3N CONVENIENCE - ESTABLISHMENTS (2) 3A/ (bAV(A10ff
3-� pataIlll (Oki
universal one
www.myuniversalop.com
phone: 1-800-756-4676
UNV16162
MADE IN USA
Commonwealth of Massachusetts
City of Salem
Board of Health Kimberley Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 12/20/2011
ESTABLISHMENT NAME: 3N Convenience
File Number:BHF-2004-000112 3-5 Paradise Road
Salem MA 01970
LOCATED AT: 03-5 PARADISE ROAD
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
RETAIL FOOD BHP-2012-0108 Jan 1,2012 Dec 31,2012 $280.00
TOBACCO VENDOR BHP-2012-0114 Jan 1,2012 . Dec 31,2012 $135.00
Total Fees: $415.00
PERMIT EXPIRES ecember3l, 2012
Board of Health
}
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must beP osted
in a prominent location in the Establishment... .
In accordance with the State Sanitary Code,beofre any rev onations,improvements,or equipment changes are made,
all plans for such must be submitted to and approved by the Salem Board of Health. Page 1
r �
` CITY OF SALEM, MASSACHUSE"ITS
' BOARD OF HF—kLTH
120 WASHINGTON STREET,4.,.FLOOR
KINIBERLEY DRISCOLL TEL.. (978) 741-1800
N1.1]'OR
FAX(978) 745-0343
lrameLn[ -dem com
LARRY RAhIDIN,RS/RF1IS,(j 10,CP-I'S
HFAi a'I i;1(i I'.NI'
2012-APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT �c� LID N V E N I.16'N ae TEL#_ O� `3
ADDRESS OF ESTABLISHMENT E14A!-W FAX#
MAILING ADDRESS(if different) TJ Ar M& p 10)7�0
EMAIL-Business`.
A F ' Website:
OWNER'S NAME N r--N- �t -----_ �V V 1��Z L lu�fEL#
ADDRESS
STREET CITY
STATE ZIP
CERTIFIED FOOD MANAGER'S NAME(S)_
(Required in an establishment where potentially hazardous food is prepared) ICERTIFICATE#(S)
EMERGENCY RESPONSE PERSON_ 6)1 I U
UDIN HOME TEL# � �4L -83��
;DAY,SOF+OPERATION ' -; - Mond Tuesda , :i. Wed �
fm,�, %Thursda si
HOURS DF OPERATION I °It I� Al I Saturda Surto
Please write in tfrne of day. 6 '111 i
AV
Forexampleltam-11pm
TYPE OF ESTABLISHMENT
RETAIL STORE NO FEE check only)
- —--
less than 1000sq.ft. _$ 7 ---
1000-10,000sq.ft. =$280
--------------------------
more than 10,000sq.ft. = 4 0
RESTAURANT --- ---
YESNO -------------- -----------------------------------------
(Outdoor Stationary Food Cart$210) less than 25 seats =$140
25-99 seats =$280
more than 99 seats =$420
BED/BREAKFAST/ YES NO-- ------ -----
- ---------------------------------------------------------- ---$100---
CHILDCARE_SERVICES/NURSING ADDITIONAL HOME--.---
PERMITS ----------------------------------------------------
MAKE(not just serve) ICE CREAM, YOGURT/SOFT SERVE YES
TOBACCO VENDOR $25
ALL NON-PROFIT(such as church kitchens) YES 'NO g
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 1,to my best knowledge and belief,have filed all state tax
returns and paid all state taxes required under the law.
Sigta[ttre Date
1 - Social Security or Federal Identification Number
Updated 523/11 FOODAP2011.adm Check#&Date ) 1 a r CY9
CITY OF SALEM, MASSACHUSETTS
I3oARD OF HE\r of
120 W1 vSHINGTON STREET,4'" FLO()li
KIMBERLEY DRISCOLL TEL.. (978) 741-1800
MAYo1Z Kmv (978) 745-0343
1ramdm@sa1cjn.com
LiARRY RANIDIN,RS/RI;I IS,CHD,CP-PS
WI Aj 171 A(;FN F
This Form will be collected during your next Board of Health inspection.
QUESTIONAIRE - GREASE TRAPS 2009
1. NAME OF ESTABLISHMENT: �� N e0rq VeN 1 EN c
2. ADDRESS OF ESTABLISHMENT:_ (DARPr 0 15 C R OA,-D � S h Letv ,
6-y10t97�0
3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP? 0
4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT HAVE?
CAPACITY IN GALLONS__ � -
5. HOW IS THE GREASE TRAP MAINTAINED? ON A DAILY BASIS? BY AN IN-HOUSE PERSON OR
BY AN OUTSIDE CLEANING SERVICE?
6. WHAT IS THE FREQUENCY THAT THE GREASE IS REMOVED FROM THE TRAP?
7. WHAT IS THE NAME OF THE FIRM WHO REMOVES AND/OR PICKS UP THE GREASE FROM
YOUR ESTABLISHMENT? r
8. WHAT IS THE DATE OF YOUR LAST INVOICE FROM THE REMOVAL FIRM?
Massachusetts Departmentl.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 Dae !M
of Ooeration(s) Tvoe of Inspection
/ ❑ Food Service ❑.Routine
Address3' is ® Retail �] Re-inspection Level ❑ Residential Kitchen Previous Inspection
Telephone
❑ Mobile Date: 'cj a6
Owner / HACCP Y E batererary ElPre-operation
❑Suspect Illness
Person in Charge(PIC) - Time ❑ Bed&Breakfast ❑ General Complaint
Inspector I
Out;24)' El HACCP
Permit No. ❑Other
Each violation checked r quires an explanation on the narrative page(s)and a citation of speclfic 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.
VI 3S ctirre cec)
FOOD PROTEgTtON MANAGEMENT __ - ❑ 12. Prevention of Contamination from Hands
El 1. PIC Assigned/Knowledgeable/Duties
�MPLOYEE HEALTH _.
--
13. Handwash Facilities
- __ PROTECTIO
: N FROM CHEMICALS
[:]
` 2. Reporting of Diseases by Food Employee and PIC -`�
r_ ❑ 14.Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded
❑ 15.Toxic Chemicals
FOOD FROM APPROVED
❑ 4. Food and Water from Approved Source TIMENEMPERATURE CONTROLS(Potentially Hazardous Foods)""
❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures
` ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling
PROTECTION FROM CONTAMINATION , ❑ 19. Hot and Cold Holding
❑ 8.Separation/Segregation/Protection ❑ 20.Time As a Public Health Control
- -
❑ 9. Food Contact Surfaces Cleaning and Sanitizing FIREQUIREMENTS FOR HIGHLY-- -SUSCEPTIBLE.POPULATIONS(HSP)!
El 21. Food and Food Preparation for HSP
El 10. Proper Adequate Handwashing
❑ 11. Good Hygienic Practices [CONSUMER.ADVISORY_ «.
E]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 iv by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2) order of the Board of Health. Failure to correct violations
24. Food and Food Protection (Fc-3)(590.0 so.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 (FO-6)(590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7)(510.118) 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:swavpec,Fom6ra.ox
Inspector's Signature: 1 Prinf:,,.
PIC's Signature: S Prink Page-, of Pages
U
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION _
$ Cross-contamination
FOOD PROTECTION MANAGEMENT 3-30111(A)(1) Raw Animal Foods Separated from
1 590.003{A) Assn+ mentofRes nnsibi,ht
_ Cooked and RTE Foods*
590.003(8) Demonstration of Knowled e* - 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 3requ -302.71(A) Food Protection"
applicants*ire repottingby food employees and 3-302.15 WashingFruits and Vegetables
applicants* 3-304.11 Food Contact with Equipment and
590.003(F) Responsibility Of A Focal Employee Or An
Uiensihs*
Applicant To Report To The Person In Contamination from the Consumer
Charge* 23
__ -1306. Returned Food and Reservice of Food*
590.003(G) Reortin b Person in Charge* Disposition of Adulterated or Contaminated
31 590.003(D) Exclusions and Restrictions* Food
590.003(E) Removal of Exclusions and Restrict ons 3-701.11 Discarding or Reconditioning Unsafe.
FOOD FROM APPROVED SOURCE Ftp*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water
3-201.12 F<xrd in a Hermetically Sealed Container* Sanitization Temperatures* -
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water
3-202.)3 Shell Eggs* Sanitization Temperatures*
3-202.14 Eggs and Milk Products.Pasteurized* 4-501,11.4 Chemical Sanitization-temp.,pH,
3-202.16 Ice Made From Potable Drinking Water* concentration and hardness.*
5-t01.i:1 Drinking Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and
590.006(A) Bottled Drinking Water* Utensils Clean*
590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food
-
Shellfish and Fsh From an Approved Source Contact Surfaces and Utensils*- '-
4-702.11. Frequency of Sanitization of Utensils and -
3-201.14 Fish and Rearoationally Canght 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
Regulatory Authority Game and Mushrooms Approved by 2-301:11 Clean Condition-Hands and Arms*'
Aut
3-202.18 Shellstock Identification Present* -2-301..12 Cl-,caning Procedure*
590.004(C) Wild Mushrooms' 2-301.14 When to Wash*
3-201.17 Game Animals* 11 i Good Hygienic Practices
5 Receiving/Condition `2-401.11 Eatin ,Drinking or Using Tobacco*
3-202.11 PHFs Received at Proper Temperatures* `2-401.12 Discharges From the Eyes,Nose and
3-20115 Package lnte-ri[ * Mouth*
3-101.11 Food Safe and Unadulterated* 3-30]12 Preventing Contamination When Tasting*
6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification,'* 590.0(14(E) Preventing Contamination from
3-203.12 Shellstock Identification Maintained* Em lovees*
Tags/Recoids: Fish Products 13 Handwash Facilities
3402.11 Parasite Destruction*
Conveniently Located and Accessible
3-402.12 Records,Creation and Retention* 5-203.17. Numbers and Capacities*
590.004(J) Labeling of Ingredients, 5-204.11 Location and Placement*
7 Conformance with Approved Procedures
5-205.1) Accessibility,Operation and Maintenance
IHACCP Plans - Suppled with Soap and Hand Drying
3-502.11. Specialized Processing Methods* Devices
3-502.12 Reduced oxygen packaging.criteria'
6-301.11 Handwashin Cleanser,Availability
8-103.12Conformance with Approved Procedures*
b-301.1.2 Hand Drying Provision
D notes critical item in the Federal 1999 Poi Cie or 105 CMR 590.000.
Massachusetts Department ;of Public.Health Salem Board of Health
Division of Food and Drugs ,., 120 Washington Street,4th Floor
Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax,(978) 745-0343
Name ` ' Dat Tvoe of Operations) Type of Inspection
13 �/ r3n VrA IP C� ❑ Food Service ® Routine
Address ( Ri Retail O Re-inspection
Level Residential Kitchen Previous Inspection
Telephone f ❑ Mobile Date:
Owner HACCP Y/N ❑ Temporary' ❑ Pre-operation
la n ElCaterer El suspect Illness
Person In Charge(PIC) l Time ❑ Bed 8 Breakfast ❑ General Complaint
El HACCP
Inspector out 3J Permit No. ❑Other
Each violation check d requires an explanation on the narrative page(s) and a citation of specific provision(s) violated.
Noncompliance 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
t. PIC Assigned/Knowledgeable/Duties
❑
EMPLOYEE HEALTH 13. Handwash Facilities
-- - - PROTECTION FROM CHEMICALS _
El 2. Reporting of Diseases by Food Employee and PIC
❑ 14.Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded
El____ _ 15.Toxic Chemicals
FOOD FROM APPROVED SOURCE.
❑ 4. Food and Water from Approved Source 71ME/TEMPERATUflE CONTROLS(Potentially HamMous Foods)
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans [118.Cooling
PROTECTION FROM CONTAMINATION k ❑ 19. Hot and Cold Holding
❑ B. Separation/Segregation/Protection ❑20.Time As a Public Health Control
[1 9. Food Contact Surfaces Cleaning and Sanitizing - REQUIREMENTS FOR HIGHLY SUSCEPTIBLE_POPULATIONS(HSP)
E]21. Food and Food Preparation for HSP
❑ 10. Proper Adequate Handwashing _
El 11.Good Hygienic Practices CONSUMER ADVISORY �+ �.. .
❑22!Posting of Consumer Advisories
Violations Related to Good Retail Practices Number of Violated Provisions Related
Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors(items 1-22):
of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code. This report,when signed below
C N by a Board of Health member or its agent constitutes an
24. Food and Food Protection (Fc-3)(590.00
4)
23. Management and Personnel (Fc-2)(sso.0 order of the Board of Health. Failure to correct violations
cited in this report may result in suspension or revocation of
25. Equipment and Utensils (FC-4)(590.005) p Y p
26. Water,Plumbing and Waste (FC-5)(590.006) the food establishment permit and cessation of food
establishment operations. If aggrieved by this order, you
27. Physical Facility (Fc-6)(590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7)(510.001) 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: ;
)lel a d 1,
S.S801nspecfPom514 Ex �( )
{,
`
Inspector's Signature: P[alt.
�-
P t;n t
PIC's Signature: S ,e C� Print: c) b Page of Pages
' f
�F
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)(1) Raw Animal Foods Separated from
1 590.003(A) Assn* mentofRes nsibility* Foods*
Conked and RTE Raw
590.003(B) Demonstration of Krtowled e* Contamination from Raw ingredients
2-103.11. Person in charge-duties 3302A I(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 I(A) Food Protection*
require reporting by food employees and 3-302.1.5 Washing Fruits and Vegetables
applicants* 3-304.11. Food Contact with Equipment and
590.003(f) Responsibility Of A Food Employee Or An
Utensils*
Applicant To Report To The Person In Contamination from the Consumer
Charge* 3-306.14(A)(B) Returned Food and Reservice of Food*
590.003(0) Reporting b Person in Charge*
3 590.003(D) Exclusions and Restrictions* Food ionotAduUeratedorContaminated
590.003(P,) Removal of Exclusions and RestrictionsDiscarding or Reconditioning Unsafe
3-701.1 I
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 Wacewashing-Hot Water
3-201.12 Food in a Hermetically Sealed Container* Sanitization Ten eratures*
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water
3-202.)3 Shell Eggs* Sanitization Tem eratures*
3-202.14 Eggs and Milk Products,Pasteurized" 4-501.1I4 Chemical Sanitization-temp.;pH,
3-202.16 Ice Made From Potable Drinking Water* concentration and hardness.*
5-1.01..11 Drink n Water fnrm an Approved System*
4-601.,11(A) Equipment Food Contact Surfaces and
590.006(A) Bottled Drinking4-602.11 ClWater*
Utensils Clean"
590.006(B) Water Meets Standards in 310 CMR 22.0* g Frequency of Equipment Food-
Shellfish and Fish From an Approved Source
Contact Surfaces and Utensils*
4-702.11. Frequencyof Sanitization of Utensils and -
3-201.14 Fish and Recreationally Caught Molluscan
Shellfish* Food Contact Surfaces of E ui ment*
3-201.15 Molluscan Shellfish from NSSP Listed 4 703.11 Methods of Sanitization-Hut Water and
Chemical*
Sources* 10 Proper,Adequate Handwashing
Re Mato AuLiorif
Game and AutWild Mushrooms Approved by 2-301.1 I Clean Condition-Hands and Arms*
3-202.18 Shellstock Identification Present* 2-301..12 Cleaniniz Procedure*
590.004(0) 3Id Mushrooms* 2-301.14 When to Wash* _
3-201.17 Game Animals* 11 Good Hygienic Practices
S Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco*
3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and
3-202.1.5 Package hue sit * Mouth*
3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Comanunation When Tasting*
6 Tags/Records:Sheiistock 12 Prevention of Contamination from Hands
3-20218 Shelistock Identification* 590.004(E) Preventing Contamination from
_ 3-203.1 Shelistoek-Identification Maintainedi0 Em to•ees* -
Tags/Records:Fish Products 13 Handwash Facilities
3-402.11 Parasite Destruction* Conveniently Located and Accessible
3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities*
590.004(7) Labeling of Ingredients' 5-204.1.1 Location and Placement*
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 packaging,criteria* - fi-301.}1 _ Hindwashing Cleanser,Availability
8-103.12 Conformance with A roved Procedures*
b-301..1.2 HandD in Provision
r
*Denotes cridud item in the federal 1999 food Code o 105 CMR 590.000.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: K�C, Vn\l,Pr1 i(7,jCL Date: Ia(a t � Page: � of
Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date.
No. Reference R-Red Item - Verified
� - PLEASE PRINT CLEARLY
o A) (�i�o-��yv ,
I J� (naAcA QrA-AJr, P t ( 3 32;- c�)y 3 f a i te- i -4i i3 r -k a- a //
ch'1 J. t C�r/ f CIT .wtaxcl
' a3 f i ))!4-(4
-7- /® At,l M d t62,M? �A/ o t
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AhCJ`1 P S Ci-f 4L/J,.�C� f t l
i Cr f in � �4 ( 0 3J2:7 J
f?�1i a 1Yr l i 5= Jell, Y V '..
ft JA !e,, Acittial
rC/) tC4, f
i I N o M C'c nG f in) /!!
r
Discussion With Person in Charge: Corrective Action Required: ❑ No f Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ oluntary Compliance ❑ Employee Restriction!
violations before the next ins ection to observe all conditions as described, and to Exclusion
p , Re-inspection Scheduled ❑ Emergency Suspension
gomply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. �Y G�
❑ Voluntary Disposal ❑ Other:
_ I
3-501.14(0 PRFs Iteceived at Temperatures .
Vtotations Related to Foodbarne 111ness Interventions and Risk According to Law Cooled to
Factors(Eters 1-22) (Cont.) 41'F/45`17 Within 4 Hoius.
PROTECTION FROM CHEMICALS 3-501..15 Cooling Methods for PHFs
..._.-_....._._ jy PHF Not and Cold Holding
jq Food or War Additives 3-501.16(B) Cold PRFs Maintained at or below
3-202.12 Additives* 590.004(17) 4101450 F*
3-302.14 Protection from Unapproved Additives* 3-501.16(A) Hot PHFs Maintained at or above
15 Poisonous or Toxic Substances 140017. *
7-101,11 identifying Information-Original 3-501.16(A) Roasts Held at or above 130'F.
Containers* Time as a Public Health Como!
7-102.11. Comm Name-WorkingContainers*
7-201.11 1 Separation-Storage* 3-501.19 Time as a Public Health Control*
7-202.11 .Restriction-Presence andUsc* 590•004(H) Variance Re uirement
7-202.12 Conditions of Use*
7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS(HSP) -
7-244.1.2 Chemicals for Washing Produce,Criteria* 21 3-801,11(A) Unpasteurized Pre-packaged Juices and
.Bevenaes with W-arnin*labels*
7-204.14 gots,Criteria° 3-801.11(B) 'Use of Pasteurized Eras* -
P7-206.13
05.11 Incidental Food Contact,Lubricants* 3-801A I(D) Raw or Partially Cooked Animal Food and
06.11 Restricted Use Pesticides;Criteria* Ram Seed Sprouts Not Served.
06.I2 Rodent Bait Stations* 3-801.11(C) Unopened Food Pack No Re-served.
Tracking Powders,Pest.Control and
Monitorin * CONSUMER ADVISORY
CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
TIMEtPEMPERATURE C
lb Proper Cooking Ing Temperatures for Animal Foods That are Raw,Undercooked or
PHFs - - Not Otherwise.Processed to Eliminate
Patbo mms.*
3-401.11A(1}(2) Eggs- 155°F 15 Sec.
EP,besve vi,2a:r
Eggs-Immediate Service 145'F15&ec- 3-302.13 Pasteurized Eggs Substitute for Raw Shell
3-401.11(A)(2) Comminuted Fish.Meats&Game
Eggs*
Animals-155'F 15 sec.*
3.401.11(B)(1)(2) Pork and Beef Roast-130'F 121 mm* SPECIAL REQUIREMENTS -
3-401.11(A)(2) Ratites,Injected Meats-155`1715 590.009(.0)-(D) Nidations of Section .590.009(.0)-(D).in
ce�* catering,,mobile ftmd,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-165F 15 sec. * above if related to foodborne illness
3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
145°17* 590.009 violations relating to good retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165'F* Special Requirements.
3-401AI(A)(1)(b) All Other PHFs- 145'F 15 sec.
17 Rahaating for Hot Holding WOLA77ONS RELATED TO GOOD RETAIL PRACTICES
3-103.41(x)&(D) PHFs 165T 15 sec.* (Items 23-30)
3403.11(B) Microwave- I65`F 2 Minute Standing Critical,and non-critical violations,which do not relate to the
Time* foodbome illness interventions and risk factors listed above, carr be
3-403AI(C) Conunerciaily Processed RTE Food- found in the following sections of the Food Code and 105 OUR
1400F* 590.000.
3-302.11(E) Remaining Unsticed Portions of Beef iHem , Good Retatl Practices I FC 590A6
Roasts: ; 23__ 1 Manamment and Personnel FC-2 .003 1
jg Proper Cooling of PHFs 24. i Food and Food Protection i FC-3 T.004
25. 1 Equipment and Utensils _ i FC-4 '0051
3-501.14(A) Cooling Cooked FRFs from 140'F to 26. 1 Water.Pltimbinq and waste FC-5 .005
70'F Within 2 Hours and From 70`F 27. 1 Physical Facility i FC-8 X007 j
to 41`Fi45°F Within 4 Hours. ° i 28. Poisonous or Toxic Materials FC-7 .008
3-501.74(B) Coating PHFs Made From Ambient
~29. S ecial Requirements 009
Temperature Ingredients to 41'F/45°F i 30. 1 Other .
Within 4 Hours* wr m zr
'Denotes critical Ivm in the L--doral 1999 Foci Cade 01 105 C-MR 590.000.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: C'!,[�V(ylil-A" Date: q) Pager of_
Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Data.
No. Reference R-Red Item Verified
�I { PLEASE PRINT CLEARLY I /i
1Pm Crena of j?-- Jrt/ I� tMJLfP Cw
A J.LI °4 t
/3
J / !
_ r
n ,
nc. On �uC�ivs
v � , -
WLJ4 �, ids
C. USG t'/f �,�' ♦' Q-�I.)�ll�i
G_-� 73 Ja u hl'r�b f.a 161 a4 , /}P2 as l; 14/4'-/ u
ro .Zw
�n r a I f7
1A Q
-,v _ I v c i 6N7
Discussion With Person in Charge: Corrective Action Required: ❑ No Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
violations before the next inspection, to observe all conditions as described, and to Exclusion
P Re-inspection Scheduled ❑ Emergency Suspension
LLntoncompliance
th all mandates of the Mass/Federal Food Code. I understand that
may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
permit. ��-
S� ❑ Voluntary Disposal ❑ Other:
3-501.141C) PHFs Received at Temperatures
Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to
Factors(Mems 1-22) {Cont.) 41'Ff45_F Within 4 Hours.
PROTECTION FROM CHEMICALS3-501..15 Coolin Methods for PRFs
ig PHF Not and Cold Holding
14 Food or Calor Additives
3-501.16(B) Cotd PRFs Maintained at or below
3-202.12 Additives*' 590.004(F) 41'145°F*
3-302.14 Protection from Unimproved Additives'¢ 3-501.16(A) Hot PHFs Maintained at or above
15 Poisonous or Toxic Subatances
t40°F.
7-101,11 ldemi6mg Information-Original 3-501.16(A) Roasts.Heid at or above 1300F.
Containers* 2® Tune as a Public Health Carrico!
7-102.11. Compton Name-Working Containers*
7-201.11 Separation-Stara e* 3-501,19 Time as a Public Health Control
7-202.11 .Resstiction-Presence and-Use* 590.004(H) Variance Requirement
7-202.12 Conditions of Use"
7-203.11 Toxic Containers-Prohibitions* REQUHRE DNS ti FOR IIlGtILY SUSCEPTIBLE
7-204.11 Sanitizers.Criteria-Chemicals* A.11(A) IONS HSP
7-204.12 Chemicals fir WashingProduce,Criteria' 21 3-$Ol.l l(A} Unpasteurized Pre-packaged Juices and
Drying encs.Criteria* Beverages with Warning Labels*
7-204.14
3-80L11iB Use of Pasteurized E *
7-205.11 Incidental Food Contact,Lubricants*
3-$01.11{D} Raw or Partially Cooked Animal Foal 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 Packs Not Re-served.
7-20fi.i3 Trat:king Powders,Pest Cantroi and
Morrtnnn * CONSUMER ADVISORY _
CONTROLS 22 3-603.11 Consumer advisory Posted fur t onsump6on gf
TIMFJTEMPERATURE Cfar Animal Foods That are Raw.Undercooked or
16 Proper Cooking ONTRTemperatures
PHFs - Not Otherwise-Processed to Eliminate
Pathogens.'
3-401.IIA(1)(2) Eggs- 155F 15 Sec txxs a:n xr
E es-Immediate.Service 145°F15see+ 3-302.13 Pasteurized Eggs Substitute for Raw Shell
3401.1I(A)(2) Comminuted Fish.Meats c4 Game Eggs*
Animals-155°F 15 sec.
3-001.11(11)(1X2) Pork and Beef Roast- 130OF 121 nip* SPECIAL REQUIREMENTS
laionsof
3-401.11(A1)(2) Ratites,Injected Meats-155`F 15 590.409(A)-(D) Violations of i Section 590.009(A)-(D)racyand .in
sec.
* catering,mobile ford temporary and
3401.1 t(A)(3) Poultry,Wild Came,Stuffed PHPs, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Poul or Ratites-165'F 15 see.* above if related to foodborne illness
3-401.11(0)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
145°F* 590.009 violations relating to good retail
3401.12 Raw Animal Fork Cooked in a practices should be debited under#29-
Micmwave 165°F* 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)&(D) PHFs 165°F 15 sec.* (items 23-30)
3-403.11(B) Microwave 165`F 2 Minute Standing Critical,acrd non-critical violations,which do not relate to the
Time* foodborne illness interventions and risk factory listed above, can be
3-403.11(C) Commercially Processed RTE Food- found in the fc1lowing sectionsofthe Food Code and I05 Cb,R
140°F* 590.004.
340111l(E) Remaining Unsliced Portions of Beef t lien ,Good Retail Practices FC 590.tiW ;
Roasts* S 23- ' Management and Personnel ! FC-2 (-003 -
ig Proper Cooling of PHFs 1 24. Feed and Food Protection FC-3 .004 I
1 25. I Equipment and utensils I FC-4 .005
3-501.14(A) Cooling Cooked PHFs from 140`F to n. Water.Plumbing and Waste i FC-5
70`F Within 2 Hours and From 70`F 2Physical Faciii FC-6 067
to 41`F/45°F Within 4 Hours. * i 26. ' Poisonous or To do Materials FC-7 1 .008
3-50L14f.6) Cooling PHFs Made From Ambient 29. Specta R uirements 009
Temperature Ingredients to 41°Ff45'F 30 -
Within 4 Hours*
'Dentis critical nara in the federal 1999 Food Cate or 105 C.MR 590.()00.
VnNVl, mcyulul
Time in: 10:03 AM 2/16/11
Time out: 11:07 AM 2/16/11
`�COMM£RCrAL Customer: 3 N CONVIENENCE
Pape: 1
Customer Information
3 N CONVIENENCE (9Y8)"0-' 0
3 PARADISE RD
SALEM, MA 01970-4229 -
Customer#: 4267513 ` 2,.
Customer Since: 9/23/04
Frequency: QTR
Last Svc Date: 11/17/10
Work Order #; 1.0507090990
Sales Agmt#; 1784644
Service Provided by
JOHN F SHEEHAN
Llcense/Cert #: 17625
ARTHUR H FLSLER(Supervisor)
Llcense/Cert#: 159y
TERMINI#INTERNATIONAL, 2397
84 CUMMINGS PARK
WOBURN, MA b1801-2125
(617)969-0038
Comments
Thank you for choosinq Terminix.Your business is appreciated.
THANK YOU
Customer payments can be made either at wwwAt-rrninix.com
or by mailing payments to: Terminix Processing Center,
PO Box 742592, Cincinnati, OH 4S274.2591. Please include
your customer number, noted above, Call 1-800-TERMINIX
with questions or to find Out about our Edey Pay 00t1011s.
Pest Control, Regular
Time in: 10:03 AM 2/16/11
Time out: 11:07 AM 2/16/11
41ilft..0-1COMM£RCIAL Customer: 3 N CONVIENENCE
Page: 2
Service Performed / Material Used /Target Pests
Mouse Glucboard- Amount: 2 EA
Cardboard Auts,Mice
STORAGE/UTILITY AREAS,6A5EMENl
- COMMERCIAL
Trap Placement
Trap
Conditions Observed
DISPLAY AREAS No Conditions
Rt51 ROOMS No Conditions
STORAGE/1.111LITY No Conditions
AREAS
T'd £U£0St?1K6T:01 TTL£0t,L82-6T 33113IN30NOO NC:WOJd 95:60 TT08-82-83d
I !
t
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 Da a TVDe of ODeration(s) T e f Inspection k1 PII lc a / E3 Food Service1.1-Routine
Address ( Risk Retail ❑ Re-inspection
'� �odiSC Level Residential Kitchen Previous Inspection
Telephone G O
/ r El Mobile Date:
Owner HACCP WIN El
Temporary ElPre-operation
j1 ❑ Caterer ❑Suspect Illness
Person in Charge(PIC) Time ❑ Bed&Breakfast ❑General Complaint
In: El HACCP
Inspector )24 Out J`� Permit No. ❑Other
Each violation checked requi s 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 [112. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
ElEMPLOYEE HEALTH 13. Handwash Facilities
EE _ - PROTECTION FROM CHEMICALS .A#, •h
❑ 2. Reporting of Diseases by Food Employee and PIC
C3 14.Approved Food or Color Additives
El3. Personnel with Infections Restricted/Excluded
_ ❑ 15.Toxic Chemicals
FOOD.FROM APPROVED SOURCE r -
❑
4--Food-and and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentlally Nazardoua Footle)'
❑ 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 HIGHLY SUSCEPTIBLEE POPULA.IIONS.(HSP,,
El21. Food and Food Preparation for HSP
El 10. Proper Adequate Handwashing
❑ 11.Good Hygienic Practices CONSUMER ADvfson a - 2
❑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-4)(590.0054)) cited in this report may result in suspension or revocation of
25. Equipment and Utensils (Fc-4)(550.005) 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)(510.006) 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:
sswinspecrFoma-ia.ex
Iuspector's Signature: - Print: J 'j
PIC's Signature: Priat: Page-L of /Pages
S Hyl J 1 U D-1) l �1
t
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION
S Cross-contamination
FOOD PROTECTION MANAGEMENT 3-302.11(A)(O Raw Animal Foods Separated from
1 590.003(A) Assignment of Responsibility* Cooked and RTE Foods*
590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients
2-103.11 Person in charge-duties 1 3-30211(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) Fnal Protection*
require reporting by food employees and 3-302.15 Washin Fmits and Vegetables
applicants* 3-304.11 Food Contact with Equipment and
590-003(F) Responsibility Ol'A Foal Employee Or An *
Applicant To Report To The Person In Utensils
Contamination from then
Co sumer
Char e* 3-306.14(A)(B Returned Food and Reservice of Food*
59(1.003 G) Reporting b Pets)n in Charge"
3 590.003(D) Exclusions and Restrictions* Disposition ofAduRerated or Contaminated
Food
590.003(E) I Removal of Exclusions and Re str et ons 3-901.11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE -- Food*
4 Food and Water From Regulated Sources r 9 Food Contact Surfaces
590.004(A-B) Compliance with Food Law*u 4-501..1.1 I 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-HotWater
3-202.13Shell Eggs* Sanitization Temperatures*
3-202.14 E s and Milk Products,Pasteurized* 4-501,11.4 Chemical Sanitization-temp.,pH,
3-202.16 Tee Made From Potable Drinking Water* concentration and hardness. *
5-101.11 DrinkingWater from an Approved System
4-601.11(A) Equipment Food Contact Surfaces and
590.006(A) Bottled Drinking Water* Utensils Clean*
590.006(B) Water Meets Standards in 310 CMR 22.0,` 4-602.11 Cleaning Frequency of Equipment Food-
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 Ree eat ona0y Caught Molluscan
Shellfish* Foal Contact Surfaces of Equipment*
4-703.11 Methods of Sanitization-}lot Water and
3-201.15 Sources*Molluscan ShellfishfrmnNSSPIa,ted Chermcal*
So10 Proper,Adequate Handwashing
Regulatory Authority Game and Mushrooms Approved by 2-301.11 - Clean Condition-Hands and Arms*
� ut
3-202.18 Shellstock Identification Present* 2-301..1.2 Cleaning Procedure*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201.17 Game Animals* 11 Good Hygienic Practices -
g Receiving/Condition 2-401.11 Eating,Drinking or Usin Tobacco*
3-202.1.1. PHFs Received at Proper Temperatures* 2401,12 Discharges From the Eyes,Nose and
3-202.1.5 Package Inte it'* Mouth*
3-101.11 Food Safe and Unadulterated* 3-301.12 PreventingContamination When Tastin *
Tags/Records: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 Destrnctiott*
Conveniently Located and Accessible
3-402.12 Records,Creation Numbers and Capacities*
and Retention* 5-204,11 Location and Placement*
590.004(1) Labeling of Ingredients'
q Conformance with Approved Procedures 5-205.l 1 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 Handwishing Cleanser, Availability
8-103.12 Conformance with Approved Procedures*
6-301.1.2 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: �/" Cln��/JI/Y/ / Date: / Pager of
Item Cafe C-Cdticaf item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Defe-
No. Reference R—Red Item Verified
PLEASE PRINT CLEARLY
if in �I /k. 0,14. A '�:T-A /.
n
�s o
7 nK is JL j f 3 r D40
f0
torr✓ v s Q ro1,9 1
I ice- I .. (6 J-CW. ) o4Vi
u.5 v AA)./ 1 17 r ?A l
i-FtJ ZE I 'Ide UAUp. n?,/
r KI �' -t¢ t/ )f A
tit, I�
Discussion With Person in Charge: Corrective Action Required: ❑ .No Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
violations before the next inspection, to observe all conditions as described, and toExclusion
comply with all mandates of the Mass/Federal Food Code. I understand that Re-inspection Scheduled 13 Emergency Suspension
noncompliance may result in daily/ of twen y-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. J ❑ Voluntary Disposal ❑ other:
3-501.t4(C) PHFs Received at Temperatures
Violations Related to Foodborne Illness interventions and Risk According to Law Cooled to
Factors(Itams 1-22) (cont.) 41'F/45'F Within 4 Hours.
PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs
14 Food or Color Additives I9 PHF Hot and Cold Holding
3-202.12 Additives*
3-50L16(B) ColdPHFs Maintained at or below
3-302.14 Protection from Una 590.004(F) 41°/45°F*roved Additives*
15 Poisonous or Toxic Substances 3-501.16(A) Hot PRFs Maintained at or above
140'F.
7-101.11 Identifying Information-Original 3501.16(A) Roasts Held at or above 130'F.
Containers*
7-102.11. Common Name-WorkingContainers* 20 Time as a Public Health Control
7-201.11 Separation-Storage* _ 3-501.19 Time as a Public Health Control"
7-202.11 .Restriction-Presence and Use*
590.004(11) Variance I nirement
7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP
7-204.11 Satntizers.Criteria-Chemicals* 21 3-801.11(A) Unpasteurized Pre-packaged Iuices and
7-204.12 Chemicals for Washing Produce,Criteria*
7-204.14 Drying Agents.Criteria* Beverages with Warning labels*
7-205.11 Incidental Food Contact,Lubricants* 3-801.1 IB} Use of Pasteurized Ea *
7-206.11 Restricted Use Pesticides,Criteria* 3-801..11(D) Raw or Partially Cooked Animal Food and
Raw Seed Sprouts 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
3-401.71A(i)(2) Eggs- 155°F IS Sec.
Pathogens.'E""'t
t
Eggs-Immediate Service 145'Fl5sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
3401.11(A)(2) - Comminuted Fish.Meats&Game Eggs*
Animals-155'F 15 sec.*
3401.11(B)(1)(2) Pork and Beef Roast- 1.30'F 121 ruin* SPECIAL REQUIREMENTS.
3-401.11(A)(2) Ratites,Injected Meats-155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
sec * catering,mobile food, temporary and
3-401.11(A)(3) Poultry,Wild Game,Stuffed 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
145OF* 590,009 violations relating to goal 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 PHFs-145'F 15 sec.
17 Reheating for Hot Holding VIOLAT)ONS RELATED TO GOOD RETAIL PRACTWES
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 intervention'and riskfaclors listed above, can be
3403.11(C) Commercially Processed RTE Food- found in the folloining sections of the Food Code and 105 CMR
140°F* 590.000.
3-403.11(E) Remaining Unsliced Portions of Beef nit Good Retail Practices I .FC 590.000
Roasts': - 2i 3. _i Manartement and Personnel I FC-2 .003 -I
18 Proper Cooling of PHFs 24. Food and Food Protection I FC-3 004
3-501.14(A) Cooling Cooked PHFs from 140'F to 25. Equipment and Utensils -� FC-4 005
26. Water,Plumbing and Waste I FC-5 006
70' Within 2 Hours and From 7V - 27. P - ical Facfii FG-6 .007
F
to 41'F/45'F Within 4 Hours.* 26. Poisonous or Toxic Materials i FC-7 .008
3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements ,00g
Temperature Ingredients to 41'F/45'F "�• Other
Within 4 Hours* s:wmwrzex
*D notes critical item in the federal 1999 Fuad Code or 105 CMR 590.000.
CITY OF SALEM
/ ��� BOARD OF HEALTH
Establishment Name:_ � tititl✓Oi11fa�l Lam/ Date: Page: of�
Nem Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date-,
140. Reference R—Red Item Verified
PLEASE PRINT CLEARLY
a /
4-- C I , o 1
f /bcl%P CvGJ _ /�n.N �� i
i Q,rl ' f T t r
,
l� I rP, , u -F itJ r
N I Z an 1-- tz
JVt n1hreI/ n� J
U.
}
/
Discussion With Person in Charge: Corrective Action Required: ❑ .No es
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
violations before the next inspection, to observe all conditions as described, and to Exclusion
comply with all mandates of the Mass/Federal Food Code. I understand that Re-inspection Scheduled ❑ Emergency Suspension
npncompliance may result in d ' Ines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. n �_ t U L3 Voluntary Disposal El Other:
i
3-501.14(0) PHFs Received at Temperatures
Violations Related to Foodborne illness interventions and Risk According to Law Cooled to
Factors(Hems 1-22) (Cont) 41'F/45"F Within 4 Hours.
PROTECTION FROM CHEMICALS
3-501A5 Cooling Methods for PHFs
14 Food or Color Additives 19 PHF Not and Cold Holding
--
3-202.12 Additives* 3-501.16(B) Cold PHFs 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'F. *
7-101.11 Identifying containers*
Information-Oziginal 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 Se aration-Storage* 3-501.19 Time as a Public Health Control*
7-202.11 .Restriction-Presence and Use* 590.004(H) Variance Re nixement
7-202.12 Conditions of Use*
7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS HSP
7-204.11 SanChemicas.ls
Criteria Chemicals* 2I 3-801.11(A) Unpasteurized Pre-packaged Juices and
7-204.12 Chemicals for WashingProduce,Criteria* Beverages with Warning labels*
7-204.14 d eats.Criteria* 3-801.11(B) Use of Pasteurized Eggs*
7-205.11 Incidental Food Contact,Lubricants,Criteria* 3-801.11(D) Raw or PartiallyCooked Animal Food and
7-218.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served*
7-206.12 Rodent Bait Statin,*
Tracking Powders,Pest Control and 3-801..1I(C) Unopened Food PackageNot Re-served.
7-206.13
Monitoring* CONSUMER ADVISORY
TIMEITEMPERATURE CONTROLS 22 3-603.11 Co,umet Advisory Posted for Consumption of
16 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or
PHFs NotOtherwise Processed to Eliminate
0c.1/1j 01
3401.11A(1)(2) Eggs- 155°F IS Sea PaWOns.*E9
Eggs-Immediate Service 145'F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
3-401.11(A)(2) Comminuted Fish.Meats&Game
Eggs*
Animal's-155°F 15 sec. *
3401.11(6)(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.* catering, mobile food, temporary and
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
3-40L 11(C)(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)(6) All Other PHFs- 145°F 15 sec.
17 Reheating for Hot Holding VIOLA77ONS RELATED TO GOOD RETAIL PRAC77CES
3-403A I(A)&(D) PHFs 165T 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(0) 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 Portio,of Beef j item Good Retail Preclices j .FC 590.000
Roasts,: �a23, Man g emeni and Personnel FC-2 _003 .!
18 Proper Cooling of PRFs 24. ( Food and Food Protection FC-3 .004
25. Equipment and Utensils
3-501.14(A) Cooling Cooked PHFs from 140'F to FC-4 .005
26. Water.Plombinmbin and Waste FC-5 .006--�
70°F Within 2 Hours and From 70'F . 27. Physical Facility FC-6 .007
to 41°F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials i FG-7 -008-1
3-501.14(B) Cooling PHFs Made From Ambient 29. S ecid R uirements I .009
Temperature Ingredients to 41'F/45°F - Other
Within 4 Hours*
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590SM.
I
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 Dat TVDe of 0 eration(s) Tvpe of Inspection
lJ inn 1 (/ ❑ Food Service ❑ Routine
Address7 J �/ Ris S Retail Re-inspection
`S /G/ r . Pt t Level ❑ Residential Kitchen Previous Inspect'on
Telephone
. 3 ( ❑ Mobile Date: a �
Owner �H HACCP V/-N- ❑ Temporary ElPre-operati n
❑ Caterer ❑ Suspect Illness
Person in Charge(PIC) Time ❑ Bed&Breakfast ❑General Complaint
In:3;,2D ❑HACCP
Inspector I Out: J 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-Chokin Tobacco
Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) � 590.009(F) ❑
action as determined by the Board of Health.
FOOD PROTECTION MANAGEMENT . _ . .�. ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
❑ 13. Handwash Facilities
[EMPLOYEE HEALTH_ _�_ - _ - _ - -_ -
- - - - PROTECTION FROM CHEMICALS
❑ 2. Reporting of Diseases by Food Employee and PIC _-
❑ 14.Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded
❑ 15.Toxic Chemicals
0 4. FROM APPROVED SOURCE Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods_).
4.
❑ 5. Receiving/Condition ~ ❑ 16.Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling
PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding
❑ 8.Separation/Segregation/Protection ❑20.Time As a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing _REQUIREMENTS FOR HIGHLY_SUSCEPTIBLE POPULATIONS_(HSP)
El21. Food and Food Preparation for HSP
' ❑ 10. Proper Adequate Handwashing
❑ 11. Good Hygienic Practices NONSUMER.ADVISORV •; � .,
❑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) 4order of the Board of Health. Failure to correct violations
24. Food and Food Protection (FC-a)(590.0oa)so.ocited in this report may result in suspension or revocation of
25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food
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: ) �t�
S'MnspeoWOo 14" IN
Inspector's Signature: Prim:
PIC'sSignature: s y ~ Print: S0.7eGQ Page_�of I Pages
LOCf CC <�q.jG� $Ir^�"A -� c"� PIC,/ /W(�w� (I} ���-'n✓f��n°c.f�.
Violations Related to Foodborne Illness
Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION
S Cross-contamination
FOOD PROTECTION MANAGEMENT 3-302.11(A}(l i Raw Animal Foods Separated from
1 590.003(A) Assignment of Responsibility* Cooked and RTE Foods*
590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients
2-1.03.11 Person in charge-duties 3-302.1,l(A)(2) Raw Ar irad Foods Separated from Each
Other"
EMPLOYEE HEALTH Contamination from the Environment
2 590.003(C) Responsibility of the person in chuge to 3-302.11(A) - Food Protection*
require reporting by food employees and 3-302.15 Washing Fruits and Vegetables
applicants* 3-304.11. Foci Contact with Equipment and -
590.003(F) Responsibility Of A Food Employee Or An *
Applicant To Report To The Person In Utensils
Contamination from the Consumer
Char e* 3-306.14(A)(B) Retuned Food and Reservice of Food*
590.003(G) RepordngbyPerson in Charge*
Disposition of Adulterated or Contaminated
3 590.003(D) Exclusions and Restrictions* Food
590.003(E) Removal of Exclusions and Restri'etions 3-701.1 t 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* 4-504.111 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-HotWater
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 Iee Made From Potable Drinking Water* concentration and hardness. *
5-101.'I I Drinking Water from an Approved System*tem* 4-60 LI I(A) Equipment Food Contact Surfaces and
590.006(A) Bottled Orin king Water* Utensils Clean*
590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food
Shefiiish and Fish From an Approved Source Contact Surfaces and Utensils`"
4-702.11 Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment*
Shellfish* 4-7033.11 Methods of Sanitization--Hot Water and
3-201.15 Molluscan Shellfish from NSSP Listed Chemical*
Sources* 10 Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Regulatory Author' 2-301.11 Clean Condition-Hands and Arms*
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure*
590,004(C) Wild Mushrooms- 2-301.14 When to Wash"
3-201.17 Game Animals* 1.1 Good Hygienic Practices
5 Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco*
3-202.11 PHFs Received at Proper Temperatures" 2-401.12 Discharges From the Eyes,Nose and
3-202.'(5 Package Integrity* Mouth*
3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting*
6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification * 590.004(F;) Preventing Contamination from
3-203.12 ShellstockIdentifrwtionMaintained* Employees*
Tags/Records:Fish Products 13 Handwash Facilities
3-402.11 Parasite Destruction*
Conveniently Located and Accessible
3-402.12 Records.Creation and Retention* 5-203.11. Numbers and Capacities*
590.004(1) Labeling of Ingredients' 5-204.11 Location and Placement*
conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance
lHAGCP Plans Supplied with Soap and Hand Drying
3-502.11 S ecialized Processing Metbods* 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 critiad item in the Federal 1999 Food Code or 105 CMR 590.000.
i
Commonwealth of Massachusetts
City of Salem
Board of Health
120 Washington Street,4th Floor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 03/29/2010
ESTABLISHMENT NAME: 3N Convenience
File Number: BHF-2004-000112 3-5 Paradise Road
Salem MA 01970
LOCATED AT: 03-5 PARADISE ROAD
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
RETAIL FOOD BHP-2010-0182 Jan 4,2010 Dec 31,2010 $280.00
TOBACCO VENDOR BHP-2010-0181 Jan 4,2010 Dec 31,2010 $135.00
Total Fees: $415.00
PERMIT EXPIRES IDecember3l, 2010
Board of Health AAASA
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all
plans for such must be submitted to and approved by the Salem Board of Health. Page 1
CITY OF SALEM, MASSACHUSETTS
• BOARD OF HEALTH
120 WASHINGTON STREET,4'FLOOR
TFL. (978) 741-1800
ICIMBERLEY DRISCOLL FAX(978) 745-0343
MAYOR DGREENBAUM&SALEM.COLI
DAVID GREENBAUIII,
ACTING HEALTH AGENT
2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
IC �� Q
NAME OF ESTABLISHMENT �/ LNIc`♦+\ ; TEL# b v ^ ✓
ADDRESS OF ESTABLISHMENT.� I Z,w,11 A E RoAb_ FAX#
MAILING ADDRESS(if different) 1� / rkT
EMAIL-Business': Website:
OWNER'S NAME ` S E TEL# 0
ADDRESS SAI E
STREET CITY STATE ZIP
CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S)
(Required in an establishment where potentially hazardous food 19 pep red) ye
EMERGENCY RESPONSE PERSON �T, RAJj V UTV I HOME TEL 03't
"bAI S O ,OPERA710NMon"day r -� Tuesday ' eline dayr .. ;',ThursdaysndaQW b%06y,.
HOURS OF OPERATION 'I
Please write in time of day.
For example Ilam-Plpm
TYPE OF ESTABLISHMENT FEE (check only)
RETAIL STORE YES NO less than 1000sq.ft.
1000-10,000sq.ft. $280
more than 10,000sq.ft. 20
------------------------------------------------------------ ----------
RESTAURANT YES NO less than 25 seats =$140
(Outdoor Stationary Food Cart$210) 25-99 seats =$280
more than 99 seats =$420
----------------------------------------------------------®R6BED
/BREAKFAST/ YES $100
CHILDCARE SERVICES/NURSING HOME -
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE NO $25
TOBACCO VENDORYES 11351
ALL NON-PROFIT(such as church kitchens) NO $2r
*Please pay total with one check payable to the City of Salem.
This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location
in the Establishment.
In accordance with the State Sanitary Code, before any renovations, Improvements,or equipment changes are made,all plans for
such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax
returns and paid all state taxes required under the law.
Signature Date Social Security or Federal Identification Number.
-------------- ------- -- -------
Revised 424/07 FOODAP2008.adm Check#&Da eir. ��a•=