The URL can be used to link to this page

EFFORTLESS EDIBLES - FIRST UNIVERSALIST CHURCH - ESTABLISHMENTS 'c EFFORTLESS EDIBLES (FiRST !!N[VFRSAL!ST CHURCH) 211 BRIDGE STREET 0 4 � e 1 ' u �I A O n II n �I !F O n Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street,4th Floor SALEM,MA 01970 DATE PRINTED: 02/10/2006 WHO'S PLACE OF BUSINESS IS: Effortless Edibles File Number:BHF-2003-0002 211 Bridge Street Salem MA 01970 LOCATED AT: 0211 BRIDGE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes TEMPORARY FOOD 13HP-2006-0407 Feb 10,2006 Feb 11,2006 $0.00 /TO BE SERVED: White Chocolate Peperment Bark,Choc. Dipped Shortbread,&Carmel Bars. Total Fees: $0.00 PERMIT EXPIRES IFebruary 11, 2006 Board of Health C� - Page 3 of 9 05 11 : 282 Joanne G.,nctt Salem BOH 078 745 0343 p, l �ITIY OF SALEM, 4ASG'ACHUSETTSU- _j(L -1 I,t cos- GOARD GF-HEALTH 12C VVA$HINGTQN STREF7, 4TH FUCN C108 P)404 �AL ., MA 0 1 1,TO TEL. 97N,;-74 1 1800 FAx 978,7a!f-0143 TAN(. ` U90VIC Jq. JOnNNSCOTT, MPH. RG: C- -HO L 7H A 0.F N T APPLICATKON FOR A TEMPORARY FOOD SEE-VICE PERMIT (O!`3' n-\eIr(e1-3 DAYS= i=c e I-or S:cs kc re)(�i,-pt-+ 4-7 DAYS= $300sse-s S�,kew So �MoRe THAN 7 DAYS 1/ $400 CHECK PAP AOLE IQ THE�-Ir'C)F$ILEN'NC)l'A"kH NAM,0=EvFxT 0,'Oc ;u*c-4-Wlv Lo ATION ,— I �U 2 co I, DATF{S}OFEVENT 4-rt "n- 422�Xlcr� luz ,_ . >NAME Of APPUCAN f__'_Tq jf e R05�( TELFPHONE-1 12k NAME CFUUSINESS -�;rTk ZELEPHONE4_ AL)DR 6c g4 CERTIFIED FOOD MANAGER�,;NAME, V_lf-f PLAN OF THE LETASUSHMENT IS __DRAVVN ON THE BACK r r , TYF�OF REFRIGERATION; --CA,9 —ICE --DRY WL _07�HFR METHOD FOR COOKiNG(HOT HOI.DING! _GAS _CTHrzR METHOD FOR SANITIZING CHEMICAL SOURCE OF Foto: NAME: __ADDRESS—, "RZQUlPIi MIEN'S cOr T2MFORARY Fk-)QQ ESTABLISHMENTS."I HAVE HAD THE Tr PORTI)NIT"( THEM,HEM, A ::Nb UNDFH=_,TANL) U�L 1UNDERST R i I-E ENAIl ES OF PLPQUR'r I Mil! 1, 7T)V1, 3FM, <NOW1 �:EDCE AVO E3E1.Ik:,F, HAVk FLEL)ALL ST ,IE TV, AND!'=AOAI S_,_-',TE 1-AXE3 RE3UPKED 6� — ? —t� 22 UNCE91AW t4 - SIZ ��;-r TS SOCIAL SECURITY DR F�CERAL ID --------------------- -------------- ------- ---------------_----------------------- --------- ------------ S� Commonwealth of Massachusetts �? City of Salem Kimberley Driscoll V- f d BoaroHealth Mayor �MINB 120 Washington Street,4th Floor SALEM,MA 01970 Temporary Food Permit DATE PRINTED: 08/18/2006 WHO'S PLACE OF BUSINESS IS: Effortless Edibles File Number: BHF-2003-0002 Salem National Maritime Historic Site 211 Bridge Street Salem MA 01970 LOCATED AT: 0211 BRIDGE STREET SALEM, MA 01970 Permit Type Permit Issued Permit Expires Fee Restrictions/Notes TEMPORARY FOOD Aug 18,2006 Aug 21, 2006 This permit for Salem National Maritime Historic Friendship at Derby Wharf. Food to be served Shrimp Cocktail, Med.Platter, Cheese Platter. Foods donated from Finz,A&J King Bakery,&Front St. Coffee House. Total Fees: PERMIT EXPIRES August 21, 2006 Board of Health Commonwealth of Massachusetts City of Salem e Kimberley Driscoll Board of Health Mayor #i .gam 120 Washington Street,4th Floor "eye SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/11/2006 WHO'S PLACE OF BUSINESS IS: Effortless Edibles File Number:BHF-2003-0002 211 Bridge Street ' Salem MA 01970 LOCATED AT: 0211 BRIDGE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2006-0330 Jan 11;2006 Dec 31,2006 $50.00 ESTABLISHMENT Total Fees: $50.00 PERMIT EXPIRES December 31, 2006 Board of Health 40 F This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 4 of 10 CITY OF SALEM, MASSACHUSETTS �e BOARD OF HEALTH ( s 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 JAN G5 2006 TEL. 978-741-1800 STANLEY J. USOVICZ, JR. FAX 978-745-0343 CITY OF SALEM MAYOR WWW.SALEM.COM BOARD OF HEALTH JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT 2� Ko. E(eS5 fid„ bleZ TEL# -2 S--77� ADDRESS OF ESTABLISHMENT �Ll t ,JTt r1r1P Sl S'a IC"" V MAILING ADDRESS (if different) pD OWNER'S NAME TEL# 7YS-/oS�s— ADDRESS cI Pi 5 CITY Salevn STATE PA/+- ZIP 0/9 >6 CERTIFIED FOOD MANAGER'S NAME(S) ERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON -IV, l"e /�d S e- HOME TEL# HOURS OF OPERATION: Mon.___y_Tue. _Wed. /_Thu. Fri. _Sat. �Sun�jS�' TYPE OF ESTABLISHMENTes RETAIL STORE YES NO SCJ less than 1 OOOs .ftft . = 50 �� ,) 1000-10,000sq. . =$100 v more than 10,000sq.ft. =$250 - ----- -- _- -- ........- -- RESTAURANT YES NO less than 25 seats $100 25-99 seats =$150 - more than 99 seats -$200 -------- - - - --------- -----... -------------- BED/BREAKFAST YES $100 - - ----------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YESnNO $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 know) a and belief, have filed all state tax returns and paid all state taxes required under the law. 11777h7 Signat re Date Social Security or Federal Identification Number --------- -----------------------------------------------------N-------------------------------------------------------------------- Revised 11/03/05 FOODAP2.adm Check#&Date / 3o is-3/-as- Jv Massachusetts Department of Public Health Salem Board S 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 T Pe of Operation(s) Tilde of tnsnection" fid' _/ac Ja-M, - 04 Food Service (] Routine Address �f Risk ❑ Retail ❑ Re-inspection -9 it 4 v. „ > Level ❑ Residential Kitchen Previous Inspection Telephone E] Mobile Date: 7u'> �/ ❑ Temporary El Pre-operation Owner HACCP Y/N ❑ Caterer [I Suspect illness i.-/ ice nor Person in Charge(PIC) Time E] Bed&Breakfast Ll General Complaint i1 r z (, �;o ❑ In: HACCP Inspector 1 f f i// ,`>7! c Out: Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 599.006(F) ❑ action as determined by the Boar2!'bofaHealthc FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH - PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/RecordslAccuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding r ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing CONSUMER ADVISORY .- ❑ 11.Good Hygienic Practices [122, Pasting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C N " by a Board of Health member or its agent constitutes an - 23. Management and Personae! (FC-2)(590.003} order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (�C-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:5901repeciFomr6-14.tloc Inspector's Signature: Print: PIC's Signature: Print: :S 4 I, f �Os e_ Page,of 9Pages t Ile Violations Related to Foodborne fitness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT K Cross-contamination 1 I 590.0031A) Assi nintent of Res aonsibilitli* 3302.11(A)(1) Raw Animal Foods Separated horn 590.603(8) Demonstration of Knowledge* Cooked and RTE Ftxxis" 2-103.11 Person in char ge-duties Contamination from Raw Ingredients 3-30111(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* aplicants*' 3-302.15 Washing Fruits and Vegetables 5920030 Responsibility Of A Food Employee Or An 3-304-11 Food Contra with Equipment and. Applicant To Report To The Person In Utensils r _ CIIW-I,,e* Contamination from the Consumer 590.003(G) Re a>rtib Pelson in Char e' 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.1 t Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food` Food and Water From Regulated Sources ') Food Contact Surfaces 590.004(-4-Bi Compliance with Food Law'" 4-507.111 Manual Warewashing-I-lot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures 3-201.13 Fluid Milk and Milk Products* 4-501.1.12 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Santtiaatian Tem eEhures* 3-202.14 Eggs and Milk Products.Pasteurized* `1'561.17 d Chemical Sanitization-temp.,pH, concentration and hardness. 3-202,10 Ice Made From Potable Drinking Wafer" 4-601.11(A) Equipment Food Contact Surfaces and 5-101.11 Drinkin^Water from an A roved Svstem* Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(13) Water Meets Standards in 310 CMR 22.0" Contact Surfaces and Utensils' ShefNish and Fish From an Approved Source 4-702.1 1. Frequency of Sanitizertion of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of E ui ment* Shellfish* 4-703.11 Methods of Sanitization-'Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources` 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms* Requiarery Authority 3-202.18 Shellst<xk Identification Present: 2-301.12 Cleatrin��Procedure* 590.004(C) Wild Mushrooms- 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices 5 Receiving/Condition 2-401.11 Eating Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyec,;Bose and 3-202-15 package Integrityo Month* 3-101.11 Food.Safe and(Unadulterated` 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.78 Shellstock identification* 590.001 Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Eiulovees* Tags/Records: Fish Products 13 Handwash Facilities Conveniently Located and Accessible 3-402.11 Parasite Destruction" 3-402.12 Records.Creation and Retention* 5-20311 Numbers and Ca acities, 590.064f1) Labeling of ingredients' 5-204.11. Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility, O eration and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502,11 1 Specialized Processin,Methods* Devices 3-502.12 Rechtcedoxy=cn Mcka*ine,criteria* 6-301.11 Handwashing Cleanser.Availabilit 8-103A2 Conformance with Approved Procedures' 6-301.12 Hand Dr in<*Provision ='Denotes critical item la the federal 1399 food Code or 105 CNIP 590.000. CITY OF SALEM BOARD OF HEALTH / r` Establishment Name: I FLi E t/ t.c s EdiA/P< Date: 3-/C>- n i Page: of 2- i Item Code C-Critical Item DESCRIPTIONOF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red item - Verified ' PLEASE PRINT CLEARLY I)/,-C /2- A/PPCf1 P vP/P�irnlP w — r�F�r TG7�7/J fO �S �ir°�/77r7•i>nfvr2 //v /r'�✓ _Pr -�D /'�� dis. / .r - /�/FrI />e �i/ice /-/.gym'✓! � GpS /,moit . al- c71-17z7 '4p /( LIP A/LV� '4i/�G v �' X >rk/3//,Vv�e°-�/ a4- /YYIA✓t,/,�.lia /A Ai[. C Geri inti �► jq .e '< /il4 — ,.ti PP /'fid/N d/�.w/�f 'Gv r7c �r-�pSS/%S rP' l!'GL 77/r;aS IA ,_Y'/,sC ,Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of LlEmbargo L) Emergency Closure your food permit. X11 - �� 11 LI Voluntary Disposal LI Other: i _I r J-501 I4(C) ( Y11 -,Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(items 1-22) (Cont.) 41'F145F Within 4 Homs. PROTECTION FROM CHEMICALS 3-501.15 Coolim,Methods for PHFs 14 Food or Color Additives 14 PHF Hot and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below, 3-202.12 Addiu"s* 590.004(£) 4F/45'H` 3-302.14 Protection from Unapproved Addifives* x-SOLI(i(A) Hot PHFs Maintained at or above. 15 Poisonous or Toxic Substances 140°F. '° 7-101.11 identifying information Origund 3-501.16(A) Roasts Held at or above 130'F. Containers* 7-102.11 Common Name-Workin-Containers* F 20 Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control* 7-202 11590.004(H)-Presence and Use* 590.004(H) variance Re uirement 7-202.12 Conditions of Use' 7-203.11 Toxic Containers-Prohibitions" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers, Criteria-Chemicals* POPULATIONS(HSP) 7--.114.t2 Chemicals for Washing Prrxtrtce,Criteria"` 21 3-801 11(A) f UnpasteinizedPre-packaged Juices and 1 Beverages with Warning Labels* 7-204.74 Dr-ins A guts,Criteria* 3-80 1 I I(B) Use of Pasteurized Eees' 7-205.11 Incidental Food Contact.Lubricants* 7-206.11 Restricted Use Pesticides.Criteria* 3-801A 1(I7) Raw or Partially Cooked Animal Food and Raw Seed S>routs Not Served. :I7-2476.12 Rodent Bait Stations" 3-80'1.11(C) Uno.enedFoodPacka>eNotRe-served. * ' 7-206.'13 Tracking Powders,Pest Control and Monitoring-^ CONSUMER ADVISORY TIMETEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods Mai are Raw.Undercooked or ;(6 R Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate � -t•., raocr 3-401.114(1)(2) Fags- 155°F 15 Sec. I atho ens Eggs-Immediate Service 145°Fl5sec" 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(AR2) Communed Fish,Meats&Game Eggs:' Animals- 155'F 15 sec. * 3-401.11(B)(1)(2) Pork and Beef Roast - 130°F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats- 155"F 1.5 590.009(Af-!)) Violations of Section 590.009(A)-(D)in sec * catering. mobile food, temporary and 3-401.1.l(A)(,3) Poultry,Wild Game,Stuffed WIN, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°P 15 sec. " above if related to foodborne illness 3-401.1 t(C)(3) Whole-muscle,hitact Beef%aaks interventions and tisk factors. Other 1450.F* 590.009 violations relating to good retail 3-401.12 Raw Aninv4 Foods Cooked in a practices should be debited under 19/29- 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 3403.11(4)&(ll) PHFs 165'F 15 see. " (Items 23-30) 3-403.11(B) Microwave- 165°F 2 Minute Standing Critical and ion-critical violations, which do not relate to the Time' .foodborne illness interventions and risk factors listed above, can be, 3403.11(C) Commercially Processed RTF Food- found in the follow=ing sections of the Food Code and 105 CMR 140°F* 590.000. 3-403 I i(F) Remaining Unsliced Portions of Beef item Good Ret_ait_P_radi es _ FC 690.000 Roasts* 23. Mama ement and P_ersonn_e_I__ _ FC 2 .003- 18 Proper Cooling of PHFs 24. Food and Food Protection FC-3 .004 25 _ _Equi merit and Utensils FC 4 .005 3-501.1.4(4} Cooling Cooked PHFs from 140°F to 26_ Water,Plumbing and Waste FC 5 ,006 111 --.-_. 70"F Within 2 Horus and From 70"F 27. Ph sical Facild+}__ FC-6 I .007 to 41.'F/45°F Within 4 Hours.* 28. Poisonous or Toxic Materials FC-7 1 .008 3-50L14(B) Cooling P1 IFI Made From Ambient 29. S ecial Re uirements _ _ .009 Temperature Ingredients to 41°£145°F 30 Other Within 4 Hours" tr s,E6'.ao, '*Denotes critical item in the.federal 1999 Food CMM or 105 CAIR 590000. .^� �• "" '.r. any A � ziur ..,rn,.-r�•ra'?,.re�'r- '#4"'-r+ ^-x�^^--`��- ---«,.s;�e- ,�4' r„� $""''”' '�`�'�.#xx�Te" , 1 CITY OF SALEM, MA$SACFIUSETTS °� >` p..'.y �.tkY i •. _ ... q,#Ych. i`} `\'Sc 1-'Yn 120 WASHINGTON STREET, 4TH FLOOR n. � 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: Effortless Edibles Address of Establishment: 211 Bridge Street Owner's Name: Julie Rose Restrictions: Application Date: 12/2/2004 Permit for Food Establishment 130-05 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. -X� ,,x6t _ HEALTH AGENT CITY OF SALEMr WkSSACHUSETTS BOARD OF HEALTH " ig 120 WASHINGTON STREET, 4TH FLOOR _ SALEM, MA 01970 TEL. 978-741-1800 Fax 978-748-745-0343 STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO NOV 2 9 2004 MAYOR HEALTH AGENT 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMgBE��9gqlfTY OF SALEM NAME OF ESTABLISHMENT Eoi (�='Sn �i c� cGj((S TEL# 9 '`/HS=grPf HEALTH ADDRESS OF ESTABLISHMENT 21Ica�dt eJ MAILING ADDRESS (if different) OWNER'SNAME Jake 6_ck TEL# X711- 7x/3"-9/r5J" ADDRESS S � CITY G Qr rn STATE OVV- ZIP 1y76 CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICA'TE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON i � HOME TEL# 7xf5--`f05 HOURS OF OPERATION: Mon. ✓/Tue. - CVVed. Thu. Fri. Sat. Sun. TYPE OF ESTABLISHMEW FEE check onl RETAIL STORE YES NO less than 1000sq.ft. _$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES NO 1��v less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. MI /, /O 7-11.7776 -7 Signature Date Social Security or Federal Identification Number —; /1 ------------------------------------- --- Revised 11/03/03 FOODAP2.adm Check#&Date kk' „ � � �� I ! S' � A 0211 Bridge Street Effortless Edibles City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Telephone: Item Status Violation Critical Urgency Nature of problem or correction 978-745-7111 Non-compliance with: Not Done .Owner: .. .. Anti-Choking PASS ❑ Julie Rose Tobacco PASS ❑ PIC: e Rose FOOD PROTECTION MANAGEMENT Not Done Julie toRo _ ; PIC Assigned/Knowledgeable/Duties PASS ❑d RED Insp'DaVld Greenbaum 1 i T " = EMPLOYEE HEALTH Not Done Date Inspected: Correct By: Reporting of Diseases by Food Employee and PIC PASS ❑o RED 3/29/2005 2 _ Personnel with Infections Restricted/Excluded PASS RED Risk Level: 9, FOOD FROM APPROVED SOURCE Not Done Permit Number: Food and Water from Approved Source PASS ❑d RED BHP-2005-0211 Receiving/Condition PASS ❑J RED Status: Tags/Records/Accuracy of Ingredient Statements PASS RED SIGNEDOFF A Conformance with Approved Procedures/HACCP PASS RED #of Critical Violations: Plans PROTECTION FROM CONTAMINATION Not Done Time IN: Time OUT: Separation/Segregation/Protection PASSd❑ RED Notes: "'' _® "' Food Contact Surfaces Cleaning and Sanitizing PASS RED 51: Proper Adequate Handwashing PASS RED s c Urgency Description(s): Good Hygienic Practices PASS RED BLUE: Prevention of Contamination from Hands PASS Q RED Violations Related to Good Retail Practices (Critical Handwash Facilities PASS ❑d RED violations must be corrected imrpediately or within 10 days)(Non-critical violations GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Mar 30,2005 ) Page 7 of 0211 Bridge Street Effortless Edibles must be corrected Immediately PROTECTION FROM CHEMICALS Not Done or Within 90 days) Approved Food or Color Additives PASS RED RED Toxic Chemicals PASS d❑ RED Violations Related to ` g Foodborne Illness Interventions TIMEITEMPERATURE CONTROLS(Potentially Haz Not Done and Risk Factors (Require Cooking Temperatures PASS ❑Q RED immediate corrective action) Reheating PASS ❑d RED Cooling PASS ❑d RED Hot and Cold Holding PASS ❑d RED Time As a Public Health Control PASS ❑ RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP PASS ❑d RED CONSUMER ADVISORY Not Done Posting of Consumer Advisories PASS ❑d RED Violations Related to Good Retail Practices (Blue Not Done Management and Personnel PASS ❑ BLUE Food and Food Protection PASS ❑ BLUE Equipment and Utensils FAIL ❑ BLUE Small freezer, RCA refrigerator, and Blue /Air refrigerator need visible, accurate thermometers. Provide protective covers on all light fixtures. 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 QeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Mar 30,2005 ) Page 2 of r� 0211 Bridge Street Effortless Edibles GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Mar 30,2005 ) Page 3 of i r' CITY OF SALEM9 MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR + SALEM, MA 01970 yq4 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: Effortless Edibles Address of Establishment: 211 Bridge Street Owner's Name: Julie Rose Restrictions: Application Date: 12/15/2003 Permit for Food Establishment 196-04 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. qoHEALTH 'AGENT BOARD OF HEALTH 120 WASH I NGTON STREET, 4TH FLOOR; SALEM, MA 01970 TEL. 978-741-1800 DEC 7 0 9003 FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO - i U i i , MAYOR HEALTH AGENT 80A, RD 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT— NAME OF ESTABLISHMENT TL-# ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different) o OWNER'S NAME TEL -� ADDRESS a CERTIFIED FOOD MANAGER'S NAME(b E*||F|Cx|E#(s (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME TEL � HOURS [}FOPERATION: yWon uo� d� hu� Fri. v/ ` TYPE OF ESTABLISHMENT FEE check only RETAIL STORE NO less(han1000uq.ft. =$ 50 ^~~' 1000'10'000oq.h. =$100 more =B250 ' � � RESTAURANT YES NO less than 25seats =$100 25-99 seats =$150 more than 09seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES $5 TOBACCO VENDOR YES $50 /�LL /V<�A-PRC/��T/sucha�rhurcb�/hc�ens) YES NCO $25 . ` `�� Please pay total with one check payable hothe City ofSalem This Permit isnot transferable and must be reissued upon change of ownership. The Permit must baposted inaprominent location inthe Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that 1, to my best knowledge and beli9f, have filed all state tax returns d paid all statetaxes required under the | Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name Date Tvpe of OT Deration(s) T of in ection 7 fells 7- Sn e`f J �f-0 r{ ©'Food Service Routine Address Risk ❑ Retail C2// ,7�//)qP S j El❑ Re-inspection Telephone / /C7 Level �YRE�efai'ta'DKitchen Previous Inspection 9 ❑ Mobile Date: 3-d1-G3 OwnerHACCP Y/N El Temporary El Pre-operation IC-14TI 114o ,F //_c 1_51'rIe-�1/ G S!,7 dem ❑ Caterer ❑ Suspect Illness Person in Charge(PIC)P,GS at N U Time El Bed& Breakfast [I General Complaint 0 In: ❑ HACCP Inspectorf4/S Out: Permit No. El Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. 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 El3. Personnel with Infections Restricted/Excluded El 14.Approved Food or Color Additives ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source - TIME/rEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION - ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) El 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, signed below, when C' N" P 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-a)(sso.00s) 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:5WInspUFOm 14do e 's Si�3 re: m... .7- Print: PIC'sSignpture• ��1� Print: �05a�- �RLOM/I✓D Page/ of C�Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT t3 Cross-contamination 1 I 590.003(A) I Asstenment of Responsibility* 3-302.11(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstn tion of Knox ledge* _ Cooked and RTE Foods* 2-103.1 I- C Person in charne--duties Contamination from Raw ingredients 3-302.11(A)(2) Raw Anunni Foods Separated from Each EMPLOYEE HEALTH Others` 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 Vcg,*stables 590D03(F} Responsibility Of A Food Employee Or An 3-304.1 1 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge,* Contamination from the Consumer 590.003(G) Re ortrna by Person in Chime* 3-306.14(A)(B) Returned Food and Reservice o1'Food'" 3 590,003(D) Exclusionsand Restrictions* Disposition of Adulterated or Contaminated 590,003(E) Removal of Exclusions and Restrictions i Food 3-701.11 Discarding or Reconditioning Unmafe 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 %Vuewashing-Hot Water 3-201.12 Food inn Hermetically Sealed Container* Sanitization Teta peratures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewastrine-Hot Water 3-202.13Shell Eaas* Sanitization Temperatures* 3-202.14 Eg is and Milk Products.Pasteurized* 4-5(11.114 Chemical Saniti>ittion-temp, pH, 3-202.,16 Ice Made From Potable Drinking Water'" concenh'ation and hardness 'K 4-60 L l I(A) Equipment Food Contact Surfaces and a 101.11 Drinkin�Water from an.4 raved S stem* � ean* Utensils Cl 590.006(A) Bottled DrinkingWater* 4b02.i 1 Cleaning Frequency acne of Equipment 590.000(B) Water Meets Standards in 310 CMR 22.0" Contact Surfaces and f iFood- Shellfish and Fish From an Approved Source LO 4-702.11 Frequency of Sanitization of Utensilsand 3-201.14 Fish and Recreationally Caught Motluseen Food Contact Surfaces of Equipment* Shellfish" 4-703.11 Methods of Sanitization-Hot Water and 3-201.'15 MORUSCan Shellfish from NSSP Listed Chemical" Sources' 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved 6y 2-301.11. Clean Condition-Hands and Anus* Re utato Authorit 3-202-18 5hellstock Identification Present* 2-381.1.2 Cleanin;Procedure* 590.004(C) _ Wild Mushrooms* 2-301.14 When to Wash- 3-201.17 Game Animals* 1.I Good_Hygienic Practices S Receiving/Condition 2-401,11 Eatin ,Drinkin r or Usina'Fobacco* 3-202.11 PHFs Received at Proper Tem eratures` 2-401.12 Discharges From the Eyes. Nose and 3-202.15 Package htte rit'* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Prerentin Contamination When'1'astinas` 6 Tags/Records:Shellstock t2 Prevention of Contamination from Hands 3-202.1$ Shellstock Identification* 590.004(E) Preventing Contamination from 3-205.12 Shellslock Identification Maintained* _. Em toees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 PzuasiteDestrnction* Conveniently Located and Accessible l - Ca acities* 3-402.12 Records.Creation and Retention" 5-203.11 Numbers and 590.00.101 Labeling of Ingredients* 5-204.11 Location and Placetnant* 7 Conformance with Approved Procedures 5-205.11 Accessibility. Operation and Maintenance , IHACCP Plans Supplied with Soap and Nand Drying 3-502.1 S ecialized Processing Methais* Devices 1 3-502.12 Ruluced osQen packanng.criteria* 6-30L1'[ Hand*vashin Cleanser, .Avarlabilit 5-103.12 Conformance with Ap roved Procedures* 6-301.1.2 Hand Drvim*Provision "Denotes critical item in the federal 1999 Pond Code of 105 01 R 59(7.000, CITY OF SALEM BOARD OF HEALTH Establishment Name: fcRS T de e'Lis % (�, �� Date: 9- :A S-0 U Page: a of Rem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date -+ No. Reference R-Red Item -'* Verified }i PLEASE PRINT CLEARLY - /PD ^ S POS17 No Q_ / // kl s J r9 YL CC/L ry O e P t a/ f- -, S N 7i i i o S I %O/L AlP,F S /-A ✓Ytile n /, ' _�Jrr/ P c a v, i B77gd22LP i i 7 r Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes / I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee RestrictionExclusion E violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure f your food permit. ✓ �J �h1n1n0 Ll Voluntary Disposal LlOther: r V 3-501.14(C) PHFs Received at Temperatures Violations Related to foodborne Illness Interventions and Risk According to Law Cowled to Factors(Items 1-22) (Cont.) 4.I Fl45'F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Conine Methods for PHR 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-20212 Addtu�as^ 3-501.16(B) Cold PAFs Maintained at or below 590.004(F) 41'145°F* 3-302.34 Prete ion from Unapproved Additives* 3-501 Poisonous or Toxic Substances . 1.5 16(A) Hot PHFs Maintained at or above _7 10i.11 ldentifyiug information-Ori nal IAO`F. * Containers' 3-501.16(A) Roasts Held at or above 13(YF. 7-10211 Connnon Name-Warkinn Containexs` 20 I Time as a Public Health Control Se.aration-Stora e" 3-50119 Tient:as a Public Health C.',ontrui 7-20211 Restriction-Presence and Ilse), 5o)Q004(1)) Variance RequhEment 7-202.12 Conditions of Use" 7-203.1E TbxicContainers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7204.11 Sanitizxrs.Cvteun Chemicals* POP( NS(HSP _ _ 720 4-12 Chemicals for Washing Pioduce,Criteria' 21 3-ROE 1.1(A)A) Unpastenrired Pre-packaged Juices and 7 204.14 Drying Agents.Crdeiia* Benet noes with Wtrnin-Labels* 7-205.1.1 Incidental Food Contact,Lnlricana* 3-801.11(13) Use of Pasteurized E�Zi* 7-206.11 Restricted Use Pesticides,Crneua* 3-801A i(D) Raw or Partially(hooked Annual Wood and Raw Seed Sprouts Not Served " 7206.12 Rodent Bait Stations* 3-801,11(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitorniv, CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-Ci03.11 Consumer Advisory Posted for Consumption of _ per Co 16 Prooking Temperatures for Animal Foods That are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.17A(1)(2) Eggs- 155°F IZ Sec. Pathogens. erne_- ,-;;zona F s-Immedi ate Service 135'FlSsec� 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game Animals- 155'F 15 sec. IREMENTS 3-401.11(B)(I)(2) Poi kand Beef Roast- 130'F121min" SPECIAL REQUnsofSeti 3-401.11(A)(2) Ratites,Injected Meats- 155'F 15 0`� �O-(Dlioldtions of Section 59Ci.Q09(A}-CD)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 underthe appropriate sections Poultry or Ratites-165'F' 15 sec. ` above if related to foodborne illness 3-401.1.1(C)(3) Whole-muscle,Intact Beet 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 tinder#29- Microwave 165'F" Special Requirements. 3-401.11(A)(1)(b) All Other PHFs -- 145'F 15 sea 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.71(A)&(D) PHT's 165'F 15 sec. :z (Items 23-30) 3-403.11(3) Microwave- 165°F 2 Minute Standing Critical and non-crorcal violations, which do not relate to the 1 Time* foodborne illxess irrterveerimu and risk factors listed above, cart be 3-403.11(0 Commercially Processed RTE Food- found in the follmaing sections of the Food Cocle and 105 CMR 14017- 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef Item Good Retail Practices FC 590.000 Roasts* :_23 Management and Personnel FC-2 ,003 Lg Proper Cooling of PHFs 24 Food and Food Protection FC 3 .004 25. E u�msnt and U#enrols _ _FC 4 -0 0-5 1 3-501.14(A) Cooling Cooked PER from 140'F to 26. Water, Plumbing and Waste _ FC-5 _ .006 XT Within 2 Hours and From 70`F 27. Physical Facility FC-6 .007 to 41'F745'F Within 4 Hours, * 28. ! Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made Front Ambient 29 1 Special_Requirements 009 Temperature ingredients to 41'F/4PF 30 Other .,__ --------- I ---.-- ; Within 4 Hours* Denote®critical item in the tederal 1999 Fgod Cale or 1M CMR 590.000. 1 wk ,f CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH g}' ♦ 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 �oTf FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Effortless Edibles Address of Establishment: 211 Bridge Street Owner's Name: Julie Rose Restrictions: Application Date: 9/9/2003 Permit for Food Establishment 316-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2003 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT � oxotr CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH . 120 WASHINGTON STREET, 4TH FLOOR m. SALEM, MA 01970 T E L. 97 B-741-1 800 FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT EAort-teSZE TEL# ADDRESS OF ESTABLISHMENTc2�� 6-1d P MAILING ADDRESS (if different) 1'/0 6 OWNER'S NAME Su tt e gos2 TEL# ADDRESS �hl✓1cjPn S� CITY !�h (P/J'I STATE ZIP 0/ 76 CERTIFIED FOOD MANAGER'S NAME(S)_"-TrR I— QSe CERTIFICATE#(s) (required in an establishment where potentially hazardous food is-prepared.) EMERGENCY RESPONSE PERSON �2rYYiPC /�Ds2 HOME TEL HOURS OF OPERATION: Mon. Tue. _Wed._ C�Thu. _Fri. Sat. LNC Sun.&L--- TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES / less than I000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR NO $50 ALL NON-PROFIT(such as church kitchen YES 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 b ef, have filed all state tax returns and paid all state taxes required under the law. moo vn , p V Xag 51— ri77�&7 Sign a — Dater Social Security or Federal Identification Number -------------------------------------------- Revised 11125/02 FOODAP2.adm Check#&Date t �y��y�� i3-1791 i 13 DATE _C^�2 FY0/) TO THE r OR ER OF.. -c.."""" OLLARS MM- 311 m311 Eastern Bank 24HWASEgWCEIB WTM ' FOR _ _.._..-.--- ^>• I:0 i 130 17981: 60 1948 is i THE COMMONWEALTH OF MASSACHUSETTS CITY,OF SALEM Address: 120 Washington Street, 4th Floor BOARD OF HEALTH Salem, MA 01970-3523 FOOD ESTABLISHMENT' INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 745-0343 Name Date T f i Type of Inspection Food Service ❑ Routine Address ' Risk ❑ Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone 97 ? til( 4/J --� ❑ Mobile Dale: Owner - HACCP 'Y/N El Temporary /j�p+l'Pre-operation ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) .. Time_ El Bed 8 Breakfast El General Complaint In: El HACCP Inspector ./Y Out: Permit No. EJOther Each violation chee�cked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/ Knowledgeable/ Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/ Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE El 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) El 16. Cooking Temperatures El 5. Receiving/Condition El6. Tags/ Records/Accuracy of Ingredient Statements [1 17. Reheating El7. Conformance with Approved Procedures/HACCP Plans El 18. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding [18. Separation/Segregation/ Protection El 20. Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 10. Proper Adequate Handwashing ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related Items) Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health..Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/Federal Food Code.This report, when signed below j C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: Inspector's Signature: Print: A oc �,/i PIC's Signature: ` Jn ,{/,y„ Print: CJ` �l Pagv. of`F_ FORM 734A HOBBSta/ARREN - BOSTON-c.-� Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION g Cross- Ontdminat'Or' FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw A imal Foods Separated from , 590.003(A) I Assignment of Responsibility* Cooked and RTE Foods* 590.003(8) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11 Person in Charge-Duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) Food Protection* -\p require reporting by Food Employees and 3-302.15 Washing Fruits and Vegetables Applicants 3.304.11 Food Contact with Equipment and 590.003(F) Responsibility of a Food Employee or an Utensils* Applicant to Report to the Person in Charge* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated 1 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE 9 Food Contact Surfaces 4' Food and Water From Regulated Sources 4-501.111 Manual Warewashing-Hot Water 590.004(A-B) Compliance with Food Law* Sanitization Temperatures* 3-201.12 Food in a Hermetically Sealed Container* 4-501.112 Mechanical Warewashing-Hot Water 3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures* 3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-tem H, P P 3-202.14 Eggs and Milk Products,Pasteurized* Concentration and Hardness* 3-202.16 Ice Made from Potable Drinking Water* 4-601.11(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved System* Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3.201.14 Fish and Recreationally caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization- Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* Il Good Hygienic Practices 3-201.17 Game Animals* 2-401.11 Eating,Drinking or Using Tobacco* 5Receiving/Condition 2-401.12 Discharges From the Eyes,Nose and 3-202.11 PHFs Received at Proper Temperatures* Mouth* 3-202.15 Package Integrity* 3-301-1-2----7 Preventing Contamination When Tasting* 3-101.11 Food Safe and Unadulterated* -.12 Prevention of Contamination from Hands 6V Tags/Records:Shellstock 590.004(E) Preventing Contamination from 3-202.18 Shellstock Identification* Employees* 3-203.12 Shellstock Identification Maintained* "•33 Handwash Facilities Tags/Records: Fish Products Conveniently Located and Accessible 3-402.11Parasite Destruction* 5-203.11 Numbers and Capacities* 3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement* 590.004(]) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance 7' Conformance with Approved Procedures Supplied with Soap and Hand Drying /HACCP Plans Devices 3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability 3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision 8-103.12 Conformance with Approved Procedures* •Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM ` BOARD OF HEALTH g Establishment Name: ll� Date: / / �� Page: Z of Z Item Code C-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item - Verified t - ...PLEASE PRINT CLEARLY x -T E Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes 4 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 it P LI Re-inspection Scheduled ❑ Emergency Suspension j comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: t 3-501.1.4(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Lew Cooled to Factors(items 1-22) (Cont.) 4111F145°F Within 4 Hours. " PROTECTION FROM CHEMICALS 3-5o 1.15 Cooling Methods for PHFs 14 Food or Color Additives t9 PHF Hot and Cold Holding 3-501.16(6) Cold PHIPs Maintained at or below 3-202.12 Additives', 590.004(F) 41'Y45°F* 3-302.14 Protection from Una towed.kddinvea" 13-501,16(A) Hot PHFs Maintained at at above 15 Poisonous or Toxic Substances 140°F.* 7-101.11 Identifying -50 Information-Original 31.16(Al Roast Held at(it above 130°F 's Containers" Time as a Public Health Control 7-102.11 Couttnon Name 20 ane-Workitttr Containers* 3-501.1.9 Time as a Public Health C:ontroP, /-201,11 Separation-Stot ave" 7-202.11 Restriction-Pretence and Use's 590A04(Hj Vaciancc Rec uh�ement 7-202.12 Conditions of Use* 7-203.1.1 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS(HSP) 7-204.12 Chemicals for Washing Produce,Criteria ZI 3-801.11(A) Unpastcuri,zerl Pre-packaged Juices and Beveras;es with Wanting L;lbek* 7-204.14 Drying Agents.Crrtuiat* 3-801A I(B) Use of Pasteurized Egos* 7-205.11 Incidental Food Contact,Lubricants* 3-801,11 1(D) Raw or Partially Cooked Anima(Food and 7-206.11 Restricted Use Pesticides.Criteria" ,Raw Seed S xouts Not Sexvc d 7-206.12 Rodent Bait Stations* 3-80I.1.l(C) Uno�encd Food Package Not Re-served, 7-206.13 Tracking Powders, Pest Control and Monitoring* CONSUMER ADVISORY TIMEtrEMPERATURE CONTROLS 2y 3 003.11 Consumer Advisory Posted for Consumption of 16 Animal Foals,chat are Raw, Undercooked or Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate 3-401.ItA(1)(2) Eesti 1557 15 Sec Patboscus °i' "onr Eggs-Immediate Service l IS FiSser% 3-302.13 Pasteurized F.-s Substitute for Raw Shell 3 401.11(A)(2) Comminuted Fish.Meats&Game 6n s* Animals- 155`F 15 see. * 3-401.11(6)(1)(2) Pork and Beef Roast- 130°F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats- 1.55°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. * catering,mobile food, temporary and 3-401.1](A)(,) 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 Steals interventions and risk factors. Other 1450F 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Crooked in a practices should be debited under#129- Microwave 165-F^ Special Requirements. 3-401.11.(A)(1)(b) All Other PHFs - 1.45°F 15 sec. I7 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.t I(A)&(D) PHFs 165°F 15 sec. " (Items 23-30) 3-403.1.1(B) Microwave- 165°P 2 Minute Standing Critical and non-critical violations, which do not relate to the Time" foodborne ilbtess interventions and risk factors listed above, can be 3-401.1.1(C) Commercially Processed RTE Food- bund in the following sections of the Food Code and 105 CMR 140°F* 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef ttein Good Retail Practices FC 590.00D Roasts* i_23. _Management and Personnel I FC-2 .003 24 Food and Food Protection TFC-3 .004 ig Proper Cooling of PHFs ment and Waste FC_ 0 006 Utensfs FC-4 '035 3-50L14(A) Cooling Cooked PHFs from 26. Wr 140 F toPlumbing 70`F Within 2 Hours and From 70°F 27. Physical Facility I FC-6 .007 to 41°F/45°F Within 4 Hours. * 1_28 Poisonous or Toxic Materials_ FC-7 .008 I 3-501.14(B) Cooling PHFs Made From Ambient (_29 _ Special Requnrients r 009 Temperature Ingredients to 41-F/45'F 30 Other Within 4 Hours* s 2.bs "Denotes critical item in the federal 1999 Foal Cate ur 1W CMR 590.000.