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Massachusetts Department of Public Health Salem Board of Health
Div/sion Of Food and Drugs 120 Washington Street,0 Floor
Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (91) 741-1800 Fax(978) 745-0343
Name DaT of Operation(s) Tvpe of Inspection
,jf) Ki �o S Food Service ❑ Routine
Address 0- r Risk I l ®Re-inspection
Level El Residential Kitchen Previous Inspection
Telephone _ Clio o ❑ Mobile Date:
Owner I HACCP Y/N El Caterer ❑ Pre-ope O�nlz(14/v
dclato Person in Charbe PIC tJ Tim ❑ Bed&Breakfast ❑Suspect Illness
g (PIC) :1 General Complaint
Inspector In � Permit No. 11 HACCP
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.
LFOOD PROTECTION MANAGEMENT _ _ ❑ 12. Prevention of Contamination from Hands
❑ 1 PIC Assigned/Knowledgeable/Duties
❑ 13. Handwash Facilities
[EMPLOYEE-HEALTH _. „ ,� ,- n m
-- PROTECTION FROM CHEMICALS
❑ 2. Reporting of Diseases by Food Employee and PIC
[114.Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excludedti
L FOOD FROM APPROVED SOURCE El 15.TOXIC Cf1emIC81S
❑ 4. Food and Water from Approved Source TIMENEMPERATURE CONTROLS(Potemlally Hazardous Foods_)
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 16. Cooling
PROTECTION FROM CONTAMINATION 3.„ „: ., µ . ❑ 19. Hot and Cold Holding
❑ B. Separation/Segregation/Protection ❑20.Time As a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR.HIGHLY SUSCEPTIBLE.POPULATIONS_(HSPIl
El21. Food and Food Preparation for HSP
[:110. 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
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)(5so.0o5) cited in this report may result in suspension or revocation of
the food establishment permit and cessation of food
26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you
27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION: . I_
s:5801repecfformB-ia.Ex 1l_AY)4-I�L7J11
Inspector's Signature: Print:
PIC's Signature: - - ' Print: /' 7 c-� G, Page of Pages
Violations Related to Foodborne illness
Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION
g Cross-contamination
FOOD PROTECTION MANAGEMENT 3-302-11(A)(1) Raw Animal Foods Separated from
1 I 590.003(A) Assig tment of Responsibility* Cooked and RTE Foods*
590.003(6) Demonstration of Knowledge* Contamination from Raw ingredients
2-103.11. Person in charge--duties 3-302.11(A)(2) Raw Animal Foods Separated from Each
Other*
EMPLOYEE HEALTH Contamination from the Environment
2 590.003(0) Responsibility of the person in charge to 3-302.,1.1(A) Food Protection*
require reporting by food employees and 3-302.15 Washing Fruits and Vegetables
applicants* 3-304.11 Fond Contact with Equipment and
590.003(,F) Responsibility OfAFuoxl Employee Or An Utensils*
Applicant To Report To The Person In - Contamination from the Consumer
Char * 3-306.14(A-)(B) Returned Food and Reservice of Food*
590.003 G) Re crating b Person in Charee* Disposition of Adulterated or Contaminated
3 590.003(D) Exclusions and Restrictions* Food
590.003(E) Removal of Exclusions and Restrictions. 3-701.11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Food4°
4 Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Compliance with Food Law* 4-501.1.11 Manual Warewashing-Hot Water -
3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures*
3-201.13 Fluid Milk and Milk Products*
4-501.112 Mechanical Warewashing- ,Hot Water
3-202.13 Shell Eggs* Sanitization Temperatures*
3-202.1.4 Eggs and Milk Products.Pasteurized* 4-501.114 Chemical.Sanitization-temp.,pH;
3-202.16 Iee Made From Potable Drinking Water* concentration and hardness. *
5-101.11 Drinking Water from an Ap2roved System* 4-001..11(A) Equipment Food Contact Surfaces and
59(L006(A) Bottled Drinking Water* Utensils Clean*
590.006(6) !Vater Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food
Contact Surfaces and Utensils*
Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sairitization-Hot Water and
3-201.15. Molluscan Shellfish from NSSP Listed Chemical*
Sources* 10 Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Regulstoty Authority 2-301.11 Clean Condition-hands and Anes*
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Proicedurc*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201.17 Game Animals* 11 Good Hygienic Practices
5 Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco*
3-202.1.1 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and
3-202.1.5 Package Integrity* Mouth*
3-101.11 Food Safe and Unadulterated* 3-301.'12 Preventing Contamination When Tasting*
6 Tags/Records:Sheiistock 72 Prevention of Contamination from Hands
3-202.18 Shellstoek Identification* 590.004(E) Preventing Contamination from
3-203.12 Shellstock Identification Maintained* Em to ees*
Tags/Records: Fish Products 13 Handwash Facilities
3-402.11 Parasite Destruction* Conveniently Located and Accessible
3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities*
590.00401 Labeling o1 Ingredients' _ 5-204.11 Location and Placement*
7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance
/HACCP Plans Suppiled with Soap and Hand Drying
3-502.11 Specialized Processing Methods* Devices
3-502.12 Reduced oxygen acka img criteria* 6-301.11 Handwashing Cleanser,Availability
8-103.12 Catfatmance with roved Procedures* 6-30]..1.2 Hand-Drying Provision
"Denotes critical item in the federal 1999 FaW Code or 105 CMR 590.000.
I
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: Dul)Ktn (�� �ya ��ch �Ga,j_ Date: Page: 0�— of
Rem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date-
140. Reference R-Red Item Verified
LEASE PRINT CLEARLY
x i
/ -
�`
.'. --z _
Discussion With Person in Charge: Corrective Action Required: ❑ No Yes
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
comply with all mandates of the Mass/Federal Food Code. I understand that ❑ Re-inspection Scheduled I] Emergency Suspension
noncompliance may result in daily fineszggizm
cation of ❑ Embargo ❑ Emergency Closure
your food permit.
_r ❑ Voluntary Disposal ❑ Other:
3-501.14(C) PRFs Received at Temperatures
Violations Related to Foodborne Illnessinterventions and Risk According to Law Cooled to
Factors(Items 1-22) (Cont.) 4/°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
3-50L16(B) Cold PHFs Maintained at or below
3-202.12 Additives* 590,004(F) 41.°/45°F*
3-302.14 Protection from Unapproved Additives* 3-501.16(A) Hot PRFs Maintained at or above
15 Poisonous or Toxic Substances
140°F. *
7-101,11 Identifying Information-Original 3-501,16(A) Roasts Heid at or above 130°F.
Containers*
7-102.11, Common Name-WorkingContainers* 20 Time as a Public Health Control
7-201.11 1 Separation-Storage* 3-501.19 Time as a Public Health Control"
7-202.11 ,Restriction-Presence and Use* - 590.004(H) Variance Requirement
7-202.12 Conditions of Ilse* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Tonic Containers-Prohibitions* POPULATIONS HSP
7-204.11 Sanitizers.Criteria-Chemicals
7-204.12 Chemicals for Washi Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Iuices and
7-204A4 ins Agents.Criteria* .Use of es with Warning Labels*
7-205.11 Incidental Food Contact,Lubricants* 3-801.11(B Use of Pasteurized C Eggs*
7-206.11 -Restricted Use Pesticides,Criteria* 3-801.1!(D} Raw or Partially Cooked Animal Food and
Raw Seed Sprouts Not Served
7-206.12 Rodent Bait Stations* 1-801.5(C)1(C) Unopened Food Package Not Re-served.
7-206.13 Tracking Powders,Pest Control and
Monitod" * CONSUMER ADVISORY
TIMEITEMPERATURE CONTROLS 22 3-60.3.11 Consumer Advisory Posted for Consumption of
16 Proper Cooking Temperatures for Animal Fools That are Raw,Undercooked or
_ PHFs Not Otherwise Processed to Eliminate
3-401.11A(I)(2) Eggs- 155°F 15 Sec. Pathogens.'
Eggs-Immediate Service 145°F15sec* 3-302.1.3 Pasteurized Egg.,Substitute for Raw Shell
3.401.11(A)(2) - Comminuted Fish.Meats&Game E *
Animals-155°F 15 sec. " SPECIAL REQUIREMENTS
3401.11(B)(1)(2) Pork and Beef Roast- 13CPF 121 min* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
3-401.11(A)(2) Ratites,Injected Meats-155°F 15
sec.* catering,mobile food,temporary and
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(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
1450F* 590.009 violations relating to good retail
3-401.12 Raw Anima)Foods Cooked in a practices should be debited under#29-
Microwave 165F* Special Requirements.
3401;11(A)(1)(b) All Other PHFs-145°F 15 sec.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3403AI(A)&(1)) PHFs 165°F 15 sec.* (Items 23-30)
3.403.11(B) Microwave 165°F 2 Minute Standing Critical,and non-critical violations, which do not relate to the
Tithe* foodborne illness interventions and risk factors listed above,can be
3403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR
140°F* 590.000.
3-403.11(E) Remaining Unsliced Portions of Beef Item Good Retail Prwdces i FC 590.E
Roasts* 23.._ Management and Personnel QFC-2 _003 .i
18 Proper Cooling of PHFs 24. Food and Food Protection _ FC-3 .004 i
3-501.14(A) Cootie Cooked PHFs from 140°F to 25. Equipment and Utensils FC-4 .ODS
Cooling 26. Water.Plumbi and Waste FC-5 .006
70°F Within 2 Hours and From 70°F 27. -Physical Facilitys FC-6 .007
to 41°F/45'F Within 4 Hours.* 28. Poisonous or Toxic Materials FG-7 .008
3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .009
Temperature Ingredients to 41°F/45°F 30. 1 Other
Within 4 Hours* "�2
'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
t � z
� y
Massachusetts Department of Public Health Salem Board of Health
DiN'ision of Food and Drugs
120 Washington Street,ie Floor
Salem, MA 01970-3523,
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978)741-1800"Fax(978) 745-0343
Name Dat TVDe of ODeration(s) T f Inspection
O g 1K Food Service Routine
Address f I Risk El Retail Re-inspection
f I{
Telephone _ Level El Residential Kitchen Previous Inspection
_ I a El Mobile Date:
Owner HACCP Y/N ❑ Temporary ❑ Pre-operation
❑ Caterer ❑Suspect Illness
Person in Charge(PIC) Time ❑ Bed 8 Breakfast ❑General Complaint
In: 17
Inspector I Permit No. ❑O heEl CP
Each violation checked requires an explanation on the narrative pages)and a citation of specific provision(s)violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors r 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. d
FOOD PROTECTION MEl:.., 12. Prevention of Contamination from Hands
El1. PIC Assigned/Knowledgeable/Duties
__ _ ❑ 13. Handwash Facilities
[EMPLOYEEHEALTN_ _ __ -- - -- pROTECTIONFROMCHEMICALS ". "_ _
❑ 2. Reporting of Diseases by Food Employee and PIC
❑ 3. Personnel with Infections Restricted/Excluded r_1 14.Approved Food or Color Additives
_..._-_ ❑ 15.Toxic Chemicals
.FOOD FROM APPROVED SOURCE -
❑ 4. Food and Water from Approved Source TiMEtrEMPERATURE CONTROLS(Potentially Hazardous Foo_ds_)
❑ 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
_.__ _-.
El 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR_HIOHLY_SUSCEPTIBLE POPULATIONS_(HSP)'.
El 10. Proper Adequate Handwashing E]21. Food and Food Preparation for HSP
❑ 11. Good Hygienic Practices CONSUMER ADVISORY I -- - ar
❑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 C Health. 590.000/federal Food Code. This report, when signed below
23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an
24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations
25. Equipment and Utensils (Fc-a)(5so.005) cited in this report may result in suspension or revocation of
the food establishment permit and cessation of food
26. Water,Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you
27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION:� �
s:5 InspeclPor 44.tl
I
Inspector's Signature) Q\ Print:
PIC's Signature: - Print: Page]02Pages
-sn
Violations Related to Foodborne Illness
interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION
g Cross-contamination
FOOD PROTECTION MANAGEMENT 3-302-11(A)(0 Raw Animal Foods Separated from
1 590.003(A) Assi nment of Responsibility* Cooked and RTE Foods*
590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients
2-103.11 Person in charge-duties 3-302.11(A)(2) Raw Animal Foods Separated from Each
Other*
EMPLOYEE HEALTH Contamination from the Environment
2 590.003(C) Responsibility of the person in charge to 3-302.1.1(A) Food Protection*
require reporting by food employees and 3-302.15 WashingFruits and Ve�retables
x licants* 3-304.11 Food Contact with Equipment and
590.003(F) Responsibility Of A Fond Employee Or An Utensils*
Applicant To Report To The Person In - Contamination from the Consumer
Charge* 3-306.14(A)(B) Returned Food and.Reservice of Food*
590.(103(3) Re ortin b Person in Charge* Disposition of Adulterated or Contaminated
3 590.003(D) Exclusions and Restrictions* Food
590.003(E) Removal of Exclusions and Restrictions 3-701..11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Food*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Compliance with Food law* 4-501.111 Manual Warewashing-Hot Water
3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures*
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water
3-202.x3 ShellEg s* SanitizationTemperatures*
3-202.14 Eggsand Milk Products,Pasteurizxd* 4-501.114 Chemical Sanitization-temp.,pH;
3-202.16 Ice Made From,Potable Drinking Water* concentration and hardness.
5401.'11 DrinkingWater from an Approved System* 4-601..11(A} Equipment Food Contact Surfaces and
Utensils Clean*
590.006(A) Battledtt=Water* 4-602.1 t Cleaning Frequency of Equipment Food
590.006(B) Water Meets
s Standards in 310 CMR 22.0' �
Shellfish and Fish From an Approved Source Contact Surfaces and Utensils'
4-702 11 Frequency of Sanitization of Utensils and
3-201.14 Fish and Rea eationally C'auglrt Molluscan Food Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and
3-201.15 Molluscan Shellfish from NSSP Listed Chemical*
Sources* 10 Proper,Adequate Handwashing
Game and NJiid,Vlushrooms Approved by
Re ulato Authorlt2301.11 - Clean Condition-Hands and Arms*
3-202.18 Shellstock Identification Present* 2301.12 Cleaning Procedure*
590.004(C) Wild Mushrkwms* 2-301.14 When to Wash*
3-201.1.7 Game Animals* 1l Good Hygienic Practices
5 Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco*
3-202.11 PHFs Received at Proper Temperatures* 2401,12 Discharges From the Eyes,Nose and
3-202.1.5 Package ante it * Mouth*
3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting*
6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands
3-20218 Shellstock Identification* 590.0(A(E) Preventing Contamination from
3-203.12 Shellstock Identification Maintained* - Employees*
TagslRecords:Fish Produc+s 13 Handwash Facilities
3-402.11 Parasite Destruction* Conveniently Located and Accessible
3-402.12 Records,Creation and Retention" 5-203.11 Numbers and Capacities*
590.004(7) Labeling of Ingredients' 5-204.1.1 Location and Placement*
9 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance
fHACCP Plans Supplied with Soap and Hand 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 Nocedurcs* 6-307..1.2 Hand Drying Provision
*Denotes criticid item in the fe4eral 1999 Food Code or 10 CMR 590.000.
CITY OF SALEM
BOARD OF HEALTH
`-Establishment Name: RA — Gil " + -,Date:- o r a Page:_ ofc:;� I
Item Code c-critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Dete-
No. Reference R-Red nem Verified
PRINT CLEARLY // ^4@
G
'�l fir V L
--'• ��
+ T
7
i
/ Q
1 t
St
/ / I J
\
Discussion With Person in Charge: Corrective Action Required: ❑ No Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
violations before the next inspection, to observe all conditions as described, and to / Emersion
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 tv e ty-f' a dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure i
your food permit. ❑ Voluntary Disposal ❑ Other:
iv
t6
T
3-501.14(C) PRFs Received at Temperatures
Violations Related to Foodborne 111ness.Interventions and Risk According to Law Cooled to
Factors{hams 1-22) (Cont.) 41'9/45°F Within 4 Hours.
PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs
14 Food or Color Additives 19 PHF Hot and Cold Holding
3-202.12 Additives*
3-50L16(B) Cold PHFs Maintained at or below
590.004(F) 41°145°F*
3-302-14 Protection from Una roved Additives*
15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above
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* 20 Time as a Public Health Control
7-201.11 Separation-Storage* 3-501.19 Titre as a Public Health Control*
7-202.11 .Restriction-Presence and Use* 590.004H) Variance Requirement
7-202.12 Conditions of Use*
7-203.11 Toxic Containers-Prohibitions* REQUDREMES(NTS FORHIGHLYSUSCEPTIBLE
7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS HSP
7-204.12 Chemicals for WashingProduce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and
7-204.14 Dryine Agents.Criteria' Beverages with Warring Labels*
3-801.11(B) Use of Pasteurized Eggs*
*
7-205.11 Incidental Foal Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and
7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Na Served
7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Packalte Na Re-served.
7-206.13 Tracking Powders,Pest Control and
Monitoring* CONSUMER ADVISORY
TIMEiTEMPERATURE CONTROLS 22 3-60.3.11 Consumer Advisory Posted for Consumption of
16 Animal Foods That are Raw,Undercooked or
Proper Cooking Temperatures for
PHFs r Na Otherwise Processed to Eliminate
3-40i.11A(l)(2) Eggs- 155F 15 See. Pathogens.'
Eggs-lmmediate Service 145'F15,wc* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
3-461.11(A)(2) - Comminuted Fish.Meats&Game
E *
Animals-155°F 15 sec." SPECIAL REQUIREMENTS
3401.11(8)(1)(2) Pork and Beef Roast- 130°F 121 min*
3.401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 540.009(A)-(D)in
sec.* catering,mobile food, temporary and
3-401 A UA)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-165°915 sec. * above if related to foodborne illness
3401.11('C)(3) Whole-muscle,tnmct Beef Steaks interventions and risk factors. Other
145°F* 590.009 violations relating to good retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165°F* Special Requirements.
3-401a11(A)(1)(b) All Other PHFs- 145'F 15 sec.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-003.11(A)&(D) PHFs 165915 sec. * (Items 23-30)
3403.11(B) Microwave- 165°F 2 Minute Standing Critical,and non-critical violations,which do not relate to the
Time* foodborne illness interventions and risk factors listed above, can be
3-403A I(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR
140°F* 590.000.
3403.11(E) Remaining Unsliced Portions of Beef Hem Good Retail Practices FC 590.0m
Roasts* 23. _ Mananement and Personnel FC-2 .003 .i
18 Proper Cooling of PHFs 24. Food and Food Protection FC-3 .004
25. Equipment and Utensils FC-4 .005
3-501.14(A) Cooling Cooked PHFs front 140°9 to 26. Water,Plumbing and WasteFC-5 .006
70°F Within 2 Hours and Front 70'F 27. ical FacilityFC-6 .007
to 41°F/45017 Within 4 Hours. * 26. Poisonous or Toxic Materials + FC-7 .008 i
3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .009
Temperature Ingredients to 41°F/45°F 30• Other -
Within 4 Hours* r.err„ .,azd
*Denoves critical item in the federal 1999 Foci Code a 105 CMR 590.000.
v
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,4'"Floor
Division of Food and Drugs Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343
Name Date Tyoe of Operation(s) Type of Inspection
n nti W -to -i o Food Service Routine
Address 1_' ,u 0 AQ_ Risk Retail H Re-inspection
KaLevel ❑ Residential Kitchen Previous Inspection
Telephone n
❑ Mobile Date:
Ownern HACCP YM El Temporary [3Pro-operation
Y ❑ Caterer ❑Suspect Illness
Person in Charge(PIC) ' Time ❑ Bed&Breakfast ❑General Complaint
ri A-\ e In: ❑ HACCP
Inspector r , Out: Permit No. ❑Other
Each violation checked require"a
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) 590.009A❑
action as determined by the Board of Health.
.FOOD PROTECTION MANAGEMENT ___ ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
�s. ❑ 13. Handwash Facilities
[EMPLOYEEHEALTH
-- - --- PROTECTION FROM CHEMICALS "'"" '•,a t s' ' tia
❑ 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 FRO M_APP-ROVE D SOURCE
❑ 4. Food and Water from Approved Source . TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling
PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding
❑ 8.Separation/Segregation/Protection ❑20.Time As a Public Health Control
- F
El9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR-HIGHLY SUSCEPTIBLE POPULATIONS(HSP),
El 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP
❑ 11. Good Hygienic Practices CONSUMER;.ADV-
III S CRY -� � - � t � "I . . •� g.
❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices Number of Violated Provisions Related
Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22):
of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health.
C N 590.000/federal Food Code. This report, when signed below
23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an
24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations
5. Equipment and Utensils (Fc a)(sso.00s) cited in this report may result in suspension or revocation of
25.
Water, Plumbing and Waste (FC-5)(590.005) the food establishment permit and cessation of food
establishment operations. If aggrieved by this order, you
27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic,Materials (FC-7)(590.008) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION:
SS IrrepecfF0m 14" n
Inspector's Signature: Prin
PIC's Signature: - - i Print: I e Page ofZPrges
• l
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION__
8 Cross-contamination
FOOD PROTECTION MANAGEMENT 3-302.11(A)0) Raw Animal Foods Separated from
1 590.003(A) Assig im} ent of Responsibility* Cooked and RTE Foods*
590.003(6) Demonstration of Knowledge* Contamination from Raw Ingredients
2-103.11. Person in charge--duties 3-302.1.1(A)(2) Raw Animal Foods Separated from Each
Other*
EMPLOYEE HEALTH Contamination from the Environment
2 590.003(C) Responsibility of the person in charge to 3-302.1.1(A) Food Protection*
require reporting by food employees and 3-302.15 WashingFruits and Vegetables
applicants* 3-304.1.1. Food Contact with Equipment and
590.003(F) Responsibility Of A Food Employee Or An Utensils*
Applicant To Report To The Person In Contamination from the Consumer
Charge* 3-306.14(A)(B) Returned Food and Reservice of Food*
590.003(G) Re ortin b Person m Charge*
* DtspostionofAduteratedorContaminated
3 590.003(D) Exclusions and Restrictions-*
Food
590.003(E) Removal of Exclusions and Restrictions 3-701_11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Food* _
4 Food and Wafer From Regulated Sources 1-2- 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 Scaled Container* Sanitization Temperatures*
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water -
3-202.13 Shell Eggs* Sanitization Temperatures*
3-202.14 Eggs and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH,
3-202.16 Ice Made From Potable Drinking*Water* concentration and hardness. s
5-101.11 Drinking Water from an Approved System* 4-001.11(A) Equipment Food Contact Surfaces and
590,006(A) Bottled Drinking Water* Utensils Clean*
590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food-
Shellfish and Fish Froman Approved Source Contact Surfaces and Utensils*
4-702.11 Frequency of Sanitization of Utensils and .
3-201.14 Fish and Recreationally Caught Molluscan F(xxi Contact Surfaces of Equipment*
Shellfish" 4-703.11 Methods of Sanitization-Hot Water and
3-201.15 Molhisc:an Shellfish from NSSP Listed Chemical*
Sources* t0 Proper,Adequate Handwashing
Re MatoAuthorty
Game and Wird onlrooms Approved try 2-;01.11 Clean Condition-Hands and Arms*
3-202.18 Shellstoek Idenrifieation Present's 2-301..12 Cleaning Procedure*
590.004(C) Wiid Mushromns* 2-301.14 When to Wash*
3-201.17 Game Animals* 1t 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 Package Integrity* Mouth*
3-101.11, 'Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting*
6 TagstRecords:Shelistock 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*
Tags/Records:Fish Products 13 Handwash Facilities
3-402.11 Parasite Dcstucdort* Conveniently Located and Accessible
3-402.12 Records,Creation and Retention_* 5-203.11 Numbers and Capacities*
590.004(1) Labeling ofingredients' - 5-204.11 Location and Placement*
q Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance
IHACCP Plans Supplied with Soap and Hand Drying
3-502.11. Specialized Processing Methods* Devices
3-502.12 Reduced ox en packagirij,criteria*
6-301.11 Hardwashing Cleanser, Availability
8-103.12 Conformance wish.'# roved Procedures* 6-301..12 Hand Drying Provision
*Denotes,critical item in the federal 1999 Food Cade or 105 CMR 590.000.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: � o nn Q12rn v ` )rn1,ti Date:_ 6- Page: a. of a
Item Cafe C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date-
NO. Reference R-Red Rem - Verified
PLEASE PRINT CLEARLY
D u -
A o. ii UV/liQ.2'14-",
O
G
`. pp1.. X /V1n n a -"TO �e b rl .r ~ a,�'.,v2 r'
n
-r Qt_plo
01
�� n _ ,�-1i .Pnl
4-
�A ,,-GO
U
Discussion With Person in Charge: Corrective Action Required: ❑ .No Yes
I have read this repoit, have had the opportunity to ask questions and agree to correct all Voluntary Compliance El Employee Restriction/
violations before the next inspection, to observe all conditions as described, and to Exclusion
❑ Re-inspection Scheduled LlEmergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars on suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. ' ��
❑ Voluntary Disposal ❑ Other:
3-501.14(C) PHN Received at Temperatures
Violations Related to Foodborne Illness.Interventions and Risk According to Law Cooled to
Foctors(items 1-22) foont.) 41°F(45'F Within 4 Hours. *
PROTECTION FROM CHEMICALS 3-501.3-501.15 CoolingMethods for PHFs
14 Food or Color Additives 19 CHot and Cold Holding
3-202.12 Additives* 590.004{F)(F) Cold PHFs Maintained at or below
4
3-302.14 Protection from Unapproved Additives* 4i.°145°F*
15 Poisonous or Toxic Substances 3-501.16(A) Hot PRFs Maintained at or above
140°F.*
7-101,11 Identifying information-Original 3-501.16(A) Roasts Held at or above 130°F.
Containers*
7-102.11, Common Name-Working Containers* 20 Time as a Public Health Control
7-201.11 Separation-Storae`
3-501.19 Time as a Public Health Control*
7-202.11 .Restriction-presence and Use* 590.004(H) Variance Requirement
7-202.12 Conditions of Use*
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 3-801.11(A) Unpasteurized Pre-packaged Juices and
7-204.14 Drying Agents.Criteria* Beverages with Warning Labels*
7-205.11 Incidental Food Contact,Lubricants* 3-801.11(B) Use of Pasteurized Eggs*
7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(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 -T801,11(C) I Unopened Food Packa Not Re-served. "
Monitoring* CONSUMER ADVISORY
TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
16 Proper Cooking Temperatures for Animal Feeds That are Raw,Undercooked or
PHFs Na Otherwise Processed to Eliminate
3401AIA(1)(2) Eggs- 155F 15 Sec. Path° ens'*
Eggs-Immediate Service 145°F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
3-401.11(A)(2) Comminuted Fish.Meats&Game
E
Animals-155°F 15 sec.*
3401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 min* SPECIAL REQUIREMENTS
3401.11(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.l l(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
3401.11(0)(3) Whole-muscle,Intact Beef Steaks 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#29-
Microwave 165°F* Special Requirements.
3.401:11(A)(1)(b) All Other PHFs-145°F 15 sec.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-403d1(A)&(1)) PHFs 165-F 15 sec. * (Items 23-30)
3-403.11(B) Microwave-965°F 2 Minme Standing Critical,acrd non-critical violations,which do not relate to the
Time* - foodborne illness interventions and riskfactors listed above, can be
3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR
140°F* 590.000,
3403.11(E) Remaining Unsticed Portions of Beef [ Nem I Good Retail Practices i .FC 590,000
Roasts* - t 23• Management .003 .i
18 Proper Cooling of PHFs 24. Food and Food Protection I FC-3 .004
25. Equipment and Utensils : FC-4 A05 I
3-501.14(A) Cowling Cooked PHFs from 140°F to 26. Water,Plumbing and Waste FC-5 906 1
70°F Within 2 Hours and From 70°F 27. -Physical FacilityFC-6 .007
to 41°F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials QFC-7 .008--I
3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .009
Temperature Ingredients to 41017/45617 30. 1 Other
Within 4 Hours* s:sve:uma..4zex
*Denotes crlficai item in the federal 1999 Food Code or 105 CMR 590.000.
Massachusetts Department�Iof Public Health `Salem Board of Health
I +120 Washington Street,4'" Floor
Division of Food and Drugs n 4 Salem, MA 01970-3523"
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343
NameDae T e of O erasion s Type of Inspection If\
n 4' 3 �1 Food Service U"Routine
Address " ' i k ❑ Retail 11'Re-inspection
Level ❑ Residential Kitchen Previous Inspection
El Mobile Date:r/3
Owner -- HACCP YM El
❑ Pre-operation}
❑ Caterer ❑ Suspect Illness
Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint
in: ,Ja ❑ HACCP
Inspector \ J r "Out: .) Permit No. ❑ Other
Each violation checked r quires an explanation on the narrative page(s) and a citation of specific provision(s)violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco
Violations marked may pose an imminent health hazard.and require immediate`corrective 590.009(E) ❑ 590.009(F) ❑
action as determined by the Board of Health. !/
FOODPROTECTION,MANAGEMENT I t_TL x4,a, € ❑ 12. Prevention of Contamination from Hands
❑ 1 PIC Assigned/Knowledgeable/Duties ❑ 13 Handwash Facilities
s EMPLOYEE HEALTH 7 `t!
��..:.',a,.a,as4 �PROTECTdON FROM CHEMICALS r!, t,'_,,
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
ngFOOD FROMAPPROVEDSOURGE ^" m:�;. --a
❑ 4. Food and Water from Approved Source TIMEfTEMPIeRATURE CONTROLS(RotendalfyHazardoua Foods) m
�_ .. _m���. .�,«. „iz,s. . v,�wnrcx:,. .'�L-�mv+,�s•�.��t_.-&Edi w.. G?r�x.:+s
❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling
f PROTECTION FROM CONTAMINATION ) i A k ❑ 19. Hot and Cold Holding
❑ 8.Separation/Segregation/Protection ❑ 20.Time As a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing �2U�RtMEkTS Food and FOoodiPreparationSC"EPTI for SP POPULATIONS(HS
py
❑ 10. Proper Adequate Handwashing
❑ 11.Good Hygienic Practices
;CONSUMERAOVISO T' _.-,6'r
❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices
Number of Violated Provisions Related
Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22):
of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code.This report, when signed below
by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2)(5s0.0 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.005) the food establishment permit and cessation of food
26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you
27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION:\ \
Inspector's Signature: ! Print:
PIC's Signature:,W; ,
Print: I I F` Page
ofd Pages
✓ ✓ r i/ -
r
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT $ Gross-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 Fcxxis*
03.11 Person in charge-duties Contamination from Raw Ingredients
3-302.11(A)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Other*
2 590.003(C) Responsibility of the person in charge to Contamination from the Environment
require reporting by food employees and 3-302.11(A) Food Protection*
applicants* 3-302.15 ..Washing Fruits and Vegetables
590.003(F) Responsibility Of A Foal Employee Or An 7304.11 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 Reserviee of Food*
3 1 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated
590.003(E) Removal of Exclusions and Restrictions Food
3-701.11 Discarding or Reconditioning IT-701
FOOD FROM APPROVED SOURCE Food*
Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Compliance with Foal.Law* 4-501_111 Manual Warewashing-Hot Water
3-201.1.2 Food in a Hermetically Sealed Container* Sanitization Temperatures*
3-20113 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water
3-202.13 Shell bg s* Sanitization Tem eratures*
3-202.14 E g>s and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp., pH,
3-202.16 Ice Made From Potable Drinking Water" concentration and hardness. '�
5-101.1.1 Drinking Water from an A roved S ,tem* 4-601..1.1(A) Equipment Food Contact Surfaces and
590.006(A) Bottled Drinking Water* Utensils Clean*
590.006(.B) Water Meets Standards in 310 CMR 22.0* 4-6011 t Cleaning Frequency of Equipment Food-
Sheltllsfl and Fish Froman Approved Source
Contact Surfaces and Utensils*
4-702.11. Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan - Food Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and
3-201.15 Molluscan Shellfish from NSSP Listed Chemical*
Sources* 10 Proper,Adequate Handwashing
Game and Wird Mushrooms Approved by
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms*
3-202.18 Shellstock Identification Present* 2-301.12 CleaningProcedure*
590.004(0) Wild Mushrooms* 2-301.14 When to Wash*
3-201.17 Game Animals* ll Good Hygienic Practices
5 Receiving/Condition 2-401.11 Eaun .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 hue it y* Mouth*
3-101.11. Food Safe and Unadulterated
3-301.12 Preventing Contamination When Tasting*
6 Togs/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*
Tags/Records:Fish Products 13 Handwash Facilities
3-402.11 Parasite Destruction* Conveniently Located and Accessible
3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities*
590.004(J) labeling of Ingredients' 5-204.1.1 Location and Placement*
9 Conformance with Approved Procedures 5-205.11 Accessibility, Operation and Maintenance
IHACCP Plans Supplied with Soap and Hand 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* 6-301.12 Hand Drying Provision
"Denotes critical Item in the federal 1999 Food Code or 105 C.MR 590.060- -
CITY OF SALEM j
BOARD OF HEALTH
Establishment Name: awn_A—; � /1.419„/'jvc Date: Page of MZ
Item Code C-Critical Item DESCRIPTION OF VIOLATION!PLAN OF CORRECTION Date
No. Reference R-Red Item ,'. ,Verified
PLEASE PRINT CLEARLY
a�G add _l ue ( ( I
U/1t C. J l ria
Ic'(1,9w - L
d
ff 1
• I - ^l / - J r O /Q
PA
J J def e
�--fs
F �( AAwor
Discussion With Person in Charge: Corrective Action Required: ❑ No 13P�-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
6pncompliance may result in daily fines of twenty'-five,dollars or suspensi
�on/revocation of L) Embargo C1 Emergency Closure
} vyour food permit. ❑ Voluntary U � ✓ c ry Dis P
It— osal ❑ Other:
v
i)1.14(C) PHFs Received at Tem- ratures
Violations Related to Foodborne illness interventions and Risk According to Lain Cooled to
Factors(Rents 1-22) (Cont) _ 41'F/45'F Within 4 Ham's.x _
PROTECTION FROM CHEMICALS3-501.75 Ccxtlim,Methods for PHFs
14 Food or Color Additives 19 PHF Hot and Cold Holding
— — 3:501.I6(B) Cold PHFs Maintained at or below
3 262.12 Addmve," 596.004(F) 41`!45"F" --II
3-302.14 Protection from Uriappro,ed kddibves" 1 t- � -----
15 Poisonous or Toxic Substances ? 5J 1.16 A) I lot I HF Maintained at or above
'- ylnfonnation -Om nal -� - i4C F`
101.11 Identifying b 1 Roasts Held atorabovet36°E'. 'r_
Cantaut r,' � = ----t--
7-101 it Cwnmon A+me N �rEi n t m ti r r," 1 ±-ZO .�- _ i Mme as a Public Health Control -�
-- — °-- ------' - rim.,ac a 1'uhttc;}lc;a7tlt Control'*
')l.I 7a trn Sn,at �� - -- —�
-- - tt.110t , i .alwc 1t ntrrnteat
' 21)2.7 t R„,t ict on Pr ,cncc wd_t_i _...._� ,.- _ . -._. .-.. 1 _- W
7-202.12 (onutmcxr.of L.s., 1
'03 11 Iaxtc a zi finex Prob hr_ot REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
— — — POPULATIONS(HSS— —
204.1i S:mnveu Criattt fhu nc iti -
7 't}t.12 ('luno tk for xT t tut. t ad u2 C nc.t.ae' 1 21 + Sl>1 It 1) liap Leu iced Pre. pac}Aged Suices aid
--- - -- I Rv"ItaffeS With Warning
f.th,.is'
k720414 U n iettcCriltit ILi3 11t ttPatcn.77edkt, __
i5 11 [ Lind nt a) f xxi C c,nr att lathe r i 1 ,' -- - s-- -
-t'---- - —� t 3 Si=1 t�)3 R, r Puts all f riok hAaunal RX'sl and
7E06.11 Rc,lm fed t .e Pr rn tde..Ca tetra I
-�--- - -- -. ---1 fix S d trioti, tie _`turves
r 266.1a RXICI 13 It St.nnn �-- - - --'--a
- _
ted
-- auu -.� ¢ Sil..i 7-u-u Iaca�4 V'21Rr creel. ",_�
r"00 3 1 I racking Po,.dcc P t rk atr + ._ _ _ �._. -.- _.._._
Itonnam
t "
CONSUMER ADVISORY
TltalE(fEi49PERATURE CONTROLS
22 T' = t j msur iat kt sc.v P q I tr t n-utnptiwt of
. 1( -� .- ProperCookirg7empr-rature_.for c io li xtit fh'at e l6 Uadeia. oledo
PHFs
s j '�. i } + Ic'Sw ns utr ie,. Raw Clay l
t+. � � - -”
? ,.nLl2l ,,r t. C n ,;airs e �r vier ev {_>i-aae L_ _
E
r I
JW ------
7 t ( t i t SPECIAL REQUIREMENTS - .--
.t it ani B o Ru
E ct - t 3 I MITI.
74)._ 1ti1} a Gtc?et. .B. t-:9aas )F.).?Atd(1, t));fa j
(hl;_, --- n nit_. tniee et tisc,r. ( r, r i5 y I
'at,xrm nobilr toliLl, t mp_rar. aitd
� _— - --
_ aeStu at tt 4atct#un opa.:ae, s tiFxtkd fie
�
C f t a?C` n irin, 1 isi .b�^n;, :ichiteci ;u der Iltc apprelariate as
V.
ix x «
...- . Ir.. s., e i ail•.�G'-"rt =�Q2:5
i
zs% iact. _ 10 t,-
to if Fr h �8!`itttJ e _.
I
3 1 Rpheanng
Ior Hol lints 0 VIOLATIONS RE)47TV TO GOOD RETAIL PRACTICES
(Ileitis 23-30) .
111GJx m- 1(5 I 'M w 'Smndlnd GI '„'_' N U Ct i wi011e ,ititl 'hd( w; rf- , P
e`tL l if 1 L,n me is It Pttc �,'of rt t t 'd t , t u i r t tc et t ,'hejr )d C )�1C and�f N� ('Sik
40f I 'GO(i
I(11 4e tuvnur;L,c, <eP+x.teai of t3 sa ; Item 1 Good RetatPactices .- FC 630.0
( - .. -1
h4atiap ma I3—,d f' , +;i FG 2 003
18 i Proper Goo3ing of PHFs -- I `_24 r F tix! n l°cab i cote tv^ _ 1 PC s oC" _J
L— — — — °)
u rpmem anciUIP( 9 F; o05
501A I/A} PH12Sf m 14 't -
er.
ocj
vid
zis
} 7
Within 2Hour,„ndfr,m0'l-
- 21 Pay ., FC-6 t,0'_
='F W ti m -i H u td os in>ss cr > "f r,t,3ts % 7 00:
3-501,hN13{ ' re.l;n,PHE Madc Hom A t„rf { L a
1 mt=cater in sad=eut;l .-� flli`F ( ;`/ `-----
i iin-1HwtrS.t
'atIgljt c r ,0=s 42 �i!iClK3 -
Massachusetts Department of Public Health Salem Board of Health 4
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 // ` Dqke Type of Operation(s) Type of Inspection
13 Food Service ®Routine ,
Address Risk ❑ Retail El Re-inspection
I` 4^J (c Level ❑ Residential Kitchen Previous Inspection
Telephone ❑ Mobile Date:
Owner `C 1 HACCP YM El
F_] Pre-operation
��,�-N ❑ Caterer El Suspect Illness
Person in Charge(PIC) Time ❑ Bed&Breakfast ❑General Complaint
In: 1;J) ❑ HACCP
Inspector Out:/. yc Permit No. ❑Other
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provisions) violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco
Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑
action.as determined by the Board of Health.
FOOD PROTECTION MANAGEMENT, MA ❑ 12. Prevention of Contamination from Hands
❑ 1 PIC Assigned/Knowledgeable/Duties
❑ 13 Handwash Facilities
i EMPLOYEE HEALTH PaM ' a �v-z-� „ a, s
f PROTECTION FROM CHEMICALs�M a { �-51..a...mm,.a'w,� �a s. �k
❑ 2. Reporting of Diseases by Food Employee and PIC ten- -r. rs�w
S c J ❑ 14.Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excludedk r ,
�,FOOO FROM APP
1 El 15.Toxic Chemicals
ROVEDSO,C7RCI`,. ,
❑ 4. Food and Water from Approved Source f :?'IMErtEMPERATURE GONTROLs(PotentlaflyHaiardous Foods `� I
E] 5. Receiving/Condition fi= ` s ❑ 16.Cooking Temperatures
j
❑ 6. Tags/Records/Accuracy of Ingredient Statements El 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling
PROtECTION FROMCOMTAMINATION''` ` r ,'r_`W` ❑ 19. Hot and Cold Holding
'AAA J
❑y 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control
IRE❑ 9. Food Contact Surfaces Cleaning and Sanitizing CREDO,
R 2O,11.' od and Qoodl_Preparation t _oTHSP POPULATION!(H§P)'
❑ 10. Proper Adequate Handwashing
El 11. Good Hygienic Practices - .CONSUMEEADVisORYii
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
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)(5so.00a) order of the Board of Health. Failure to correct violations
25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of
the food establishment permit and cessation of food
26. Water,Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you
tPhysical 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,:, 41�
S5HOina fFom 14.Lx IIV(.lw., it _
Inspector's Signature: Print: \ �
PIC's Signature:^ Print: �� I r I Page of7 Pages
v
Violations Related to Foodborne Illness
Interventions and Risk Factors(Items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT S Cross-contamination
1 596.003(A) Assignment of Resporsibillty* 3-30211(A)(I) 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 fngradrents
3-302.11(A)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Other`
2 590.003(C) Responsibility of the person in charge to Contamination from the Environment
require repotting by food employees and 3-302.11(A) Food Protection*
applicants* 3-302.1.5 Washing Fruits and Vegetables
590.003(F) Responsibility Of A Food Employee Or An 3-304.1 I. Food Contact with Equipment and
Applicant To Report To The Person In Utensils*
Charge* - Contamination from the Consumer
5%003(G) Ka orfing b Person in Char c� 3-306.14(A)(B) Returned Food and Resetvicc of Ford*
3 590.003(D) Exclusions and Restrictions* Disposition ofAdulterated orContaminated
590.003(E) Removal of Exclusions and Restrictions Food
3-701.11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCEFood*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Compliance with Food Law* 4-501111 Manual Warewashing-Hot Water
3-201.12 Food in a Hermetically Sealed Container* Smitization'rem eratures*
3-20113 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashina Hot Water
3-202.13 Shell Eggs* Sanitization Temperatures*
3-202.t4 Eggs and Milk Products.Pasteurized* 4-50[.114 Chemical Sanitization-temp.,pH,
3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. *
5-101.11 DrinkinE Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and
LO CMR 22.0"
590.00590.006(A) Bottled Drinkin Water* Utensils Clean*
590.006(B) Water Meets Standards in:3 4-602.11 Cleaning Frequency of Equipment FcxA-
Contact Surfaces and Utensils*
Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of E u] meet*
Shellfish* 4-703.11 Methods of Sanitization-I-lot Water and
3-201.15 Molluscan Shellfish from NSSP Listed Chemical*
Sources*
Game and Wild Mushrooms Approved by 10 Proper,Adequate Handwashing
Regulatory Authority 2-301.11Clean Condition-Hands and Alms"
3-202.18 Shellstock Identification Present* 2-301.1.2 Cleaning Procedure*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201.1.7 Game Animals* 11 Good Hygienic Practices
5 ReceivinglCondition 2-401.11 Eating,Drinking or Using Tobacco*
3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and
3-202.15 Package hate it * Mouth*
3-10L11. Food We and Unadulterated* 3-301.12 Preventing Contamination When Tasting*
6 TagsfRecords:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* 590k04(E) Preventing Contamination from
3-203.12 Shellstock Identification Maintained* - Employees*
Tags/Records: Fish Products 13 Handwash Facilities
3-402.11 Parasite Destruction* - Conveniently Located and Accessible
5-203.11 Numbers and Capacities*
3-402.12 Records,Creation and Retention*
Labeling of Ingredients*
5-204.11 Location and Placemen)"
540.004(1) 9 9 5-205.11 Accessibility.Operation and Maintenance
? Conformance with Approved Procedures
lHACCP Plans Supplied with Soap and Nand Drying
-
3-502.11 -Special Methods* 6301 i i Devices
3-50212 Redued ox gen packaging.criteria* Handwashing Cleanser,Availability
-
&-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drying Provision
°Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000- -
i
CITY OF SALEM
BOARD OF HEALTH
f Establishment Name: J1� �— ��-y - k�, n� � - Date: > k?(04 Page: . of
Item „ Codec C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
fw z rh y.t ss,.F� ,r- si==p rte, Verified
No. Reference 'R`-Red Item` ,ty '� -.; f.G}, sus, =' ?n' pEASE PRINT CLEARLY I"t "�'»'�'
_
-,5U �i »ae (n oro eXnlubsb
l
I r /
cJ. _,l �/ r•I �V--I-� .-r-,v !:�- �.�,� i, s n. �,.,n�-� K�L.o•,/I ..1/I-;N../r
;27� -'94)7
l
r Js C t�ci el rn n�_Df49
i
/L
l
K" .wIJAh -Z
t (CP ,t t , Ac
1
Discussion With Person in Charge: Corrective Action Required: ❑ No Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction /
inspection, to observe all conditions as described, and to Exclusion
violations before the next ins
p 13 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 dolls or suspension/revocation of ❑ Embargo Ll Emergency Closure
your food permit. t`� %
❑ Voluntary Disposal ❑ Other:
lit
S celve at peirature's
Violations Related to Foodborne Illness Interventions and Risk ue Law Coolod to
Factors(items 1-22) (Cont)
-4 1''F/45"F A�Libin 1 Hous,
Con firll,4Feuaxls for PliFs
PROTECTION FROM CHEMICALS
�T----F�dor Color Additives LL9 PHF Hot and Cold Holding
—Ioi ff= Add3-501.16(B) Cold PHI-z; at or tedow
1 3-302,14 Protection front
3--01' �10 Hia PHI� Madnimed at or above
15 Poisonous of Toxic Substances
lfe
7 tol'if rout n" n onnalion vnInn'' —
1 11 1-501.162 A, Roasic Held at or ab,,e 13VI
ConurineW
—
7-3 011 Coronion Name- W orki nkConi,'Liners*& 2=0 -- 1 Time as a Public Heafth Control
C--': --Fin—v,"—�as a�Ilubfw I ll�aith CoTtrol-
7-241.1 J 3 to
art e,
Variarlq�R
-20111 Restriction-
7-202.12 cocafitnlfvof Ulo'
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-20.3.11Tor to CrtntairrloProllibi6oni" POPULATIONS
7-204AT Sannt/,,,,, riterili-Chemic als*
21
7-204.12 Cbellucal�for Warcc,CtitziW' Flf7
='-- Ill iln(24-�' Bc;lrraees' lvith Wattling LaWbs*
20414 _D )iir AEqs..Criteria, L--�—, —
fireidental Food(Arntc7(t,EltmricallW`
I-- — 3 '(d and
[L-n06 I Rcliinod L"Se Pe�tjcideN,Criteria' -801 i I(D) Raw or PalualN Cooked i'mimal Fit
I Raw Sr ed
7-2 06.12 Roilloo Bait Station,' —-----L�21-2-111 I
206.13 1 i-acking 11,m Control and b -1 _Lm"LtLril,-d�
(L r!.n,
-i2—r�- CONSUMER ADVISORY------
TIME)TEMPERATURE CONTROLS 3 t,W I I Con tit ter Aavircc y Posted for Consumption of
Proper Cooking Temperatures for-- AninwF
l lxkls Tbat inc Raw. Uc!to
ndercookt
PHFs Not Other wire Processed to Elitainauc
P h
;_401,11 A(l)(4"' Fgg'- 15,5'F 15 Sec.
—+1,73(21-73 P.iitcurtred Egg';Substituir ba Raw Shelf
lTim.dia�Serviev
Com minutod 'Aelns& Gamic
Animals- 155"F 15 sec.
7101.1 F(B)(1),2) Poik and beef Ritilst - 1301` 121 nuSPECIAL REOUIREMENTS
3-401.11(A)(2) Riqitcs. luliec;ed Wdt� - 155 F IS t IS 590.0f)9(A)-(f Viehitiorls oj Secituil �9(fi��-)(A) (D)in
ser cattering, mobilo Icor' leurportu v clad
3-401.11(.A3(3) Poalrry, Wdd(5ame, Stuffed 111-T[cs, resident-al kitchen operations Should be
Stuffing Containing Fish-Meat, debiled under the appropriate ,echoes
Poultr;s(it*Ran tes-1651' 15 sec. above if related to foodborne illnes;
-3-40i�Hi'C)(3�) Wholle-mugole,bloat Beef Steaks intervuritions and cisk lactors. Otber
145T 590.009 violations relating to rood retail
-71
practices should be debited under #29 401.12� fE,, ',mtn;t1Tot&C�alkcd uta
microwave loS'F Speeird Requirements-
ZJAI(A)(I)(b) All Othei l"IfFs-- 145"F 15 sec.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-403.1](AWD) Plfl7 165'T I scc. (Items 23-30)
3403.11(8) Mac rowaN e- 165'F 2 Nbriwe Sutndin.,, Crit i`rl ulld cora-cribra(oolaiicln'l' which do not lviate to the
Tuce' d K kiac*ori li�tcd above.can bc
h0fla"H
CornmerciZv—P0101ed'TTE—111xi— (nund ill the
jbilawokq seiiionu of the Food Code and 105 CMR
140"F� !-�90'000.
T4;�--T T-,
3-403A VF) Reirarnin,Unshced Pordolls of ficef L ac ces, Jec 590,00
23� i Maly -2 �003
and Petsortnel I FC
Food Proiectior, W4
Proper Cooling of PHFs
---- iZLu�;xnena and Utereaig IPC-
501 WA) Owl]ing Cook�d PRF's from l4WF I �26-------- Water,Pilantluriand %6
10'F Within 2 lfour�and From-`01 2T
to 41 T/45�F Within 4 Houfr. 28, Materials FG -7 1 008
'009
1 14(11) Cooling PRFs Made Front Ambient -s-p2qia�
Temperature lneredi(aas to 41'1745'F
Witlo n 4 Hours*
'Blac Ccs critical jr�m in 1909 Fort Coje or 105 CNIR 590 000,
E'
• V-41
• • • •
OPEN, 1 \ • I
/ � �.� 1. � �.��� �• �
L • 1 �� � � � � � ILL.•
I
• ♦ r. �r I �
�IM, • .a ' ►�
M ► . .
141PIRIMIll", Mill
. . �!
�, ► . , s "'o,0ri .: rLlwo Is AT r �
-
0232 Highland Avenue Dunkin Donuts/Michael Donuts
City of Salem
FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection
HACCP: ❑
Item Status Violation Critical Urgency
Telephone: PROTECTION FROM CONTAMINATION
978-745-6110 Food Contact Surfaces Cleaning and Sanitizing FAIL Critical RED
Owner: Comment:All ice scoops to be stored in ice handle side out.
Cladio Santo Violations Related to Good Retail Practices (Blue Items)
PIC:
Equipment and Utensils FAIL Non-Critical BLUE
Taina Curtis
Inspector Comment: Baxter oven needs general cleaning.
Elizabeth Salandrea Tempguard freezer needs general cleaning.
Date Inspected:Correct By:
1/30/2008
Risk Level:
,Permit Number:
BHP-2008-0191
Status:
SIGNED OFF
#of Critical Violations:
1
Time IN: Time OUT:
Urgency Description(s):
BLUE:
Violations Related to Good
Retail Practices (Critical
violations must be corrected
immediately or within 10
days)(Non-critical violations
must be corrected immediately
or within 90 days)
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 30,2008 ) Page ! of
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®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 30,2008 ) Page 2 of2
0232 Highland Avenue Dunkin Donuts 232
City of Salem
FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection
HACCP: ❑
Item Status Violation Critical Urgency
Telephone: PROTECTION FROM CONTAMINATION
978-745-6110 Good Hygienic Practices FAIL Critical ❑J RED
Owner: Comment: Employee drinks observed in food prep area. Employees must eat and drink in a designated employee area to prevent
Clad'lo Santo cross contamination.
PIC:
Ysairis Capellan
Inspector:
David Greenbaum
Date Inspected:Correct By:
6/18/2007
Risk Level:
.Permit Number:
BHP-2007-0270
Status:
SIGNED OFF
#of Critical Violations:
1
Time IN: Time OUT: j
Urgency Description(s):
BLUE:
Violations Related to Good
Retail Practices (Critical
violations must be corrected
immediately or within 10
days)(Non-critical violations
must be corrected immediately
or within 90 days)
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 18,2007 ) Page I oft
Item Status Violation Critical Urgency
RED:
Violations Related to
Foodborne Illness Interventions
and Risk Factors (Require
immediate corrective action)
GJ
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 18,2007 ) Page 2 of
0232 Highland Avenue Dunkin Donuts
City of Salem
FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection
HACCP: ❑
Item Status Violation Critical Urgency
Telephone: Violations Related to Good Retail Practices (Blue Items)
978-745-6110 Equipment and Utensils FAIL Non-Critical BLUE
Owner: j Comment:The Baxter oven needs a general cleaning
Cladio Santo
PIC: The microwave unit#2 needs a general cleaning.
Ysairis Capellan GENERAL COMMENTS:
Inspector: 1013:
David Greenbaum
Date Inspected:Correct By:
11/22/2006
Risk Level:
Permit Number:
BHP-2006-0322
Status:
SIGNED OFF
#of Critical Violations:
0
Time IN: Time OUT:
Urgency Description(s):
BLUE:
Violations Related to Good
Retail Practices (Critical
violations must be corrected
immediately or within 10
days)(Non-critical violations
must be corrected immediately
or within 90 days)
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 22,2006 ) Page I oft
Item Status Violation Critical Urgency
RED:
Violations Related to
Foodborne Illness Interventions
and Risk Factors (Require
immediate corrective action)
P05�A
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 22,2006 ) Page 2 oft
a
A w
-._. .. .... 5,.+.r,..+r . .aa re;4n4ar�' +F.a-u.+.#...-"sw�Wfvaa.tr... ..o.., .xa.,...3'�,^:-i �F sih,'.'P� r4 �``w•L"'F +`-r�`"H �F
CITY OF SALEM9 MASSACHUSETTS
BOARD OF HEALTH
120.WASHINGTON STREET, 4TH FLOOR
a SALEM, MA 01970
- TEL. 978-741.1800
FAX 978.745-0343
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO -
MAYOR HEALTH AGENT
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter 94,
Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food
Establishment in the City of Salem is hereby granted to:
Type of Establishment: FOOD SERVICE
Name of Establishment: Dunkin Donuts - Michael Donuts
Address of Establishment: 232 Highland Avenue
Owner's Name: Claudio Santos
Restrictions:
Application Date: 12/22/05
Permit for Food Establishment 144-06
Frozen Desserts/Ice Cream
Permit for the Sale of Tobacco Products
These Permits Expire December 31, 2006
This permit is not transferable and must be reissued upon change of
ownership or location. The permit must be posted in a prominent location
in the Establishment,
In accordance with the State Sanitary Code, before any renovations,
improvements, or equipment changes are made, all plans for such must be
submitted to and approved by the Salem Board of Health.
HEALTH AGENT
e CITY OF SALEM, MASSACHUSETTS
„ BOARD OF HEALTH !lIJJJ
J 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970 QFC V
FAX 978-741-0343 e0q �� OIIoof
STANLEY J.MAYOOVICZ, JR. y WW.SALEM.COM 1%op
v
MAYOR JOANNE SCOTT, MPH, RS, CHO Fy�Filj
HEALTH AGENT
2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT 7
NAME OF ESTABLISHMENT iY-�� e D/J TEL# g J:6—
ADDRESS OF ESTABLISHMENT��� `lQ/��
MAILING ADDRESS (if different)
OWNER'S NAME_424aZ&1-11A,P6 j'� c�� 2� TEL# q
ADDRESS
CITYS STATE S S ZIP—_4
CERTIFIED F AGE 'S NAME(S) n� ,ja n i^ � CERTIFICATE#(s) 9,5 z
(required in an establishment where potentially hazardous food is prepared.)
EMERGENCY RESPONSE PERSON / 4!0 a HOME k-WTEL# �—(p
HOURS OF OPERATION: MonTue�Wed1_A_aThu.L,�{_, Fri.�QSat. Sun.�A
TYPE OF ESTABLISHMENT FEE (check only)
RETAIL STORE YES NO less than 1000sq.ft. =$ 50
1000-10,000sq.ft. =$100
more than 10,000sq.ft. =$250
---------------------------------------------------------- ........................
RESTAURANT YES NO ' n I / less than 25 seats 10
J Y L�'�� 25-99 seats =$150
( more than 99 seats =$200
- -------------------------------------------------------------------------------$- -10- -----.......-----
BED/BREAKFAST YES O 0
ADDITIONAL PERMITS
----------------------------------------------------------------------------------------------------------------------------
MAKE (not just serve) ICE CREAN't, YOGURT, SOFT SERVE YES " $5
TOBACCO VENDOR YES ; $50
ALL NON-PROFIT(such as church kitchens) YES $25
*Please pay total with one check payable to the City of Salem .
This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted
in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes
are made, all plans for such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best
Lnled and belief, have filed I state tax returns and aid all state taxes required under the law. /
3IJ S— `— — I
Signature Date Social Security or ederal Identifi-Cation Number
-------------------------------------------------------------- + � --------------- -------------
Revised 11/03/05 FOODAP2.adm Check#&Date �j? -a)- O
L
0232 Highland Avenue Dunkin Donuts, Michael Donuts LLC
City of Salem
FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection
HACCP: ❑
Telephone: Item Status Violation Critical Urgency Nature of problem or correction
978-745-6110 ., „, Non-compliance with: Not Done
Owner: Anti-Choking PASS ❑
Michael Donuts LLC Tobacco PASS ❑
PIC
YSairis Capetian FOOD PROTECTION MANAGEMENT Not Done
Inspector: PIC Assigned/Knowledgeable/Duties FAIL Critical ❑� RED There is no knowledgeable Person In
P _ �` i Charge assigned. A knowledgeable PIC
David Greenbaum must be designated in the abscence of the
Date Inspected: Correct By: Certified Food Manager.
EMPLOYEE HEALTH Not Done
9/14/2005 Reporting of Diseases by Food Employee and PIC PASS RED
Risk Level:'
Personnel with Infections Restricted/Excluded PASSd❑ RED
Permit Number: s X FOOD FROM APPROVED SOURCE Not Done
BHP-2005-0278 Food and Water from Approved Source PASS RED
Status: .,+ 0 17 " 45 SIGNED OFF ' Receiving/Condition PASS RED
#,of Critical Violations',. Tags/Records/Accuracy of Ingredient Statements PASS RED
2 Conformance with Approved Procedures/HACCP PASS ❑d RED
.Time IN ,-, Time OUT. Plans -
Notes
295 h
Urgency Description(s): .
BLUE a=
Violations Related to Good
Retail Practices (Critical
violations must be corrected'
immediately or within 10
days)(Non-critical violations`
GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 15,2005 ) Paee I of
0232 Highland Avenue Dunkin Donuts, Michael Donuts LLC
must be corrected immediately PROTECTION FROM CONTAMINATION Not Done
or within 90 days) Separation/Segregation/Protection PASS RED
RED
Violations Related to
Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑d RED The cutting board is stained and scored.
ce
Foodborne TheResice Illness Interventions mor replace the cutting board.
The ice machine ice scoop had some
and Risk Factors(Require - grime around the handle. Clean the ice
.Immediate corrective action) scoop on a regular basis.
The ice dispenser on the left side of the
store had no ice scoop. Provide a
sanitized ice scoop handle side up in the
ice dispenser.
Proper Adequate Handwashing PASS ❑Q RED
Good Hygienic Practices PASS ❑d RED
Prevention of Contamination from Hands PASSd❑ RED
Handwash Facilities PASS RED
PROTECTION FROM CHEMICALS Not Done
Approved Food or Color Additives PASSd❑ RED
Toxic Chemicals PASS ❑d RED
TIME/TEMPERATURE CONTROLS(Potentially Haz Not Done
Cooking Temperatures PASS RED
Reheating PASS ❑Q RED
Cooling PASS ❑Q RED
Hot and Cold Holding PASS Q RED
Time As a Public Health Control PASS Q RED
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done
Food and Food Preparation for HSP PASS Q RED
CONSUMER ADVISORY Not Done
Posting of Consumer Advisories N/A Q RED
GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 15,2005 ) Page 2 of
.F
0232 Highland Avenue Dunkin Donuts, Michael Donuts LLC
Violations Related to Good Retail Practices (Blue Not Done
Management and Personnel PASS ❑ BLUE
Food and Food Protection PASS ❑ BLUE
Equipment and Utensils FAIL Critical ❑ BLUE The Delfield drawer unit#2 missing a
thermometer. Provide a visible,accurate
thermometer in this unit.
There are no test strips to check the
concentration of the sanitizing solution.
Provide the proper test strips at all times.
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
GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 15,2005 ) Page 3 of
m A N`� � I���3 K I,, x�yg'�rd�' F ys✓fa�.Y �al �'t�A =: ?' ".nM^ !YS �'°'K�
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CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH !,'4 `
120 WASHINGTON STREET 4T11 FLOOR , ra
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745.0343
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter 94,
Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food
Establishment in the City of Salem is hereby granted to:
Type of Establishment: FOOD SERVICE
Name of Establishment: Dunkin Donuts
Address of Establishment: 232 Highland Avenue
Owner's Name: Claudio Santos
Restrictions:
Application Date: 12/6/2004
Permit for Food Establishment 176-05
Frozen Desserts/Ice Cream
Permit for the Sale of Tobacco Products
These Permits Expire December 31, 2005
This permit is not transferable and must be reissued upon change of
ownership or location. The permit must be posted in a prominent location
in the Establishment,
In accordance with the State Sanitary Code, before any renovations,
improvements, or equipment changes are made, all plans for such must be
submitted to and approved by the Salem Board of Health.
HEALTH AGENT
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
' 120 WASHINGTON STREET, 4TH FLOOR
q SALEM, MA 01970
.� TEL. 978-741-1800
FAX 978-745-0343
STANLEY J. UISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT h ti n1 Ic t w n to t,T S TEL#
ADDRESS OF ESTABLISHMENT P36? K1.14 JE!
MAILING ADDRESS (if different) ' g A LR 14 P"-.4 &-S r) I* 7U'
OWNER'S NAME ZcCAQ t6t 6 SA-n,i h S TEL# � 79- 24t -0
ADDRESS_-� _ '�?6 p f��5x FoeL� rn-.r�S4
CITY STATE ZIP p 190? ;
CERTIFIED FOOD MANAGER'S NAME(S) N R/,/ i& g2 CERTIFICATE#(s) , T°-7 9-
(required in an establishment where potentially hazardous food is prepared.)
EMERGENCY RESPONSE PERSON, CL 1u ro S,Aw TOS HOME TEL# C1Jk- 76G_aA50
h top"
HOURS OF OPERATION: Mon. (oTue.6 Atop Wed.6tNoPThu.6A/he Fri.(441 rsat.6R IDP Sun6,4/6
TYPE OF ESTABLISHMENT FEE check only
RETAIL STORE YES NO less than 1000sq.ft. =$ 50
1000-10,000sq.ft. =$100
more than 10,000sq.ft. =$250
RESTAURANT YES NO 710/�� less than 25 seats -$100
25-99 seats =$150
more than 99 seats =$200
BED/BREAKFAST YES NO $100
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5
TOBACCO VENDOR YES NO $50
ALL NON-PROFIT(such as church kitchens) YES NO $25
Please pay total with one check
payable to the City of Salem
This Permit is not transferable and must be reissued upon change of ownership. The Permit must
be posted in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment
changes are made, all plans for such must be submitted to and approved by the Salem Board of
Health.
Pursuant to MGL Chapter 6Naliled
ction 49A, I certify under the pains and penalties of perjury that I, to my
best ledge d bell , all state tax returns and paid all state taxes required under the law.
�< R 11-14-04 35 � �� U
Signature Date Social Security or Federal Identficatl n Number
------------------------------------------------------------- ----------------,-r -------------------------------
Revised 11/03/03 FOODAP2.adm Check#&Date �w/79
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Massachusetts Departmen# of Public Health Salem Board of Health
120 Washington Street,0 Floor
Division of Food and Drugs Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343
Name Date T e of Operation(s T e of inspection
Oe.Jd�f 4-Lc, /fr/NrCtN deN�IJ df Food Service outi
Address 2-32 16&fe
t ' Risk ❑ Retail ❑ Re-inspection
TelephoneLevel EI Residential Kitchen Previous Inspection
74/,(,-sw^ / ❑ Mobile Date:
Owner HACCP Y/N El Temporary ElPro-operation
CL �V r D j El El Suspect Illness
Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint
Inspectorn 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. revention of Contamination from Hands
E] 1. PIC Assigned/Knowledgeable/Duties
EMPLOYEE HEALTH
• 13. Handwash Facilities
.
PROTECTION FROM CHEMICALS
❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded
❑ 15. Toxic Chemicals
,. FOOD FROM APPROVED SOURCE
❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
[1 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)
10. Proper Adequate Handwashing E] 21. 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
ofC Health. 590.000/federal Food Code. This report, when signed below
23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an
4. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations
25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of
26. Water, Plumbing and Waste (FC-5)(550.005) the food establishment permit and cessation of food
establishment operations. If aggrieved by this order, you
27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address
PF129. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION:
S:5Mns ctFo.m 14.dx
Inspector's Signature: Print: [�ISh L��.�
PIC's Signature: /, , Print: .t'�I SG, ��� Page�of�Pages
r
Violations Related to Foodborne Illness
Interventions and Risk Factors(Items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT FS Cross-contamination
I 590003(A) Assignment of Responsibility* 3-302.1](A)(1) haw Animal Foods Separated from
X90 003(B) Demonstration of Knowledge* Cook d and RIF Foods*
2-103.11 Person in charge-duties Contamination from Raw Ingredients
3-30111(A)(2) Raw Animal Fogs 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 3-3011.1(A) Food Protection*
a)phcants* 3-302.15 Washing Fruit.and Veg-eribles
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*
Charne* Contamination from the Consumer
590,003((") Re acting-by Personrn Chir e* 3-306.14(A)(B) Returned Food and Reservice of Faxl*
3 -)90 001(f)) Exclusions and Restrictions* Disposition ofAdulterated or Contaminated
590.003(F..) Removal of Exclusions and Restrictions Food
3-701..11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCEFood*
4 Food and Water From Regulated Sources F 9 Food Contact Surfaces
590.004(A-B) Cam tliance with Food Law* 4-a01.111. Manual Warewashing-Hot Water
3-20L 12 Food in a Hermetically Scaled Container" Sanitization'temperatures*
" 4-501.112 Mechanical H
4 201.1.3 Fluid d Whi
Milk and Milk Products"` g- ot Water
-
3-20213 Shell E -s'" Sanitization Teraerat❑res*
3-202.14 Eggs and Milk Products.Pasteurize& 4-501.114 Chemical Sanitization-temp.,pH,
3-202.16 Ice Made from Potable Drinking,Water*
concentration and hardness
5-101.1 I Drinking Water from an A raved Svstem`" 4-601.11(A) Equipment Food Contact Surfaces and
Utensils Ciean,�
590.006(A) Bottled Drinking Water"
590.006(11) Waua Meets Standards in 31.0 CMR 21(vt 4-6U_.11 Cleaning Frequency of Equipment Fnod-
Contact Surfaces a,rd Utensils-
Shelf/ash and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment'
Shellfish* 4-703.11 Methods of Sanitization--Hot Water and
-T-20-115 Molluscan Shellfish from NSSP Listed Chemical-
sources" 10 Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Re [dato Anthori 2-301.11 Clean Condition-Hands and Arens*
3-202.LS Shellstock Identification Present* 2-301.12 Cleaning-Procedure*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201.17 Game Animals" LLI Good Hygienic Practices
5 Receiving/Condition 2-401.11 _ Eating-, Drinking or Using Tobacco*
3-202.11. PHF's Received at Pro ger Temperatures* 2-401.12 Discharges From the Eyes,Nose and
3-20215 Package Integrity* 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
-T-2021 8 Shellstock Identification* 590.004(E) Preventing*Contamination from
3-203.12 Shellstock Identification Maintained* Em to gees*
Tags/Records: Fish Products I3 Handwash Facilities
3-402.17. Parasite Destruction* Conveniently Located and Accessibio
3402.12 Records.Creation and Retention* 2031.1 Numbers and Ca asides*
59U04(J) Labeling of Ingredients' 5-204.11 Location and Placement*
7 Conformance with Approved Procedures 5-20511 Accessibility,Operation and Maintenance
/HACCP Plans Supplied with Soap and Nand Drying
3-502.1( S ecializedProcessin>Methuds* - Devices
3-50212 Reduced oxygen tackag ng,criteria* 6-301.11 llandwxshing C(eanaer.Availahilit
8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drvio>Prosdsion
'"Denole$critical item in[he federal 1999 Food Code or 105 CNI72 590.000.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: 1016%lsL 0er..Ur r 44-c. Aywwid sm' i r Date: / 6 Page: of 2
Item bode C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R—Red Item - - Verified
PLEASE PRINT CLEARLY
U y .0 a� d y Fxuer,09, 144 r /c peew v1d
A cG JS a .Et ffS'�¢ vfJ�
7 S rBlNi nytawa#a a ArAlt rA-e4t(`7Affk lbws,OA/ PAo/U1- •/V
A#psr , i r err! .o-. 67AIC w""
929!:C
PKo c� c�•� �v GrV rt� n / t f 6 'tai✓
t tvs U e r"Gv rWx e.01 l:
I ' L r _ �Sbi+6
J
a•
rff oa 6'
4,10vire"444 AA
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 Ll Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars ,or suu'sppension/revocation of LI Embargo ❑ Emergency Closure
t� your food permit. ��V ` �X
❑ Voluntary Disposal ❑ Other:
y
r
f
-,-501,14(C) PRFs Received at Temperatures
Violations Related to Foodborne Illness interventions and Risk According to Iaw Cooled to
Factors(items 1.22) (Cont.) 4I'F/45'F Within 4 Hours.
PROTECTION FROM CHEMICALS 3-501.15 Coolin_Methods for PHFs
14 u Fond or Color Additives 19 PHF Hot and Cold Holding
3-202J2 Add fives'" 3-501.16(8) Cold PHFs Maintained at or below
590.004(F) 41V45°F`
3-302.14 Protection from Unapproved Additives" 3.50116(A) Hot PHFs Maintained at or above
15 Poisonous or Toxic Substances
40°F. *
7-IOi.11 Identifyingl'nfonnation-C)rig-ittat 3-501.1:6(A) Roasts Held at or above 130°P. *
Containers*
7-102.11 Common Name-Working Containers" 2g Time as a Public Health Control
7-201.11 3e.auation-Stonnae"` 3-501.19 Time as a Public Health Control*
7-202.11 Restriction-Presence and Use"
590.004(H) Variance Requirement
7-202.12 Conditions of Use*
7-203.1.1 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11 Sanitizeas,Criteria-Chemicals* POPULATIONS(HSP)
7-204.1.2 Chemicals for Washinz Produce,Giteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and
7-204.14 D •in t cuts.Criteria*
Beverages with Warning Labels*
--7--205 11 Incidental Food Contact. Lubricants* 3-801,11(B) Use of Pasteurized
3-801.11(D) Raw or Partially Cooked Animal Faxl and
7-206.1 1 Restricted ilSt Pesticides. Criteria* Raw Seed Smuts Not Served.
7-2G6J2 Rodent Bait SCations*
Una cued Food Packa re Not Re-served.
7-2G6.13 `Freaking Powders,Pest Control and 3-801.11(C)
Mmil[orin�*
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
't-40'LIIAll)(2) Eggs- 155F 15 Sec.
E cs-Innnedtate Service 145°F]Ssec' 3-302.13 Pasteurized Eggs Substitute for Raw Shell
3-401.11(AA)(2) Comminuted Fish,Meats&Game g ,sir
Animals- 155'F 15 sec.
3-401.t I(B)(1)(2) Pork.and Beef'Roast- 130"F 121 min* SPECIAL REQUIREMENTS
3-401.11(A)(2) Ratites, Injected Mcats- 155'F 1.5 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
sec. * catering,mobile food,temporary and
3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residentiat'kitchen operations should be
Stuffing Containing Fish,Meat, debited ander the appropriate sections
Poulir or Ratites-165°F 15 sec. * above if related to foodborne illness
3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and tisk 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-
Micmwave 165"F* Special Requirements.
3401-1l(A)(1)(b) All Other PHFs'- 145'515see.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-403.1 I(A)&(I)) PHFs 165'F 15 sec. * (Items 23-30)
3403.11(B) Microwave-165'F 2 Minute Standing Critical and non-critical violations, which do not relate to the
Time* foodborne illness interventions and risk factors lusted above. can be
3-403.11(C) Corumercially Processed R'PE Food- ,fund in the following,sections of the Food Code and 105 CMR
1400F* 590.000.
3-403.1I(E) Remaining Unsliced Portions of Beef ' Item Good Retail Practices FC 590.0007
Roasts* 23. Mena anent and Personnel_ FC --2 .003
1g Proper Cooling of PHFs 24._ Food and Food Protection_ FC--3 .004
3-501.14(A) Cooling Cooked PHFs from 140`P to 25 Epwpment and Utonslls FC 4 005
26 Water Plumbingand Waste FC 5 1 .006
70'F Within 2 Hours and From 70"F 27. Physic Facility 6 1 007
to 41.'F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 1 .008
3-501.14(13) Cooling PHFs Made From Ambient -29. S genal 1?e uiremenis -- 1 .009
Temperature Ingredients to 41'F/45°F 30, Other
Within 4 Hours:x ssvo[o,m�xrtam,
'*Denotes critical iters in the federal 1999 Food Code or 105 CMR 596.000.
+r
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
_ 120 WASHINGTON STREET, 4TH FLOOR
c SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter 94,
Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food
Establishment in the City of Salem is hereby granted to:
Type of Establishment: FOOD SERVICE
Name of Establishment: Michael Donuts LLC
Address of Establishment: 232 Highland Avenue
Owner's Name: Claudio Santos
Restrictions:
Application Date: 6/15/2004
Permit for Food Establishment 310-04
Frozen Desserts/Ice Cream
Permit for the Sale of Tobacco Products
These Permits Expire December 31, 2004
This permit is not transferable and must be reissued upon change of
ownership or location. The permit must be posted in a prominent location
in the Establishment,
In accordance with the State Sanitary Code, before any renovations,
improvements, or equipment changes are made, all plans for such must be
submitted to and approved by the Salem Board of Health.
HEALTH AGENT
ca CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
'+ a • 120 WASHINGTON STREET; 4TH FLOOR
a R SALEM, MA 01970
TEL. 978-741-1800
�pry� FAX 978-745-0343
STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
2004 APPLICATION �F�O"R PERMIT TO OPERATE A FOOD ESTABLISHMENT /
NAME OF ESTABLISHMENT ////%l POW I/JS Z—Ze—TEL# �A?—
ADDRESS OF ESTABLISHMENT 2d W/6e
MAILING ADDRESS (ifdifferent)
OWNER'S NAME ( ' lAa.4 l�j) -TEL#
ADDRESS C G(
CITY x4rzv STATE ZIP
CERTIFIED OD MANAGER'S NAME(S) CERTIFICATE#(s)
(required in an establishment where potentially hazardous food is prepared.)
EMERGENCY RESPONSE PER//SON ��)) HO/ME TEL# Cyd'-S6Z
HOURS OF OPERATION: Mon t9 1 Tue. Wed.�Thul?—I'D Fri. 63at. o Sun. ��
TYPE OF ESTABLISHMENT FEE check only
RETAIL STORE YES NO less than 1000sq.ft. =$50
1000-10,000sq.ft. =$100
(3/6 ,0 more than 10,000sq.ft. =$250
RESTAURANT YES NO less than 25 seats 63�
25-99 seats =$150
more than 99 seats =$200
BED/BREAKFAST YES NO $100
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5
TOBACCO VENDOR YES $50
ALL NON-PROFIT(such as church kitchens) YES $25
Please pay total with one check
payable to the City of Salem
This Permit is not transferable and must be reissued upon change of ownership. The Permit must
be posted in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements,or equipment
changes are made, all plans for such must be submitted to and approved by the Salem Board of
Health.
Pursuant to Chapter 62C, S 49A, I certify under the pains and penalties of perjury that I, to my
best kn and b f, hav ile II state tax returns and paid all state taxes required under the law.
Signature Date Social Security or Federal Identificati n Number
------------------------------------------------------------ - - ------��---J ---
Revised 11/03/03 FOODAP2.adm Check#&Date / Ro-F — �_��,0 fTi
M
Mike Plante
Oirectm of Operegom `
l:a/ua Manegemwd Co.
99 Winthrop Ave, DUNNi a
Lawrence,MA LDON N"
01843
Mobil: (978)265-8502 ®�
Fa X: (781)723-8032
E-Mail:
mike.plante®oomomt.net
✓
aCITE' OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
STANLEY LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT YY) J of h AAFZ n ON yy TS ' I EL#
ADDRESS OF ESTABLISHMENT nO2 �C B- b/f.J N 14 't- D
O'
MAILING ADDRESS (if different) 4 R 14 /�Al«awp Y P' .S A L€W m MAr�s
V
OWNER'S NAME t L° C AQ o t 0 S/1 hlT6 S TEL#
ADDRESS e013 LAwetpwcO j2[7Clof
CITY aX Fn et� STATE YYl FI SS ZIP
CERTIFIED FOOD MANAGER'S NAME(S) S CERTIFICATE#(s) �S�SS3g
�^o-4 K_ Iwo
(required in an establishment where potentially hazardo s food is prepared.) 7f
EMERGENCY RESPONSE PERSON L'L P0,11) ON S /q vv 7-1$'-57-1$'-5HOME TEL# `97 Z -
HOURS OF OPERATION: Mon.—Tue.—Wed.—Thu.—Fri.—Sat.—Sun.
TYPE OF ESTABLISHMENT FEE check only
RETAIL STORE YES NO less than 1000sq.ft. =$ 50
1000-10,000sq.ft. =$100
more than 10,000sq.ft. =$250
RESTAURANT )4W NO less than 25 seats 100
25-99 seats 0
more than 99 seats =$200
BED/BREAKFAST YES NO $100
ADDITIONAL PERMITS
MAKE 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 kin I ge an belief, v filed all state tax returns and paid all state taxes required under the law.
!� -/�' o� a3o ,;.required
Signature Date , Social Security or Federal Identification Number
------------------------------------
Revised 11/25/02 FOODAP2.adm Check#&Date
Holly D. Zhang
American Account Manager
Red Cross 285 Columbus Avenue
Boston,Massachusetts 02116
of Massachusetts Bay (617)375-0700 phone x 374
(617) 375-0727 fax
ZhangH@usa.redcross.org
October 17, 2002
Ms. Joanne Scott
Town of Salem
Board of Health
Re: Restaurant/Food Service Training and Certification
M.G.L. Chapter 94: Section 305D
Dear Joanne:
It was a pleasure to speak with you today about the Chokesaver with Restaurant Emergencies course. The
following is a brief summary of the skills that Restaurant and Food Establishment employees will learn in just
two hours:
1. Recognizing an Emergency
2. Emergency Action Steps; Check, Call, Care.
3. Protecting Yourself
• Good Samaritan Laws
• Obtaining consent
• Preventing disease transmission
• Demonstrate Glove Removal
4. Before Providing Care
5. Prioritizing Care
• Demonstrate conscious choking skills (Adult,Child&Infant)
• Have students practice abdominal thrusts.
• Demonstrate unconscious choking skills (Adult, Child& Infant)
6. Wounds
• Controlling severe bleeding
• Care for Burns
Course Materials: 2 Adult Choking Posters(One side English,the other in Spanish).Each participant receives
a`Til Help Arrives Booklet and a wallet card"Emergency action steps to save a life".
Course Cost: $240.00 flat fee for a maximum of 20 employees. It is$7.00 per person over the maximum.
Certificate:A"Chokesaver"certificate(wallet size)will be sent approximately 10 days after course completion
expiration date.
it does not have an ex
and p
For the M.G.L Chapter 94: Section 305D go to http://www.state.ma.us/legis/laws/mgl/index.htm then
click on"Link to a specific Chapter or Section"then fill in the Chapter and or section number.
Please call me with any questions you may have or to schedule a class for a"best time"in January or February.
Thank you for your interest!
Best regards,
g ,
United QWay Visit us at www.bostonredcross.org
k;�.•s�.A ) '.'•r' a�S ,xx' " 4.y., rysyr � .. � ef t r 4 ct m'n+'>v r r t , t ,.e,l
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`.._ A v __` rr}4C ri rJ''b? Sv? ✓ t ✓ ,CPR;;&
First'.
Training •z,as ., ;- t ,
FP. Bog'3002
Salem,MA.01970 ''
978-744;.479,9 '
www.whe nsecondscouuf;net
ATTENTION
Did you know that the State of Massachusetts.Code for Food Establishments, Chapter X, 105
CMR 590 009(E)states "each food.establishment having a seating•capacity of 25 persons or
snore shall
(t) Have on sts premises while food is being served, an employee trained in manual
procedures approved bythe Department of Public Health to remove food`lodged in a
' person's throat;and
{2) Make adequate-provissonfor insurance to cover employees trained in rendering such
assistance
-s
Are:you`prepared to comply with the code?
When Seconds Count a CPR&Fust Aid Training Company is working with the City of Salem
Board of Health;to provide;you and your employees with the;trai*g necessary to fulfill the
requirements ofthe state code Weave developed a course specificallyfor restaurant employees
that will train them to effectively be�abte to perform the`Heimlich Maneuver and'other necessary
-
procedures 6o removezfood.lodged`in a person's throat:''
We are offering fhis class on Monday,December 2 2002 from 6:00 pan.until?_30 p.m.,
Wednesday,December 4,2002 from 9 00 a.m.until 10;30.a m.,`Monday,December 9,2002
from 6;00 p m':i ntit 7:3Q p.m andi*ednesday,December t 1,2002 from2 00 P.m.uritrl
3.30 pan. All classes'will be.held at.the Enterprise Centerat Salem State College, 121 Loring
Avenue; Salem. Pre-registration is required asspace is limited..
-Ifyouare unableto.attend one ofthese course offerings,please contact When Secon&Vtiuntto ,
schedule a course at your.location or ours:We also carry a wide variety of First Aid supplies and
barrier device 'tq'aid in the successful,sanitary and safe food:rernoval.
For more information,please salt 978-744-4799 and ask how you can receive a free`;"
Face Shield Key Cham
t
Sincerely
r
When Seconds Count
c
IMPORTANT IiIIESSAGE
FOR �p
DATE [o TIMF�LP.
OF
PHONE 97� .� i/ � �loSO
AREA CDDE C�oNUMBER EX FNSI N
❑ FAX
❑ MOBILE
AREA CODE N MBER TIME TO CALL
TELEPHONED PLEASE:CALL r.
CAME TO SEE YOU WILL CALL AGAIN
WANTS TO SEE YOU RUSH
RETURNED YOUR CALL FWILL FAX TO YOU
MESSAGE
SIGNED
�psFORM 400
YY MARE IN U.S.A.
I�
NOTES
IM
P
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ANT MESSAGE
FOR -
DATE C� 7 " TIME4
M /x�
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PHONE �78 � -6"Ild
AREA CODE NUMBER EXTENSION
O FAX
O MOBILE
AREA CODE NUMBER TIME TO CALL
TELEPHONED PLEASE CALL
CAME TO SEE YOU WILL CALL AGAIN
WANTS TO SEE YOU RUSH
-RETURNED YOUR CALL WILL FAX TOYOU
MESSAGE
SIGNED
OpsFOR ❑9
MAGE 11.5.A.
NOTES
r
IMPARTAPJT MESSAGE
FOR
DATE TIME :�Q P.
M ^�
OF �Y
PHONE
AREA CODE NUMBER EXTENSION
❑ FAX
❑ MOBILE
AREA CODE MBER TIME TO CALL
TELEPHONED: .PLEASE CALL
CAME TO SEE YOU WILL CALL AGAIN
WANTS TO SEE YOU ':- RUSH:
RETURNED YOUR CALL WILL FAX TO YOU
MESSAGE
SIGNED
FORM 4009
MARE IN U.S.A.
NOTES
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! :� e � � '�� � �
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: ����/n %�lrJi.�s Date: 4 4z D Page: of
Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R—Red Item Verified.
- PLEASE PRINT:CLEARLY
<:21 ow
P
Q
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 i
Exclusion
violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. 1 understand that.
noncompliance may result in daily fines of twente dollars or suspenn--ion/reation of ❑ Embargo ❑ Emergency Closure
your food permit. `///�� � ❑ Voluntary Disposal 11 Other:
3- 01 14(C) 'PH'F's Received at Temperatures
Violations Related to Foodborne iciness interventions and Risk According to Law Cooled to
Factors(items 1-22) (Cont.) 4 YF/45'F Within 4 Hours.
PROTECTION FROM CHEMICALS 3-501.15 Coohn"Methods for PHFs
19
14 Food or Color Additives PHF Hot and Cold Holding
3-501.16(6) Cald PHPs Maintained at or below,
3-20112 Addtuses* 5901104(F) 41'145°P"
3-302.'14 Protection from Una roved Additives" 3-501.I O(A) Hix PHFs Maintained at or above
15 Poisonous or Toxic Substances
140'F. *
7-1(11.1.1 Identifying Information-Ohio nal 3-50116(A) Roasts Held at or above 130°F.
Containers'"
7-10111 Common Name-Working Containers* 20 Time as a Public Health Control
7-201.11 Separation-Storage" 3-501.19 Time as a Public Health Contra(*
7-202.11 Restriction-Presence and Uces
590.004(H) Variance:Requirement
7-202.12 Toxic
ons of Use, REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7.203.11 Toxuxic Containers Prohibitions* POPULATIONS(HSP)
7-2tk1.]t Smrifizers,Criteria-Chemirnls* �
7-204.12 Chemicals for Washing Produce. Criteria* 21 3-801..1 1(A) Unpasteurized Pre-packaged Juices and
Beverages with Warm_ Libels*
7-204.14 Drying Agents.Criteria* -
7-205.11 Incidental Food Contact.Lubricants* 3-801.11(B) Use of Pasteurized fu„>s*
7-206.11 Restricted Use Pesticides.Criteria* 3-801.11(D) Raw or Partially Cooked.Animal Fad and
Raw Seed S grouts Not Served.s
7-206.12 Rodent Bait Stations'
en ,Pe 3-801.11(Cj Unopened Food Packa*e Not Reserved.
7-206.13 Tracking Powders,Pest Control and
Monitoring*
CONSUMER ADVISORY
TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer AdtiisoryPosted for C:onsutnption of
Annnsd Foods'I'hat are Raw. Undercooked or
PHFs
16 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate
3-40111A(1)(2) Eggs- 155°F 15 Sec.
Pa,th119cns.*`nr000�
Eggs-Ininiediate Service 145°1715sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
3-401.1 I(A)(2) Comminuted Fish,Meats&Game Eggs* -
Anirn ds- 155'F 15 sec. x
3-401.11(13)(1.)(2) Park and Beef Roast-13WF 121 min* SPECIAL REQUIREMENTS
3-401.11(A)(2) Ratites,Injected Meats-155'F 15 590 009(A)-(D) Violations of Section 590.009(A)-(D)in
sea. * catering, mobile food, temporary-and
3-401.19(A)(3) Poultry, Wild Came, Stuffed PHF,, residential kitchen operations should be
Stuffing Containing Fish, Meat, debited ander the appropriate sections
Poultr or Ratit�sec. * above it related to foodborne illness
3-401.11(C)(3) Whole-nmscle,Intact Beef Steaks interventions and risk factors. Other
145°F* 590.009 violations relating to good retail.
3-401.1.2 Raw Animal Foods Cooked in a practices should be debited under#29--
Microwave l65°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
3-103.11(A)&(I)) PHFs l65°f 15 sec.* (Items 23-30)
3-403.11(B) Microwave- 165'F 2 Minute Standing Critical mid non-critical violations, which do not relate to the
Time* .foodborne illness interventions and risA-factors listed above, can be
3-403.11(C) Commercially Prcxessed RTF Food- hound irr the fallo"ing sections q/the Food Code and 105 CMK
140'F* 590.000.
3-403.11(E) Remaining Unsliced Portiansof'Beef item Good Retali Practices FC 588.000
Roasts': 23. Mance ement and Personnel......__ FC-2 .003
1g Proper Cooling of PHFs _24. Fuad and Food ProtectionF-C-3 004
25 Equipment and Utensils _ FC 4 .005
3-501,W(A) Cooling Cooked PHFs from 140`F to 26 Water, Plumbin and Waste ___Fe 5 .006___
70'F Within 2 flours and From 70'F 27. Physical Facility FC-6 .007
to 41"F/45"F Within 4 Hours. '" 28. Poisonous or Toxic Materials FC-7 .008
3-501.14(B) Cooling Pl Made From Ambient 29. S ecial R . viremenis 009
Temperature Ingredients to 41°F/45'F 30 __Other
Within 4 Hours* `sr'01-"""•`"ti-2°"
^'Denotes critical item in!ha fodera1 1999 Food Code or,105 CMR 590-000.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: Date: b Page: of
Item Code C-Critical Item DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date
No. Reference R—Red Item A S Verified
..-... PLEASE PRINT CLEARLY -
d ve
- d
e
lee
e
�d i
G
Discussion With Person in Charge: coirmpt ve Action Required: ❑ No ❑ Yes
I have read this report, have had the opportunity to ask questions and agree to correct all Ll 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 finesof tw" five dollars or susp sign/r vocation of ❑ Embargo ❑ Emergency Closure
your food permit.
�A ❑ Voluntary Disposal ❑ Other:
3-501.td(C) PHFs Rei_-3ved 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 a Hours.
PROTECTION FROM CHEMICALS 19 3-501.15 Coolinn Methods for PHFs
14 Food or Color Additives PHF Hot and Cold Holding
3-202.12 Additives*
3-501.16(9) Cold KIPS Maintained at or below
590.004(F) 41'14S° F-
3-302,14 t14 Protection from Unapproved Additivell
Poisonous or Toxic Substances 3-50l A 6(A) Ifor PHFs Maintained at or above
15
140'F.
7-101.11 Idenineglnfomration-Original 3-501.16(A) RoastsHeldatorabove130'F.*
Coruwiners*
7-102.11 Common Name-Working Containers* Time as a Public Health Control
7-201.11 Separation-Stora*e* 3-501.19 Time as a Public Health Connvls`
7-202.11 Restriction-Presence and(1Se'°
590.004(H) varianu;Re'ulrement
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 Washin¢Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and
Beveraees with Warning Labels
7-204.14 Drvin>Aants.Criteria* -
7-205.11 Incidental Food Contact. Lubricants* 3-801.11(B) Use of pasteurized Eags=*
7-206.1 1. Restricted Use Pesticides, Criteria* 3-301.11(D) Raw of Partially Cooked Animal Food and
Raw Seed Sprouts; Not Served.
7-206,12 Rodent Bait Stations*
7-306.13 Tracking Powders,Pest Control and 3_801.11(C) Unopened Food Package Not Re-served,
Monitoring*
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
PHFs_ Not Otherwise Processed to Eliminate
rnrzoo
3-401.1.1A(1)(2) Eggs- 155'F 15 Sec. Pathogens.* EallfL. t
E s,e-homed[tze Service 145°P15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
3-401.11(A)(2) Comminuted Fish,Meats&Game E s*
Animals- 155'F 15 sec. `f
3-401.1 l(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
see.x catering. mobile food,temporary wild
3-401.11(,c)(3) Poultry,Wild Game, Stuffed PHFs, residential.kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-I650F 15 sec. * above if related to foodborne illness
3-401A 1(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
145'F* 590.009 violations relating to good retail
3-401.12 Raw Anknid Foods Cooked in a practices should be debited under 7129-
Microwave 165cF* Special Rectunernents.
3-401.11(&(1)(6) All Other PHFs-145"F 15 sec. *
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-403.11(A)&(D) PHFs 165°.F 15 sec. x (items 23-30)
3-403.11(B) Microwave- 165'F 2 iMinu e Standing Critical and non-critical violations, which do not relate to rhe
Times' foodborne illness interventions and risk jactors listed above, can be
3-403.11(C) Commercially Pnxessed RTE Food- found in the follurviug sections of the Food Code and 105 CMR
140'F* 590.000.
3-403.11(E) Remaining Undiced 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 _ _ FG-3 .004
25 Equipment and Utensils __FC 4 _ .005
3-501.14(A) Cooling Cooked PHFs from 140'F to 26 W atec Piumbin and Waste FC 5 008
- --Phvsic-
70°F Within 2 Hours and From 70°F 27. Ph slcal Facility_ __ _- FG-6 .007
to 41-F/45°F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008
3-50L14(B) Cooling PHFs Made From Ambient 29, SpeciaiRequtrements .009
TempeiatureIngredients to4l`F/45'F _30_ _other _
Within 4 Hours" srsvor» -za,�
*Denotes critical item in the leAeral 1999 Food Code or 105 C Ptft 590.000.
i
f � Y
t
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,4t"Floor
Division of Food and Drugs Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343
NameDa
!� e T e of 0 eration s RouTvoe of Inspection I/ Food Service ❑ tine
Address �l Rik Retail Re-inspection
o� Level El Residential Kitchen Previous Inspection
Telephone , „ I I J ❑ Mobile Date: ( 1
Owner ((��� 1 HACCP YM ❑ Temporary El Pre=S�erat on
❑ Caterer ❑ Suspect Illness
Person in Charge(PIC) Time ElBed&Breakfast ElGeneral Complaint
In: Q,S?J ElHACCP
Inspector Out. Permit No. ❑Other
Each violation checked req fres 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.
-y_ -
F000 PROTECTION MANAGEMENT_ _ [112. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
-' w.. ❑ 13. Handwash Facilities
`EMPLOYEE HEALTH
PROTECTION FROM CHEMICALS .....- ,
❑ 2. Reporting of Diseases by Food Employee and PIC
El3. Personnel with Infections Restricted/Excluded [114.Approved Food or Color Additives
_ _ ❑ 15.Toxic Chemicals
FOOD FROM APPROVED SOURCE -- _ _. . e - _--
❑ 4. Food and Water from Approved SOUfCe TiMErfEMPERATURE CONTROLS(Potentially Hazardous Foo_d_a)
❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures T
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling
r PROTECTION FROMCONTAMINATION ❑l 19. Hot and Cold Holding
❑ 8 Separation/Segregation/Protection ❑20.Time As a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing fiO PU'RFood andFOoodlPrepa Preparation HSP POPULATIONS(HSP);
❑ 10. Proper Adequate Handwashing
❑ 11. Good Hygienic Practices ':.CONSUMERADVISORY- -
❑ 22. Posting of Consumer Advisories
Violations Related to Good Retail Practices Number of Violated Provisions Related
Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22):
of Health. Non-critical (N)violations.must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code. This report, when signed below
C x by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations
24. Food and Food Protection (FC-3)(590.0044))) cited in this report may result in suspension or revocation of
25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food
26. Water,Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you
27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION:
S.59omsoe FoPo 14,rc
17
Inspector's Signature: X `Print
IC's Sipature: � Print e C i. 1 ,f'� Page. of ages
I
Violations Related to Foodborne Illness
Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT 8 Cross-contamination
1 590.003(A) - Assignment of Res nsibilit • - 3-302.11(A)(1) Raw Animal Foods Separated from
Cooked and RTE Foods*
590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients
2-103.11 Person in charge--duties 3-302.11(A)(2) Raw Animal Foods Separated from Eacb
Other"
EMPLOYEE HEALTH Contamination from the Environment
2 590.003(C) Responsibility of the person in charge to - 3-302.11(A) Food Protection*
require reporting by food employees and 3-302.15 Washing Fruits and Vegetables
applicants* 3-304.11 Food Contact with Equipment and
590.003(F) Responsibility Of A Food Employee Or An
Utensils*
Applicant To Report To The Person In Contamination from the Consumer
Char
3-306.141 A B Returned F
r )( .} and and Resorvice of Food
5)0.003(G Reporting b Person to Charge* Disposition ofAdi rated or Contaminated-
31
A
590.003(D) Exclusions and Restrictions* Food
590.003(F.) Removal of Exclusions and Restrictions 3-701.1't Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE rte*
4 Food and Water From Regulated Sources F 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 Te eratures*
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water
3-202.33 Shell E as* Sanitization Temperatures* `
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH,
and hardness. * -
3-202.16 Ice Made From Potable Drinking Water* concentration -
r* 5-101.11 DrinldnWater from an Approved S stem* 4-601.,11(A) Equipment Food Contact Surfaces and
590.006(A) Bottled Drinking Water* Utensils Clean*
4-602.11 Cleaning Frequency of,Equipment Food-'
5590.0(6(B) Water Meets Standards in 310 CMR 22.0* -
ShefHish and Fish From an Approved Source Contact Surfaces and Utensils"
4702.11 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.ofSanitization-HotWaterand
3-201.15 Molluscan Shellfish from NSSP lasted Chemical*
Sources* 1Q Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by 2-301.1 t
toAuthorff ' Clean Condition-Hands and Arms*
Re Ma
3-202.18 Shellstock.Identification Present* 2-301..12 Cleaning Procedure*
590.004(C) Wild Mushrooms* 2-301.14 When to Nash*
3-201.17 Game Animals* l.i Good Hygienic Practices
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco*
3-202.11 PHFs Received at Proper Temperatures* 1,401.1.2 Discharges From the Eyes,Nose and ,
3-202.1.5' Package Inte itv*. Mouth*
3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contatnination When Tasting*
6 Tags/Records:Sheiistock 12 Prevention of Contamination from Hands,
3-202.18 Sbellstock Identification` 590.004(E) Preventing Contamination from
3-203.12 Shellstoek Identification Maintained* _ Employees*
Tags/Records:Fish Products 13 Handwash Facilities
3-402.11 Parasite Destruction*
Conveniently Located and Accessible
5-203.1.1 . Numbers and Capacities*
3-002.12 LabRecelingrds,ofIngredients*
Creation and Retention* 5-204.11 Location and Placement*
590.004(1) Labeling o4ingredients'
Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance
lHACCP Plans Supplied with Soap and Hand Drying
3-502.11 Specialized processing Methods* Devices
3-502.12 ' Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser,Availability
8-103.12 Conformance with Approved Procedures*
6-301.12 HandDr 'n Provision
Denotes critical item in the Iederal 1999 Food Code or 105 CMR 590.000.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: �/ t � _ �� � 4 L/1 yc Date: f -5-4 2 Pager` of
Item Code C-Crmeal Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R-Red Item Verified
PLEASE PRINT CLEARLY
O
U WQ E 7C 7 n
OA.
u D
9
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/
violations before the next inspection, to observe all conditions as described, and to Exclusion
❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo Ll Emergency Closure
your food permit. 1 � �) 7� /
7(/ L3 Voluntary
Disposal ❑ Other: i
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) (Cont.) 41'F/45"F Within Hours.
PROTECTION FROM CHEMICALS
3-501.15 C(x)ling Methods for PHFs
14 Food or Color Additives 29 - � PHF Hot and Cold Holding
3-202.12 Additives*
3-501.I6(B) Cold PRFs Maintained at or below
_ 590.004(F) 410/450 F*
3-302.14 Protection from Unapproved Additives"
15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above
140
7-101..11 Identifying Information-Original Roasts
3-501.16(A) Roasts Held at or above t30°F.
Containers*
7-102.11. Common Name-WorkingContainers* 20 Time WS-8 Public Health Control
3-501.19 Time as a Public Health Control"
7-201.1.1 1 Separation-Storae* 590.004(H} Variance Requirement
7-202.11 ,Restriction-PresenceandUse*
7-202.12 Conditions of Use*
7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11 Samtizers.Criteria-Chemicals* POPULATIONS HSP
7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.t](A) Unpasteurized Pre-packaged Juices and
Beverages w th Warning Labels*
7-204.14 Drying Agents.Criteria* 3-801.1 1B) Use of Pasteurized Eggs*
7-205.11 Incidental Food Contact,Lubricants* 3-8(1.11(D) Raw or Partially Cooked Animal Food and
7-206.11 Restricted Use Pesticides,Criteria* Raw Seed S outs Not Served,
7-206.12 RodenC Bait Stations* 3-80).11(C) Unopened Food Packs Not Reserved.
7-206.13 Tracking Powders,Pest Control and
Monitoring* CONSUMER ADVISORY
TIME/I EMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
16 Proper Cooling Temperatures for Animal Foods That are Raw.Undercooked or
PHFs - Not Otherwise Processed to Eliminate
3-401.11A(t)(2) Eggs- 155°F 15 Sec. Pathogens.,E" ""°'"a t
Eggs-Immediate Service 145'Fl5sec* 3-302.13 Pasteurized Eggs Substitute for Raw She11
3-401.11(A)(2) Comminuted Fish.Meats&Game Eggs*
Animals-155'F 15 sec. *
3401.11(B)(1)(2) Pork and Beef Roast- 130'F 121 min* SPECIAL REQUIREMENTS
3401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
sec.* catering,mobile food, temporary and
3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be
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
1450F* 590,409 violations relating to good retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165°F* Special Requirements.
3-401AI(A)(1)(b) All Other PHFs-145'F 15 sec.
17 Reheating for Hot Holding VIOLA77ONS RELATED TO GOOD RETAIL PRACTICES
3-403.11(A)&(D) PHFs 165°F 15 sec.* (Items 23-30)
3.403.11(B) Microwave- 165'F 2 Minute Standing Critical and non-critical violations,which do not relate to the
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 C.kIR
1400F* 590.000.
3-403.11(E) - Remaining Unsliced Portions of Beef Item 1 Good Recall Practices I FC 590.000
Roasts+: 21 3• Management and Personnel FC-2 _003 .1
18 Proper Cooling of PHFs i 24. Food and Food Prateclion FC-3 .00
25. Equipment and Utensils FC-4 .005
3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Water.Plumbing and WasteFC-5 .006
70'F Within 2 Hous and From 70'F 27. -Physical Facility FC-6 .007
to 41`F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008
3-501.14(B) Cooling PHFs Made From Ambient 29. -Special Requirements .009
Temperature Ingredients to 41°F/45°F 30. Oiler
Within 4 Hours* s:sunfK x a
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
Massachusetts Department of Public Health SalemLBoard of Health
120 Washington Street,0 Floor
Division Of Food and Drugs Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978)741-1800 Fax(978) 745-0343
NameI Dae T e of O eration s T f Inspection
K 1 Food Service Routine
Addressa?� - Gn L l V i t ❑ Retail Re-inspection
Level ❑ Residential Kitchen Previous Inspection
Telephone _ ( 1 ❑ Mobile Date: r Jr/z / .
OwnerII HACCP Y/N C3Temporary ElPre-operation
C "IL, 4, ❑ Caterer ❑ Suspect Illness
Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint
Inspector In: �f'aJ Permit No. El Other-
Each
0 Out:S'��.
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 t
�e-.tom ❑ 12. Prevention of Contamination from Hands
E] 1 PIC Assigned/Knowledgeable/Duties
El--
13. Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑ 2. Reporting of Diseases by Food Employee and PIC -
❑
E] 3. Personnel with Infections Restricted/Excluded 14.Approved Food or Color Additives
FOOD FROM.APPROVEO SOURCE _ El 15.Toxic Chemicals
El4. Food and Water from Approved Source TIMEREMPERATUREcONTROLS(Potemlalty,Hazardoua Fooda)�
y�-
❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements e ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans [118.Cooling
O EI TION FROM CONTAMINATION - 5j 9. Hot aOAsublic
olding
ED 8. Separation/Segregation/Protection El 20.Time Health Control
El9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS.(HSP).
El21. Food and Food Preparation for HSP
❑ 10. Proper Adequate Handwashing
❑ 11.Good Hygienic Practices iCONSUMER ADVISORY.!.
❑22 Posting of Consumer Advisories
Violations Related to Good Retail Practices Number of Violated Provisions Related
Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22):
of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code. This report,when signed below
C x by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations
24. Food and Food Protection (Fc-a)(sso.004))' cited in this report may result in suspension or revocation of
25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food
26. Water,Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you
27. Physical Facility (FC-5)(590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION:
Inspector's Signature: Print:
PIC's Signature: ( Print: U<" Pa eg!�of?Pages v )
v '
t(
Violations Related to Foodborne Illness
Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION
8 Cross-contamination
FOOD PROTECTION MANAGEMENT
1 590:003(A) Assignment of Responsibility*, 3-302.11(A)(1) Raw Animal Foals Separated from
____ Cooked and RTE Foods*
590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients
2-103.11 Person in charge-duties 3-302.11(A)(2) Raw Animal Foods.Separated from Each
Other*
EMPLOYEE HEALTH Contamination from the Environment
2 590.003(C) Responsibility of the person in.charge to 3.302,1 L(A) Fual Protection"
require reporting by fuel employeesand3-302.15 Washing Fruits and Ve Eetables
a licams* 3-304.11 Food Contact with Equipment and
590.003(F) Responsibility Of A Foal Employee Or An
Utensils*
Applicant To Report To The Person In Contamination from the Consumer
Charge*
3
590.003(G) Reporting b Person in Chsu ge*
-306.14(A)(B) Returned Food and Reservice of Food*
3 590.003(D) Exclusions and Restrictions* Dosoposition of Adulterated or Contaminated
590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE FaxP
4 Food and Water From Regulated Sources ET Food Contact Surfaces
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water
3-201.12 Foal in a Hermetically Sealed Container* Sanitization Temperatures* -
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-I-lotWater
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 Drinkin 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" 4.6102.11 Cleaning Frequency of Equipment Food
Contact Surfaces and Utensils*
Shellfish and Fishreal From an Approved Source 4-702.11,. - Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught MolluscanFood Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and
3-201.15 Molluscan Shellfish from NSSP Listed Chemical*
Sources* - SO Proper,Adequate Handwashing
RMatoAuthor
Game and Mushrooms Approved by, 2_30]11 Clean Condition-Hands and Arms*
- e Aut
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* ll Good Hygienic Practices -
g Receiving/Condition 2A0].11 Eating,Drinking or Using Tobacco*
3-202.11 PHFs Received at Proper Temperatures* 2401.12 Discharges From the Eyes,Nose and
3-202.15 Package lute it * Mouth*
3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting*
6 - Tags/Records;Shelistock 12 Prevention of Contamination from Hands
5-202.18 Shellstock Identification
590.004(F,) Preventing Contamination from
3-203112 Shellstock Identification Maintained* Employees* "
Tags/Records:Fish Products 13 Handwash Facilities
3-402.11 Parasite Destruction*
- Conveniently Located and Accessible -
- 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Ca acifies*
590.004(J) Labeling of Ingredients* 5-204.11 Location and Placement*
7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance
/HACCP Pians Supplied with Soap and Hand Drying
3-502.11. Specialized Processing Methods* - Devices
3-502.12 Reduced oxygen p packaging,criteria* 6-301.11 _ Handwashing Cleanser,.Availabilit
8-103.12 Confatmance with Approved Procedures*
6-301.1.2 Hand Drying Provision
Denotes critics]item in the federal 1999 Food Code or 105 CMR 590.000
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: lant4�t 0-w-, aha it, Jc Date: CfalfxPage: d Of
Rem Code C-CriticalItem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date.-
No. Reference R-Red Item Verified
PLEASE PRINT CLEARLV-
v.co ri n UIrC�/PIP_ to
arc Q ukra S^ C
Val c
l vSz=
-� 10' � .
,
J 1) ,
I L V i
� s
3� ( u o rK
Discussion With Person in Charge: . Corrective Action Required: ❑ .No
have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee R striction
violations before the next inspection, to observe all conditions as described, and toe-inspection Scheduled El Emergency Suspension Exclusion
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollar or suspension/revocation.of ❑ Embargo ❑ Emergency Closure
your food permit.
0 Voluntary Disposal ❑ Other:
3-501.14(C) PRFs Received at Temperatures
Violations Related to Foodborne 111nesslnterventions and Risk According to Law Cooled to
Factors(Items 1-22) (Cont.) 41°F/45°F Within 4_Hours.
PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs
14 Food or Color Additives 19 PHF Hot and Cold Holding
3-202.12 Additives* 3-50L16(B) Cold PHFs Maintained at or below
3-302.14 Protection from Unapproved Additives* 590.004(F) 410/450 F*
15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above
140°F. *
7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130°F.
Containers*
7-102.11. Common Name-Working Containers* 20 Time as a Public Health Control
701.11 Separation-Storage* 3-501.19 Time as a Public Health Control*
7-202.11 .Restriction-Presence and Use*
590.U04(H) Variance Requirement
7-102.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP
7-204.11 Sanitizers.Criteria-Chemicals*
7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Iuices and
Beverages with Warning labels*
7-704.14 ants.Criteria* 3-801.11(8 Use of Pasteurized Eggs*
7-205.t I Incidental Foal Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Foci and
7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served*
7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.
7-206.13 Tracking Powders,Pest Control and
Monitoring* CONSUMER ADVISORY _
TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
16 Proper Cooking Temperatures for Annual Foods That are Raw.Undercooked or
PHFs _ Not Otherwise Processed to Eliminate
3.401.11A(1)(2) Eggs- 155°F 15 Sec. Pathogens.
E"" " za r
Eggs-Immediate Service 145°Fl5sec* 3-302.13 1
EPasteuAwd Eggs Substitute for Raw Shell
31101.11(0)(2) Comminuted Fish.Meats&Game
Animals-155°F 15 sec.
3-401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 min* SPECIAL REQUIREMENTS
3-401.1.1(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
3401.11(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(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
145°F* 590.009 violations relating to good retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165°F* Special Requirements.
3-401;11(A)(1)(b) All Other PRFs-145°F 15 sec.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRAC77CES
3-403AI(A)&(1)) PHFs 165°F 15 sec.* (Items 23.30)
3-403.11(B) Microwave- 165'F 2 Minute Standing Critical,and non-critical violations, which do not relate to the
Time* foodborne illness interventions and ris&_factors listed above,can be
3403.11(C) Commercially Processed RTE Food- found in rhe following sections of the Food Code and 105 CMR
140°F* 590.600.
3403.11(E) Remaining Unsliced Portions of Beef Item I Good Retail Practices I .FC 590
Roasts* 23. 1 Man •lament and Personnel FC-2 .003
f 24. Food and Food Protection _ ! FC-3 .004
18
Per Cooling of PHFs 25. Equipment and Utensils 1 FC-4 .005- -
3-501.14(0) Cooling Choked PHFs from 140°F to26. Water.Plumbing and Waste FC-5
70°.F Within 2 Hours and From 70T 27. Physical FacilityFC-6 067
to 41°F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials 1 FC-7 .008 j
3-501.14(B) Cooling PHFs Made From Ambient 29. S ecial Requirements i ,003
Temperature Ingredients to 4I°F/45°F 30. Other
Within 4 Hours* s:swram 2�
'Denotes critical item in the federal 1999 Food Cade or 105 CMR 590.000.
6�
tip
CITY OF SALEM
2D OF HEALTH tl
Establishment Name: �q(��/� I/�y1h�rjAir Date: f Page: .3 hof _ i
Item Code C-Critical Item DESCRIPTION OF VIOLATION./PLAN OF CORRECTION Date•,- - "
No. Reference R-Red Item /� �> ;
PEASE PRINT CLEARIIY t Verified
2
C n S Sc �1 l II.J
- -(A 1, cd 0, h( f C: l 0(_ 44 O'� 10 h-T
u
w I� Uo a
/1
4
,t
y
Discussion With Person in Charge: \ , Corrective Action Required: ❑ No Yes
I have readth s,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 a /described, and to
Exclusion
( / ; Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code: Lunde! tand-that.
noncompliance may resulttin_ daily fines of twenty`-five dolla%or-sutension/revacation of ❑-'Emba go ❑ Emergency Closure
your food permit. 1
(� ❑ Voluntary Disposal ❑ Other.
t
3-501.14(C) PHFs Received at Temperatures
Violations Related to Foodborne Olness,interventlons and Risk According to Law Cooled to
Factors(Heins 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
3-50IA6(B) Cold PHFs Maintained at or below
3-202.12 Additives* 590,O04(F) 410/45'F*
3-302.14 Protection from Unapproved Additives*
15 Poisonous or Toxic Substances 3-501.16(A) Hot PRFs Maintained at or above
140°F.
7-I OL11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130°F.
Containers*
7-102.11. Common Name-WorkingContainers* 20
Time as a Public Health Control
7-201.1.1 Separation-Storage* 3-501.19 Time as a Public Health Control*
7-20111 ,Restriction-Presence and Use*
590.004(H) Variance Requirement
7-202.12 Conditions of Use*
7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
LATI
7-204.11 Chemicals
Criteria HSP
7-204.12 micals for WishingProduce,CriChemicals* POPUONS 21 3-801.11(A) Unpasteurized Pre-packaged Iuices and
teria*
7-204,14 Drying Agents.Criteria* Beverages with Rranring Labels*
3-801.11B) Use of Pasteurized Eons*
7-205.11 Incidental Food PesticContaides,
,Criteria** 3-801..11(0) Raw or Partially Cooked Animal Food and
7-206.11 Restricted Use Pesticides,Criteria Raw Seed S ants Not Served*
7-206.12 Rodent Bait Stations* 3-801.11(C) Uno ned Food Packa 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
16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or
PHFs Not Otherwise Processed to Eliminate
3-40i.11A(1)(2) Eggs- 155'F 15 Sec.
Pathogens.*F"°`"" 1/1? 1
Eggs-Immediate Service 145°F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
3-401.11(A)(2) Comminuted Fish.Meats&Game
Eggs*
Animals-155°F 15 sec. *
3.401.11(8)(1)(2) Pork and Beef Roast-130°F 121 min* SPECIAL REQUIREMENTS
3-401.11(A)(2) Ratites,Injecte Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
sec. * catering,mobile food, temporary and
3-401A I(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be
Stuffing Containing Fish,bleat, debited under the appropriate sections
Poultry or Ratites-165°F 15 sec. * above if related to foodborne illness
3-401.11('C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
145°F 4' 590.009 violations relating to gaol retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165°F* Special Requirements.
3-40L I1(A)(1)(b) All Other PHFs-145°F 15 sec.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3403.11(A)&(D) PHFs 165-F 15 sec. * (Items 23-30)
3403.11(B) Microwave-165'F 2 Minute Standing Critical,and non-critical violations,which do not relate to the
Time* foodborne illness interventions and risk factors listed above, can be
3403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR
140°F* 590.000,
3403.11(E) Remaining Unsliced Portiims of Beef - nem I Good Retail Practices .FC 590.000
M;Roasts* 23. Mnt and Personnel FC-2 .003
1g Proper Cooling of PHFs 24. Food and Food Protection { FC-3 .004 i
3-501.14(A) Coolie Cooked PHFs from 140°F to 25. Equipment and Utensils _ 1 FC-4 .005
S 26. Water,Piumbin and W ante FC-5 .006
70°F Within 2 Hours and From 70'F 27. Physical Facility , FC-6 .007
to 41°F/45°F Within 4Hours. * 28. PdsonousorToxic.Materials f FG-7 .008 i
3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements
Temperature Ingredients to 41°F/45°F 30. Other
Within 4 Hours*
'Denotes critical item in the federal 1999 Foal Cafe a 105 CMR 590.000.
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,4s'Floor
Division of Food and Drugs Salem, MA 01970-3523
Tel. (978)741-1800 Fax(978) 745-0343
City/Town of Address:
FOOD ESTABLISHMENT INSPECTION REPORT Tel.
Name Date I Type ofOperationis) Type of Inspection
Food Service ❑Routine
Address Rik I Retail J Re-inspection
Telephone Level El Residential Kitchen Previous nspection
_ Can ❑ Mobile Date: q-4-to
-4 r
Owner HACCP YIN [I Temporary ElPre-operation
❑ Caterer ❑Suspect Illness
Person-in-Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint
In:a �J ❑ HACCP
Inspector Out Permit No. El.Other
Each violation checked requires an explanation on the narrative pag (s)and a citation of specific provision(s)violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors_(Red
Items) Anti-Choking 590.009(E) ❑
Violations marked may Tobacco 590.009(F) ❑
y pose an imminent health hazard and require immediate Allergen.Awareness 590.009(G) ❑
corrective action as determined by the Board of Health.
T_FOOD.PROTECTION MANAGEMENT.' _. _ _ _ _ _ ❑ 12. Prevention of Contamination from Hands
[3 1. PIC Assigned/Knowledgeable/Duties
' " "' - _ _ - _ _ ❑ 13. Handwash Facilities
EMPLOYEE HEALTH
.:PROTECTION�FROWCHEMICACS'
E] 2. Reporting of Diseases by Food Employee and PIC 1
❑ 14.Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded
FOOOF.ROMApPROVEDSOU. R_CE- __ -_- ) E] 15.Toxic Chemicals
r � ._ -_. at
ElF14. Food and Water from Approved Source
❑ 5. Receiving/Condition ❑16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy.of Ingredient Statements ❑ 17.Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling
PROTECTION FROM CONTAMINATION _ _ _ _� ❑ 19. Hot and Cold Holding
❑ 8.Separation/Segregation/Protection ❑ 20.Time as a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLYSUSCEPTIBCE=POPULATIONS';(HSP).`
❑ 10. Proper Adequate Handwashing ❑21. Food and Food Preparation for HSP
❑ 11. Good Hygienic Practices ADYISORY.A.
❑22.Posting of Consumer Advisories
Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related
Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22):
of Health. Noncritical(N)violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health.
C N 590.000/federal Food Code.This report,when signed below
23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an
24. Food and Food Protection (FC-3X590.004) 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-4X990.009) the food establishment permit and cessation of food
26. Water, Plumbing and Waste (FC-5X590.006) establishment operations. Ifaggrieved b thi rder
py so ,you
27. Physical Facility (FC-6X590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7X590.008) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION:
s d,e. ' `Q, (_ �J� o
Inspector's Signature: -Print: �( , 1 w
PICS Signature: Print: 11,0
Page_40 Pa
. . ..-.yr.-.-...�-�..✓�..y"� r-�._..+�_1,.`..+..--._..-.._�.Y,-'-^ __ -�.-.-.-...--v-..�.'_1N'w"'�-.lti.i-.�- .".....�... ._••4-..-�^�o-..n-'�"' `�r...�-a�
Violations Related to Foodborne Illness
Interventions and Risk Factors(Nems 1-22) PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT 8 Cross-contamination
1 590.003(A) Assi,ptmentafRestonsibilit * 3-302.11(A)(1.) Raw Animal Foods Separated from
Cooked and RTE Foods*
590.003(6) Demonstration ofKnowledge* Contamination from Raw ingredients
2-103.11. Person in charge-duties 3-302-11(A,)(2) Raw Animal Foods Separated from Each
Other*
EMPLOYEE HEALTH Contamination from the Environment
2 590.003(0) Responsibility of the person in charge to 3-302.1 RA) Food Protection*
require reporting by food employees and 3-902.15 Washing Fruits and Ve etables
applicants* 3-304.11 Food Contact with Equipment and
590.003(F) Responsibility Of A Fixxl Employee Or An
Utensils*
Applicant To Report To The Person In Contamination from the Consumer
Charge*
590.003 G) Re 'n by Person in Charge* 3-306.14(A)(B) Returned Food and or of Food*
Disposition of Adulteratedaced or Contaminated
3 590.003(D) Exclusions and Rcsuictions* Food
590.003(E) Removal of Exclusions: Restrictians 3-701_it 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* 4-501.11 1 Manual Warewashing-Hot Water -
3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures*
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical W'arewashing-Hot Water
3-202.13 Shell Eggs* - Sanitization Tem ratures*
Eggs 3-202.14 E =s and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH,
3-202.16 Ice Made From Potable Prinking Water* concentration and hardness. *
5-101.11 Drinking Water from an Approved System- 4-601.11(A) Equipment Rood Contact Surfaces and
590.006(A) Bottled Drinking Water" Utensils Clean*
a 4-602.11 Cleaning Frequency of Equipment Food
Shellfish and Fish Froman
5')0.006(B)) Water Meets.standards Approved ScuroCMR.2-ce x` Contact Surfaces and Utensils*
4-70111 Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreadonafly Caught Molluscan Food Contact Surfaces of E ui moot*
Shell.uh* ._ 7-703.11 Methods of Sanitization-Hot Water and
3-201.15 Molluscan Shellfish from NSS^r Listed Chemical*
Sources* 10 Proper,Adequate Handwashing
Regulatory Autho
Game and Mushrooms Approved try 2-303.11 Clean Condition-Hands and Arms*
Autrity
3-202.13 Shellstcxk identification present`" 2-301.12 Cleanin2 Procedure*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201.17 Game.Animals* it Good Hygienic Practices "
i ReceivingfCondition 2401.11 Eating,Drinking or Usina Tobacco*
3-202.1.1 PHFs Received at Proper Tem ramres* 2-401.12 Discharges.From the Eyes,Nose and
3-202.1.5 Package Into rit * _ Mouth*
3-1CIL IlFcrodSafeandUnadulterated* 3-301,12 PreventingContamination When Tasting*
6 Tags/Records:ahelistock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from
3-203.12 SheilstackIdentification Nlaintaiaed'* Em l_o ees*
Tags/Reeords:-Fish Products 13 Handwash Facilities
3402.11 Parasite Dcecmction*
Conveniently Located and Accessible
3-402.12 Records.Creation and Retention* 5-203.11 . Numbers and Capacities*
590.004(1) Labeling of Ingredients' 5-204.11 Location and Placement*
7 Conformance with Approved Procedures 5-205.11 Accessibilit ,Operation and Maintenance
/HACCP Plans Supplied with Soap and Hand Drying
3-502.11. Specialized Processing Methods* Devices
3-502:1.2Reduced ax gen acka"ng,criteria* - 6-301.11 Handwashin Cleanser,Availability
8-103.!2 Conformance with A roved Procedures* 6-301.12 Hand Drying Provision
Denotes critical item in the federal 1999 Focal Code or 105 C41R 590.000.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: Date: Page:_ of':L
Rem Code . C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION `
No. Reference R-Red Item Verified
PLEASE PRINT CLEARLY
c -
t~h
G
Discussion With Person in Charge: Corrective Action Required: ❑ No
1 have read this report, have had the opportunity to ask questions and agree to correct allolExclusion Compliance ❑ Employee Restriction/
violations before the next inspection, to observe all conditions as described, and to Li Re-inspection Scheduled C3 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 uspens. /revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
❑ Voluntary Disposal ❑ Other:
3-501.14(0) PHFs Received at Temperatures
1 Violations Related to Foodborne Illnesstntereentlons and Risk According to Law Cooled to
Factors(items 1-22) (Cont.) 41'7l45'F Within 4 Hours.
PROTECTION FROM CHEMICALS 3-501..15 C rolin Methods for PHFs
� 19
ri4 Food or Color Additives Mot and Cold Holding
3-20232 Additives* 3-501.16(6)590.0t)4(F) 41 145 F*
Codd PHFMainained at or below
3-302.14 Protection from iln roved;kdditives'k 3-501.16(A) Hot PRFs Maintained at or above
15 Poisonous or Toxic Substances 140 *
7-101,11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 1300F. "
Containers* 20 Time as a Public Health Control
7-102.11. Common Name--WorkingContainers* -
7-201.11 Separation-Storage* 3-50I A9 Time as a Public Health Control*
7-20111 ,Restriction-Presence and Use* 590.004(H) Variance Requirement
7-202.12 Conditions of Usc* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP
7-204.11 Sanitizers.Criteria-Chemicals*
7-204.1.2 Chemicals for WashiM Produce,Criteria° 21 3-801.11(A) Unpasteurized Pte-packaged Iuices and
7-204.14 encs.Criteria* Beverages with Wart»na Labels*
3-801.11(6) Use of Pasteurized Eggs*
7-2{}5,11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and
7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprains Not Served.'
7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re=served. "
7-206.13 Tracking Powders,Pest Control and
l
Monitoring* CONSUMER ADVISORY
TIMErrEMPERATURE CONTROLS 22 3-603,11 Consumer:Adiisory Posted for Consumption of
16 Proper Cooking Tempetstures for Animal Foods That are Raw,Undercooked or
� Not Otherwise,Proc�essed to Eliminate
PHFs f Pathogens.'ero""a rnaa!f
3-401.IIA(1)(2) Eggs- 155F 15 Sec.
Eg -Immediate Semi 145'F15secs 3-30113. Pasteurized Eggs Substitute for Raw Shell
J 3.401.11(A)(2) Comminuted Fish.Meats&Game
E r.
Animals-155°F 15 sec. * SPECIAL REQUIREMENTS
3.401.11(8)(1)(2) Pork and Beef Roast-130'F 121 min* 590.009(A)-(D) Violations f Section .590.009(A)-(D)in
3-401,11(A)(2) Ratites,Injected Meats-155`F 15
see,* catering,,mobile food,temporary and
3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-165'F 15 sec. * above if related to foodborne illness
i' 3401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
145°F* 590.009 violations relating to good retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
L Microwave 165F* Special Requirements.
3-401.11(A)(1)(b) All Other PHFs- I45'F 15 sec.
17 Reheating for Not Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-103Ai(.AWD) PHFs 165'F 15 sec.x (Items 23-30)
l 3403.11(B) Microwave--165`F 2 Minute Standing Critical,and non-critical violations, which do not relate to the '
1 Time* - foodborne illness interventions and risk,factors listed above, can be
3-403.11(C) Commercially Processed RTF Food- found in the following sectionsofthe Food Code and 105 CMR
1400F* 590.000.
3403.11(E) Remaining Unsliced Portions of Beef Item 1 Good Retail Practices FC 590.000 i
t Roasts" 23. i Management and Personnel ; FC-2 .003
18 Proper Cooling of PHFs 24. 1 Food and Food Protection I FC'-3 .004
i 125. 1 Equipment and Utensils I FC-4 .005 j
3-501,i4(A) Coating Cooked PHFs from 140`F to f 26, 1 Water,Piumbinq and Waste _IFC-5 .006
70'F Within 2 Hours and From 70'F 27, I Physical Facility 1 FC-6 .007
i
tit 41`Ff45'F Within 4 Hours.° i 26_ Poisonous or Toxic Materials ' FC 7 .008
3-501.14(E} Cquiing PHFs Made From Ambient X29. S iia!R uiremetiLS f .009
[1 Temperature Ingredients to 41'F/45'F ' 30. I Other
J
Within 4 Hours* S+Vff'a�i-."L•c
Denotes critical imam in the federal 1999 FwA Cale ur 105 CMR 590.000.
1
_/ n
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,4h Floor
Division of Food and Drugs Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343
Name DJAVDat a of O eration s T e f Ins action
n Food Service Routine .
AddressRIs Retail Re-inspection
Level ❑ Residential Kitchen ' Previous Inspection
Telephone
gig Io_ ❑ Mobile Date:
Owner ` HACCP YM C1 Cate caterer ary ❑ Pre-operation
,
❑Suspect Illness
Person In Charge( IC) Time ❑ Bed&Breakfast ❑ General Complaint
Inspector7 In: 'El HACCP
� )DW Out. iQ� Permit No. ❑Other
Each violation check d requires an explanation on the narrative page(s) and a citation of specific provisions) violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco
Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑
action as determined by the Board of Health.
FOOD PROTECTION MANAGEMENT ' _ _ + ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
EMPLOYEE HEALTH C313. Handwash Facilities
" ---- PROTECTION FROM CHEMICALS
❑ 2. Reporting of Diseases by Food Employee and PIC '
❑ 14.Approved Food or Color Additives .
❑ 3. Personnel with Infections Restricted/Excluded
5.Toxic Chemicals
FOOD FROM APPROVED SOURCE
❑ 4 Food and Water from Approved Source TIMEITEMPERATURE CONTROLS(Potentially Hazardous FOoda)
❑ 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 CONTAMINA11ON ❑ 19. Hot and Cold Holding
.❑- /8. Separation/Segregation/.Protection ❑20.Time As a Public Health Control
-. Food Contact Surfaces Cleaning and Sanitizing -REQUIREMENTS FOR-HIGHLY SUSOEPTIBLE POPULATIONS(HSP) 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
C x by a Board of Health member or its agent constitutes an
Management and Personnel FFo-2)(590.0 order of the Board of Health. Failure to correct violations
24. Food and Food Protection (Fc-3)(5so.004)) cited in this report may result in suspension or.revocation of
5. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food
26. Water,;Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you
27. Physical Facility (FC-6)(590.007) 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.SBOlnspeclPo 14.tl 3
Inspector's Signature: Prin : «l
PIC's Signature: Print: Page of-7 Pages
.aaN ry"3�."`w, jJ -�•-� �•. an;'ja t\. ..Y - � .. .:y wY+Y`.'y, _ -_
�,..,._r.., ter./ r'RJ ~'� �� ^t3f.....r..•IVi 11i'`V a..ii 'f�/ �1,�,,,.�..�e,�,,w.*. ..s._..• �. •' ,-.+-.�,.
Violations Related to Foodborne Illness
interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION
8 Cross-contamination
FOOD PROTECTION MANAGEMENT 3-302.11(A)(]) Raw Animal Foods Separated from
1 590.003(A) Assignment of Res>onsibilit * Cooked and RTE Foods*
590.003(B) Demonstration of Knowledge" Contamination from Raw Ingredients
2-103.1.1. Person in charge-duties 3-302.1.1(A)(2) Raw Animal Foods Separated from Each
Other*
EMPLOYEE HEALTH
Contamination from the Environment
2 590.003(C) Responsibility of the person in charge to 3-302.11(A) Fwd Protection*
require reporting by food employees and 3-302.15 1 Washing Fruits and Vegetables
applicants* 3-304.11 Food Contact with Equipment and
590.003(.F) Responsibility Of A Pool Employee Or An
Utensils*
Applicant To Report To The Person In -
Contamination from the Consumer
Charge* 3-306.14(A)(B) Returned Food and Reservice of Food*
590.003(G) Reporting by Person in Charge*
3 590.003(D) Exclusions and Restrictions* DisposdonotAduitaratedorContaminated
Food '
590.003(F.) Removal of Exclusions and Restrictions 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* 4501_Il L Manual Warewashing-Hot Water
3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures*
3-201.13 Fluid Milk and Milk Products* - 4-501.112 Mechanical Warewashing-Hot Water
3-202.13Shell 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 Drinkin 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.W 4-602.11 Cleaning Frequency of Equipment Food
Shelilish and Fish From an Approved Source Contact Surfaces and Utensils'!
4702.11 Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment*
p
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and-
3-201.15 Molluscan Shellfish from NSSP Listed Chemical*
Sources* 10 Proper,Adequate Hand
washing
Game and Win Mushrooms Approved by
Re u/atoAuthodt 2-301.11 - Clean Condition-Hands and Atms*
3-202.18 Shellstock Identification Presem* 2301.12 Cleaning Procedure*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201.17 Game Animals* 11 Good Hygienic Practices
5 ReceivingfCondition 2401.11 Eating,Drinking or Using Tobacco*
3-202.11 PRFs Received at Proper Temperatures* 2-407.12 Discharges.From the Eyes,Nose and
3-202.15 Package Inte it * Mouth*
3-101.11. Food Safe and Unadulterated* 3-30 L.12 1 Preventing Contamination When Tasting*
6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from
3-203.12 Shellstock Identification Maintained* .-Employees*
Tags/Records:Fish Products 13 Handwash Facilities - -
3-402.11 Parasite Destruction* Conveniently Located and Accessible
3-402.12 Records.Creation and Retention* 5-203.11. . Numbers and Capacities*
590.004(1) Labeling of Ingredients' 5-204.11 Location and Placement*
7 Conformance with Approved Procedures 5-205.11. Accessibility,Operation.and Maintenance
/HACCP Pians Supplied with Soap and Hand Drying
3-502.11 Specialized processing Methods* Devices
6-301.11 Handwashin Cleanser,Availability
3-502:12 Reduced oxygen acka hg,criteria* b-301..1.2 Hand Drying Provision
8-103.12 Conformance with A roved Procedures*
*Denotes critical item in the fedend 1999 Foot Cale m 105 CMR 590000.
P ,i . , �/ ` _ _ e - . • u • �.�a 3/ 7 17!
m I NOW WON
I
•rA •1Il
3-501,14(C) PRFs Received at Temperatures
Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to
l factors(ItemsY-22) {Cont.) 41'F/45`F Within 4 Maim°
PROTECTION FROM CHEMICALS3-501.15 Cooluip Methods for PRFs
19 PHF Hot and Cold Holding
I) lq d sAdditives 3-501.16(B) Cold PRFs Maintained at cr below
590.
3-202.12 A Additivves**, 004(F) 4101450 F*
3-302.14 Protection from Lrn roved additives" 3-501.16(A) Hot PRFs Maintained at or above
15 Poisonous or Toxic Substances - 1400F. *
7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 1300F.
Containers* 20 Time as a Public Health Control
7-102.11. Comment Name-Working Containers*
7 201.11 Separation-Storage* 590.0119 Tittle as a Public Health Ctmtrat*
i
` 7-202.11 .Restriction-PresenceandUse° 590.004(H) Variance Requirement
7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Containers-Prohibitions* POPULATIONS MSF
7-204.11 Sanitizers.Criteria-Chemicals" 21 3-801.11(A) Unpastetnized Pre-packaged Juices and
7-204.1.2 Chemicals for WashingProduce,Criteria'
7-204.14 eats.Criteria*
:Beverages with Warning Labels*
F - 3-801.11(B) Use of Pasteurized$ *
4 7-205.11 incidental Food Contact,Latbtioants* 3-801.1 I(D) Raw or Partially Cooked Animal Food and
f 7-206.11 Restricted Use Pesticides;Criteria* Raw Seed Sprouts Not Served
7206.I2 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.
7-206.13 Tracking Powders,Pest Control and
Monittxm * CONSUMER ADVISORY -
22 3-603.11 Consumer Advisory Posted for Consumption of
TiMEfFEMPERATURE CONTROLSAnimal FoodsThat
Proper Cooking Temperatures are Raw.Undercooked or
for
PHFs Not Otherwise-Processed to Eliminate
Pathogens.*�° '""t
3-401.11A(1)(2) Eggs- 155`F 15 Sec:
E ggs-immediate Service 145'Fi5sec* 3-302.13_ Pa 'zed Eggs Substitute for Raw Shell
i E
3.401.1I(A)(2) Comminuted Fish.Meats&Game
Animals-155'P 15 sec.* SPECIAL REQUIREMENTS ,
3.401.11(13)(1)(2) Pork and Beef Roast- I300F'121 min*
3-401.11(A)(2) Ratites,Injected Meats-155'F 15 590.004(A)-{D) Violations of Section temporary and .in
I * catering, mobile food,temporary and
sec.
3-401.11(A)(3) Poultry,Wild Game,Staffed PHFs, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-165'F 15 sec. * above if related to foodborne illness
{ 3-401.11(C)(3) Whole-muscle,law Beet Steaks interventions and risk factors. Other
145°F* 590.009 violations relating to-ZOd retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165F* Special Requirements.
3-101A I(A)(1)(b) All Other PRFs-145 F 15 sec.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICE'S
3-403A I(A)&(D) PHFs I65-F 15 sec. * (Items 23-30)
3-403.11(B) Microwave 165`F 2 Minute Standing -Critical,mrd non-critical violations, which do not relate to the
Tire* - foodborne illness inlervendfam and risk factors listed above, carr be
3403.11(C) Commercially Processed RTE Food- found in the following sectionsofthe Food Code mrd 105 CMR
1400F* 590.0010.
3403.11(E) Remaining Unsliced Portions of Beef item I Good Retail Practices FC 590.000
Roasts* - 23. ; Management and Personnel
18 Proper Cooling of PHFs 24 1
'Food and Food Protection FC-3 .004
e�
3- 125. Equipment and Utensils ^_i FC-4 .005
501.14{A) Cooling Cooked PHFs from 140'F m i A, Water.Plumbing and Waste i FC-5 006
70'F Within 2 Hates and From 70'F 27. ( physical Facia FC-6 .007
rf to 41`F/45'F Within 4 Hours.* i 28. ' Poisonous or Toxic Materials FC 7 .008
3-501.14(B) Cooling PHFs blade F1vm Ambient 29. Special Requifernaints -- .008
Temperature Ingredients to 41 0171450F 1 30, I Other
` Within 4 Hours*
[ "Denotes critical acro in the federal 1999 Food Cale w'103 CYIR 590.000,
t
l
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: Date: / Pager_ of
Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION tete,
No. Relerence R-Red Item Verlfled
PLEASE RINT CLEARLY
c 1 a z l'J
t 4
C (0641
t
L� V s :
e
f 1J c".14.65 f e Y
C
s OrLI.
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 t my-five dollars or uspension/revocation of c3 Embargo ❑ Emergency Closure
your food permit. Q
'l���JJJAAA���.��� XA 13 Voluntary Disposal ❑ Other:
,
r
3-501.14(C) PHRs Received at Temperatures
Violations Related to Foodborne Illness interventions and Risk According to Law Cooled to
S Factors(Hems 1-22) (Cont.) _41°F/45`F Within_4_Hoins. *
PROTECTION FROM CHEMICALS 3-501.15 Coolie Methods for PHFs
19 Food or CA r Additives 3-501.16(B)
PHF Hot and Cold Holding
3-501.16(B) Cold PHFs Maintained at or below
( 3-202.12 Additives*'
3-302.14 Protection from Una ,roved Additives" 3-50-501L16(A) °/d5°F*
4{F) 41 H
3Hot PtIF3 Maintained of or above
Ig Poisonous or Toxic Substances 140°F *
7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130'F.
Cantainers* 20 Time as a Public Health Control
7-102.11. Common Name-Working Contamers* -
* 3-501:19 - Troia eve a Public Health Cerntrat*
7-201.11 Separation-Stora
7-202.11 .Restriction-Presence and Use* - 590.()44{Hl Variance Re uirement
7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP
7-204.11 Sanitize".Criteria-Chemicals*
7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and
7-204.14 Drying Altmt&Criteria* Bevera s with Wanting Labels*
3-801.11(B Use of Pasteuriml Eggs*
` E7-206.1
Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and
t Restricted Use Pesticides,Criteria* Raw Seed S ms Not ServedRodent Bait Stations* 3-801.11 C Uno ned Ftwd Pucka Not Re-served.
Tracking Powders, Peat Control and
Monitor n * CONSUMER ADVISORY
i ,
! - 22 3-603.11 ConstmterAdvisory Posted for Consumption of
TIME(FEMPERATURE CONTROLS Animal Foods That are Raw.Undercooked or
16 - Proper Cooking Temperatures for
r PHFs Na Otherwise Processed to Eliminate
1 - - Pathogens."me°rre tn.-mei
3-40f.lIA(1)(2) Eggs- 155°F 15 See.
Eggs-Immediate.Service 145°Fl5see- 3-302.13 Pasteurized Eggs Substitute for Raw Shell
3401.11(A)(2) Comminuted Fish.Meats&Game
E *
Animals-155°F 15 sea
t TS
3-401.11(11)(1)(2) Pork and Beef Roast- 130°F 121 min* SPECIAL REOUns of Section
3-401.11(A)(2) Rallies,Injected Meats-155°F 15 590.009(A)-(D1 Violations of Section 590.x}9{A}-(D)in
4 sea * catering,mobile food,temporary and
{ 3-401.1I(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be
Jt Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-165°F 15 sec. * above if related to foodborne illness
3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
145*F* 590.009 violations relating to good ter,1
3401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165°F* Special Requirements.
9 3-401:11(A)(1)(b) All Other PHFs- 145'F 15 sec.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
r 3-403A 1(A)&(D) PHFs 165°F 15 sec. * (Items 23-30)
?,t 3403.11(B) Microwave-I65`F 2 Minute Standing Critical..wid non-critical violations,which do not relate to the 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 Cade and 105 CMR
r 140°F* 590.000.
3403.11(E) Remaining tinsticed Portions of Beef t itemi Good Retail Practices .fC 590.000 i
i Rests* } 23. Managementand Personnel _FC-2 .003 i
t Ig Proper Cooling of PHFs ! 2rt Food and Food Protection FC-3 .004
11
25, 1 Equipment and Utensils i FC-4 .005 7
3-501.14(A) Cooling Cooked PHFs from 140`F to 26, Water.Plumbing and Waste l FC-5 .006
70`F Within 2 Hours and From 70°F 27. ' Ph sical Faci' FC-6 007
to 41°F/45°F Within 4 Hours. * i 28. I Poisonous or Toxic Materials ! FC=7 .008 {
4 3-501.14(B) Cooling PHFs Made From Ambient 29. Special R uirements l .003 1
S1( Temperature Ingredients to 41'17/45°F ' 30 1 Other
Within 4 Hours* s:worm ::z=zc:
'Denotes crineai iv^m in the f--doral 1999 F<md Cmie at 105 CMR;90.000:
i
10
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,0 Floor
Division of Food and Drugs Salem, MA 01970-3523
Tel. (978)741-1800 Fax(978) 745-0343
City/Town of Address:
FOOD ESTABLISHMENT INSPECTION REPORT Tel.
Name 7HACCP
Type of Operation(s) T pe of Inspection
I F73 Food Service Routine
Address 2 Retail Reinspection
Telephone J ❑ Residential Kitchen Previous I sped''
tP� ❑ Mobile Date: (t (Q-'f'2
Owner YM ❑ Temporary ❑Preop ratio
❑ Caterer ❑Suspect Illness
Person-in-Charge(PIC) Time ❑ Bed&Breakfast ❑General Complaint
Inspector In: [I HACCP
09' Ou Permit No. ❑.Other
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Anti-Choking 590.009(E) E]IViolations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) [I.
corrective action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑
FOOD:,PROTECTION MANAGEMENT-: �_ _ _ _ _ - , ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
E]. - _ _ 13. Handwash Facilities
EMPLOYEEHEALTH _ ` - - - - - �: - ,
PROTECTION FROM'CHEMICACS;
❑ 2. Reporting of Diseases by Food Employee and PIC -
[114. Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded
- , __.� ,� __ _ ❑ 15.Toxic Chemicals
FOOD'FROM APPROVED SOURCE_ __ _.._a_ -
❑ 4. Food and Water from Approved Source , �TIME/TEMPERATURE"CONTROLS�(PotentlaltyMaiallous_F.oals) „'
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy.of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling
m
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-SUS.I:EPTIBLE=POPULATIONS':(HAP).
El21. Food and Food Preparation for HSP
El 10. Proper Adequate Handwashing
❑ 11. Good Hygienic Practices CONSUMER ADVISORY
❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related
Items) Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22):
of Health. Noncritical(N)violations must be corrected Official Order for Correction:Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code.This report,when signed below
C N by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2x590.0 order of the Board of Health. Failure to correct violations
24. Food and Food Protection (Fc-axsso.004)) cited in this report may result in suspension or revocation of
25. Equipment and Utensils (FC-4x590.005) the food establishment permit and cessation of food
6.Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order,you
27. Physical Facility (Fc-6x590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7x590.008) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION
S 4fadac
Inspector's Signature: Print rl
PICS Signature: Print: ✓Ct .Y Pagel oll
Violations Related to Foodborne Illness
Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT 8 ICrass-contamination
3-302.11(A)(1) Raw Animal Foods Separated from
I 590.003(A) Assn(meat of Res oosibilit Cooked and RTE Foods*
590.003(B) Demonstration of Knowledge" Contamination from Raw ingredients
2-103.11. Person in charge-duties 3-302.11(A)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTHOther*
Contamination from the Environment
2 590.003(C) Responsibility of the person in charge to 3-302.11(A) Food Protection*
require reporting by food employees and 3-302.15 WashinE Fruits and Vegetables
applicants* 3-304,11. Food Contact with Equipment and
590.003(F) Responsibility Of A Food Employee Or An
Utensils*
Applicant To Report To The Person In Contamination from the Consumer
Charge*
590.003(G) Reporting by Person in Charge* 3-306.14(A)(.B- Returned Food and Reservice of Food*
3590.003(D) EecIusionS and Restrictions* Disposition of Adulterated or Contaminated
Food
590.003(E) Rmovad of Exclusions and 1Restdctions 3-7111.11 Disvarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Fotxf*
d 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*
3201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water
3-202.13 Shell Eggs* Sanitization Temperatures*
3-202.l4 Eg,,s and Milk Pr ducts.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH,
3-202.16 Ice Made From Potable Drinking water" concentration and hardness. *
5-101.11 Drinking Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and
590.006(A) Bottled Drinking Water' Utensils Clean*
4-602.11 Cleaning Frequency of. ui -mentFood
590.006,(B) Water Meets Standards,is 310 CMR 22.0* Contact Surfaces and Utensils*
Shei ish and Fish From an Approved Source -
4-702.11 Frequency of Sanitization of Utensils and
3-201.14 Fish and Re reahonaily Caug t Mohascan Food Contact Surfaces of Equipment*
Shellfish*
4-703.11 Methods of Sanitization-Hot Water and -
3-201.15 Menu sag Shellfish from NSSP l star Chemical*
Sources* 10 Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Re MatoAuthcrt 2-301.11 - Clean Condition-Hands and Arms*
3-202.18 Shellstock ldentiflcationPresent` 2-301..1'2 Clearrine Procedure*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3=201.17 Game Animals* . Il Good Hygienic Practices
3 Receiving/Condition 2-401.11 Eatin ,Drinking or Using Tobacco*
3-202.11PHFs Received at Proper Temperatures* - 2401.12 Discharges.From the Eyes,Nose and
3-202.15 Package lute sit * Mouth*
3-10L]t _ Food We and Unadulterated* 3-301.12 Preventing Contamination When Tasting*
6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* 590.004(F,) Preventing Contamination.from
3-203.12 Shellstock Identification Maintained* Employees*
Tags/Records;Fish Products 13 Handwash Facilities
3-40^<.11 Parasite Destruc;ion* �-
Conveniently Located and Accessible
3-402.12 Records.Creation and Retention* 5-203.11 . Numbers and Capacities*
590.004(1) Labeling of Ingredients' 5-204.11 Location and Placement*
7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance
/HACCP Plans Supplied with Soap and Hand Drying -
3-502.11 Specialized Processing Methods* Devices
3-502.1.2 Reduced oxygen packaging,criteria* 6-301.11 Handwashin Cleanser-Availability
8-103.12 Conformance with Approved Procedures" F6-301.12 Hand-D -n Provision
Denotes critical item io.the federal t999 rood Code or 105 CMR 590.0(N).
CITY OF SALEM
I
BOARD OF HEALTH
Establishment Name: 12r C f�i1�t/�r 3sa v Date: k'I Page:_ of
Rem Code C-Critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date`
No. Reference R-Red Item Verified
PLEASE PRINT CLEARLY
�J� N10 ZA I IL
J
5�)l.v _r
r IS
O
c15 /-rc _64
6U - ,c/.
f Al.A„ f-
n1
9z C
wAbh/1 ✓- Fes'.
a
Discussion With Person in Charge: Corrective Action Required: ❑ No Yea
I have read this report, have had the opportunity to ask questions and agree to correct all Voluntary Compliance ❑ Employee Restriction
113 /
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
noncompliance may result in daily fines of twenty-five dollarsoY�! --ion/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
❑ Voluntary Disposal ❑ Other:
3-501.14(C) PHR Received at Temperatures
Violations Related to Foodborne 111ne,ss.interventions and Risk According to Law Cooled to
Fmctors(Itema 1-22) (Cont.) 41°F145°F W thio 4 Hours. *
3-501.15 C(*Iing Methods for PRFs
PROTECTION FROM CHEMICALS 19 PHF Hot and Cold Holding
14 - Food or Color Additives 3-501.76(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 PRFs Maintained at or above
15 Poisonous or Toxic Substances 1407
7-101.11 Identifying Information-Original 3-501.16(.9) Roasts Held at or above 130°F.
Containers* 20 Time as a Public Health Control
7-i 02.11. Common Name-Working Containers*- 3-501.19 Time as a Public Health Control*
7-201.i I Separation-Storage* - 590.004(H) Variance Requirement
7-202.21 .Restriction-Presence and Use*
7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP
7-204.11. Sanitizers.Criteria-Chemicals* 21 3-801.12(.0.) Unpasteurized Pre-packaged Juices and
7-204.12 Chemicals for WashingProduce,Cdtena* - Beverages with Warning Labels*
7-204.14 Drying Agents.Criteria* 3-801.118 Use of Pasteurized E mss*
7-205.11 Incidental Food Contact,Lubricants* 3-801.11 @) Raw or Partially Cocked Animal Food and
7-206.11 Restricted Use Pesticides;Criteria* Raw Send Sprouts Not Served
,,-206.12 Rodent Halt Stations' 1-801.11(C) Unopened Food Package Not Re-served.
7-206.13 Tracking Powders,Pest Control and
Monitorin * CONSUMER ADVISORY
CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
TlMEII EMPERATURE CON
16 Proper Coal TRing Temperatures for . Animal Foods That are Raw,Undercocdted or
Not Otherwise Processed to Eliminate
PHFs Proper
Pathogens,'`'b`"'a"4`
3-401.11A(1)(2) Eggs- 155F 15 Sec.
Eggs-Immediate Service 145°F15sec* 3-302.13. Pasteurized Eggs Substitute for Raw Shell
E �`
3-467.11(A)(2) -Comminuted Fish.Meats&.Game -
Animals-155°F 15 sec.* SPECIAL REQUIREMENTS
3.401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 min* 590-009(A)-(D) Violations of Section 590.009(A)-(D)in
3-401.11(A)(2) Ratites,Injected Meats-155°F 15
catering, mobile food,temporary and
sec.*
3401.11(A)(3) Poultry,Wild Game,Stuffed PBFs, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-165°F 15 sec. * above if related to foodborne illness
3401..11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
145T* 590.009 violations relating to good retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165°F* Special Requirements.
3.401.11(,A)(1)(b) All Otber PHFs-145°F 13 sec.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-403.11(A)&(D) PHFs I65-F 15 sec.* (Items 23-30)
3-403.11(B) Microwave 165`F 2 Minute Standing Crilical,and non-critical violations,which do not relate to the
Time* foodborne illness interventions and risk factors listed above, can be
3-403AI(C) Commercially Processed RTE Food- found in the folloxing sectionsof the Food Code acrd l05 CMR
140°F* 590.000.
3-403.11(E) Remaining Unslioed Porti ns of Beef Beret . Good Retell Practices FC 58tLOg0
:Roasts* 23. I Management and Personnel -FC 2 .003
18 Proper Cooling of PRFs 24. Food and Food Protection FC-3 .004
25. a moment and Uteostis + FG-4 .005 I
3-501.14(0) Coating Cooked PHFs from 140°F to 26, Water.PlumbirM and Waste I FC-6 .006
70°F Within 2 Hours and From 70cT F 27. Physical Facility FC-6 007
to 410F/45°F Within 4 Hours. * i 2& Poisonous or Toxic Materials ! FC 7 .ow
3-501.14(B) Cooling PHFs Made From Ambient Special Requirements,
.009 I
Temperature Ingredients to 41°F/45°F 1 I def --------.---_
Within 4 Hours* ss r mea
"I7enc4 is critical item in the federal 1999 Fcmd Code or IV CMR 590.000.