GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Apr 05,2005 ) Page I of 03-5 Paradise Road 3N Convenience must be corrected Immediately PROTECTION FROM CONTAMINATION Not Done or within 90 days) Separation/Segregation/Protection PASS ❑Q RED RED: Violations Related to, Food Contact Surfaces Cleaning and Sanitizing PASS SO! RED Foodborne Illness Interventions Proper Adequate Handwashing PASS ❑S/ RED and Risk Factors(Require , immediate corrective action) Good Hygienic Practices PASS ❑J RED Prevention of Contamination from Hands PASS ❑J RED Handwash Facilities FAIL Critical ❑d RED Back handwash sink obstructed. Handwash sinks must be clear and accessible at all times. Ladies room missing soap. Provide soap in ladies room at all times. PROTECTION FROM CHEMICALS Not Done Approved Food or Color Additives PASS ❑V1 RED Toxic Chemicals PASS ❑d RED TIMEITEMPERATURE CONTROLS(Potentially Haz Not Done Cooking Temperatures N/A ❑d RED Reheating N/A Q RED Cooling NIA ❑d RED Hot and Cold Holding PASS 0 RED Time As a Public Health Control N/A RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP N/A RED CONSUMER ADVISORY Not Done Posting of Consumer Advisories N/A Q RED GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Apr 05,2005 ) Page 2 of 03-5 Paradise Road 3N Convenience Violations Related to Good Retail Practices (Blue Not Done Management and Personnel PASS ❑ BLUE Food and Food Protection FAIL Critical ❑ BLUE Upon inspection 98 items were found outdated. Owner must closely monitor all expiration dates. Equipment and Utensils PASS ❑ BLUE Water, Plumbing and Waste PASS ❑ BLUE Physical Facility PASS ❑ BLUE Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other-See Notes PASS ❑ BLUE OWNER WAS WARNED DURING 9/14/04 INSPECTION THAT REPEAT VIOLATIONS WOULD RESULT IN A FINE BEING ISSUED. THEREFORE A MONITARY FINE WILL BE ISSUED DUE TO EXCESSIVE OUTDATED PRODUCT. GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Apr 05,2005 ) Page 3 of j)OURf DOCKETNO: ___ f --CRATIOH NO 0 CITY OF SALEM 0 o VIOLATION NOTICE PD �� t• m . . NAME(LAST.FIRST:INITIAL) :: ... . ... 3n/ CoNv �& car Ln 1 STREETADDRESS CITYROWN STATE ZIP r y 7,6- irg .4�_ J N{ a•77,0 to �. I w r O d OU 1-4 > . 2 LICENSE NO. LIC.EXP.DATE DATE OF BIRTH �� ' m N n vO g 3xz OWNERS NAME(LAST,FIRST,INITIAL) ./ w 9y (� y N m 0 9 o m Z STREETADDRESS CITYROWN STATE ZIP O az 0.?93 tip H.S Sift�rl rT.F ui97y m REGISTRATION NO. STATE EXP.DATE MAKERYPE YEAR COLOR r 0 r ^ r m DATE OF VIOLATION TIME DATE CITATION KITTEN Pm50NP� (� AM N�R r y ./ �' PM 7 �'D El No .O K /1 LOCATION OF VIOLATION ENFORCING DEPT i f O U� OFFENSE CHAP. SECT FINES Ln O D Un A R 'c£�r bio �J S I p sN B J c T- g o CL g0 OFnFIC Hum I.D.NO. TOTAL �^ O Eo'l DUE OFFICER CERTIFIES COPY GIVEN TO VIOLATOR L 8 q I N /=;//-�� INHAND /q X/"YCfe.lrc.(✓ f `c-o1%.^--- ❑ 13Y MAIL g lyoi cn DO NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY j y l Ln ORDER OR BY CHECK MADE PAYABLE TO: CITY CLERK CITY HALL 93 WASHINGTON STREET SALEM,MA 01970 vi TEL.(508)745-9595 X 251 I HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE PAYMENT IN THE AMOUNT OF 1_ i $ CASE# SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL COURT DOCKET NO. QCITY OF SALEM CITATION NO. VIOLATION NOTICE PD 1122 NAME(LAST,FIRST,INITIAL) �N C�Nt rJ/�r/Cer STREETADDRESS CITYrrOWN STATE ZIP t'��stlJir� .f Ht sI4?d LICENSE NO. LIC.EXP.DATE DATE OF BIRTH OWNER'S NAME(LAST,FIRST,INITIAL) STREETADDRESS CITYaOWN STATE ZIP M //L4'-tO rh5 S-AL.&q Hsi a'i974 REGISTRATION NO. STATE EXP.DATE I MAKE/TYPE I YEAR COLOR DATE OF VIOLATION TIME DATE DATE CITATION WRITTEN PENSONAL 4I y t0,OEM PM I '7 /d7 El NO LOCATION OF VIOLATION - ENFORCING DEPT. 3 t4AVfooloric OFFENSE CHAP. SECT. FINES A jl"t tr yloL4ftrrJ df .9 S B r?fC rte- �a OFFICER I.D.NO. TOTAFI EL J �dC !c N DUE $ /LM OFFICER CERTIFIES COPY GIVEN TO VIOLATOR N HAND ❑ 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 INTHIS ENVELOPE,PEEL AND SEAL 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 D el Operation (s)of Operatios) T e of inspection 214C614 /� CSI t ❑ ood Service Routine Address r� Risk Detail ❑ Re-inspection 5 .1r Level ❑ Residential Kitchen Previous Inspection Telephone ' A_ / I%t ❑ Mobile Date: Owner HACCP YM ❑ Temporary ❑ Pre-operation Y- ko ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint Inspector t r4(S Out: Permit No. ❑ Other Each violation c ecked 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 El12. Prevention of Contamination from Hands El 1. PIC Assigned/Knowledgeable/Duties EMPLOYEE HEALTH , i ❑ 13. Handwash Facilities - . PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC 14 Appr•ved Food or Color Additives El 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxiemicals 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),,a [3 10. Proper Adequate Handwashing [:121. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices . CONSUMER ADVISORY , _ " , 11 ' ❑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 3Cr� 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 eaN I 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils cited in this report may result in suspension or revocation of (Fc-a)(sso.00s) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S'5XInVp Form 14 dC Inspector's Signature: Print: Q PIC's Signature: ' _ L Print: F ) I fm A Pagel of J Pages � 1 Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 1 Cross-contamination 1 590.C103(A) Assinnment of Responsibility* 3-30111(A)(1) Raw Animal Focxls Separated from 590.003(8) _Demonstration of Knowledge* Caked and RTE Foods* 2-103.11. Person in charge-duties Contaminairon from Raw Ingredients 3-302.1.1(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other' 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require repotting by Coal employees and 3-302,11(x1) Food Protection" applicants* 3-302.15 WashlnvFruas and Viceetables 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* Chat LeY Contamination from the Consumer 590.003(0) Re horfrn b Perstnt 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 Fund* 4 F Food and Water From Regulated Sources 9 and Contact Surfaces 590.o04(A-Bl Compliance with Food Law* 4-501..1.11 Manual Wtu'ewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization'fepn eratures' ro Mechanical Warewashin< Hot Water 3-201.13 Fluid M1ik and Milk Products* 4-501.1(2 * 3-202.13 Shell &*Rs* Sanitizafion Tem eratures* 3-202.(4 E..Us and Milk Produets..Pasteudzed* 4-501.114 Chemical Sanifiz000n-temp., pH, concentp:ation and hardness. 'k 5-102.16 Ice Made From Potable Drinkin e W iter* 4-601.11(A) Equipment Food Contact Surfaces and 5-101.11 Drinkin Waterfi:wn m A raved S stem* Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 clennine Frequency of Fe❑i anent Food- . 590.006(8) Water Meets Standards in 310 CMR 22.0"" Contact Surfaces and Utensils Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfuees of H ui stent* Shellfish, 4-70311 Methods of Sanitization-HotWaterand 3-201,15 Molluscan Shellfish from NSSP Listed ChemicaP" Sources* 10 Proper,AdequateHandwashing Game and Wild Mushrooms Approved by 2-301.1 1. Clean Condition-Hands and Arms* Re Mato Authori 3-202.78 Shellsiock Identification Present* 2-30112 Geanina Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* t1 Good Hygienic Practices 5 Receiving/Condition 2-401.11 Eatiniz,Drinkin,or Usinn'robacco* 3-202.11 PHFs Received at Proper Tem eratures* 2401.12 Discharges From the Eyes, Nose and 3-202,15 Packa eln[e rat * .Mouth* 3-101.11_ Food Safe and Unadulterated* 3-301.12 Preventin>Cvntaminatimt When Tasting` 6 TagstRecords:Shelistock 12 Prevention of Contamination from Hands 3-202.18 Shelistock Identification* 590.004(E) Preventing Contamination from 3-20112 Shellstock Identification Maintained" m lovees* F Tags/Records:Fish Products 13 Handwash Facilities Conveniently Located and Accessible 3-402.11 Parasite Destruction* 3-402.12 1 Records,Creation and Retention* 5-203.11 Numbers and Ca acojes* 590.0040 Labeling of Ingredients' 5-204.11 Location and Placement* ry Conformance with Approved Procedures 5-205.11 Accessibilit Operation and Maintenance. /HACCP Plans I Supplied with Soap and Hand Drying 3-50211 Specialized Processus'Met hods* Devices 3-502.12 Reduced oxvaen acka in--criteria* &301.11 Handwashin Cleanser,Availabilit 8-103.12 Conformance with Approved Procedures" 307.12 Hand Drvi PrProvision IDenoles critical item in the tederal 1999 Foal Code or I0S C�7R 590.000. CITY OF SALEM . BOARD OF HEALTH Establishment Name: 51A/ �Jn/ V GAN/�s NCS Date: t y Ay Page: 2 of Item code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY rV L L-.CI / W hi rjiftr 17 1!�14C or r &&QVP r.� 2 • �i vz ,z /td o 3 2 R v r !t M/ GAS � S ClUl AIM OF- W r Z �r'la 1 t.4N .T- \ Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. Q \ a �I 1AAen � ❑ Voluntary Disposal ❑ Other: 1 44 3-501 H(C) PRFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to law Cooled to Factors(items 1-22) (Cont.) 41°F/45°F Within 4 Hoias. PROTECTION FROM CHEMICALS3-501.15 CoolimT Methods for PHFs 1=414 7Food or Color Additives 1 PHF Hot and Cold Holding 3-202.12 AddurNcs'6 ---"- 3-501.1fi(B) Cold PHFs,Maintained at or below 590.004(F) 4lV45°F* 3-302.14 Protection from Una2 roved Additives* i - 3-507.16(A) Hof PHFs Maintained at or above 15 Poisonous or Toxic Substances 4WF. C,ontainer"` 7-101.1,1 Identifying l'nformation-Chipnnat 3-501.16(A) Roasts Held at or above 130°F." 7-1.02.11 Cotnrnon Natne-Workin*Containers* 20 Time as a Public Health Control 7-201.11 Se aradon-Storage* 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use* 5919-004(}1) Variance Re uirenuent 7-202.12 Conditions of Use* 7- 03.11 Toxic Containers-3rohibioas* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7,-204.11 Seutitizers,Criteria-Chemicals* POPULATIONS(HSP) _T-Y0-4 12 Chemicals for Washing Produce,Criteria* 21 3-901..11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drying Agents,Criteria` Serer tges with Warning labels* 7=205.11 Incidental Food Contact. Lubticanis* 3-501.11(B) Cee of Pastennze<t Ee,gs* 7-206,11 Restricted Use Pesticides.Criteria* 3-80 1 A I(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. 7-206.12 Rodent Bait Stations* : � � 3-801.11(CJ Uno erred F'aod Parka re Nat Re-served. 7-206.13 Trsck'ing Powders,Pest Control and ivtonrtorin°* - CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of r - - Animal Foods That are Raw.Undercooked or 16 Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate 3-40111 A(])(2) f),be- t55°F 1.5 Sec. Parho°ens E t,c-immedratc Service I<!5°F155ec* 3-302.13 Pnstennrca Eggs Substitute'for Raw Shell 3-40J.I I(A)(2) Comminuted Fish,Meats&Game Animals- 1550F 15 sec. 3-401.1l(B)(1)(2) Pork and Beef Roast-�13(f F 121 min* SPECIAL REQUIREMENTS -401.11(A)(2) Ratites,injected Meats-155°F 15 590.009(A)-(D) Violations of Section 59(l D09(A)-(D)in sec.* catering, mobile food,ternportny and 3-401.1.1(N)(3) Poultry,Wild Game, Stuffed PRFs, residential.'kitchen operations should be Stuffing Containing Fish,Meat, debited ander the appropriate sections Poultr,or Ratites-165°F 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 1450F* 590.009 violations relating to good retail 3-=01.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requh'ements, 3-401.1l(A)(1)(b) All Other PHFs-l45°F 15 sec. 17I Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) 1 PHFs 165°.F 15 sec. * (Items 23-30) 3-403.11(B) Microwave-165°F 2 Minute Standing Ci-ideal and non-critical violations, which do net relate to tire Time* 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 1.40°F` 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef item Good Retail Practices FC 590.000 Roasts* 23. Mona ement and Personnel _ FC--2 .003 18 Proper Cooling of PHFs 24. Food and Food Protection FC-3---,004 25. E uq iprient and Utensils _ FC 4 .005 _ 3-501.14(.A) Cooling Cooked PHFs from 14WF to 26 Water,_P and W asie FC 5 006 707 Within 2 Plours and From 70°F 27. Physical Facili FG-6 .007 -- --- Co 41°Ft45°F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .00II 3-501.14(B) Cooling PHFs Made From Ambient _29. S ecial Re uiremsnts _ ` .009 Temperature Ingredients to 41'F/45'F30._.,...._ Other -------____ Within 4 flours)' ssw>m,»a„k6-2s,c '°Denotes critical item in the re clexal 1999 Food Code or 105 CMR 590-000. CITY OF SALEM BOARD OF HEALTH Establishment Name: 3?4 C0NVtfN19a t49_ Date: Q / Page: 3 of DESCRIPTION OF VIOLATION"/PLAN OF CORRECTION Item Code C—Critical Item Date No. Reference R—Red Item Verified a "PLEASE PRINT CLEARLY A zz V6 r /t E ati- n dJ' t/as'rf D UNA � M f 3 . ,,^z/sr wtG ✓H �P dT w. .AIAD CX v0 Mfr sr t r n►{� U" V I a t-,A at oNr e7r V l*tc MAs'vAa W tL 3 tJi r Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ 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. n ❑ Voluntary Disposal ❑ Other: I A 3SOL.lA(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk .According to Law Cooled to Factors(items 1-22) (Cont.) �41°F/45'F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Coolin=g Methods for PRFs 14 Food or Color Additives y PHF Hot and Cold Holding 3-202.32 Additives" 3-50116(B) Cold PEIFs Maintained at or belors 3-302.14 Protectionfrom lJna r roved Additive, 590.004(F) 41°145°F* 'k 3-501.16(A) flat' PIIFs Maintained at or above 15 Poisonous or Toxic Substances 140°F. 7-1{)1..11 IdeContainers Information-Ch'iginal 3-501,1.6(A) Roasts Held at or above I-30°P '" Containers* 7-102.11 Common Narne-Working Containers* 20 Time as a Public Health Control 7-201.11 Se aration-Stora ev 3-50119 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use'E 590.004(H) Variance Re ufrement 7-202.12 Conditions of Use' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.1.1 Toxic Containers-Pzohibitions* POPULATIONS(HSP) 7-204.11 Sandizers,Criteria-Chcmicrls* 7-204.12 Chenecak for Washing Posture,Criteria* 21 3-801.1I(A) Unpasteurized Pre-packaged Juices and 7-204.14 Dr m A guts,Criteria* Beverages with Warning labels* 3-80111(B) Use of Pasteurized Eggs* 7-205.11 incidental Food Contact,Lubrie3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides.Criteria*rin* Raw Seed Sprouts Not Served. " 7-206.12 Rodent Powders.Pest Control and Bait Stationse 7-206.13 Tracking 3-801.11(C) -Unopened Food Package Not Re-served. Monitoring* CONSUMER ADVISORY TIMEtTEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw.Undercooked or T6 Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate 3-401.11A(1)(2) Eggs- 155F1x. .SSeo. Pathogens,* Eteaeve r;"" h gs-Lnnredr rte Service 145'Fl Ssec* 3-302.13 Pasteurized Eggs Substitute'for Raw Shell 3-401.1I(A)(2) Comminuted Fish,Meats&Game Animals- 155'F 15 sec. - 401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats- 155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec.` catering, mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PFIFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultr or Ratites-165'F 15 see. * above if related to foodborne illness 3-40111(C)(3) Whole-muscle,Intact Beef Steaks interventions and tisk factors. Other 1450F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Crooked in a practices should be debited under#29- Microwave 165'F* Special Requirements. 3-401.11(A)(I)(b) All Other PHFs-145'F 15 sec " 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3 403.11(A)&(D) PHFs' 165'F 15 see.'° (Items 23-30) 3-403.11(B) Microwave- 165'F 2 Minute-Standing Critical and non-critical vioiertlans, which do nor relate to the Time" / odborne Illness interventions and reo(factors listed obove can be. 3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Cade and 105 CMR 140'F* 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef Item I Good Retail Practices Q FC 580.000 l Roasts'= 23. Marra ement and Personnel_ FC-2 .003 1A Proper Cooling of PHFs 24. Food and Food Protection _FC3 .004 25 _ Equ�ment and Utensils FC 4 ,005 3-501.14(A) Confine Cooked PHFs from 140°F to -- --- 26 __ Water Plu_mbin and Waste FC 5 .006_ 70'F Within 2 Hou s and From 70°F2-7- Ph sical Faotli ' FG-S 007 .. -__.-_ to 41°F/45°F Within&Hours. ^` 28. Poisono-uor Toxioxis c Materials FC -7 I .008 3-501-'14(13) Cooling PFIFs Made From Ambient 29- S ecial R uir®mems - __._ .009 Temperature Ingredients to 41'F145'F 30----------Other Within 4 HourE's spoor„msa-za„� "Denotes critical item in the.faderal 1994 Food Code.or 105 C'MR 590.000. COURT DOCKET NO. CITATION NO. CITY OF SALEM A QQ�'' VIOLATION NOTICE A 2 07 NAME O AST,FIRST,INITIAL) Raz 'iud )r)I STREETAGDRESS CITY/TOWN STATE ZIP LICENSE NO. LIC.EXP.DATE DATE OF BIRTH OWNER'S NAME�(LArST,FIRST,INITIAL) �tct �'C I/1G7d I n S�t STREETADDRESS Y CITY/TOWN STATE ZIP REGISTRATION NO. STATE EXP.DATE MAKEITYPE I YEAR COLOR DATE OF V FVIOATIO/TN// TIMEDATTEEC�ITATION WRITI-EN PERONAL 7./47. (VIVdRPM 17 01 ❑NO rLOCATION OF VIOLATION ENFORCING DEPT. 5 Pr�radrsed a 'iiea OFFENSE CHAP. SECT. FINES A Jf{�t70fZUD 59i. l,6j B t c OFFICERI.D.NO. TOTAL FINE $a5 OFFICER CERTIFIES COPY GIVEN TO VIOLATOR �` s y. -1 ❑ IN HAND X 3 i!�{/h ..�J/✓ ./ ©°'BV MAIL DO NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY ORDER OR BY CHECK MADE PAYABLE TO: `f CITYCLERK 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 DOCKETNO CITATION NO. _ CITY OF SALEM 9O7 VIOLATION NOTICE- AZ9 NAME(LAST,FIRST,INITIAL) J(N' :. YI S eco Convt O p x y STREET DRESS CITYrrOWN STATE ZIP O '' ° - �. 1 m mio OO m LICENSE NO, LIC.EXP DATE DATE OF BIRTH Ln I-s OWNER'S NAME(LAST,FIRST,INITIAL) Ln moil px /UQd)n. �m O STRE DDRESS CITY/TOWN STATE ZIP .y ` � j:yy p -,3 W D D C REGISTRATION N0, STATE EXP DATE MAKET'PE YEAR COLOR mzLw am_ M DATE OF VIOLATION TIME DATE CITATION WRITTEN ce"W"^L O Z ❑AM INJURY� ) m ¢ l7•ll4 a '�' �i •D� ONO I LOCATION OF VIOLATIONENFORCING DEPT. Sn/ern�%-?)ca r� �rA �r of Ip ' 1 1 OFFENSE CHAP. SECT. FINES _ A { 10� rOdi2 O C 54c e,2) 1 e f 8 O w n G 'm I, i OFFICER LD.NO. TOTAL FINE DUE �L I,t C OFFICER CERTIFIES COPY GIVEN TO VIOLATOR j � '. ❑ IN HAND to © ©'� n AIL YM ri DO NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY G !I ORDER OR BY CHECK MADE PAYABLE TO: D O CITY CLERK a (l � r CITY HALL 93 WASHINGTON STREET B) N SALEM,MA 01970 gx, W TEL.(508)745-9595 X 251 sl: N I HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED 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 Establishment Name: Date: �3 1 i / Y Page: 1 of DNfti (t f1! Ia 110QatAT4P1 \N DE F Cl1T ATE RCA #� C�rc �a YodUr j t F t s t -5 x •X n Discussion With Person in Charge: O Voluntary Compliance +O Employee Restriction/ Exclusion t O Re-inspection Scheduled O Emergency Suspension O Embargo O Emergency Closure L f' 4 0 Voluntary Disposal 0 Other: 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodbome Illness Interventions and Risk According to Law Cooled to Factors(Red Items 1.22) (Cont.) 41°F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs 14: Food or Color Additives 19 PHF Hot and Cold Holding 3-501.16(B) Cold PRFs Maintained at or below 3-202.12 Additives* 590.004(F) 410/450 F* 3-302.14 Protection from Unapproved Additives* 3-501.16(A) Ho[PHFs Maintained at or above Poisonous or Toxic Substances 7-101.11 Identifying Information-Original 1400F.* . Containers* 3-501.16(A) Roasts Held at or above 130°F. 7-102.11 Common Name-Working Containers* 1,20 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(1-)) Variance Requirement 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers,Criteria-Chemicals* POPULATIONS(HSP) 7-204.12 .Chemicals for Washing Produce,Criteria* '21 3.801.1 I(A). Unpasteurized Pre-packaged Juices and 7-204.14 Drying Agents,Criteria* I Beverages with Warning Labels* 7-205.11 Incidental Food Contact,Lubricants* 3-80LI l(B) Use'of Pasteurized Eggs* 7-206.11 Restricted Use Pesticides,Criteria* 3-801.1 I(D) Raw or Partially Cooked Animal Food and 7-206.12 Rodent Bait Stations* Raw Seed Sprouts Not Served.* 7-206.13 Tracking Powders,Pest Control and 3-801.1 I(C) Unopened Food Package Not Re-served. Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of _16- Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.11A(1)(2) Eggs- 155°F 15 Sec. Pathogens.*e"eLrvvin"001 Eggs-Immediate Service 145°F 15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* 3-401.11(A)(2) Comminuted Fish,Meats&Game Animals- 155°F 15 see. * SPECIAL REQUIREMENTS 3-401.1 I(B)(I)(2) Pork and Beef Roast- 130°F 121 min* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3.401.1 l(A)(2) Ratites,Injected Meats-155°F IS sec. catering,mobile food,temporary and operations should be residential kitchen o * P h d d biteunder the appropriate 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, depp Priate sections Stuffing Containing Fish,Meat, above if related to foodbome 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 3-401.1 I(A)(1)(b) All Other PHFs-145°F 15 sec.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 1T. 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 riskfactors listed above, can be found in the following sections of the Food Code and 105 CMR Time* 590.000. 3-403.11(C) Commercially Processed RTE Food- Item Good Retail Practices FC 590.000 140°F* 23. Management and Personnel FC-2 .003 3-403.11(E) Remaining Unsliced Portions of Beef 24. Food and Food Protection FC-3 .004 Roasts* 25. .Equipment and Utensils FC-4 .005 Proper Cooling of PHFs 26. Water,Plumbing and Waste FC-5 .006 3-501.14(A) Cooling Cooked PHFs from 140°F to 27. Physical Facility FC-6 .007 28. Poisonous or Toxic Materials FC-7 .008 70°F Within 2 Hours and From 70°F 29. Special Requirements .009 to 41°F/45°F Within 4 Hours. * 30. Other 3-501.14(B) Cooling PHFs Made From Ambient SS f.�nke-:.a« Temperature Ingredients to 41°F/45°F - Within 4 Hours* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM, MASSACHUSETTS i BOARD OF HEALTH $j 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978.741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter I II, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: 3N Convenience Address of Establishment: 3-5 Paradise Road Owner's Name: Syed M. Rajiuddin Restrictions: Application Date: 3/31/2004 Permit for Food Establishment 285-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 63-04 These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT o CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH '� 3s 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2004 APPLICATION FOR 1V R P^ErRMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT S CON M OE TEL# b-7-2)740 3111 ADDRESS OF ESTABLISHMENT '5-F PARADISE RDAJ/ SALEM ,, NA MAILING ADDRESS (if different) NIA p p OWNER'S NAME 1�D �I• IZA�II�17D1 TEL# I �I-I1 1 1� Lf ADDRESS M4 iNATNAPIM �T APT I - CITY L`(yN STATE PA ZIP NIA 1 CERTIFIED FOOD MANAGER'S NAME(S) FA CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON N A}}I D S UC T A LA R HOME TEL# 7 9 INS 1 HOURS OF OPERATION: Monti-11 Tue.611 Wed.6-11 Thu.6--I( Fri.6-11 Sat. -i1 Sun. 6•- I 1 TYPE OF ESTABLISH M /f FEE check only RETAIL STORE YES NO o2-S,5 less than I000sq.ft. 50 1000-10,000sq.ft. 4= 2 00 more than 10,000sq.ft. RESTAURANT YES NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES $100 ADDITIONAL PERMITS MAKE (notjust serve) ICE CREAM, YOGURT, SOFT SERVE Y S NO $5 TOBACCO VENDOR & '3 T -O S NO 50 $J5-0 ALL NON-PROFIT(such as church kitchens) S NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Signatureto Social Security or Federal Identification Number fo Revised 11/03/03 FOODAP2.adm Check#&Date 3-RI -04 A l0, J-T I tr b M d O 4//So CITY OF SALEM J AJ BOARD OF HEALTH Establishment Name: . Date: 3 a 9- D Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item - Verified PLEASE PRINT CLEARLY _5V .� ; d �P � �i /wig.S ,t W /0 Le, dZ� o94 . i. . Al s wa /,(-14 64 /l �? vu.� Baru Luu ( 12� t2 ce w/ Su 1 �v/cls G►�rse� -P� DT�� d d oma-, 3 - 3/ -05/ Q � � O Discussion With Person in Charge: Corrective Action Required: ❑ 'No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/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: 3-501.14(0) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(items 1-22) (Cont.) 4'1'F7457 Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.19 Couline Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below 590.004(F) 4l i45°F* 3-302.1.4 Protection From Una .loved Additives* 3-501..16(A) tIot PHFs Maintained at or above 15 Poisonous or Toxic Substances 140`P. 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above I30'F. Containers* 20 Time as a Public Health Contras 7-102.11 Common Narne-Working Containers', 3-501.14 Time as s Public Health Control* '" Separation 7-202.11 Restriction-Presence and User 590.004(H) Variance Retuiretnent 7-202.12 Conditions of Use" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-20311 Toxic Containers-Prohibitions* POPULATIONS NSP 7-204.11 Sanidzers.Criteria-Chemicals* 7-204.12 Chemicals for Washing , Criteria* 21 3-80LlI(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drvin� Agents.Criteria* Beverages with Warning Labels* 7-20511 Incidental Food Contact Lubricants* 3801.11(6) Use of Pasteurized Eggs, 7-2(lG.l l Restricted Use Pesticides,Criteria"` 3-801.11(D) Raw or Partially Cooked Animal Foul and Rain Seed Sprouts Not Served 7.206,1.2 Ralent Bait Stations" 3-801.11(C) Unopened Food nEck e Nut'Re-served. 7-205.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods]'hat are Raw, Undercooked or 7,h Proper Cooking Temperatures for PHFs Not Otherwise Processed to Elitninate Frtece'vs r^r2oai 3-401.11A(1)(2) Eggs- 155'F li Sec. Pathogens.* Itgs-fmmedntteService 115'Fl5su* 3-302.13 Pasteurized Eggs Substitute for Raw Shelf 3-401.11(A)(2) Comminuted Fish.Meats&Game Animals- 155'F 15 sec. * 3-401.11(13)(I)(2) Pork and Beef Roast- 130°F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,hjected Meats- I55'F IS 590.009(.4)-(I)) Violations of Section 590.009(A)-(D)in sec. * catering,mobile tood, temporary and 3-401.11(A)(3) Poultry,Wild Game.Stuffed PHFs. residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec. * above if related to foodborne illness 3-401.11(0)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145"F 590.009 violations relating to-0od retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165'F* Special Requirements. 3-401.11(A)(I)(b) AtIOther PHFs,- '145'F15see, 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165'F 15 sec. * (Items 23-30) 3-40311(6) Microwave-165'F 2 Minute Standing Critical and non-critical violations, which do not relate to the Time` joodhorne illness interventions and risk factors listed above, can be 3-403.1.1(0) Commercially Processed RTE Food- toluol in the follmrtng sections of the Food Code and 105 CMR 140°F* 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef Item ' Good Retail Practices FC 590.000 Roasts* t,._23.__ ,_Management and Personnel PC-2 .003 lg Proper Cooling of PHFs 24. Food and Food Protection _ FC-3 .004 FC 4 3-50114(4) tooting Ccm25 E ked PHFs from 140°F to quipment and Utensils 005 - ' 26. Water,Plumbing and Waste FC-5 .006 7W F Within 2 Hours and Front 70'F 27. Physical Facillt FC-6 .007 to 41'F(45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(6) CoolingPHFs Made From Ambient 29_ Special Regulrements_ 009 Temperature Ingredients to 41'F/45°F L30. Other _ _� _ _ Within 4 Hours* s ' -.w-022 *Denotes crllical item in the federal 1999 Food Cade or 10i CMR 590900. 3 D ./` (I) \ 0 tl1 r \ A / \� OCT b C) n = s (�/1 1 s n � ; mss• \ � ol 9 \ SLSK \ / °SC[CE CHECKOUT ss seri. � I 7 3' 3' T 3' T I34 •"x sI�xI srA E cors/>+�aEs a i f L The STOR=24 Canponies Inc. 03 O — SOUARE FOOTAGE SHELM14G TOTALS` 164 RKRAE'R A5£. WALTHAM, MA. fIAR: RH30: 09AM1 BT: D p��A_ L� coxoU - 11/4101 11/23/01 TPT r FEW AYJA au��s EM rJp Ve:wa [^_1 5:a t 1157 u m -w m22*n San ue�-wE-- IVB_ SALE41• YA Pi T SiJ.Y M`A IEY6ALWS-- S lrvfl M.OFFICE iS 22i S?R 1Gzlt t I I >t;E E N eA4uWt—�. �—�—/-J~��_ . MEP.CHA'�CISE PUH J m 31U Wdat,&(